The nurse has reviewed the information from the Nurses' Note...

The nurse has reviewed the information from the Nurses' Notes. Complete the following sentence/sentences by choosing from the list/lists of options. After removing the blankets from the client's room, the nurse should ----------------and ----------

A. Initiate 1-to-1 observation
B. Request a prescription for alprazolam
C. Lock the door to the client's room during the day
D. Notify the health care provider
E. Document the client's behavior
F. Restrict the client to the unit unless accompanied by a family member

Correct Answer: D,A

Rationale: After removing the blankets from the client's room, the nurse should notify the health are provider and initiate 1-to-1observation.This client is at high risk for imminent suicide. The client has severe depression, suicidal ideation with a plan, and access to lethal means (eg, blankets that can be used for self-hanging). This client requires constant visual ontact (ie, 1-to-1observation) to ensure safety 24 hours a day. The nurse should also notify the health care provider to assess for underlying psychiatric disorders (eg, psychosis) that could contribute to the situation.

The nurse has reviewed the information from the Laboratory Results and Nurses' Notes. Which of the following nursing actions are anticipated? Select all that apply

A. Adds 5% dextrose to continuous IV fluids
B. Administers potassium chloride
C. Administers sodium bicarbonate
D. Discontinues insulin infusion
E. Encourages the client to drink orange juice

Correct Answer: A,B

Rationale: The goal of treatment of diabetic ketoacidosis (DKA) is to normalize fluid volume, decrease blood glucose levels, balance electrolytes, and
correct metabolic acidosis. On administration of insulin, potassium and glucose shift from the extracellular space to the intracellular space.
Clients with DKA require potassium administration due to low intracellular potassium levels.
Insulin is administered to facilitate glucose transport into the intracellular space to resolve DKA and should be continued until the metabolic
acidosis resolves. When caring for clients with DKA, the nurse should anticipate:
• Adding 5% dextrose to continuous IV fluids when the serum blood glucose level reaches approximately 200 mg/dL (11.1 mmol/L) to
prevent hypoglycemia and cerebral edema resulting from levels decreasing too quickly (Option 1). This is done because insulin is still
required to resolve DKA. If the DKA is resolved, insulin can also be decreased instead of adding dextrose to the IV fluids.
• Administering potassium chloride for a client with hypokalemia and adequate urine output (ie, >30 mL/hr) to prevent life-threatening
arrhythmias

The client returns to the clinic 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy?

A. My child will eat but only if I cook the same meal every day.
B. My child will make only brief periods of eye contact with the teacher.
C. My child will occasionally play with other children at the park.
D. My child will squeeze a soft toy instead of banging the head.

Correct Answer: A

Rationale: Early childhood intervention programs (eg, behavioral therapy) are a critical component for clients with autism spectrum
disorder and can have positive long-term effects on presenting symptoms and social skills. Therapy helps increase
communication and language skills; improve focus, social skills, memory, and academic functioning; and decrease problematic
behaviors through positive reinforcement and other behavioral approaches
When evaluating the outcomes of therapy, the nurse should recognize that clients who demonstrate narrowed, restricted
interests (eg, eating the same foods) indicate a need for additional therapy

For each finding below, click to specify if the finding is consistent with the disease process of acute upper gastrointestinal bleed or acute lower gastrointestinal bleed. Each finding may support more than one disease process.

A. Melena
B. NSAID use
C. Hematemesis
D. History of diverticulosis
E. History of Helicobacter pylori infection

Correct Answer:

Rationale: Upper gastrointestinal (Gl) bleeding can occur in the esophagus (eg, esophageal varices or in the stomach and duodenum
(eg, peptic ulcer). Findings associated with upper GI bleeding include the following:
• Melena (ie, dark, tarry stools) is due to the release of iron (heme) as blood passes through the entire GI tract and
hemoglobin becomes partially digested
• NSAID use increases the risk of peptic ulcer formation by inhibiting cyclooxygenase-1, an enzyme that helps protect the
stomach lining and promote platelet aggregation.
• Hematemesis (ie, vomiting blood) is due to the presence of blood in the upper GI tract (eg, esophagus, stomach,
duodenum); the blood usually has a coffee ground appearance due to digestion by gastric acid
• Helicobacter pylori infection increases gastric secretions, promoting peptic ulcer formation.
Lower Gl bleeding occurs in structures past the duodenum (eg, small and large intestine, rectum, anus) and is commonly
associated with inflammatory (eg, Crohn disease, ulcerative colitis, diverticulosis) or vascular (eg, hemorrhoids) conditions.
Diverticulosis is a condition where diverticula (ie, hollow outpouchings from the intestine) develop, usually in the large
intestine and occasionally in the small intestine. Diverticula weaken the intestinal wall and increase the risk for GI bleeding.

For each finding below, click to specify if the finding is consistent with the disease process of acute angle-closure glaucoma, cataracts, or macular degeneration. Each finding may support more than one disease process.

A. Blind spots
B. Opaque lens
C. Blurred vision
D. Unilateral headache
E. Conjunctival redness
F. Nausea and vomiting
G. Increased intraocular pressure

Correct Answer:

Rationale: Acute angle-closure glaucoma (ACG) is the sudden onset of increased intraocular pressure (IOP) due to impaired aqueous humor drainag
through the angle of the anterior chamber. Acute ACG typically occurs spontaneously but may be triggered by impaired aqueous outflow frol
pupillary dilation (eg, emotional excitement, medications (decongestants, anticholinergics, antihistamines], darkness). As IOP increases,
clients report seeing halos around lights and/or develop blurry vision, unilateral headache, conjunctival redness, and nausea and
vomiting. Increased IOP damages the optic nerve, and the cornea becomes edematous; therefore, light cannot travel effectively from the
cornea to the optic nerve, causing halos to be seen.
Cataracts are a slowly progressive pacification of the lens that results from oxidative damage. Refractive changes in the lens cause clients
to initially develop difficulty reading fine print because of the opaque lens. As the cataract progresses, clients develop painless, blurry visio
and have difficulty with nighttime driving because they see a glare and halos around lights. Halos and glare occur because light cannot
travel through the opacified lens effectively and instead disperses in various angles.
Age-related macular degeneration (AMD) is a progressive, incurable disease of the eye characterized by deterioration of the macula, the
central portion of the retina. This deterioration causes visual disturbances (wavy or blurred vision), blind spots, or loss of the central field
vision; peripheral vision remains intact. AMD has a vascular pathogenesis that is unrelated to increased IOP. Clients with AMD have a norm
cornea, lens, and optic nerve; therefore, halos are not seen.

NCLEX PN Test Questions with NGN

NCLEX PN Test Questions with NGN Related

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