1013 Communication (Patient Teaching) Quiz

What should the nurse's initial discussion include to best help new parents understand the unique characteristics of a newborn? Auditory and visual acuity Expected movements and behaviors The need for parent-infant attachment The need to establish a feeding schedule

Expected movements and behaviors Information on typical behaviors helps parents understand the unique features of their newborn and promotes interaction and appropriate care. Auditory and visual acuity is too limited; the parents need a broader discussion of infant behaviors. Although important, this can best be fostered if parents know what behaviors to expect from their infant. Need to establish a feeding schedule is too limited; in addition, most infants are on a demand feeding schedule, which fosters individuality.

The nurse is providing care for a client that had an endarterectomy one month ago. The nurse explains the reason that clopidogrel (Plavix) is being prescribed. The nurse concludes that the teaching is understood when the client says, "The medication will: Limit inflammation around my incision." Help prevent further clogging of my arteries." Lower the slight fever I have had since surgery." Reduce the discomfort I feel at the surgical incision."

Help prevent further clogging of my arteries." Clopidogrel interferes with platelet aggregation, which impedes the formation of thrombi. Clopidogrel is a platelet aggregation inhibitor, not an anti-inflammatory. Clopidogrel is a platelet aggregation inhibitor, not an antipyretic. Clopidogrel is a platelet aggregation inhibitor, not an analgesic.

A client newly diagnosed as having type 1 diabetes is taught to exercise on a regular basis primarily because exercise has been shown to: Decrease insulin sensitivity Stimulate glucagon production Improve the cellular uptake of glucose Reduce metabolic requirements for glucose

Improve the cellular uptake of glucose Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.

A client is scheduled to begin chemotherapy two weeks after the client had surgery for colon cancer. The nurse explains to the client that the delay in instituting drug therapy is planned because the chemotherapy: Interferes with cell growth and delays wound healing Causes vomiting, which endangers the integrity of the incisional area Decreases red blood cell production and the resultant anemia will add to postoperative fatigue Increases edema in areas distal to the incision by blocking lymph channels with destroyed lymphocytes

Interferes with cell growth and delays wound healing Chemotherapeutic agents can attack healthy as well as malignant cells; they generally interfere with protein synthesis and cell division in all rapidly dividing cells, including those regenerating traumatized tissue (as in wound healing), bone marrow, and cutaneous and alimentary tract epithelial tissue. Vomiting should not disturb the integrity of the area. Decreased red blood cell levels caused by bone marrow depression can be corrected with transfusions. Chemotherapy should not cause a blockage of lymph channels, with destroyed lymphocytes increasing edema.

When answering questions from the family of a client with Alzheimer disease the nurse explains that the disease: Emerges in the fourth decade of life Is a slow, relentless deterioration of the mind Is functional in origin and occurs in the later years Is diagnosed through laboratory and psychological tests

Is a slow, relentless deterioration of the mind Alzheimer disease is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease.

What should the nurse explain to a newly pregnant client with cardiac disease? Palpitations are expected as pregnancy progresses. Other cardiac medications will be substituted for digoxin. It is not safe to administer prophylactic penicillin during pregnancy. Maintenance dosages of cardiac medications will probably be increased.

Maintenance dosages of cardiac medications will probably be increased. During the second and third trimesters blood volume and cardiac output increase, placing a greater workload on the heart. Women with preexisting heart disease may require larger doses of cardiac medication to prevent cardiac decompensation. Palpitations may occur when the heart rate reaches 120 beats/min. A heart rate of more than 100 beats/min may be an indicator of cardiac decompensation; further assessment and treatment are required. Digoxin (Lanoxin) is a category C medication and is prescribed during pregnancy. Penicillin is a category B medication and is relatively safe to take during pregnancy.

A nurse is teaching the parents of an infant with a cleft lip and palate how to prevent infection. What information should the nurse include about why the infant is predisposed to infection? Waste products accumulate along the defect. Circulation to the defective area is insufficient. Inefficient feeding behaviors result in inadequate nutrition. Mouth breathing dries the oropharyngeal mucous membranes.

Mouth breathing dries the oropharyngeal mucous membranes. Infants with cleft lip and palate breathe through their mouths, bypassing the natural humidification and filtration provided by the nose; as a result, the mucous membranes become dry and cracked and are at risk for infection. It is not difficult to keep the area clean by cleansing it with water after a feeding. Circulation to the area is unimpaired. Feeding can be adequate with the use of special equipment and a slow approach.

A nurse is reinforcing a teaching plan for a client with a history of a myocardial infarction (MI). The client requests information on how to prevent a future MI. The nurse determines that additional teaching or clarification is needed when the client states, "I will: Restrict my physical activity." Take one baby aspirin every day." Continue my smoking cessation program." Try to lose the extra weight I'm carrying around."

Restrict my physical activity." Physical activity need not be restricted; clients who have had a myocardial infarction have a cardiovascular rehabilitation exercise program prescribed. Exercise should become a part of the client's lifestyle. Taking one baby aspirin every day is desirable because aspirin decreases platelet aggregation. Continuing a smoking cessation program is desirable because cigarette smoking causes arterial constriction. Trying to lose the extra weight the client is carrying around is desirable because obesity increases the body's oxygen demands, which increase the workload of the heart.

Which position does the nurse teach the client to avoid when she experiences back pain during labor? Sims position Supine position Right lateral position Left side-lying position

Supine position Back pain in labor is aggravated when the mother is in the supine position because fetal pressure on the sacral nerves is increased. The Sims position relieves back pain during labor but may not be as comfortable as the other lateral positions. The right lateral position relieves back pain during labor. The left side-lying position relieves back pain during labor.

During assessment of a newborn, a practitioner diagnoses cephalhematoma and informs the parents. The mother asks why her baby's head looks different. What does the nurse take into consideration before responding in terms that the mother will understand? Edema of soft tissue over the scalp is a result of pressure during labor. Overlapped fetal scalp bones are a result of the head's conforming to the shape of the pelvic outlet. Swelling that is confined to one part of the scalp is caused by hemorrhage beneath the periosteum. Widening of the sutures between the scalp bones is caused by a partial blockage of cerebrospinal fluid drainage.

Swelling that is confined to one part of the scalp is caused by hemorrhage beneath the periosteum. A cephalhematoma occurs during labor when the rim of the pelvis exerts pressure on the fetal occiput, causing bleeding between the cranial bone and the periosteum; the hematoma does not cross the suture line. A diffuse pattern of edema above the periosteum is caput succedaneum; it results from an even distribution of pressure on the presenting part. Overlap of fetal bones occurs during the second stage of labor, when the fetus' head molds to the shape of the birth canal. When there is a blockage of cerebrospinal fluid, the circumference of the head is larger than expected (hydrocephalus).

After being bitten by a rabid dog a 4-year-old child is to receive a series of antirabies inoculations. The nurse who is to administer the injections should recall that rabies is a: Viral infection characterized by seizures and difficulty swallowing Bacterial infection characterized by encephalopathy and opisthotonos Bacterial infection characterized by septicemia and bone deterioration Viral infection characterized by immunosuppression and opportunistic infections

Viral infection characterized by seizures and difficulty swallowing Seizures and swallowing difficulties are characteristics of rabies infection, which affects the nervous system; the disease is usually fatal if it goes untreated. Rabies is not a bacterial infection. Although rabies is a viral infection it is not characterized by immunosuppression and opportunistic infections. Immunosuppression and opportunistic infections are associated with AIDS.

A client is scheduled for arthroscopic knee surgery and asks the nurse about the procedure. The statement by the nurse that best describes the procedure is: "It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it." "It is a radiological procedure where dye is injected to help diagnose the extent of the knee injury." "The procedure will determine the type of treatments the health care provider will prescribe." "You will be anesthetized so that you do not remember anything about the procedure."

"It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it." The response "It is surgical repair of a joint under direct visualization using a device with a tiny video camera attached to it" describes the procedure in which the health care provider uses a scope to visualize and operate on the knee. Arthroscopic surgery is not a radiological procedure and does not involve the injection of dye. This is a surgical procedure; the only treatment prescribed is physiotherapy after surgery. Although the client will be anesthetized and he or she will not remember anything about the procedure, it evades the client's concern and does not describe the procedure.

A client with a seizure disorder is receiving phenytoin (Dilantin) and phenobarbital (Barbital). What client statement indicates that the instructions regarding the medications are understood? "I will not have any seizures with these medications." "These medicines must be continued to prevent falls and injury." "Stopping the drugs can cause continuous seizures and I may die." "By my staying on the medicines I will prevent postseizure confusion."

"Stopping the drugs can cause continuous seizures and I may die." Sudden withdrawal of antiepileptic medication can cause status epilepticus. It is important to take medication as prescribed to lessen the frequency of seizures; there is no guarantee that seizures will stop. Medication may or may not eliminate the seizures; stress may precipitate a seizure. Anti-epileptics are not prescribed to prevent falls and injury. Although seizures may occur while the client is taking the medications, the medications do not stop post-seizure confusion.

Which client statement indicates an understanding of the nurse's instructions concerning a Holter monitor? "The only times the monitor should be taken off is for showering and sleep." "The monitor will record my activities and symptoms if an abnormal rhythm occurs." "The results from the monitor will be used to determine the size and shape of my heart." "The monitor will record any abnormal heart rhythms while I go about my usual activities."

"The monitor will record any abnormal heart rhythms while I go about my usual activities." The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then analyzed in relation to the client's activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.

Which statement made by a client after attending a class on nutrition indicates an understanding of the importance of essential amino acids? "Amino acids can be made by the body because they are essential to life." "They come from the diet because they cannot be synthesized in the body." "They are used in key processes essential for growth once they are synthesized by the body." "Essential amino acids are required for metabolism, whereas the other amino acids are not."

"They come from the diet because they cannot be synthesized in the body." The body does not synthesize these amino acids ; they must be ingested in the diet. The essential amino acids cannot be made by the body. All amino acids are needed for metabolism; however, arginine and histidine are necessary for growth, but not during adulthood.

After having a transverse colostomy, the client asks what physical effect the surgery will have on future sexual relationships. Which information should the nurse include in a teaching plan for this client? "You will be able to resume usual sexual relationships." "Surgery will temporarily decrease your sexual impulses." "Your sexual activity must be curtailed for several weeks." "Partners should be told about the surgery before any sexual activity."

"You will be able to resume usual sexual relationships." Surgery on the bowel has no direct anatomical or physiological effect on sexual performance. However, psychological factors may hamper this function, and the nurse should encourage verbalization. Although it may take several months to resume satisfying sexual relationships, the surgery has no direct physiological effect. There is no reason why sexual activity must be curtailed. Although a partner should understand the nature of the surgery, the focus at this time should be on the client.

Isoniazid (INH) is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? (multiple) "I plan to start taking vitamin B 6 (NesTrex) with breakfast." "I'll still be taking this drug six months from now." "I sometimes allow our children to sleep in our bed at night." "I know I also have tuberculosis because the skin test was positive." "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

***"I sometimes allow our children to sleep in our bed at night." ***"I know I also have tuberculosis because the skin test was positive." ***"I'll be skipping the wine but enjoying the cheese at my neighbor's party." The children are at an increased risk because the client's spouse has TB; the children should be screened as members of the household. The positive skin test indicates that the client has been exposed to the bacilli and developed antibodies, not necessarily the disease itself; further diagnostic studies are indicated. Both wine and aged cheese contain tyramine and histamine, which when taken concurrently with INH can cause headache, flushing, and a drop in blood pressure; these should be avoided when taking INH. Pyridoxine (vitamin B 6 ) should be taken to prevent neuritis, which is associated with INH. The prophylactic drug therapy will be continued for 6 to 12 months.

