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Terms in this set (144)
The nurse reviews the C, E
electrolyte results of a client
with chronic kidney disease Rationale:
and The client with chronic kidney disease is at risk for hyperkalemia. The
normal
notes that the potassium level
potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum
is 5.7 mEq/L (5.7 mmol/L). potassium level
Which patterns would the greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia.
nurse watch for on the cardiac Electrocardiographic changes associated with hyperkalemia
monitor as a result of the include flat P waves, prolonged PR intervals, widened QRS
laboratory value? Select all complexes, and tall peaked T waves. ST depression and a
that apply. prominent U wave occurs in hypokalemia. A prolonged ST
segment occurs in hypocalcemia.
A. ST depression
B. Prominent U wave
C. Tall peaked T waves
D. Prolonged ST segment
E. Widened QRS complexes
A
The nurse is instructing a
client how to perform a
Rationale:
testicular self-examination
The nurse needs to teach the client how to perform a TSE.
(TSE). The nurse should
The nurse should instruct the client to perform the exam on
explain that which is the best
the same day each month. The nurse should also instruct the
time to perform this exam?
client that the best time to perform a TSE is after a shower
or bath when the hands are warm and soapy and the scrotum
A. After a shower or bath
is warm. Palpation is easier and the client will be better able
B.While standing to void
to identify any abnormalities. The client would stand to
C. After having a bowel movement
D. While lying in bed before
perform the exam, but it would be difficult to perform the
arising exam while voiding.
Having a bowel movement is unrelated to performing a TSE.
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The clinic nurse prepares A, B, D
to perform a focused
assessment on a client who Rationale:
is complaining of symptoms A focused assessment focuses on a limited or short-term problem, such
as the
of a cold, a
client's complaint. Because the client is complaining of symptoms
cough, and lung congestion.
of a cold, a cough, and lung congestion, the nurse would focus
Which should the nurse
on the respiratory system and the
include for this type of
presence of an infection. A complete assessment includes a
assessment? Select all that
complete health history and physical examination and forms
apply.
a baseline database. Assessing the strength of peripheral
pulses relates to a vascular assessment, which is not related
A. Auscultating lung sounds
to this client's complaints. A musculoskeletal and
B. Obtaining the client's
temperature neurological examination also is not related to
C. Assessing the strength of this client's complaints. However, strength of peripheral pulses
peripheral pulses and a musculoskeletal and neurological examination would be
D. Obtaining information about included in a complete assessment.
the client's respirations Likewise, asking the client about a family history of any
E. Performing a illness or disease would be included in a complete
musculoskeletal and assessment.
neurological examination
F. Asking the client about
a family history of any illness
or disease
The clinic nurse is preparing to D
,explain the concepts of
Kohlberg's theory of moral Rationale:
development with a parent. In the preconventional stage, morals are thought to be motivated
The nurse by punishment and reward. If the child is obedient and is not
should tell the parent that punished, then the child is being moral. The child sees actions
which factor motivates good and as good or bad. If the child's actions are good, the child is
bad actions for the child at the praised.
preconventional level? If the child's actions are bad, the child is punished.
Options 1, 2, and 3 are not associated factors for this
A. Peer pressure stage of moral development.
B. Social pressure
C. Parents' behavior
D. Punishment and reward
The maternity nurse is A
providing instructions to a new
mother regarding the Rationale:According to Erikson, the caregiver should not try
psychosocial development of the to anticipate the newborn infant's needs at all times but
newborn infant. Using must allow the newborn infant to signal needs. If a newborn
Erikson's psychosocial infant is not allowed to signal a need, the newborn will not
development theory, the nurse learn how to control the environment. Erikson believed that
instructs the mother to take a delayed or prolonged response to a newborn infant's signal
which measure? would inhibit the development of trust and
lead to mistrust of others.
A. Allow the newborn infant
to signal a need.
B. Anticipate all needs
of the newborn infant.
C. Attend to the
newborn infant
immediately when
crying.
D.Avoid the newborn infant
during the first 10 minutes of
crying.
, A nursing student is presenting A
a clinical conference to peers
regarding Freud's Rationale:
psychosexual stages of In general, toilet training occurs during the anal stage.
development, According to Freud, the child gains pleasure from the
specifically the anal stage. The elimination of feces and from their retention. Option 2
student explains to the group relates to the oral stage. Option 3 relates to the latency period.
that which Option 4 relates to the phallic stage.
characteristic relates to the anal
stage?
A. This stage is associated
with toilet training.
B. This stage is
characterized by the
gratification of self.
C. This stage is characterized by
a tapering off of conscious
biological and sexual
urges.
D.This stage is associated with
pleasurable and conflicting
feelings about the genital
organs.
A client with diabetes mellitus D
has a
glycosylated hemoglobin A1c level Rationale:
of 8%.
The normal reference range for the glycosylated hemoglobin
On the basis of this test result,
A1c is less than 6.0%. This test measures the amount of
the nurse
plans to teach the client about the glucose that has become permanently bound to the red
need for which measure? blood cells from circulating glucose. Erythrocytes live for
about 120 days, giving feedback about blood glucose for the
A. Avoiding infection past 120 days. Elevations in the blood glucose level will
B. Taking in adequate fluids cause elevations in the amount of glycosylation. Thus, the
C. Preventing and test is
recognizing useful in identifying clients who have periods of
hypoglycemia hyperglycemia that are undetected in other ways. The
D. Preventing and estimated average glucose for a glycosylated hemoglobin A1c of
recognizing 8% is 205 mg/dL (11.42 mmol/L). Elevations indicate
hyperglycemia continued need for teaching
related to the prevention of hyperglycemic episodes.