SATA Flash Cards.docx

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• Share 

• rint 

• +"port 

• 'lone 

!" Car#s in this Set

 

$ront

 

%a&k

#.The nurse is ,onitoring a client who is

receiving o"ytocin (itocin to induce labor. The

nurse should be prepared for which ,aternal

adverse reactions-Select all that apply

#. Hypertension

/. 0aundice

3. 1ehydration

&. Fluid overload

%. 2terine tetany

. )radycardia

#. #4 &4 %

/. 5 client who is /6 weeks pregnant co,es to

the labor and delivery unit. She states that she7s

having contractions every 8 ,inutes. The client

is also 3 c, dilated. 9hich ,edications can the

nurse e"pect to ad,inister-

Select all that apply#. Folic acid (Folvite

/. Terbutaline ()rethine

3. )eta,ethasone

&. !ho (1 i,,une globulin (!hoga,

%. :.;. fluids

. <eperidine (1e,erol

/. /4 34 %

3. The nurse is evaluating a client who is 3&

weeks pregnant for pre,ature rupture of the

,e,branes (!O<. 9hich findings indicate

that !O< has occurred-

Select all that apply

#. Fernlike pattern when vaginal fluid is placedon a glass slide and allowed to dry

/. 5cidic pH of fluid when tested with nitra=ine

paper 

3. resence of a,niotic fluid in the vagina

&. 'ervical dilation of c,

%. 5lkaline pH of fluid when tested with nitra=ine

paper 

. 'ontractions occurring every % ,inutes

3. #4 34 %

public

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&. 9hat infor,ation should the nurse include

when teaching postcircu,cision care to parents

of a neonate before discharge fro, the

hospital-

Select all that apply

#. The infant ,ust void before being discharged

ho,e./. etroleu, >elly should be applied to the glans

of the penis with each diaper change.

3. The infant can take tub baths while the

circu,cision heals.

&. 5ny blood noted on the front of the diaper

should be reported.

%. The circu,cision will re?uire care for / to &

days after discharge.

&. #4 /4 %

%. 5 /8@year@old client is ad,itted with

infla,,atory bowel syndro,e ('rohn7s

disease. 9hich therapies should the nurse

e"pect to be part of the care plan-

Select all that apply#. Aactulose therapy

/. High@fiber diet

3. High@protein ,ilkshakes

&. 'orticosteroid therapy

%. 5ntidiarrheal ,edications

%. &4 %

. The nurse is assisting in the discharge

planning for a client with alcoholis,. 9hich of

the following should be included in the

discharge plan-

Select all that apply

#. Strongly encourage participation in 5lcoholics

 5nony,ous (55./. rovide nutritional infor,ation and

counseling.

3. +stablish an e"ercise progra,.

&. 1iscuss relapse prevention.

%. Have the client introduce hi,self slowly to

people fro, his for,er lifestyle.

. #4 /4 34 &

B. The nurse receives a change@of@shift report

for a B@year@old client who had a total hip

replace,ent. The client is not oriented to ti,e4

place4 or person and is atte,pting to get out of

bed and pull out an :.;. line that7s supplying

hydration and antibiotics. The client has a vest

restraint and bilateral soft wrist restraints. 9hichaction by the nurse would be appropriate-

Select all that apply

#. 5ssess and docu,ent the behavior that

re?uires continued use of restraints.

/. Tie the restraints in ?uick@release knots.

3. Tie the restraints to the side rails of the bed.

&. 5sk the client if he needs to go to the

bathroo, and provide range@of@,otion

B. #4 /4 &

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e"ercises every / hours.

%. osition the vest restraints so that the straps

are crossed in the back.

8. The nurse is perfor,ing a 1enver

1evelop,ental Screening Test :: on a & #$/@

year@old child. 9hat behaviors should the nursee"pect the child to de,onstrate-

Select all that apply

#. He balances on each foot for at least

seconds.

/. He copies a s?uare using straight lines and

s?uare corners.