A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet (400 mg/day). The nurse concludes that the teaching was effective when the client selects what food items from the menu? (multiple) Baked chicken Chocolate pudding Salmon loaf with cheese sauce Roast beef with mashed potato Vanilla ice cream with chocolate syrup

*Baked chicken *Roast beef with mashed potato Baked chicken is relatively low in calcium. Roast beef and mashed potato have moderate amounts of calcium. Pudding is made with milk and is high in calcium. Cheese is high in calcium. Ice cream is made with milk and is high in calcium.

An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should be included in the teaching plan? (multiple) Insulin therapy Prophylactic antibiotics Blood glucose monitoring Oral hypoglycemic agents Adherence to the treatment regimen

*Insulin therapy *Blood glucose monitoring *Adherence to the treatment regimen Because clients with type 1 diabetes have little or no endogenous insulin, they must take insulin; dietary control and exercise reduce the amount of exogenous insulin needed. Blood glucose monitoring is an important aspect of therapy because it aids evaluation of the effectiveness of diabetic control. Although adhering to the diabetic regimen is difficult, especially for adolescents, who need to identify with their peers, its importance in promoting euglycemia should be discussed. Although infection increases insulin requirements, prophylactic antibiotics are not needed. Oral hypoglycemics are ineffective in stimulating insulin secretion in clients with type 1 diabetes.

The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? (multiple) Cheese omelet Creamed spinach Roast beef sandwich Chicken noodle soup Spaghetti and meatballs

*Roast beef sandwich *Chicken noodle soup *Spaghetti and meatballs Bread contains gluten, which is irritating to the gastrointestinal mucosa and should be avoided. Noodles are made from flour and are high in gluten, which is irritating to the gastrointestinal mucosa and should be avoided. Pasta is made from flour and is high in gluten, which is irritating to the gastrointestinal mucosa and should be avoided. Eggs and cheese do not contain gluten and can be ingested. Creamed spinach does not contain gluten and can be ingested.

A client who menstruates regularly every 30 days asks a nurse on what day she is most likely to ovulate. Because the client's last menses started on January 1, the nurse should tell her that ovulation should occur on which day in January? 7 16 24 29

16 January 16. The time between ovulation and the next menstruation is relatively constant. In a 30-day cycle the first 15 days are preovulatory, ovulation occurs on day 16, and the next 14 days are postovulatory. January 7, January 24, and January 29 all reflect inaccurate calculation of the date of ovulation.

The urinary output of a 9-year-old child with acute glomerulonephritis decreases to 250 mL/24 hr. A diet low in sodium and potassium is prescribed. What should the nurse encourage the child to have for lunch? Baked chicken, green beans, and lemonade Cream of tomato soup, salami sandwich, and cola Grilled cheese sandwich, sliced tomatoes, and milk Peanut butter and jelly sandwich, celery, and orangeade

Baked chicken, green beans, and lemonade The foods in this grouping have the least sodium and potassium. Cream of tomato soup, a salami sandwich, and cola are high in sodium; some colas also have a high potassium content. A grilled cheese sandwich, sliced tomatoes, and milk are high in sodium. Celery is high in sodium; the sodium content is moderately high in bread and peanut butter.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. Clean the insertion site daily using a solution of one part vinegar to two parts water. Change the drainage bag at least once a week as needed.

Change the drainage bag at least once a week as needed. Once a day, the client should wash the first inches of the catheter starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution. It is recommended to change the bag at least once a week.

The parents of a gifted 4-year-old notice that their child has been showing signs of rebellion and acting out. One important thing to teach the parents about gifted children is: They need boundaries like any other child Intense emotions require an outlet, not punishment All discipline models approval of physical aggression Gifted children should be allowed to freely express themselves

They need boundaries like any other child Gifted children need discipline like any other child to feel loved and safe. Punishment is appropriate for behavior that is unsafe or falls outside set boundaries. Discipline appropriately applied does not lead to physical aggression. Free expression does not mean overstepping the boundaries of appropriate behavior.

A client is scheduled for a laminectomy. What should the nurse review with this client preoperatively? Use of a trapeze Contour position Traction apparatus Logrolling technique

Logrolling technique Logrolling technique maintains vertebral alignment, decreasing trauma to the operative site. Use of a trapeze is contraindicated; it does not maintain vertebral alignment and may increase cerebrospinal fluid pressure. Contour position is contraindicated; the contour position flexes the vertebral column. Traction is not used with this surgery.

During a childbirth class the nurse determines that the women understand how to use effleurage correctly when they are observed: Rocking gently on their knees Practicing panting to avoid pushing during labor Taking deep breaths before imagined contractions Massaging their abdomens gently with their fingertips

Massaging their abdomens gently with their fingertips Effleurage is a gentle massage of the abdomen that is effective during the first stage of labor because it distracts the client from the discomfort of the contractions. Rocking gently on the knees, known as the pelvic rock, is used during pregnancy to relieve backache. Practicing panting to avoid pushing during labor is a technique of breathing. Taking deep breaths before imagined contractions is also a technique of breathing.

A client with cancer of the thyroid is scheduled for a thyroidectomy. What should the nurse teach the client? The dietary intake of carbohydrates must be restricted. Chemotherapy may be used in conjunction with the surgery. Thyroxine replacement therapy will be required indefinitely. A tracheostomy requires an alternate means of communication.

Thyroxine replacement therapy will be required indefinitely. Thyroxine is given postoperatively to suppress thyroid-stimulating hormone (TSH) and prevent hypothyroidism. Increased intake of carbohydrates and proteins is needed because of the increased metabolic activity associated with hyperthyroidism. Chemotherapy is uncommon; radiation may be used to eradicate remaining tissue. A tracheostomy is not planned; it is needed only in an emergency related to respiratory distress.

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? An irreversible phenomenon A failure of the circulatory pump Usually a fleeting reaction to tissue injury Generally caused by decreased blood volume

A failure of the circulatory pump Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia is only one cause.

The nurse discusses fetal weight gain with a pregnant client. When does it usually show a marked increase? During the third trimester During the second trimester At the end of the first trimester No difference is observed.

During the third trimester During the is laying down fat deposits and gaining the most weight. Fetal weight gain occurs throughout pregnancy, but it is most marked in the third trimester. There is little fetal weight gain during the first trimester, when organ development is occurring.

An 11-year-old child with juvenile idiopathic arthritis will be receiving continued nonsteroidal anti-inflammatory drug (NSAID) therapy at home. Which important toxic effect of NSAIDs must be included in the nurse's discharge instructions to the child and family? Diarrhea Hypothermia Blood in the urine Increased irritability

Blood in the urine Hematuria may result from the use of NSAIDs because they may cause nephrotoxicity. Diarrhea can occur but is not a sign of toxicity. Hypothermia does not occur with NSAIDs. Drowsiness, not hyperactivity, may occur.

A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? Deep-breathing techniques Performing productive coughing Turning from side to side frequently Pant breathing while gently closing the eyelids

Deep-breathing techniques Deep breathing is an intervention to prevent respiratory complications that does not increase intraocular pressure. Coughing is contraindicated because it increases intraocular pressure. Although turning from side to side is permitted, it is not as effective as deep breathing in preventing respiratory complications. Pant breathing is shallow breathing and will not prevent respiratory complications.

A 4-year-old child with a new colostomy is to be discharged in several days. What should the nurse teach the parents about their child's home care? Inspecting the stoma once a day Restricting daily fluid intake Instituting dietary restrictions Encouraging physical activity

Encouraging physical activity Contact games may be restricted, but other physical activities should be encouraged. The stoma should be inspected more often than once daily to ensure adequate circulation. Increased fluid intake is needed to compensate for fecal fluid loss. The diet should not be restricted at the time of discharge. Both the parents and the child will learn which foods are poorly tolerated, and they will adjust the diet accordingly.

A client who is at 10 weeks' gestation returns for her second prenatal visit. She asks why she has to urinate so often. The nurse tells her that urinary frequency in the first trimester is: Caused by the descent of the baby's head into the uterus Influenced by the enlarging uterus, which is still within the pelvis Caused by maternal renal filtration of waste products excreted by the growing fetus Mostly a psychological phenomenon that results from the knowledge that one is pregnant

Influenced by the enlarging uterus, which is still within the pelvis The uterus remains in the pelvis until the second trimester, placing pressure on the bladder. The fetus is in the uterus, but head descent occurs in preparation for delivery in the third trimester; fetal waste products are minimal at this time and do not influence urinary frequency. is a physiological, not a psychological, sign of early and late pregnancy.

Which information should be included in the teaching plan for the client who is prescribed sumatriptan (Imitrex) for migraine headache? Should be administered when headache is at its peak Should be administered by deep intramuscular injection Is contraindicated in people with coronary artery disease Injectable sumatriptan may be administered every six hours as needed

Is contraindicated in people with coronary artery disease In addition to promoting therapeutic cerebral vasoconstriction, sumatriptan promotes undesirable coronary artery vasoconstriction. Coronary vasoconstriction may cause harm to the client with coronary artery disease. For maximum effectiveness, sumatriptan should be administered at the onset of migraine headache. Sumatriptan may be given orally, subcutaneously, or as a nasal spray. The maximum adult dose of sumatriptan is two 6 mg doses in a 24 hour period for a total of 12 milligrams. The two doses must be separated by at least an hour. The second dose should not be administered unless some response was observed with the first dose

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care? Use calamine lotion for pruritus Keep skin lubricated with lotion Apply warm soaks to inflamed areas Take frequent baths to remove scaly lesions

Keep skin lubricated with lotion With scleroderma, the skin becomes dry because of interference with the underlying sweat glands. Pruritus, inflamed areas, and skin lesions are not associated with scleroderma.

A client with chronic hepatic failure is to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider's prescription? High fat Low-calorie Low protein High sodium

Low protein With liver failure, the protein intake is limited to 20 g daily to decrease the possibility of hepatic encephalopathy. A high fat diet is avoided because of the related cardiovascular risks and the related demand for bile. Regeneration of tissue requires a high-calorie, high carbohydrate diet. Sodium usually is restricted to decrease the accumulation of fluid and help limit ascites and edema.

An 8-year-old child is being given insulin glargine (Lantus) before breakfast. What is the most appropriate information for the nurse to give the parents concerning a bedtime snack? Offer a snack to prevent hypoglycemia during the night. Give the child a snack if signs of hyperglycemia are present. Avoid a snack because the child is being treated with long-acting insulin. Keep a snack at the bedside in case the child gets hungry during the night.

Offer a snack to prevent hypoglycemia during the night. Insulin glargine is released continuously throughout the 24-hour period; a bedtime snack will prevent hypoglycemia during the night. Providing a snack when signs of hyperglycemia are present is unsafe because it intensifies hyperglycemia; if hyperglycemia is present, the child needs insulin. Because insulin glargine is a long-acting insulin, bedtime snacks are recommended to prevent a hypoglycemic episode during the night. When hypoglycemia develops, the child will be asleep; the snack should be eaten before going to bed.

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: In the axillae. On the hands. On the right side. On the side that the client prefers.

On the hands. Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side.

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8 AM the next day. The nurse advises the client to: "Have your dinner completed by 6 PM tonight and then no food or fluids after that." "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." "Consume a light evening meal tonight and then no food or fluids after midnight." "Eat lunch today and then do not drink or eat anything until after your surgery."

