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Glossary of NR203 Test 4 NCLEX Questions

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You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment?
1. An advanced practice nurse and an experienced LPN/LVN
2. An experi
3. An experienced RN and an inexperienced RN
You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients.
1. An ambulatory, dazed 25-year-old male with a bandaged head wound
2. An irrita
2,1,4,3
2. An irritable infant with a fever, petechiae, and nuchal rigidity
1. An ambulatory, dazed 25-year-old male with a bandaged head wound
4. A 50-year-old female with moderate abdominal pain and occasional vomiting
3. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
1. Complete set of vital signs
2. Palpation and auscultation of the abdomen
3. Brief neurologic
3. Brief neurologic assessment
4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category?
1. High urgent
2. Urgent
3. Non-urgent
4. Emergent
4. Emergent
The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant?
1) Assist the child to remove outer
1) Assist the child to remove outer clothing.
It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?
1) An elderly person complains of dizziness and syncope after standing in the sun for several hours to vie
4) A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
1. Perform the chin lift or jaw thrust maneuver.
2. Establish unresponsiveness.
2, 4, 1, 3, 5

2. Establish unresponsiveness.
1. Perform the chin lift or jaw thrust maneuver.
4. Call for help and activate the code team.
3. Initiate cardiopulmonary resuscitation (CPR).
5. Instruct a nursing assistant to get the crash cart.
The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to d
1. Chest compressions
An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take?
1. Notify the physician immediately.
3. Have the student breathe into a paper bag.
An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for this nurse?
1. Trauma team
2. Triage
3. Ambulatory or fa
3. Ambulatory or fast track clinic
A tearful parent brings a child to the ED for taking an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician?
1. The inges
1. The ingested children's chewable vitamins contain iron.
11. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
1. Assess immediate emotional state and physical injuries.
2. Collect hair samples, saliva swabs, and scrapings beneath fingernails.
3. Provide
3. Provide emotional support and supportive communication
12. You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order.
1. Apply a loose, sterile, bulky dressing.
2. Give pain medication.
3. Remove the victim from the cold environment.
3,2,4,1

3. Remove the victim from the cold environment.
2. Give pain medication.
4. Immerse the feet in warm water 1000 F to 1050 F (40.60 C to 46.1 0 C).
1. Apply a loose, sterile, bulky dressing.
14. A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN?
1. Gently cleanse the amputated digits with Betadine solution.
2. Place the amputated digits directly i
3. Wrap the amputated digits in sterile gauze moistened with saline.
A 36-year-old patient with a history of seizures and medication compliance of phenytoin (DilanĀ¬tin) and carbamazepine (Tegretol) is brought to the ED by the EMS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anti
2. IV lorazepam (Ativan)
You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What inforĀ¬mation should you immediately report to the physician?
1. The parent is unsure about the child's tetanus immunization status.
2. The child
3
In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN
1. Talk to a community group about water safety issues.
2. Stabilize the cervical spine for an unconscious drowning victim.
3. Remove wet cloth
4. Monitor an asymptomatic near-drowning victim.
An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to "drinking a few on the weekend. What is the priority nursing action for this patient?
1. Obtain an o
4. Administer IV fluid support with supplemental thiamine as ordered.
When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant
1. Escort the family to a place of privacy.
2. Go with the organ donor specialist to talk to the family.
3.
3. Assist with postmortem care.
Following emergency endotracheal intubation, you must verify tube placement and secure the tube.
List in order the steps that are required to perform this function.
1. Obtain an order for a chest x-ray to document tube placement.
2. Sec
3,4,2,1
3. Auscultate the chest during assisted ventilation.
4. Confirm that the breath sounds are equal and bilateral
2. Secure the tube in place.
1. Obtain an order for a chest x-ray to document tube placement.
1. A client who presents to the emergency room with vision loss would be classified in which triage category?

A. Nonurgent

B. Urgent

C. Emergent

D. Severe
C. Emergent
2. During a disaster situation following a tornado a client is found to have a head injury with a decreased level of consiousness and is hypoxic. Which triage category would this client be assigned to?

A. Black

B. Green

C
D. Red
3. Which best describes the meaning of the word "triage"?

A. Assembling

B. Dispersing

C. Labeling

D. Sorting
D. Sorting
4. Which of these injuries is an example of what would be categorized as a Green Priority during triage in a disaster situation?