3. He prepares his own cereal without help.

&. He copies a circle that7s closed or very nearly

closed.

%. He speaks clearly.

. He draws a person with at least three body

parts.

8. 34 &4 %4

6. The nurse is caring for a &%@year@old ,arriedwo,an who has undergone he,icolecto,y for

colon cancer. The wo,an has two children.

9hich concepts about fa,ilies should the nurse

keep in ,ind when providing care for this client-

Select all that apply

#. :llness in one fa,ily ,e,ber can affect all

,e,bers.

/. Fa,ily roles don7t change because of illness.

3. 5 fa,ily ,e,ber ,ay have ,ore than one

role at a ti,e in a fa,ily.

&. 'hildren typically aren7t affected by adult

illness.

%. The effects of an illness on a fa,ily dependon the stage of the fa,ily7s life cycle.

. 'hanges in sleeping and eating patterns ,ay

be signs of stress in a fa,ily.

6. #4 34 %4

#C.5 client is receiving chlordia=epo"ide

(Aibriu, to control the sy,pto,s of alcohol

withdrawal. The chlordia=epo"ide has been

ordered as needed. 9hich sy,pto, ,ay

indicate the need for an additional dose of this

,edication-

Select all that apply

#. Tachycardia

/. <ood swings

3. +levated blood pressure and te,perature&. iloerection

%. Tre,ors

. :ncreasing an"iety

#C. #4 34 %4

##. The nurse is assisting in the discharge

planning for a client with alcoholis,. 9hich of

the following should be included in the

discharge plan-

##. #4 /4 34 &

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Select all that apply

#. Strongly encourage participation in 5lcoholics

 5nony,ous (55.

/. rovide nutritional infor,ation and

counseling.

3. +stablish an e"ercise progra,.&. 1iscuss relapse prevention.

%. Have the client introduce hi,self slowly to

people fro, his for,er lifestyle.

#/. The nurse is caring for a client with anore"ia

nervosa who has a nursing diagnosis of

:,balanced nutrition Aess than body

re?uire,ents related to dysfunctional eating

patterns. 9hich of the following interventions

would be supportive for this client-

Select all that apply

#. rovide s,all4 fre?uent ,eals.

/. <onitor weight gain.3. 5llow the client to skip ,eals until the

antidepressant levels are therapeutic.

&. +ncourage the client to keep a >ournal.

%. <onitor the client during ,eals and for # hour 

after ,eals.

. +ncourage the client to eat three substantial

,eals per day.

#/.. #4 /4 &4 %

#3. 9hen assessing a client diagnosed with

i,pulse control disorder4 the nurse observes

violent4 aggressive4 and assaultive behavior.

9hich assess,ent is the nurse also likely to

find-

Select all that apply

#. The client functions well in other areas of his

life.

/. The degree of aggressiveness is out of

proportion to the stressor.

3. The violent behavior is ,ost often >ustified by

a stressor.

&. The client has a history of parental alcoholis,

and chaotic abusive fa,ily life.

%. The client has no re,orse about the inability

to control his behavior.

#3. #4 /4 &

#& .5 /8@year@old client is ad,itted withinfla,,atory bowel syndro,e ('rohn7s

disease. 9hich therapies should the nurse

e"pect to be part of the care plan-

Select all that apply

#. Aactulose therapy

/. High@fiber diet

3. High@protein ,ilkshakes

#&. &4 %

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&. 'orticosteroid therapy

%. 5ntidiarrheal ,edications

#%. 9hich findings are co,,on in neonates

born with esophageal atresia-

Select all that apply#. 1ecreased production of saliva

/. 'yanosis

3. 'oughing

&. :nade?uate swallow

%. 'hoking

. :nability to cough

#%. /4 34 %

#. 9hile preparing a client for an upper D:

endoscopy (esophagogastroduodenoscopy4

the nurse should i,ple,ent which

interventions-

Select all that apply

#. 5d,inister a preparation to cleanse the D:tract4 such as Dolytely or Fleets hospha@Soda.