"Consume a light evening meal tonight and then no food or fluids after midnight." Eating a light meal and eliminating food and fluids after midnight limit complications during and after surgery, which include aspiration, nausea, dehydration, and possible ileus. A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. Clear liquids in the morning can cause nausea, vomiting, and aspiration. Fluids should not be withheld for more than eight hours, to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.

A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. The nurse responds: "Scratching causes lesions to become more contagious." "Scratching spreads dermatitis to other areas of the body." "Scratching results in skin breaks that can lead to infection." "Scratching produces changes that are precursors to skin cancer."

"Scratching results in skin breaks that can lead to infection." Scratching can break the integrity of the skin, leaving it vulnerable to infection. Dermatitis is a response to an allergen; it is not contagious. Scratching will not cause the dermatitis to spread. There are no data to indicate that scratching or dermatitis is a precursor to skin cancer.

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" The nurse's best response is: "Most individuals with your disease live a normal life span." "Is your family here? I would like to explain your disease to all of you." "The prognosis is variable; most individuals experience remissions and exacerbations." "Why don't you speak with your health care provider? You probably can get more details about your disease."

"The prognosis is variable; most individuals experience remissions and exacerbations." "The prognosis is variable; most individuals experience remissions and exacerbations" is a truthful answer that provides some realistic hope. The response "Most individuals with your disease live a normal life span" provides false reassurance; repeated exacerbations may reduce the life span. The response "Is your family here? I would like to explain your disease to all of you." avoids the client's question; the family did not ask. The response "Why don't you speak with your health care provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

Three months after beginning chemotherapy, a client develops severe anorexia, stomatitis, and episodes of diarrhea. The nursing plan includes increasing fluid and caloric intake and measures to relieve discomfort caused by stomatitis. To address the plan, the nurse should recommend that the client: Drink water frequently Suck on an ice pop every two hours Swallow warm tea throughout the day Rinse the mouth with the prescribed nystatin after meals

Suck on an ice pop every two hours Ice pops provide calories and fluid, and the cold relieves discomfort associated with the stomatitis. Water does not provide calories, only fluid. Tea has no calories, and warm drinks will increase, not decrease, the discomfort associated with the stomatitis. Although rinsing the mouth with nystatin after meals may prevent infection, it does not provide calories or fluid, or relieve discomfort associated with the stomatitis.

The nurse has completed a prenatal class for women who are expecting their first babies. Which statement by a pregnant woman indicates the need for additional teaching? "During pregnancy it's safe for me to use my regular herbal remedies." "My doctor will tell me if it's safe for me to take my allergy medications." "I should avoid all x-rays unless absolutely necessary and tell the technician that I'm pregnant." "I'm only 18 weeks pregnant, so it's safe for me to go through the airport security check when I go on vacation next month."

"During pregnancy it's safe for me to use my regular herbal remedies." Herbal remedies can be harmful to the fetus. All medications should be cleared through the health care provider. Radiation can be harmful to the fetus. The amount of radiation encountered in airport security over the course of a single trip would not pose a risk to the fetus.

Which statement by the client indicates to the nurse that the teaching about taking an antidepressant medication has been understood? "I need to take every dose of my medication as prescribed." "I need to discontinue the medication if I have side effects." "I don't have to be concerned about taking my medications." "I can double the dose of the medication if I still feel depressed."

"I need to take every dose of my medication as prescribed." The client should be encouraged to follow the medical regimen to maximize response to drug therapy. The client needs further teaching. The health care provider should be notified of side effects. The drug should not be discontinued without the health care provider's supervision. The client should be concerned about taking the medication. The health care provider should make the decision to increase the dosage.

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching was effective? "I should call the clinic if my eye begins to hurt." "I am so glad that I can take a shower tomorrow." "There will be bright flashes of light for a few days." "My vision should show some improvement by tomorrow."

"I should call the clinic if my eye begins to hurt." Pain after a cataract extraction and intraocular lens implant may indicate infection or hemorrhage and should be reported immediately. Soap may irritate the eye, and showers or shampooing of the hair should be avoided as instructed, usually from several days to two weeks. Seeing bright flashes of light is a symptom of retinal detachment and is not expected. Although rapid vision improvement may occur in some people, others may require several weeks to achieve improved visual acuity.

The nurse is providing instruction to a parent of a child with influenza. Which statement by the parent indicates the need for further instruction? "I'll manage the fever with baby aspirin." "We'll make sure to get a flu shot next season." "Providing fluids will help relieve the symptoms." "Staying home from school will prevent transmission."

"I'll manage the fever with baby aspirin." The use of aspirin to treat the fever associated with influenza is contraindicated; it is associated with Reye syndrome, which involves a toxic encephalopathy and hepatic dysfunction. Inactivated influenza viral vaccines are effective in the prevention of influenza. Fever may lead to dehydration; fluids help maintain hydration. The influenza virus can be spread by direct contact or through contact with surfaces contaminated with the virus; staying home prevents the spread of the disease to other students.

A nurse teaches the parents of a 5-year-old boy with type 1 diabetes about blood glucose monitoring at home. What statement by the parents indicates that the teaching has been effective? "Our child is old enough to do his own blood testing." "Our child will need only two tests a day as he gets older." "We'll notify the clinic if the blood sugar is higher than 200." "We'll discard the first blood sample in case it's contaminated."

"We'll notify the clinic if the blood sugar is higher than 200." A blood glucose higher than 200 mg/dL indicates that the insulin dosage may need to be adjusted. A 5-year-old child is not old enough to reliably test his or her own blood. The frequency of blood glucose testing depends on the degree of control. The area that is being sampled should be cleansed before the sample is obtained.

A client at 35 weeks' gestation asks a nurse why her breathing has become more difficult. How should the nurse respond? "Your lower rib cage is more restricted." "Your diaphragm has been displaced upward." "Your lungs have increased in size since you got pregnant." "The height of your rib cage has increased since you got pregnant."

"Your diaphragm has been displaced upward." The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration. The lower rib cage expands. There is no change in the size of the lung during pregnancy. The thoracic cage enlarges; it does not rise.

Which nursing activities are examples of primary prevention? Preventing disabilities Correcting dietary deficiencies Establishing goals for rehabilitation Assisting with immunization programs Facilitating a program about smoking cessation

*Assisting with immunization programs *Facilitating a program about smoking cessation Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.

To be most effective when teaching colostomy care to a client, the nurse must first: Wait until a family member is present Assess barriers to learning colostomy care Begin with simple written instructions concerning the care Wait until the client has accepted the change in body image

Assess barriers to learning colostomy care Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.

A nurse who is teaching a growth and development class to a group of parents at the daycare center explains that the toddler strives for a sense of: Trust Industry Initiative Autonomy

Autonomy According to Erikson, the toddler strives for autonomy; most exploratory and negativistic behavior is based in the need to achieve this developmental task. Trust is the developmental task of the infant. Industry is the developmental task of the school-age child. Initiative is the developmental task of the preschool child.

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for: Bile production. Blood production. Blood clotting. Digestion of fats.

Blood clotting. Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions such as bone health, blood clotting, and muscle contraction and nerve impulses; however it is not directly related to bile and blood production or digestion of fats.

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? Ambulation Blowing the nose Visiting with children The semi-Fowler's position

Blowing the nose Patients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the patient to avoid blowing their nose as this activity can increase the risk of bleeding. The following activities are not contraindicated with thrombocytopenia: ambulation, visiting with children, and semi-Fowler's position.

A 12-year-old child is to be bedridden at home for several weeks after orthopedic surgery. What activity should the nurse encourage the parents to plan? Drawing pictures Playing card games Watching television Continuing schoolwork

Continuing schoolwork Schoolwork provides the child with a familiar routine; it encompasses the age-appropriate developmental tasks of industry versus inferiority. Drawing pictures is an appropriate activity for the preschooler. Although social interaction and mental stimulation are important at this age, continuing with schooling is the priority. Television watching is satisfactory but should not replace active participation.

After taking spironolactone (Aldactone), a potassium-sparing diuretic, the client inquires about foods and fluids that are low in potassium. Which juice should the nurse teach the client contains the least amount of potassium? Apple juice Orange juice Tomato juice Cranberry juice

Cranberry juice Cranberry juice contains approximately 46 mg of potassium per 8 ounces. Apple juice contains approximately 295 mg of potassium per 8 ounces. Orange juice contains approximately 496 mg of potassium per 8 ounces. Tomato juice contains approximately 535 mg of potassium per 8 ounces.

The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make? Join a gym. Drink fewer diet sodas. Decrease fast food intake. Take a multivitamin daily.

Decrease fast food intake. Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.

A nurse is teaching a client about the differences between the terms saturated and unsaturated, when used in reference to fats. Which important factor in relation to these types of fats should the nurse include in the teaching? Taste Color Density Digestibility

Density Saturated fats , found in animal tissue, are denser than unsaturated fats, which are found in vegetable oils. Taste, color, and digestibility are characteristics of food and have no bearing on fat saturation.

A client is found to have preeclampsia, and bedrest at home is prescribed. It is doubtful that this client will be able to comply because she has two preschool children. What should be included in the plan of care that may help the client follow the prescribed regimen? Discuss why bedrest is necessary Warn of the risks of noncompliance Suggest a housekeeper for 4 hours a day Contract for 3 hours of naptime each day

Discuss why bedrest is necessary Clients who understand the "why" of treatment are more likely to comply. Warning of the risks of noncompliance is a negative approach; the , not the risks, should be discussed. Suggesting a housekeeper for 4 hours a day may be unrealistic; more data are needed. Contracting for 3 hours of naptime each day does not meet the requirement of bedrest.

A client returns to work as a carpenter after surgery for carpal tunnel syndrome of the right hand. What instructions should the nurse give to help prevent further problems with the hands when the client returns to work? Avoid carrying tools with the arms Learn to hammer with the left hand Do stretching exercises during breaks Avoid power tools such as cordless screwdrivers

Do stretching exercises during breaks Stretching exercises will assist in keeping the muscles and tendons supple and pliable, thus reducing the traumatic consequences of repetitive activity. The problem is not caused by carrying articles in the arms but by repetitive-type trauma. Learning to hammer with the left hand is not a satisfactory alternative for a skilled carpenter. The use of power tools will not be a problem.

Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identify that indicates the need for further instruction about complications associated with a multiple gestation? Preterm birth Down syndrome Twin-to-twin transfusion Gestational hypertension

Down syndrome Chromosomal anomalies are not associated with a multiple gestation; therefore the client needs further instruction. Preterm birth with multiple gestation occurs for a variety of reasons (e.g., spontaneous rupture of the membranes, abruptio placentae, marked uterine distention). Shunting of blood between placentas may occur with a multiple gestation if there are multiple placentas. The increased blood volume and metabolism necessary to sustain a multiple gestation predispose the client to hypertension.

A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. What is a nursing responsibility common to preparing both of these clients for these procedures? Withholding food for several hours Giving castor oil the afternoon before Administering soapsuds enemas until clear Ensuring an understanding of the procedure

Ensuring an understanding of the procedure To promote understanding and to allay anxiety, all diagnostic tests should be explained to the client. Preparations for tests may vary depending on the client's condition

A client has a permanent sigmoid colostomy as a result of cancer of the rectum. The primary health care provider prescribes daily colostomy irrigations. The nurse explains that the primary purpose of these irrigations is to: Prevent straining at passage of stool Establish a regular elimination schedule Decrease the amount of flatus in the bowel Limit the amount of fluid lost from the intestine

Establish a regular elimination schedule Irrigations regulate the bowel to function at a specific time for the convenience of the client. Although irrigations will prevent straining, this is not the purpose of the irrigation. Irrigations will facilitate expulsion of flatus but will not decrease the amount; avoidance of gas-forming foods will accomplish this. Bowel irrigations do not limit the amount of fluid lost from the intestine; most ingested fluid already is absorbed in the large intestine by the time it reaches the sigmoid colon.