A. Psychological disorders

B. Spinal cord injury

C. Burns over 10% of the body

D.
A. Psychological disorders
Which is the best example of a natural disaster?

A. Terrorism

B. Building collapse

C. Flooding

D. Train crash
C. Flooding
Which is a common injury seen following a tornado?

A. Drownings

B. Insect bites

C. Gastrointestinal illnesses

D. Multiple fractures
D. Multiple fractures
3. Which of these is not classified as a Category A biologic agent?

A. Anthrax

B. Botulism

C. Hantavirus

D. Smallpox
C. Hantavirus
4. Which disease can be contracted through human contact with infected rabbits, deer, or other wildlife?

A. Tularemia

B. Smallpox

C. Botulism

D. Tuberculosis
A. Tularemia
Serum T4 concentration is an effective indicator of thyroid function. How are serum T 4 levels affected in hyperthyroidism?
A. T4 levels increase.
B. T4 levels decrease.
C.T4 levels remain the same.
D.T4 levels rise then fall.
a. T4 levels increase.
Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Tremors.
A. Addison's disease
B.Cushing's disease
C.Diabetes mellitus
D.Hyperthyroidism
D.Hyperthyroidism
Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Tachycardia.
A. Addison's disease
B.Cushing's disease
C.Diabetes mellitus
D.Hyperthyroidis
D.Hyperthyroidism
Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Hirsutism (excessive body hair).
A. Addison's disease
B.Cushing's disease
C.Diabetes mellitus
B.Cushing's disease
25. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Exophthalmos (bulging eyes).
A. Addison's disease
B. Cushing's disease
C. Diabetes mellitu
D.Hyperthyroidism
Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Buffalo hump and moon facies.
A. Addison's disease
B. Cushing's disease
C. Diabetes mellitus
B. Cushing's disease
Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Constipation.
A. Addison's disease
B. Cushing's disease
C. Diabetes mellitus
D. Hyperthy
E. Hypothyroidism
28. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Diarrhea.
A. Addison's disease
B. Cushing's disease
C. Diabetes mellitus
D. Hyperthy
D. Hyperthyroidism
Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Dry, brittle hair.
A. Addison's disease
B. Cushing's disease
C. Diabetes mellitus
D. Hyp
E. Hypothyroidism
Why is iodine therapy prescribed for Graves' disease?
A. To reduce vascularity of the thyroid gland
B. To increase vascularity of the thyroid gland
C. To treat thyroid storm
D. Both a and c
D. Both a and c
4. Which of the following disorders is characterized by an excessive secretion of TH?
A. Hypothyroidism
B. Exophthalmos
C. Hyperthyroidism
D. Thyroid storm
C. Hyperthyroidism
5. Hyperthyroidism is characterized by which of the following?
A. Loss of the normal regulatory controls of TH
B. Hypometabolism
C. Tachycardia
D. Both a and c
D. Both a and c
The major complications of Graves' disease are:
A. exophthalmos, heart disease, and thyroid storm.
B. thyroid storm and heart disease.
C. heart disease and exophthalmos.
D. exophthalmos, heart disease, and thyroiditis.
A. exophthalmos, heart disease, and thyroid storm.
7. Which of the following is a major medication used to control hypothyroidism?
A. Nonsteroidal, anti-inflammatory agents
B. Oral glucocorticoids
C. Propylthiouracil
D. Prednisone
C. Propylthiouracil
8. In the treatment of hyperthyroidism and to prevent urolithiasis, acidification is used to:
A. prevent renal stones.
B. prevent renal failure.
C. decrease blood in urine.
D. None of the above are correct
A. prevent renal stones.
Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Lethargy and apathy.
A. Hyperthyroidism
B. Hypothyroidism
B. Hypothyroidism
Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Exophthalmos.
A. Hyperthyroidism
B. Hypothyroidism
A. Hyperthyroidism
Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Thick, brittle nails.
A. Hyperthyroidism
B. Hypothyroidism
B. Hypothyroidism
22. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Weight loss.
A. Hyperthyroidism
B. Hypothyroidism
A. Hyperthyroidism
Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Warm, smooth skin.
A. Hyperthyroidism
B. Hypothyroidism
A. Hyperthyroidism
Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Profuse sweating.
A. Hyperthyroidism
B. Hypothyroidism
A. Hyperthyroidism
Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Emotional instability.
A. Hyperthyroidism
B. Hypothyroidism
A. Hyperthyroidism
How are burn injuries categorized?
A. By the extent of the burn
B. By the type of burn
C. By the mechanism of injury
D. None of the above are correct
C. By the mechanism of injury
2. Which category of burn injury is the least common?
A. Chemical
B. Electrical
C. Thermal
D. Radiation
D. Radiation
3. What is the leading cause of burn injury?
A. Radiation
B. Scalding
C. Chemicals
D. Electricity
B. Scalding
Regarding the medical management in the emergent phase of a burn injury, clients with moderate burns:
A. are usually transferred to a specialized care facility.
B. can usually be managed on an inpatient basis at the receiving hospital.
B. can usually be managed on an inpatient basis at the receiving hospital.
9. What factors influence burn severity?
A. Burn depth
B. Burn size
C. Burn location
D. All of the above are correct.
D. All of the above are correct.
Where is the IV access site for a client with extensive burns or a limited peripheral IV?
A. Subclavian vein
B. Internal jugular vein
C. Femoral vein
D. Any of the above would be appropriate.
D. Any of the above would be appropriate.
Which is not recommended in wound care?
A. Neutralizing agents
B. Removal of smoldering clothing
C. Irrigation of chemical burns
D. All of the above are recommended
A. Neutralizing agents
12. Which of the following is not an appropriate method of wound care?
A. Debridement
B. Removal of damaging agents
C. Application of a topical agent and dressing
D. All of the above are appropriate.
D. All of the above are appropriate.
13. Which management strategy in the acute phase of burn injuries concentrates on the maintenance of adequate nutrition?
A. Preventing infection
B. Providing metabolic support
C. Minimizing pain
D. Providing wound care
B. Providing metabolic support
15. What type of debridement involves the application of commercially prepared proteolytic and fibrinolytic substances?
A. Mechanical
B. Enzymatic
C. Surgical
D. Hydrotherapeutic
B. Enzymatic
17. Autograft procedures can be performed by applying the autografts in what two ways?
A. Meshed and sheet
B. Split and thick
C. Meshed and split
D. Sheet and split
A. Meshed and sheet
In the administration of an antidiuretic hormone, the nurse would recognize that which medication could be easily self-administered by a client? [Hint]
1. Desmopressin (DDAVP)
2. Vasopressin
3. Somatotropin
4. Glucocorticoids
1. Desmopressin (DDAVP)