/. Tell the client he shouldn7t eat or drink for to

#/ hours before the procedure.

3. Tell the client he ,ust be on a clear li?uid diet

for /& hours before the procedure.

&. :nfor, the client that he7ll receive a sedative

before the procedure.

%. Tell the client that he ,ay eat and drink

i,,ediately after the procedure.

#. /4 &

#B. 5 client with a retroperitoneal abscess is

receiving genta,icin (Dara,ycin. 9hich signs

should the nurse ,onitor-

Select all that apply

#. Hearing

/. 2rine output

3. He,atocrit (H'T

&. )lood urea nitrogen ()2N and creatinine

levels

%. Seru, calciu, level

#B. #4 /4 &

#8.The nurse is e"plaining the )ill of !ights for

psychiatric patients to a client who has

voluntarily sought ad,ission to an inpatient

psychiatric facility. 9hich of the following rights

should the nurse include in the discussion-

Select all that apply

#. !ight to select health care tea, ,e,bers

/. !ight to refuse treat,ent

3. !ight to a written treat,ent plan

&. !ight to obtain disability

%. !ight to confidentiality

. !ight to personal ,ail

#8. /4 34 %4

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#6. :n the e,ergency depart,ent4 a client

reveals to the nurse a lethal plan for co,,itting

suicide and agrees to a voluntary ad,ission to

the psychiatric unit. 9hich infor,ation will the

nurse discuss with the client to answer the

?uestion4 EHow long do : have to stay here-E

Select all that apply

#. Eou ,ay leave the hospital at any ti,e

unless you are suicidal.E

/. EAet7s talk ,ore after the health tea, has

assessed you.E

3. EOnce you7ve signed the papers4 you have no

say.E

&. E)ecause you could hurt yourself4 you ,ust

be safe before being discharged.E

%. Eou need a lawyer to help you ,ake that

decision.E

. EThere ,ust be a court hearing before you

leave the hospital.E

#6. #4 /4 &

/C. The nurse has developed a relationship with

a client who has an addiction proble,. 9hich

infor,ation would indicate that the therapeutic

interaction is in the working stage-

Select all that apply

#. The client addresses how the addiction has

contributed to fa,ily distress.

/. The client reluctantly shares the fa,ily history

of addiction.

3. The client verbali=es difficulty identifying

personal strengths.

&. The client discusses the financial proble,srelated to the addiction.

%. The client e"presses uncertainty about

,eeting with the nurse.

. The client acknowledges the addiction7s

effects on the children.

/C. #4 34

/#.The nurse is assessing a client7s e"traocular

eye ,ove,ents as part of the neurologic

e"a,ination. 9hich cranial nerves are the

nurse assessing-

Select all that apply Ncle" S5T5

#. 'ranial nerve ::

/. 'ranial nerve :::3. 'ranial nerve :;

&. 'ranial nerve ;

%. 'ranial nerve ;:

. 'ranial nerve ;:::

/#. /4 34 %

//. The nurse is assessing a /@year@old client

diagnosed with bacterial ,eningitis. 9hich of

the following signs and sy,pto,s of ,eningeal

//. /4 34 &4

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irritation is the nurse likely to observe-

Select all that apply Ncle" S5T5

#. Denerali=ed sei=ures

/. Nuchal rigidity

3. ositive )rud=inski7s sign

&. ositive Gernig7s sign%. )abinski refle"