A 7-year-old child with cerebral palsy who wears leg braces has a slight sensory loss in the lower extremities. What is the most essential information for the nurse to teach the child and parents? Examine the skin for evidence of pressure points. Keep the braces in good repair and pad them well. Select shoes that have heels that are wide and low. Check that the brace joints are aligned with body joints.

Examine the skin for evidence of pressure points. When sensory perception is impaired, with resultant lack of effective specific motor responses, the child will be more vulnerable to skin irritation and trauma. Although it is important for the braces to be usable and well padded, the skin must be assessed daily when there is a sensory loss. Pressure may still occur even if the braces are well padded. Although this type of shoe will facilitate balance, assessing the skin for breakdown is the priority. Although alignment of brace joints to body joints is important in facilitating joint mobility, assessment for skin breakdown takes priority.

A client is receiving a 2-gram sodium diet. The family asks whether they can bring snacks from home. The nurse suggests that they bring foods low in sodium such as: Ice cream Celery sticks Fresh orange wedges Peanut butter cookies

Fresh orange wedges An orange contains only trace amounts of sodium. One cup of ice cream contains approximately 115 mg of sodium. One cup of celery contains approximately 106 mg of sodium. Four peanut butter cookies contain 142 mg of sodium.

A nurse is caring for four clients, each with a different medical condition. Which condition should the nurse anticipate will result in the client's being instructed by the health care provider not to breastfeed? Mastitis Inverted nipples Herpes genitalis Human immunodeficiency virus

Human immunodeficiency virus Breastfeeding by a mother infected with HIV is contraindicated because breast milk can transmit the virus to the infant. Breastfeeding by a mother with mastitis is not always contraindicated; during antibiotic treatment the mother can maintain lactation by pumping the breasts and discarding the milk. Once the infection has resolved, breastfeeding may be resumed. Breastfeeding is not contraindicated with inverted nipples because a breast shield can provide mild suction to help evert the nipples. Breastfeeding is not contraindicated in a client with genital herpes. The newborn may contract the infection during a vaginal birth, not in breast milk.

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide (Diuril). What should the nurse instruct the client to do regarding nutrition? Eat more citrus fruits Take protein supplements Return to previous eating habits Increase intake of dairy products Increase intake of dried cooked beans

Increase intake of dried cooked beans The client should increase the dietary intake of potassium because of potassium loss associated with chlorothiazide. Citrus fruits are high in potassium and should be encouraged. Legumes, such as dried beans, are high in potassium and low in saturated fats. Protein should be obtained from foods, such as fish and fowl. Returning to previous eating habits is unsafe; the client should be taught about medication-induced deficiencies and how to try to prevent future TIAs. Dairy products should be limited, unless fat free, because they are high in saturated fats.

A nurse is teaching a prenatal class about smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? Low birth weight Facial abnormalities Chronic lung problems Hyperglycemic reactions

Low birth weight Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal: Kidney defects Cardiac anomalies Neural tube defects Urinary tract anomalies

Neural tube defects The α-fetoprotein test can detect not only neural tube defects but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the α-fetoprotein test

A pregnant woman tells a nurse, "I think I can feel the baby move now. It feels like butterflies in my stomach. My friend calls it feeling life." What term should the nurse include when discussing fetal movement with the woman? Lightening Quickening Engagement Ballottement

Quickening The word originates from the middle English word quik , which means "alive." Lightening is the descent of the fetus into the birth canal toward the end of pregnancy. Engagement occurs when the presenting part is at the level of the ischial spines. Ballottement refers to the technique that causes the fetus to rebound in the amniotic fluid after pressure has been exerted against the fetus.

What should the nurse teach a mother that will best help her 2½ -year-old son learn to control his behavior? Reward good behavior. Set limits and be consistent. Punish the child for misbehavior. Help the child learn through trial and error.

Set limits and be consistent Acceptable behavior should not always be rewarded, or rewards will become expected. Children learn socially acceptable behavior when consistent, reasonable limits that provide guidelines are established. Punishment should not become the major means of teaching children to control their behavior; motivation is stimulated more effectively by positive, not negative, interventions. Trial and error is not always safe or reasonable for very young children.

The nurse is counseling a client with type 1 diabetes about the client's favorite foods that are lowest in carbohydrates (CHO). The nurse determines that this concept is understood when the client chooses eight ounces of: Skim milk Apple juice Nonfat yogurt Fresh orange juice

Skim milk Skim milk contains about 12 grams of CHO per cup. There are about 30 grams CHO in 1 cup of apple juice. There are about 16 grams CHO in 1 cup of nonfat yogurt. There are about 25 grams CHO in 1 cup of orange juice

An obese client must self-administer insulin at home. The nurse should teach the client to use what technique? Pinch the tissue and inject at a 45-degree angle Pinch the tissue and inject at a 60-degree angle Spread the tissue and inject at a 45-degree angle Spread the tissue and inject at a 90-degree angle

Spread the tissue and inject at a 90-degree angle In the obese individual, spreading the tissue and injecting at a 90-degree angle helps to inject the medication into subcutaneous tissue rather than adipose tissue, where its absorption is poor. Pinching the tissue and injecting at a 45-degree angle or a 60-degree angle or spreading the tissue and injecting at a 45-degree angle will result in injection of the drug into adipose tissue, where it is absorbed poorly.

A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when: Sublingual tingling is experienced. The tablets are more than three months old. The pain is unrelieved, but facial flushing is increased. Onset of relief is delayed, but the duration of relief is unchanged.

The tablets are more than three months old. Nitroglycerin tablets are affected by light, heat, and moisture. Loss of potency can occur after three months, reducing the drug's effectiveness in relieving pain. A new supply should be obtained routinely. Experiencing sublingual tingling indicates the tablets have retained their potency. Unrelieved pain with an increase of facial flushing and delayed relief with the duration of relief remaining the same do not necessarily indicate loss of potency.

A client says, "I take baking soda in water when I get heartburn." The nurse suggests an antacid containing aluminum and magnesium hydroxide instead of baking soda. What is the advantage these antacids have over baking soda? They contain little, if any, sodium. Absorption by the stomach mucosa is markedly enhanced. There is no direct effect on the systemic acid-base balance when taken as directed. Fewer side effects, such as diarrhea or constipation, are experienced when they are used properly.

There is no direct effect on the systemic acid-base balance when taken as directed. Nonsystemic antacids are not readily absorbed, so they do not alter acid-base balance. Sodium bicarbonate is absorbed and can alter acid-base balance. These preparations do contain sodium. Nonsystemic antacids are insoluble and not readily absorbed. Diarrhea and constipation are side effects of nonsystemic antacids.

A client at 7 weeks' gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the: Fifth month Third month Fourth month Second month

Third month Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin.

A client cannot understand how syphilis was contracted because there has been no sexual activity for several days. Which length of time associated with the incubation of syphilis should the nurse include in the teaching plan? One week Four months Two to six weeks 48 to 72 hours

Two to six weeks Although the usual incubation period of syphilis is about three weeks, clinical symptoms may appear as early as nine days or as long as three months after exposure. The usual incubation period is 21 days.

A client who has peripheral arterial disease of the lower extremities tells the nurse, "I walk so slowly that no one wants to walk with me." What is the best response by the nurse? "A vascular rehabilitation program may help you." "You should be sitting with your feet elevated, not walking." "Try again tomorrow because maybe you will have a better day." "They are not good friends if they are not willing to walk with you."

"A vascular rehabilitation program may help you." Peripheral vascular rehabilitation includes exercise and walking programs that encourage new growth of vessels around the obstructed artery; this may improve peripheral perfusion and the ability to walk; eventually, walking with friends may be introduced into the walking program. Inactivity is contraindicated; elevation of the legs diminishes peripheral arterial circulation. The response "Try again tomorrow because maybe you will have a better day" provides false reassurance. The response "They are not good friends if they are not willing to walk with you" is an opinion that should be avoided; it does not focus on the client's need to improve walking ability.

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. Which plan reported by the client supports the nurse's conclusion that the teaching was effective? "Eliminate excessive blinking." "Not move my extraocular muscles." "Keep the head of my bed elevated." "Avoid using a sleeping mask at night."

"Avoid using a sleeping mask at night." A mask may irritate or scratch the cornea if the client turns and lies on it during the night. Blinking will bathe the eyes and prevent corneal ulceration. Not moving the extraocular muscles will do nothing to relieve edema or prevent corneal ulceration. Although keeping the head of the bed elevated will help reduce periorbital edema, it will not prevent corneal ulceration.

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? "Urinary control may be permanently lost to some degree." "An indwelling urinary catheter is required for at least a day." "Your ability to perform sexually will be impaired permanently." "Burning on urination will last while the cystotomy tube is in place."

"An indwelling urinary catheter is required for at least a day." An indwelling urethral catheter is used because surgical trauma can cause edema and urinary retention, leading to additional complications, such as bleeding. Urinary control is not lost in most cases; loss of control usually is temporary if it does occur. Sexual ability usually is not affected; sexual ability is maintained if the client was able to perform before surgery. A cystotomy tube is not used if a client has a transurethral resection; however, it is used if a suprapubic resection is done.

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? "It is used to prevent you from getting a bladder infection before surgery." "It will decrease your kidney function and lessen urine production during surgery." "It will kill the bacteria in your bowel and decrease the risk for infection after surgery." "It is used to alter the body flora, which reduces spread of the tumor to adjacent organs."

"It will kill the bacteria in your bowel and decrease the risk for infection after surgery." Neomycin provides preoperative intestinal antisepsis. It is not administered to prevent bladder infection. Nephrotoxicity is an adverse, not a therapeutic, effect. Neomycin will not prevent metastasis of the tumor to other areas.

A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse? "Wear warm clothes to keep moisture in the skin." "Use a moisturizer on the skin daily to help reduce itching." "Take hot tub baths only twice a week to reduce drying of the skin." "Expose the skin to the air to help reduce the sensation of itching."

"Use a moisturizer on the skin daily to help reduce itching." Lubricating the skin with a moisturizer effectively relieves dryness and thus the pruritus. Wearing warm clothing will do nothing to lubricate the skin or relieve the pruritus. Warm or cool, not hot, tub baths will decrease itching. Exposing the skin to the air causes further drying and will not relieve pruritus.

A tuberculin skin test with purified protein derivative (PPD) tuberculin is performed as part of a routine physical examination. The nurse instructs the client to make an appointment so the test can be read in: 12 hours 24-48 hours 48-72 hours 1 week

48-72 hours It takes 48-72 hours for antibodies to respond to the antigen and form an indurated area. The results of tuberculosis skin tests that are not read within this timeframe will not be accurate.

A client is brought to the emergency department with chest pain. The client asks why an electrocardiogram (ECG) has been prescribed. The nurse explains that the ECG will: Aid in detecting heart damage Detect altered heart sounds Determine the flow of blood to the heart muscle Evaluate the spatial relationship of structures within the heart

Aid in detecting heart damage Various waveforms of an electrocardiogram can indicate damage to different areas of the heart. Auscultation can detect various heart sounds. Blood flow to the heart muscle is assessed during a cardiac catheterization. Spatial relationships of structures within the heart are assessed via an echocardiogram.