Desmopressin (DDAVP) is available as a nasal spray and can be easily self-administered by a client
Myxedema, which includes fatigue, general weakness, and muscle cramps is a symptom of which endocrine disorder?
1. Hyperthyroidism
2. Hypothyroidism
3. Cushing's syndrome
4. Addison's disease
2 Hypothyroidism
Which drugs cause increased risk for peptic ulcers, decreased wound healing, and increased capillary fragility?
1. Glucocorticoids
2. Antidiuretic hormones
3. Growth hormones
4. Antithryroid hormones
1. Glucocorticoids

Glucocorticoids can cause increased risk for peptic ulcers, decreased wound healing, and increased capillary fragility.
Which disease is characterized by increased body metabolism, tachycardia, increased body temperature and anxiety?
1. Hashimoto's Disease
2. Grave's disease
3. Addison's disease
4. Cushing's syndrome
Grave's disease

2. Grave's disease is characterized by all of the symptoms
In the administration of Hydrocortisone (Aeroseb-HC, Alphadern, Cetacort), it is vital that the nurse recognize that this drug may mask which symptoms?
1. Signs and symptoms of infection
2. Signs and symptoms of heart failure
3. Hearing
Signs and symptoms of infection
When hydrocortisone use is discontinued, the nurse must recognize the possibility of what side effect, if this drug is stopped abruptly?
1. Development of myxedema
2. Circulatory collapse
3. Development of Cushing's syndrome
4. De
Circulatory collapse
A client who is taking Levothyroxine (Synthroid) begins to develop weight loss, diarrhea and intolerance. The nurse should be aware that this might be an indication of what hormonal condition?
1. Addison's Disease
2. Hyperthyroidism
3.
Hyperthyroidism
Which organ is responsible for secreting chemicals called releasing factors?
1. Pituitary gland
2. Adrenals
3. Parathyroid
4. Hypothalamus
Hypothalamus
What precautions should a client who is receiving radioactive iodine be made aware of?
1. Drink plenty of fluids, especially those high in calcium
2. Avoid close contact with children or pregnant women for 1 week after administration of drug
Avoid close contact with children or pregnant women for 1 week after administration of drug
In the administration of an antithyroid drug such as Propacil, the nurse must be aware that the client may be at risk for the development of which skin condition?
1. Contact dermatitis
2. Varicella
3. Circumoral cyanosis
4. Jaundi
Jaundice

The nurse needs to be aware of the risk of developing the skin condition called jaundice
The client asks how too much calcium could be dangerous. The nurse explains that hypercalcemia could cause
1. convulsions.
2. osteomalacia.
3. cardiac dysrhythmias.
4. muscle spasms
cardiac dysrhythmias.