. hotophobia

/3. The nurse is assessing the level of

consciousness of a client who suffered a head

in>ury. She uses the Dlasgow 'o,a Scale and

deter,ines that the client7s score is #%. 9hich

responses did the nurse assess in this client-

Select all that apply Ncle" S5T5

#. Spontaneous eye opening

/. Tachypnea4 bradycardia4 and hypotension

3. 2ne?ual pupil si=e

&. Orientation to person4 place4 and ti,e%. <otor response to pain locali=ed

. :nco,prehensible sounds

/3. #4 &

/&. The nurse is caring for a client with a

co,plete T% spinal cord in>ury. 2pon

assess,ent4 the nurse notes flushed skin4

diaphoresis above T%4 and a blood pressure of

#/$6 ,, Hg. The client reports a severe4

pounding headache. 9hich nursing

interventions would be appropriate for this

client-

Select all that apply Ncle" S5T5#. +levating the head of the bed 6C degrees

/. Aoosening constrictive clothing

3. 2sing a fan to reduce diaphoresis

&. 5ssessing for bladder distention and bowel

i,paction

%. 5d,inistering antihypertensive ,edication

. lacing the client in a supine position with

legs elevated

/&. #4 /4 &4 %

/%. The nurse is preparing a fe,ale client with

tonic@clonic sei=ure disorder for discharge.

9hich instructions should the nurse include

about phenytoin (1ilantin-

Select all that apply Ncle" S5T5

#. E<onitor for skin rash.E

/. E<aintain ade?uate a,ounts of fluid and fiber 

in the diet.E

3. Eerfor, good oral hygiene4 including daily

brushing and flossing.E

&. E!eceive necessary periodic blood work.E

%. E!eport to the physician any proble,s with

/%. #4 34 &4 %

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walking4 coordination4 slurred speech4 or

nausea.E

. EFeel safe about taking this drug4 even during

pregnancy.E

Signs and sy,pto,s of Tuberculosis

9aking up sweating at night

Aow grade fever  1ull aching chest pain

'ough streaked with blood

9eight loss

5nore"ia

Fatigue

Signs and sy,pto,sof )acterial <eningitis

N I ;

Sei=ures

Stiff Neck

hotophobia

ositive )rudin=ki sign

Signs and sy,pto,s of 1G5

Fruity breath Odor 

Oliguria Gaus,all )reathing (deep I nonlabored

Ovarian 'ancer 

!isk factors

Ovarian dysfunction

;aginal use of talcu, powder 

5lcohol

!ace @ 9hite wo,en I fa,ily history

:nfertility

5ge @ eakJ%th decade of life

Nulliparity

Denetic predisposition

Site For :< :n>ection 5dult

1eltoid

;entrogluteal ;astus Aateralis

Dluteus <a"i,us

Signs and sy,pto,s of Aiver 'irrhosis

Nausea I ;o,iting

+de,a

5scites

)ladder 'a

!isk Factors

H" of s,oking

+"posure to radiation

9orking in industrial Factory

9hat to avoid when taking 1ilantin

do not floss throughout the day

do not use hard bristled toothbrush

Dingivitis

Signs and sy,pto,s of Hydrocephalus 5nterior fontanel bulges I nonpulsating

)ones of head separated (cracked pot sound

'heck for sun@setting eyes

:ncrease :'

+vidence of Frontal )ossing

Failure to thrive

:rritability

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High@pitched cry

1iabetic <ellitus Foot 'are

<eticulous care to feet

9ash feet with war, water not hot I dry

'an use lotion but No lotion in between toes

9ear socks to keep feet war,

5void ther,al baths4 heating pads 1o not soak feet

:nspect feet daily

1o not treat corns4 blisters

9ear loose socks and no barefoot

'hange into clean cotton socks daily

)reak in new shoes gradually

2se e,ery board

1o not s,oke

1o not wear sa,e pair of shoes / days in a

row

Nor,al :n 8 <onths Old 'hild

can sit without support

can roll fro, front to back

can hold a bottle closure of ant. fontanel

can say ,a,a and dada

/ teeth present

Signs and sy,pto,s of 5cute ancreatitis

5bdo,inal ain severe Kacute s"