A nurse is caring for a client with acute kidney failure who is receiving a protein-restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions? A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys The amount of protein permitted in the diet (usually less than 50 g) depends on the extent of kidney function; excess protein causes an increase in urea concentration, which should be avoided Adequate calories are provided to prevent tissue catabolism, which also results in an increase in metabolic waste products. In kidney failure the kidneys are unable to eliminate the waste products of a high protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.

The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will first be heard with: A fetoscope around 8 weeks A fetoscope at 12 to 14 weeks Electronic Doppler ultrasonography after 17 weeks Electronic Doppler ultrasonography at 10 to 12 weeks

Electronic Doppler ultrasonography at 10 to 12 weeks The can be heard on electronic Doppler ultrasound between 10 and 12 weeks' gestation. Around 8 weeks is too early for the heartbeat to be heard with a fetoscope; a fetoscope can pick up the fetal heartbeat around the 20th week, not at 12 to 14 weeks or before the 17th week. The fetal heartbeat can be heard at least 5 weeks earlier with the use of electronic Doppler ultrasound.

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? Placing the old dressing in a plastic bag Changing the dressing without wearing a mask Donning nonsterile gloves for removing the old dressing Using a back-and-forth motion while cleaning the wound

Using a back-and-forth motion while cleaning the wound Each swipe with sterile gauze should be discarded, and another sterile gauze should be used for the next swipe. Placing the old dressing in a plastic bag confines the soiled dressing to a leakproof bag, which prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated; sterile gloves are required for dressing application.

A client with tuberculosis is started on a chemotherapy protocol that includes rifampin (RIF). The nurse evaluates that the teaching about rifampin is effective when the client states: "I need to drink a lot of fluid while I take this medication." "I can expect my urine to turn orange from this medication." "I should have my hearing tested while I take this medication." "I might get a skin rash because it is an expected side effect of this medication."

"I can expect my urine to turn orange from this medication." RIF causes body fluids, such as sweat, tears, and urine, to turn orange. It is not necessary to drink large amounts of fluid with this drug; it is not nephrotoxic. Damage to the eighth cranial nerve is not a side effect of rifampin; it is a side effect of streptomycin sulfate, sometimes used to treat tuberculosis. A skin rash is not a side effect of rifampin.

A client asks for information about glaucoma. The nurse explains that glaucoma is: An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina

An increase in the pressure within the eyeball An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow through the trabecular meshwork, Schlemm's canal, and the episcleral venous system. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.

A nurse is educating a client with a colostomy of the ascending colon about using a colostomy appliance. Which instruction should the nurse provide to help prevent leakage of stool from the appliance? Irrigate the colostomy to establish an expected pattern of elimination. Empty the appliance when it is approximately one half full with feces. Use an antiseptic to clean the peristomal skin before applying the appliance. Select an appliance with a pouch opening of at least 5 cm larger than the stoma.

Empty the appliance when it is approximately one half full with feces. Emptying the appliance when half full will help prevent the weight of the fecal drainage from pulling the appliance away from the seal, thus preventing leakage. A colostomy of the ascending colon usually is not irrigated because the feces will be semi liquid. The peristomal skin is cleaned with soap and water; an antiseptic is too caustic. The pouch opening should be approximately 1/8 inch larger than the stoma. This limits exposure of peristomal skin to irritation from feces.

A primigravida in the first trimester tells a nurse that she has heard that hormones play an important role in pregnancy. Which hormone should the nurse tell the client maintains pregnancy? Prolactin Estrogen Progesterone Somatotropin

Progesterone Progesterone is a female sex hormone, produced by the ovaries and placenta, that prepares the endometrium for implantation of the fertilized ovum, maintains pregnancy, and plays a role in the development of the mammary glands. Prolactin is secreted by the anterior lobe of the pituitary gland; it is responsible for initiating and maintaining milk secretion from the mammary glands. Estrogen is a female sex hormone that starts to prepare the endometrium for implantation and promotes development of secondary sex characteristics. Somatotropin is a growth hormone secreted by the anterior pituitary gland.

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies that further teaching about the hypophysectomy is necessary when the client states, "I know I will: Be sterile for the rest of my life." Require larger doses of insulin than I did preoperatively." Have to take cortisone or a similar drug for the rest of my life." Have to take thyroxine or a similar medication for the rest of my life."

Require larger doses of insulin than I did preoperatively." The hypophysis (pituitary gland) does not directly regulate insulin release. This is controlled by serum glucose levels. Because somatotropin release will stop after the hypophysectomy , any elevation of blood glucose level caused by somatotropin also will stop. Infertility may be expected after a hypophysectomy because the follicle-stimulating hormone and its releasing factor will no longer be present to stimulate spermatogenesis. When adrenocorticotropic hormone (ACTH) is absent, cortisone will have to be administered. Thyroid-stimulating hormone will not be present; extrinsic thyroxine will have to be taken.

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Skip the oral hypoglycemic pill, drink plenty of fluids, and rest. Avoid food, drink clear liquids, take the daily medication, and stay in bed. Take the oral medication, drink fluids, and monitor capillary glucose levels. Delay taking the medication until tolerating food, and call the office the next day.

Take the oral medication, drink fluids, and monitor capillary glucose levels. Physiologic stress increases gluconeogenesis, requiring continued pharmacological therapy despite an inability to eat; fluids prevent dehydration; monitoring of glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. Delaying an oral hypoglycemic may precipitate hyperglycemia.

A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety? Requesting that the child write at least three safety rules Asking the child to verbalize as many safety rules as possible Talking with the child about the importance of using a seat belt Encouraging the child to talk with other children about their opinions of safety rules

Talking with the child about the importance of using a seat belt Focusing on specifics is important for children who are easily distracted. Focusing on more than one item at a time might be difficult for an easily distracted child. Hyperactive children respond best to concrete tasks; this is not a concrete task. A child who is easily distracted has difficulty talking to a group of children regarding a particular topic.

A nurse is giving discharge instructions to a client who has undergone anterior colporrhaphy. The nurse knows the teaching has been understood if the client says: "I know that my sutures need to be removed in a week." "I'm ready to start my aerobics class again next week." "I'm glad I can help get my bedridden husband up to his chair now." " For discomfort I can try using warm compresses on my abdomen."

" For discomfort I can try using warm compresses on my abdomen." After colporrhaphy (vaginal wall repair) surgery, heat, either as a moist heating pad or warm compresses, may be applied to the abdomen to relieve discomfort. This statement by the client is correct. The client should limit her activities for 6 weeks, so aerobic exercise should not be resumed in a week. The client should avoid lifting anything heavier than 5 lb, so getting her bedridden husband up to a chair would be too strenuous. The client does not need to have sutures removed. Some sutures used for colporrhaphy repair are absorbable; others will fall out as healing occurs.

A nurse teaches a client with asthma about her illness during pregnancy. Which statement by the client indicates that the nurse's teaching has been effective? "Prednisone is safe to use during pregnancy." "My asthma will get worse as my pregnancy progresses." "I can use my albuterol inhaler if it's absolutely necessary." "I'll have to have a cesarean to prevent a severe attack during labor."

"I can use my albuterol inhaler if it's absolutely necessary." (Proventil HFA) is classified as a pregnancy category C medication. It is not known whether albuterol poses risks to the human fetus; however, it may be used if its benefits outweigh the potential risks. Prednisone is also classed in pregnancy category C medication. It is not recommended during pregnancy unless absolutely necessary because of its many adverse effects. During pregnancy asthma symptoms ease because of the increased production of corticosteroids. Labor will not precipitate an attack of asthma. A cesarean birth is not necessary for this reason alone.

A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching? "After it gets done healing in a few weeks, I will begin irrigating it just before going to bed each day." "It will need to be irrigated each morning before I can eat any food." "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." "I can wait to start irrigating it until after I have gotten used to this bag and change in lifestyle."

"I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." Although most people defecate after breakfast because ingestion of food on an empty stomach initiates the gastrocolic reflex, not all people defecate at this time. Irrigation should be performed at the time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Irrigations should be performed at the same time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Clients can eat before irrigating the colostomy. An irrigation cannot be postponed until the client accepts the altered body image, because this may take weeks or months.

When talking with a client who has been receiving Paroxetine (Paxil), the nurse determines that more clarification is needed when the client says: "I'll be a little drowsy in the mornings." "I'm expecting to feel somewhat better, but I may need other therapy." "I've been on the medication for 8 days now, and I don't feel any better." "I know that I'll probably have to take this medication for several months."

"I've been on the medication for 8 days now, and I don't feel any better." The response "I've been on the medication for 8 days now, and I don't feel any better" indicates that the client has not been taking the drug long enough to expect a therapeutic response; clients who begin taking antidepressants usually begin to feel a lightening of depression in approximately 14 to 20 days, with the full antidepressant effects being felt between 3 and 4 weeks. Drowsiness, fatigue, and insomnia are common side effects. Medication alone may not be effective; some form of psychotherapy often is needed. Clients usually remain on these medications for several months.

A female client who has been sexually active for 5 years is found to have gonorrhea. The client is upset and asks the nurse, "What can I do to keep from getting another infection in the future?" Which statement by the client indicates that the teaching by the nurse was effective? "I'll douche after each time I have sex." "Having sex is a thing of the past for me." "My partner has to use a condom all the time." "I'll be using a spermicidal cream from now on."

"My partner has to use a condom all the time." Although not 100% effective, a condom is the best protection against gonorrhea in a sexually active person. Douching has no proven protective effect against sexually transmitted infections; excessive douching can alter the natural environment of the vagina and may even promote an ascending infection. Although abstaining from sex is the best way to prevent a sexually transmitted Infection; it is not the most realistic response for a sexually active person. Once people become sexually active, they usually remain sexually active. Spermicidal creams do not have a protective effect against sexually transmitted infections; spermicides kill sperm and limit the risk for pregnancy.

A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement? "Breastfeed four times a day, then offer water if the baby cries." "Offer just one bottle a day when you're experiencing discomfort." "Nurse at least every 3 hours for at least 10 minutes on each breast." "Limit nursing to 4 to 6 minutes on each breast at least six times a day."

"Nurse at least every 3 hours for at least 10 minutes on each breast. Frequent nursing reduces engorgement. A 10-minute session permits complete emptying of the breast. Offering water will not decrease engorgement; in addition, the infant will be deprived of nourishment. A relief bottle will prevent emptying of the breasts; it will increase pain and swelling. Limiting nursing does not permit complete emptying of the breasts.

A client who is scheduled for an amniocentesis says, "I'm glad that this test will show if my baby is well." How should the nurse respond? "The test will confirm your baby's health." "It will identify any congenital defects." "New technologies have made these tests even more reliable." "Potential defects caused by chromosomal errors can be detected."

"Potential defects caused by chromosomal errors can be detected." Amniocentesis has proved useful in detecting potential defects resulting from chromosomal errors such as Down syndrome, Tay-Sachs disease, hemophilia, and thalassemia, as well as other maternal and fetal problems. Stating that the baby's health will be confirmed is false reassurance, and it may stop further communication. Amniocentesis does not reveal all congenital defects. Stating that new technologies have made these tests even more reliable is nonspecific and does not address the client's statement.