Calcium ions influence the excitability of all neurons. Whenever calcium concentrations are too high, sodium permeability decreases across cell membranes. This is a dangerous state because nerve conduction depends on the proper influx of sodium into cells
The nurse completing a physical exam on a child diagnosed with osteomalacia would expect to find
1. bowlegs and a pigeon breast.
2. deformities of the fingers and toes.
3. shortness of breath.
4. the use of crutches for walking.
bowlegs and a pigeon breast.

Osteomalacia, referred to as rickets in children, is a disorder characterized by softening of bones without alteration of basic bone structure. Classic signs of rickets in children include bowlegs and a pigeon breast.
The client's calcium level is reported as 5.6 mg/dL. The nurse should assess the client for
1. headache.
2. anorexia.
3. muscle spasms.
4. drowsiness.
muscle spasms.

Normal serum calcium level is 8.5-11.5 mg/dL. Signs of hypocalcemia include seizures, muscle spasms, facial twitching, and paresthesias.
The nurse cautions the client receiving Calcium Gluconate to avoid adding foods such as nuts, legumes and tofu to the diet. The rationale for this instruction is that
1. these foods cause GI distress.
2. these foods may cause hypercalcemia.
these foods, rich in zinc, may decrease calcium absorption.

Consuming food rich in zinc may decrease calcium absorption. Teach clients to avoid zinc-rich roods such as nuts, legumes, seeds, sprouts, and tofu.
A client in the health department asks what purpose the pituitary gland serves. The nurse plans to provide the client information based on the knowledge that the function of the pituitary gland is which of the following? [Hint]
1. The pituitary glan
2. The pituitary gland serves as the body's "master gland" because its hormones regulate many body functions.

The pituitary gland is the body's master gland because its hormones regulate many body functions. The anterior pituitary secretes the growth hormone (GH), prolactin (PRL), thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), gonadotropin hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The posterior pituitary secretes the antidiuretic hormone (ADH) and oxytocin.
Thyroxine (T4) and triiodothyronine (T3) are secreted by the thyroid gland, mineralcorticoids and glucocorticoids are secreted by the adrenal cortex.
When implementing a teaching session on endocrine disorders to a group of nurses, the nurse educator explains that which of the following endocrine glands is responsible for increasing metabolism and for growth and development in children?
1. Thyro
1. Thyroid gland
A nurse is formulating a plan of care for a male client admitted with pancreatitis. In establishing teaching information for the client, the nurse will explain to the client the function of the pancreas includes which of the following?
1. Secretes a
4. Secretes hormones such as insulin necessary for carbohydrate metabolism
A nurse, teaching a group of clients with endocrine disorders, is evaluating their understanding of the teaching session. Which of the following statements made by one of the clients indicates an understanding regarding negative feedback and hormone regu
1. "When my body detects a change in hormone levels, the hormones adjust secretion to maintain stable levels."
A nurse is performing a routine health screening on a 42-year-old female who reports that her necklaces seem to be tighter around her neck and that her neck appears swollen to her. Which of the following identifies the nurse's most appropriate action at
2. Assess the client's thyroid gland
A nurse is providing preventive health teaching to a 40-year-old, obese African-American female with a family history of diabetes. The nurse educates the client that which of the following of the identified risk factors is modifiable?
1. Maternal h
2. Obesity
A nurse assessing the thyroid gland while performing a physical assessment is performing the technique correctly when which of the following is demonstrated?
1. Standing behind the client and placing fingers on either side of the trachea below the
1. Standing behind the client and placing fingers on either side of the trachea below the thyroid cartilage
2. Standing in front of the client and placing fingers on either side of the trachea below the thyroid cartilage
A nurse, assessing a client, knows that which of the following symptoms would cause the suspicion that the client has hyperthyroidism?
1. Dry, brittle nails
2. Dry coarse hair
3. Exophthalmos (protruding eyes)
4. Yellow cast to sk
3. Exophthalmos (protruding eyes)
An advance practice nurse is performing a physical assessment on a client suspected of having an endocrine disorder. During testing of stereognosis in the client, the nurse implements which of the following?
1. Place a rubber band in the client's h
Place a rubber band in the client's hand and ask to the client to identify the object

Stereognosis is the ability to identify an object merely by touch. The use of rubber bands, buttons, cotton balls or other common items are recommended. The pinprick tests pain; the cold water tests temperature; and the tuning fork tests vibration.
Assessment; Health Promotion and Maintenance; Application
An elderly client in the physician's office complains of changes in memory and ability to concentrate, as well as a change in hair texture. Which of the following represents the most appropriate response to the client?
1. "I will inform the ph
1. "I will inform the physician and she may want to run some lab tests on you."

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