'o,plication Shock4Hypovole,ia

Ai,ited fat I protein intake

+S!1 1:+T

!estricted protein intake

:ncrease 'HO

Aow G4

!estrict Na

Signs and sy,pto,s of H+!TH!O:1:S<

Soft s,ooth skin I hair 

<ood swings

HN

1iaphoresis

:ntolerance to heat

T2 drug to block thyroid synthesis

<anage,ent of 5N5HA5'T:' !+5'T:ON

Stop ,edication

<aintain airway

Notify <1

<aintain :; access of C.6 NSS

lace in supine position with legs elevated

<onitor ;S

5d,inister prescribed e,ergency drugs

Signs and sy,pto,s of 2A'+!5T:;+ 'OA:T:S Severe diarrhea with blood I ,ucus

5bdo,inal tenderness I cra,ping

5nore"ia

9t. Aoss

;it. G deficiency

5ne,ia

1ehydration

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+lectrolyte i,balance

Aow residue I high protein diet

Signs and sy,pto,s of S2+!:O! ;+N5

'5;5 O''A2S:ON

S" occur in the ,orning

+de,a of face4 eyes I tightness of 

shirt$ (StokeLs sign

Aate s" ede,a of ar,s4 hands4dyspnea4 erythe,a4 epista"is

'+!;:'5A '5N'+!

!isk Factors

5frican@ 5,erican$ Native wo,en

)ehavior (Se"ual pro,iscuity

'hronic instru,entation of cervi"

1isease KST1

+arly age of Se"

High arity

oor Hygiene

Aow econo,ic status

<ultiple se"ual partners

artner with rostate '5

Signs and sy,pto,s of 5!G:NSONS

Tre,ors4 akinesia4 rigidity 9eakness4 M,otori=ed propulsive gait

Slurred speech4 dysphagia4 drooling

<onotonous speech

<ask like e"pression

Teach a,bulation ,odification goose

stepping walk (,arching4 !O< e"ercises

5ctivities should be scheduled for late ,orning

when energy level is highest

+ncourage finger e"ercises.

ro,ote fa,ily understanding of disease

intellect$sight$ hearing not i,paired4

#. The nurse is planning care for a client withhyperthyroidis,. 9hich nursing interventions

are appropriate-

Select all that apply

#. :nstill isotonic eye drops4 as necessary.

/. rovide several s,all4 well@balanced ,eals.

3. rovide rest periods.

&. Geep the environ,ent war,.

%. +ncourage fre?uent visitors and

conversation.

. 9eigh the client daily.

#. 5nswer #4 /4 34

/. The nurse is caring for a client with

e,physe,a. 9hich nursing interventions are

appropriate-Select all that apply Ncle" S5T5

#. !educe fluid intake to less than /4%CC ,l$day.

/. Teach diaphrag,atic4 pursed@lip breathing.

3. 5d,inister low@flow o"ygen.

&. Geep the client in a supine position as ,uch

as possible.

%. +ncourage alternating activity with rest

periods.

/. 5nswer /4 34 %4

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. Teach use of postural drainage and chest

physiotherapy.

3. The nurse is caring for a client who

underwent surgical repair of a detached retina

of the right eye. 9hich interventions should the

nurse perfor,-Select all that apply Ncle" S5T5

#. lace the client in a prone position.

/. 5pproach the client fro, the left side.

3. +ncourage deep breathing and coughing.

&. 1iscourage bending down.

%. Orient the client to his environ,ent.

. 5d,inister a stool softener.

3. 5nswer /4 &4 %4

&. The client has a tu,or of the posterior

pituitary gland. The nurse planning his care

should include which interventions-

Select all that apply Ncle" S5T5

#. Take daily weight.

/. !estrict fluids.3. 5ssess urine specific gravity.

&. +ncourage intake of coffee or tea.

%. <onitor intake and output.

&. 5nswer #4 34 %

%. The nurse is developing a care plan for a

client with in>ury to the frontal lobe of the brain.

9hich interventions should be part of the care

plan-

Select all that apply Ncle" S5T5

#. Geep instructions si,ple and brief because

the client will have difficulty concentrating.

/. Speak clearly and slowly because the client

will have difficulty hearing.3. 5ssist the client with bathing because he will

have vision disturbances.

&. Orient the client to person4 place4 and ti,e as

needed because of ,e,ory proble,s.

%. 5ssess vital signs fre?uently because vital

bodily functions are affected.