A pregnant client tells the nurse in the prenatal clinic that although she and her husband do not have the disease, she has a 1-year-old daughter with sickle cell anemia. She asks the nurse, "Will this baby also have sickle cell anemia?" How should the nurse respond? "The chance that another child will have sickle cell anemia is 25%." "Only one child in a family is affected, so the others probably will be all right." "The most likely conclusion is that your children will have sickle cell anemia." "If your partner has the sickle cell gene, 50% of your children will have sickle cell anemia."

"The chance that another child will have sickle cell anemia is 25%." According to Mendel's Law , the sickle cell gene is recessive. If neither parent has the disease, both of them have the sickle cell trait; there is therefore a 25% chance that a child will have sickle cell anemia, a 50% chance that a child will have the sickle cell trait, and a 25% chance that a child will be unaffected. Saying that only one child in a family is affected and that the others probably will be all right is too vague. Stating that the children will have sickle cell anemia is not an accurate answer. The client should be told the probability of a child's inheriting the disease, but 50% is too high.

A client is learning alternate site testing (AST) for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary? "I need to rub my forearm vigorously until warm before testing at this site." "The fingertip is preferred for glucose monitoring if hyperglycemia is suspected." "Alternate site testing is unsafe if I am experiencing a rapid change in glucose levels." "I have to make sure that my current glucose monitor can be used at an alternative site."

"The fingertip is preferred for glucose monitoring if hyperglycemia is suspected." The fingertip is preferred for glucose monitoring if hypoglycemia, not hyperglycemia, is suspected. The response "I need to rub my forearm vigorously until warm before testing at this site" indicates that the client understands that this will increase blood flow, which helps to minimize the difference between forearm and fingertip results, although it does not eliminate them. In a study in which rapidly fluctuating glucose levels were initiated, glucose levels at the forearm were significantly lower than samples from the fingertips. The fingertip should be used when testing before, during, and after exercising, before driving, after eating, and during illness; the fingertip most closely reflects a current glucose level. Not all glucose monitors on the market can be used for AST.

A 17-year-old child was recently found to have type 2 diabetes mellitus. What information will the nurse include when providing education to the family? "Your child will need insulin injections for the rest of her life." "The most important interventions are good nutrition and portion control." "This is a condition where the body produces antibodies against its own cells." "This condition causes weight loss and increased appetite, thirst, and urination."

"The most important interventions are good nutrition and portion control." Most children with type 2 diabetes are overweight or at risk for becoming overweight. With nutritional intervention to promote proper weight, the condition may often be managed with diet and exercise alone. A lifelong insulin regimen, the production of antibodies against the child's own cells, and weight loss with increased appetite, thirst, and urination are all typical of type 1 diabetes.

An infant is found to have communicating hydrocephalus. The parents ask for clarification of the health care provider's explanation of the problem. How should the nurse respond? "Too much spinal fluid is being produced within the spaces (ventricles) of the brain." "The flow of spinal fluid through the brain cells does not empty effectively into the spinal cord." "The spinal fluid is prevented from being adequately absorbed by a blockage in the spaces (ventricles) of the brain." "There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately."

"There is a part of the brain surface that usually absorbs spinal fluid after its production that is not functioning adequately." In communicating hydrocephalus, a part of the brain surface that usually absorbs spinal fluid after its production does not function adequately. Too much spinal fluid is often a result of a choroid plexus tumor. It does not interfere with the flow of cerebrospinal fluid through the ventricles. Stating that the flow of spinal fluid through the brain cells does not empty effectively into the spinal cord is inaccurate; brain cells and the spinal cord are not involved. Stating that the spinal fluid is prevented from being adequately absorbed by a blockage in the spaces (ventricles) of the brain reflects the pathophysiological process of noncommunicating hydrocephalus.

A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse's best response to this question? "There is no difference between readings." "These types of monitors are meant for children." "Readings are on a different scale for each monitor." "Faster readings can be obtained from a fingerstick."

"There is no difference between readings." The forearm glucose monitor is calibrated to be consistent with results obtained from a fingerstick. Individuals of all ages can use these glucose monitors. A different scale is not used for each monitor; accompanying literature will indicate if the monitor reading reflects venous blood values even though capillary blood is used. There is no difference in the time required to complete the test.

An 8-year-old child with cerebral palsy is admitted to the hospital for a tendon-lengthening procedure. After the surgery the parents ask a nurse why their child must wear braces and shoes for at least 12 hours a day, even while in bed. What is the best response by the nurse? "Ambulation should be encouraged as soon as possible." "They maintain body alignment and help prevent foot drop." "They stretch your child's ligaments and strengthen muscle tone." "It helps your child accept the physical constraints of the condition."

"They maintain body alignment and help prevent foot drop." Braces are worn to enable the spastic child to control movement. They also prevent deformities that can occur as a result of misalignment. Early ambulation is promoted by maintaining muscle strength and tone, but it is not the reason for applying braces. Exercises, not braces, are used to stretch ligaments and improve muscle strength and tone. Promoting acceptance is not the purpose of braces and shoes. The child is in Erikson's stage of industry versus inferiority, and the braces and shoes will promote independence.

A nurse is giving discharge instructions to a new mother. What is the most important instruction to help prevent postpartum infection? "Don't take tub baths for at least 6 weeks." "Wash your hands before and after changing your sanitary napkins." "Douche with a dilute antiseptic solution twice a day and continue for a week." "Tampons are better than sanitary napkins for inhibiting bacteria in the postpartum period."

"Wash your hands before and after changing your sanitary napkins." Infection is most commonly transmitted through contaminated hands. Tub baths are permitted. Douching is contraindicated. Tampons are contraindicated in the postpartum period until the cervix has closed completely; they may promote infection when used too early.

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? "You will receive the anesthesia through a face mask." "You will receive medication through an intravenous catheter." "We will give you an oral medication about one hour before the procedure." "The nurse anesthetist will inject the medication into the epidural space of your spine."

"You will receive medication through an intravenous catheter." Conscious sedation is administered by direct intravenous (IV) injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for moderate sedation. The oral route of drug administration is commonly used for pediatric clients, not adults.

Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse? "Bone marrow transplantation is rarely performed in children these days." "The hematopoietic stem cells are surgically implanted in the bone marrow." "Your child's immune system must be destroyed before the transplantation can take place." "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."

"Your child's immune system must be destroyed before the transplantation can take place." An intensive preparatory regimen is needed to destroy the child's immune system. Once the process is started, no rescue therapy except for the transplant is provided. The procedure is performed in children for recurrent malignancies. The child's bone marrow must be clear of all cells before transfusion of the stem cells is performed.

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? (multiple) Cardiac output increases. Blood pressure decreases. The heart is displaced upward. The blood plasma volume peaks. The hematocrit level is lowered.

*Cardiac output increases. *Blood pressure decreases. *The heart is displaced upward. Cardiac output increases during the second trimester because of an increasing plasma volume. The blood pressure decreases because of the enlarged intravascular compartment and hormonal effects on peripheral resistance. As the fetus grows and the enlarging uterus outgrows the pelvic cavity, it displaces the heart upward and to the left. The blood volume starts to increase earlier but does not peak until the third trimester. The reduction in hematocrit occurs in the first trimester; the erythrocyte increase may not be in direct proportion to the blood volume, lowering hematocrit and hemoglobin levels, which remain lower throughout pregnancy.

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Eat foods high in vitamin C. Take your temperature daily. Balance periods of rest and activity. Use a strong soap when washing the skin. Expose the skin to the sun as often as possible.

*Eat foods high in vitamin C. *Take your temperature daily. *Balance periods of rest and activity. Vitamin C should be encouraged because it is essential for the biosynthesis of collagen. A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not necessary. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? (multiple) Food cravings increase. Nesting needs increase. Dependency needs decrease. Anxiety about childbirth increases. Gastrointestinal motility decreases.

*Nesting needs increase. *Anxiety about childbirth increases. *Gastrointestinal motility decreases. Nesting needs increase as pregnancy reaches term; it is a psychological preparation for motherhood. As pregnancy nears term, maternal thoughts turn to the problems that may occur during labor and birth. Because the enlarged uterus is pressing on the organs of the gastrointestinal tract, digestive and elimination problems increase. Food cravings start early in the pregnancy and do not commonly intensify as the pregnancy nears term. Maternal dependency needs increase as the pregnancy nears term; there is a need for being nurtured in preparation for providing it to the newborn.

A nurse teaches the parents of a school-aged child with celiac disease about the foods that should be eliminated from the diet. Which foods do the parents name that indicate to the nurse that the teaching has been understood? (multiple) Milk Cheese Oatmeal Rice cakes Corn on the cob Whole-wheat bread

*Oatmeal *Whole-wheat bread Oat grain, in addition to wheat, rye, and barley grains, contains gluten, which should be eliminated from the diet in children with celiac disease. Foods made with wheat grain, a major source of gluten, must be eliminated from the diet of a child with celiac disease. Gluten contains the gliadin fraction that causes celiac syndrome. There is no gluten in milk or other dairy products. There is no gluten in rice grain; it is a substitute for the grains that must be eliminated from a diet that should be gluten free. Corn can be eaten safely because it does not contain gluten.

A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? Resume usual activities. Report swelling of fingers. Keep the affected shoulder immobilized. Elevate casted arm when the child is standing. Lower the casted arm when the child is lying down.

*Report swelling of fingers. *Elevate casted arm when the child is standing. Rationale: When swelling of the fingers occurs, the cast may become too tight, resulting in neurovascular damage; permanent damage can occur in 6 to 8 hours. The casted arm should be in a sling when the child is upright to promote venous return. Rest with elevation of the extremity is recommended; strenuous activity should be avoided for several days. Joints above and below the cast should be moved to maintain flexibility. The casted arm should be elevated when the child is resting to promote venous return.

A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience: Transient headaches." An elevated temperature." Paroxysmal hiccoughs." A sore throat."

A sore throat." A general anesthetic is delivered via an endotracheal tube that irritates the posterior pharynx and larynx. Side effects of general anesthesia do not include transient headaches or an elevated temperature. Hiccoughs, headaches, and an elevated temperature are systemic effects, not local effects, and are not side effects of general anesthesia

A newborn male is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do? Apply the diaper loosely for several days Give a crushed baby aspirin if there is irritability Check for bleeding every 2 hours during the first day home Call the practitioner if there is whitish exudate around the glans

Apply the diaper loosely for several days Applying the diaper loosely is done to avoid pressure on the circumcised area because the glans remains tender for 2 to 3 days. Aspirin may prolong clotting and is contraindicated in children because of its relationship to Reye syndrome. Acetaminophen and comfort measures may be prescribed. The caregiver should check for bleeding every hour for the first 12 hours after the circumcision. Whitish exudate around the glans is expected and does not indicate an infectious process.

The nurse is teaching a client who is scheduling a vasectomy. What information is essential that the nurse explain to the client? Recanalization of the vas deferens is impossible. Unprotected coitus is safe within 1 week to 10 days . Some impotency is to be expected for several weeks after the procedure. At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked. Some spermatozoa will remain viable in the vas deferens for a variable time after vasectomy. There has been some success in reversing vasectomy. Precautions must be taken to prevent fertilization until absence of sperm in the semen has been verified. The procedure does not affect sexual function.

An adolescent child who has sustained full-thickness burns is to undergo skin grafting. The nurse explains to the child's parents that for permanent grafts the child must have: Steroids Autografts Homografts Immunosuppressants

Autografts Autografts consist of tissue from the individual's own body, meaning that the chance of rejection is minimal. Steroids are not part of the therapy for skin grafts. Homografts consist of tissue from genetically different members of the same species, usually a cadaver; they are used as temporary grafts. Immunosuppressive drugs are not part of the therapy for skin grafts.

A client has surgery for an incarcerated hernia. The health care provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. What specific instructions should be included in the discharge instructions? Reduce dietary roughage. Avoid lifting heavy items. Increase dietary potassium intake. Keep the head of the bed elevated.

Avoid lifting heavy items. Avoiding lifting helps prevent increased intraabdominal pressure that may disrupt the surgical repair. Roughage helps prevent constipation, which leads to straining, increasing intraabdominal pressure. There is no indication for potassium supplements. The client can assume any position of comfort.

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states that it is important to: Plan activities for later in the day Eat meals in a semi-recumbent position Avoid people with respiratory infections Take muscle relaxants when under stress

Avoid people with respiratory infections Respiratory infections place people with myasthenia gravis at high risk because they do not cough effectively and may develop pneumonia or airway obstruction. Activity should be conducted earlier in the day before the energy reserve is depleted; periods of activity should be alternated with periods of rest. The client should eat sitting in a chair to prevent aspiration. Taking muscle relaxants when under stress is contraindicated; these potentiate weakness because of their effect on the myoneural junction.

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding? They are common and will disappear in 2 to 3 days. They are birthmarks that will disappear in 3 to 4 months. Avoid squeezing them and don't try to wash them off. Proper handwashing technique is important because milia are infectious.

Avoid squeezing them and don't try to wash them off. Although milia are common, they do not disappear for several weeks after birth. Milia are not birthmarks; the tiny plugged sebaceous glands are the result of maternal hormonal influence. Attempts to remove milia will irritate the infant's skin, and such attempts are not needed because the milia will disappear during the first month of life. The white material is not purulent and is not infectious.

A client with chronic gastritis is being treated with medication and diet. What should the nurse teach the client when discussing the therapeutic regimen? Lie down after eating when possible Take an antacid preparation with meals Limit high carbohydrate foods in the diet Avoid using analgesics that contain aspirin

Avoid using analgesics that contain aspirin Aspirin interferes with the gastric mucosa's natural protection from pepsin and hydrochloric acid, worsening the gastritis. The client should avoid lying down after eating; sitting up for one hour after meals uses gravity to minimize esophageal reflux. Antacids usually are prescribed after meals. Small, frequent, bland feedings are preferred; carbohydrate intake may be increased to provide calories needed during tissue repair.

A nurse is counseling a pregnant client with iron-deficiency anemia about when and how to take supplemental iron. What time of day and with what drink is iron absorption most efficient? Dinnertime with water Bedtime with a milkshake After lunch with cranberry drink Before breakfast with orange juice

Before breakfast with orange juice Iron should be taken before breakfast, on an empty stomach, to permit maximal absorption; ascorbic acid enhances the absorption of iron. Iron should not be taken with or after meals. Iron should not be taken with milk, which may interfere with its absorption.

A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will: Cut my toenails before bathing." Soak my feet daily for one hour." Examine my feet using a mirror at least once a week." Break in my new shoes over the course of several weeks."

Break in my new shoes over the course of several weeks." A slower, longer period of time to break in new, stiff shoes will help prevent blisters and skin breakdown. The toenails should be cut by a podiatrist; they usually are cut after a foot bath when the nails are softer. Soaking the feet daily for one hour will cause maceration of the skin and should be avoided. Examining the feet using a mirror at least once a week is too long a period of time; the client should examine the feet daily for signs of trauma.

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference? Bloody show is rare with false labor. Cervix effaces and dilates during true labor. Membranes rupture at the start of true labor. Fetal movement slows and contractions accelerate with false labor.

Cervix effaces and dilates during true labor. Effacement and dilation of the cervix during true labor is . Some women have a bloody show without cervical dilation. The membranes may rupture before or after labor has started. Fetal movement continues unchanged throughout labor; contractions are irregular with false labor.

A nurse teaches a client how to perform diaphragmatic breathing. The nurse advises the client to: Take rapid, deep breaths Breathe with hands on the hips Expand the abdomen on inhalation Perform exercises leaning forward while in a sitting position

Expand the abdomen on inhalation Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Rapid breathing promotes respiratory alkalosis; diaphragmatic breathing includes slow deep breathing. The hands should be placed lightly on the abdomen to verify abdominal excursion. Diaphragmatic breathing may be performed in any position other than the prone or Trendelenburg; usually the semi-Fowler position is used.

The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of: Restricting fluid intake Choosing fresh or frozen vegetables instead of canned ones Eating a low-calorie diet to reduce weight Recognizing which products are high in cholesterol

Choosing fresh or frozen vegetables instead of canned ones The key principle to teach CHF clients is the importance of decreasing sodium in their diet and which foods contain sodium. If sodium is decreased, water retention will decrease also. Fresh or frozen vegetables have less sodium than canned ones. If the client is on a low-sodium diet and receiving diuretics but continues to be fluid overloaded, then fluid restriction may be instituted. A low-calorie diet is not indicated for all CHF clients. Some are very thin because of various factors, including the work of breathing and rapid heart rate. A low-cholesterol diet is important for clients with coronary artery disease and for the American population in general, but is not specifically related to CHF.

A client is taking a progesterone oral contraceptive (minipill). The nurse instructs the client to take one pill daily during the: Five days of the ovulatory cycle Latter part of the ovulatory cycle First week of the menstrual cycle Entire menstrual cycle

Entire menstrual cycle Maintenance of serum progesterone levels keeps cervical mucus thick and hostile to sperm at all times. Telling the client to take the pills for five days of the ovulatory cycle is inaccurate information; the pill must be taken throughout the menstrual cycle. Whereas progesterone oral contraceptives (minipills) must be taken throughout the cycle, combined estrogen and progesterone oral contraceptives are taken during the second, third, and fourth weeks of the cycle. Fertility drugs are often taken during the first part of the cycle to encourage ovulation, not for contraception.

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique? Exercise daily Read in bed before sleeping Avoid naps during the daytime Have a hot cup of tea at bedtime

Exercise daily Exercise, such as walking or other activity appropriate for the older adult, will be invigorating during the day and prime the client for a better night's sleep. Reading is relaxing before sleeping, but the client should avoid reading in bed; a pattern of using the bed to sleep should be established. Naps should be limited, but not necessarily eliminated; research has demonstrated that a short nap (20 to 30 minutes) in the afternoon will not appreciably affect nighttime sleep. Caffeinated beverages should be avoided before bedtime because caffeine is a stimulant that generally interferes with sleep.

A nurse admits a client with a diagnosis of cholelithiasis for surgery. The client asks many questions about the postoperative course after laparoscopic surgery. What is most important for the nurse to include in the teaching plan? Need for long-term dietary restrictions Type of surgical incisions and wound care Explanation of abdominal and scapular pain Encouragement to perform abdominal exercises

Explanation of abdominal and scapular pain Mild shoulder pain is commonly a response to nerve irritation from insufflating the abdomen with carbon dioxide gas to permit visualization and introduction of instruments. Understanding what to expect supports control and decreases fear. There are no long-term dietary restrictions related to this surgery. Although it is important for the client to understand that generally there are one or more small puncture wounds made through the abdominal wall and how to care for them after surgery, it is more important for the nurse to explain about the mild shoulder pain, which may frighten the client if it is unexpected. Postoperative abdominal exercises are not necessary.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? Taking exogenous insulin stimulates fetal growth. Consuming more calories covers the insulin secreted by the fetus. Extra circulating glucose causes the fetus to acquire fatty deposits. Fetal weight gain increases as a result of the common response of maternal overeating.

Extra circulating glucose causes the fetus to acquire fatty deposits. It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, in whom it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases because pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.

A nurse is caring for a 3-year-old child with acute laryngotracheobronchitis. The child has severe dyspnea and a temperature of 104.0º F (40.0° C) and is receiving cool mist by way of a facemask. The mother asks why her child is not receiving warm mist. The nurse explains that cool mist: Helps dry mucosal secretions faster Facilitates reduction of mucosal edema Provides a more comfortable environment Assists in absorption of fluid by the mucosa

Facilitates reduction of mucosal edema Cool mist helps reduce edema; it may also help reduce the fever. Edema in the airway is a priority of care. The mucosal secretions should be kept moist, not dry. Heat not only dries secretions but can also increase inflammation. Cool mist is less comfortable because the environment becomes cold and damp. Absorption by way of the mucosa is insignificant.

The parents of a sick infant talk with a nurse about their baby. One says, "I'm so upset; I didn't realize that our baby was ill." What major indication of illness in an infant should the nurse explain to the parent? Grunting respirations Excessive perspiration Longer periods of sleep Crying immediately after feedings

Grunting respirations Grunting and rapid respirations are signs of respiratory distress in an infant. Grunting is a compensatory mechanism by which the infant attempts to keep air in the alveoli to increase arterial oxygenation; increased respirations increase oxygen and carbon dioxide exchange. Sweating in infants usually is scant because of immature function of the exocrine glands; profuse sweating is rarely seen in a sick infant. Longer periods of sleep are not necessarily a sign of illness, nor is crying immediately after feedings.

A nurse is developing a discharge plan for a client who was hospitalized with severe cirrhosis of the liver. The plan should include the: Need for a high protein diet Use of a sedative for relaxation Need to increase fluids Importance of reporting personality changes to the health care provider

Importance of reporting personality changes to the health care provider The damaged liver may cause increased ammonia levels, resulting in central nervous system (CNS) irritation, which produces behavioral changes. A damaged liver does not metabolize protein adequately; a low protein diet is indicated. Sedatives are detoxified by the liver and are contraindicated in severe hepatic disease. Kidney function usually is not affected.

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? Perform the procedure once in the morning and once at night Move the trunk to an upright position and then exhale while bending over Inhale completely and then blow out as hard and as fast as possible through the mouthpiece Place the mouthpiece between the lips and in front of the teeth before starting the procedure

Inhale completely and then blow out as hard and as fast as possible through the mouthpiece A peak flow meter measures the peak expiratory flow rate, the maximum flow of air that can be forcefully exhaled in one second; this monitors the pulmonary status of a client with asthma. The peak flow measurement should be done daily in the morning before the administration of medication or when experiencing dyspnea. The client should be standing or sitting upright. Placing the mouthpiece between the lips and in front of the teeth before starting the procedure will interfere with an accurate test; the mouthpiece should be in the mouth between the teeth with the lips creating a seal around the mouthpiece.

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about post-procedure interventions that protect the catheter insertion site. The nurse instructs the client that the leg used for catheter insertion will be: Elevated on a pillow Kept extended while on bed rest Positioned dependent to the level of the heart Put through range of motion exercises several times an hour

Kept extended while on bed rest Bed rest with the leg extended prevents trauma caused by hip flexion and provides time for the insertion site to heal. Elevating the leg on a pillow will flex the hip, which may traumatize the catheter insertion site and impede healing. The leg is kept even with the level of the heart because the client usually is placed in the supine position with the leg extended. Range of motion will flex the hip, which may traumatize the catheter insertion site and impede healing.