%. 5nswer #4 &

. The nurse is caring for a client whose cultural

background is different fro, her own. 9hich

actions are appropriate-

Select all that apply Ncle" S5T5

#. 'onsider that nonverbal cues4 such as eye

contact4 ,ay have a different ,eaning in

different cultures./. !espect the client7s cultural beliefs.

3. 5sk the client if he has cultural or religious

re?uire,ents that should be considered in his

care.

&. +"plain the nurse7s beliefs so that the client

will understand the differences.

%. 2nderstand that all cultures e"perience pain

in the sa,e way.

. 5nswer #4 /4 3

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B. 5 /@year@old client has >ust been diagnosed

with ter,inal cancer and is being transferred to

ho,e hospice care. The client7s daughter tells

the nurse4 E: don7t know what to say to ,y

,other if she asks ,e if she7s going to die.E

9hich of the following responses by the nurse

would be appropriate-Select all that apply Ncle" S5T5

#. E1on7t worry4 your ,other still has so,e ti,e

left.E

/. EAet7s talk about your ,other7s illness and

how it will progress.E

3. Eou sound like you have so,e ?uestions

about your ,other dying. Aet7s talk about that.E

&. E1on7t worry4 hospice will take care of your

,other.E

%. ETell ,e how you7re feeling about your ,other 

dying.E

B. 5nswer /4 34 %

8. 5 /@year@old client has >ust been diagnosed

with ter,inal cancer and is being transferred toho,e hospice care. The client7s daughter tells

the nurse4 E: don7t know what to say to ,y

,other if she asks ,e if she7s going to die.E

9hich of the following responses by the nurse

would be appropriate-

Select all that apply Ncle" S5T5

#. E1on7t worry4 your ,other still has so,e ti,e

left.E

/. EAet7s talk about your ,other7s illness and

how it will progress.E

3. Eou sound like you have so,e ?uestions

about your ,other dying. Aet7s talk about that.E&. E1on7t worry4 hospice will take care of your

,other.E

%. ETell ,e how you7re feeling about your ,other 

dying.E

8. 5nswer #4 /4 &

6. 9hile providing care to a /@year@old ,arried

fe,ale4 the nurse notes ,ultiple ecchy,otic

areas on her ar,s and trunk. The color of the

ecchy,otic areas ranges fro, blue to purple to

yellow. 9hen asked by the nurse how she got

these bruises4 the client responds4 EOh4 :

tripped.E How should the nurse respond-

Select all that apply Ncle" S5T5

#. 1ocu,ent the client7s state,ent andco,plete a body ,ap indicating the si=e4 color4

shape4 location4 and type of in>uries.

/. !eport suspicions of abuse to the local

authorities.

3. 5ssist the client in developing a safety plan

for ti,es of increased violence.

&. 'all the client7s husband to discuss the

situation.

6. 5nswer #4 34

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%. Tell the client that she needs to leave the

abusive situation as soon as possible.

. rovide the client with telephone nu,bers of

local shelters and safe houses.

#C. 5 nurse is working with the fa,ily of a client

who has 5l=hei,er7s disease. The nurse notesthat the client7s spouse is too e"hausted to

continue providing care all alone. The adult

children live too far away to provide relief on a

weekly basis. 9hich nursing interventions

would be ,ost helpful-

Select all that apply Ncle" S5T5

#. 'alling a fa,ily ,eeting to tell the absent

children that they ,ust participate in helping the

client.

/. Suggesting the spouse seek psychological

counseling to help cope with e"haustion

3. !eco,,ending co,,unity resources for

adult day care and respite care

&. +ncouraging the spouse to talk about thedifficulties involved in caring for a loved one with

 5l=hei,er7s disease.

%. 5sking whether friends or church ,e,bers

can help with errands or provide short periods

of relief.

. !eco,,ending that the client be placed in a

long@ter, care facility.

#C. 5nswer 34 &4 %

age of #

 

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• revious

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'ra, has partnered with the National Tutoring 5ssociation Claimyour access

!eady To Det Started-

#

#CC

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