The nurse is caring for a client with arthritis. The client asks, "Can I take Tylenol instead of aspirin? Aspirin irritates my stomach." The nurse explains that acetaminophen (Tylenol): Lacks anticoagulant action Has the same action as aspirin Lacks an anti-inflammatory action Has more severe side effects than aspirin

Lacks an anti-inflammatory action Although acetaminophen (Tylenol) reduces pain, it lacks the anti-inflammatory action needed to limit joint inflammation associated with arthritis. People with arthritis do not need anticoagulants unless prescribed for a concomitant cardiovascular problem or cardiovascular prophylaxis. Although they are both analgesics, acetaminophen is not an anti-inflammatory agent. There are fewer side effects with acetaminophen than with aspirin.

The nurse is teaching crutch-walking to a 12-year-old child. What does the child do that indicates the need for more teaching? Takes short steps of equal length Looks forward to maintain balance Looks down when placing the crutches Assumes an erect posture when walking

Looks down when placing the crutches The child should maintain an erect walking posture, without looking down, to ensure equilibrium and avoid losing balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips

A nurse explains to the parents of a toddler with a diagnosis of tetralogy of Fallot that the aim of palliative surgery is to directly increase the blood flow to the: Brain Heart Lungs Kidneys

Lungs By improving blood flow to the lungs, the surgery increases the oxygen content of the blood, thereby increasing oxygen to all body cells. Tetralogy of Fallot causes the obstruction of blood flow to the lungs, not the brain, heart or kidneys.

A client is receiving a monoamine oxidase inhibitor (MAOI). What should the nurse teach the client? It is necessary to avoid the sun. Drowsiness is an expected side effect of this medication. The therapeutic and toxic levels of the drug are very close. Many prescribed and over-the-counter drugs cannot be taken with this medication.

Many prescribed and over-the-counter drugs cannot be taken with this medication. MAOIs interact with many other medications to produce harmful side effects. Clients must be taught to check with the prescribing health care provider before taking any new medications. Photosensitivity has not been reported in clients who are taking MAOIs. Drowsiness is not an expected side effect, but it may occur as an adverse reaction. The therapeutic and toxic levels of the drug are not close for these medications.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: Picks up the walker and carries it for short distances. Uses the walker only when someone else is present. Moves the walker no more than 12 inches in front of the client during use. States that a walker will be purchased on the way home from the hospital.

Moves the walker no more than 12 inches in front of the client during use. Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

A 4-year-old child is undergoing a diagnostic workup for pulmonic stenosis. The mother asks the nurse about the diagnosis. The nurse bases the response on the fact that pulmonic stenosis is: Narrowing of the valve between the left atrium and left ventricle Hardening of the valve between the right atrium and right ventricle Hardening of the valve between the right ventricle and the arch of the aorta Narrowing of the valve between the right ventricle and the pulmonary artery

Narrowing of the valve between the right ventricle and the pulmonary artery The pulmonic valve is located between the right ventricle and pulmonary artery. The cusps of the valves may be fused, or the infundibulum below may be hypertrophied, thereby restricting blood flow to the lungs. The mitral, tricuspid, and aortic valves are not involved in pulmonic stenosis.

Thiamine (vitamin B 1) and niacin (vitamin B 3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? Neuronal activity Bowel elimination Efficient circulation Prothrombin development

Neuronal activity Thiamine and niacin help convert glucose for energy, and therefore influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin.

A client who is 60 pounds more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight? Obesity leads to insulin resistance Surplus fat causes excretion of insulin Fat cells absorb insulin and prevent its circulation to other cells Lipids accumulate in the pancreas and interfere with insulin production

Obesity leads to insulin resistance Excess fat alters glucose metabolism, causing cells to become insulin resistant. Fat cells have no relationship to the function of the kidneys. Fat cells do not absorb insulin and therefore do not prevent the circulation of insulin to other cells. Clients with type 1 diabetes do not produce insulin. If lipids should accumulate in the pancreas of a healthy adult, they do not interfere with insulin production.

A parent tells a nurse at the clinic, "Each morning I offer my 24-month-old juice, and all I hear is 'No.' What should I do? I know she needs fluid!" What is the best response by the nurse? Offer the child a choice of two juices. Distract the child with a favorite food. Offer the child the glass in a firm manner. Allow the child to see the parent getting angry.

Offer the child a choice of two juices. Children who are expressing negativism need to have a feeling of control. One way of achieving this within reasonable limits is for the parent or caregiver to provide a choice of two items instead of forcing one on the child. Distracting the child with a favorite food will not achieve the goal of giving fluids. Offering the child the glass in a firm manner will probably not be successful with a toddler. Allowing the child to see the parent getting angry will complicate the situation and further inhibit the child's willingness to take fluids.

Enoxaparin (Lovenox) 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given to: Control expected postoperative fever Provide a constant source of mild analgesia Limit the inflammatory response associated with surgery Provide prophylaxis against postoperative thrombus formation

Provide prophylaxis against postoperative thrombus formation Enoxaparin (Lovenox), a low-molecular-weight heparin, prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin by enhancing the inhibitory effects of antithrombin III. Enoxaparin is not an antipyretic. Enoxaparin is not an analgesic. Enoxaparin is not an anti-inflammatory drug.

A nurse is preparing to teach a client to apply a nitroglycerin patch (Nitro-Dur) as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? Apply the patch on a distal extremity Remove a previous patch before applying the next one Massage the area gently after applying the patch to the skin Apply a warm compress to the site before attaching the patch

Remove a previous patch before applying the next one Removing the previous patch before applying the next patch ensures that the client receives just the prescribed dose. Ideally, a patch should be removed after 12 to 14 hours to avoid the development of tolerance. The patch should be rotated among hair-free and scar-free sites; acceptable sites include chest, upper abdomen, proximal anterior thigh, or upper arm. The patch should be gently pressed against the skin to ensure adherence; it should not be massaged. Appling a warm compress to the site before attaching the patch is unnecessary and can result in an excessive absorption of the medication.

The nurse is explaining the Client Bill of Rights to a female client whose psychiatrist has admitted her to an inpatient facility. Her admission is voluntary. The statement that is not a client right is the right to: Personal mail Refuse treatment Written treatment plans Select health team members

Select health team members Clients may not select the members of the health care team when admitted to an inpatient setting that delivers care 24 hours a day, 7 days a week. The other rights are included in the Client Bill of Rights.

The parents of a boy with hypospadias with chordee ask a nurse why their child should undergo corrective surgery. What problem that may develop eventually should the nurse discuss with the parents? Renal failure Testicular cancer Testicular torsion Sexual difficulties

Sexual difficulties Chordee can affect the child's future reproductive capabilities, which are related to the inability to inseminate directly. Kidney function is not affected by hypospadias with chordee. The incidence of testicular cancer is not increased; nor is the risk for testicular torsion.

A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing: Sodium Calcium Aluminum Magnesium

Sodium If the client consumes more than the usual daily sodium intake, excess fluid retention results; this will increase the cardiac workload. Antacids that do not contain sodium do not cause fluid retention; it is best for this client to seek medical advice before taking an antacid.

A health care provider prescribes steroid therapy for a 4-year-old child who has nephrotic syndrome. What goal of this treatment does the nurse explain to the child's parents? Prevents infection Stimulates diuresis Provides hemopoiesis Reduces blood pressure

Stimulates diuresis Although the exact mechanism is unknown, steroids produce diuresis in most children with nephrotic syndrome. Steroids will not prevent infection and will mask the signs and symptoms of infection. Steroids have no effect on the production of red blood cells. Steroids do not reduce hypertension, and hypertension is not a common finding in children with nephrotic syndrome.

A 16-year-old male asks the nurse about the use of condoms. He states, "I've used condoms in the past, but I'm not sure I'm using them correctly." What should be included as part of the teaching about condoms? Petroleum jelly should be used as a lubricant. The condom must be positioned after an erection has occurred. Withdrawal after ejaculation should be delayed until the penis has become flaccid. The condom should be fitted against the tip of the penis with no space left at the end.

The condom must be positioned after an erection has occurred. The condom should be positioned after the penis is erect to achieve the desired fit. Vaseline can break down the material used for the condom; a water-based lubricant should be used if lubrication is desired. A space should be left at the tip of the penis to provide room for the ejaculate and prevent breakage of the condom. The penis should be withdrawn immediately after ejaculation, while the penis is still erect; if the penis is allowed to become flaccid, semen may leak from the loose-fitting condom.

A couple at the prenatal clinic for a first visit tells the nurse that their 2-year-old child has just been found to have cystic fibrosis. They state there is no family history of this disorder. They ask the nurse about the chances of their having another child with cystic fibrosis. Knowing that this disorder has an autosomal recessive mode of inheritance, how should the nurse respond? There is a 50% chance that this baby will also be affected. If this baby is male, there is a 50% chance of his being affected. If this baby is female, there is no chance of her being affected, but she will be a carrier. There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier.

There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier. According to , because both parents are carriers this baby has a 50% chance of being a carrier, a 25% chance of having the disease, and a 25% chance of being unaffected. Because this is an autosomal recessive gene and not X-linked, there is no difference in prevalence between male and female genetic distribution. Regardless of sex, the infant will have the same risk of being a carrier or noncarrier or having the expressive trait for cystic fibrosis.

A young client tells the nurse that her mother complains about having dysmenorrhea and asks the nurse what this means. How should the nurse describe dysmenorrhea? Cessation of menstrual periods Spotting between menstrual periods Uterine pain during the menstrual period Scant bleeding at the time of an expected menstrual period

Uterine pain during the menstrual period Uterine pain during the menstrual period is the definition of dysmenorrhea. Cessation of menstrual periods occurs with menopause and during pregnancy. Spotting between menstrual periods is bleeding that occurs at any time other than during the menstrual period; there may or may not be pain. Scant bleeding at the time of an expected menstrual period may occur if the client is taking an oral contraceptive or in the first month or two of pregnancy.

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs? During early adolescence Throughout the entire pregnancy When she is planning to become pregnant At the beginning of the first trimester

When she is planning to become pregnant The greatest danger of drug-induced malformations is in the first trimester of pregnancy, during the period of organogenesis; because a woman may not know that she is pregnant, she should be aware of this possibility before becoming pregnant. Although adolescent girls may be made aware of the risk of damage to the fetus posed by drugs, it is not a priority concern at this time. Drugs should be avoided throughout pregnancy, but the first trimester (period of organogenesis) is the most critical. If the client is not aware of her pregnancy, it may be too late to discontinue drug use.

What is most important information to teach to a client who has had a mastectomy before she leaves the hospital? Why a breast prosthesis is necessary Which of the more strenuous activities to curtail What household tasks that require stretching to avoid Why self-examination of the remaining breast is important

Why self-examination of the remaining breast is important A person who has is at risk for the development of cancer in the other breast. A breast prosthesis is not used until healing has occurred. Most clients are able to resume full activity as strength returns. Stretching activities are considered helpful in regaining full movement.

A young adult client with schizophrenia is prescribed haloperidol (Haldol). When the nurse administers the medication, the client asks, "What's this for?" The nurse responds that the medication: Will help him relax and think more clearly Fights "the blues" and helps keeps thoughts together Maintains an even mood and will control his temper Will raise his seizure threshold by letting him think more clearly

Will help him relax and think more clearly Stating that the medication will help the client to relax and think more clearly is an accurate and concise explanation of the effects of haloperidol (Haldol); it blocks postsynaptic dopamine receptors in the brain. Haloperidol lowers, not increases, the seizure threshold. Haloperidol is a neuroleptic; it does not alter mood.

A client seeking advice about contraception asks a nurse about how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond? "It covers the entrance to the cervical os." "The openings to the fallopian tubes are blocked." "The sperm are kept from reaching the vagina." "It produces a spermicidal intrauterine environment."

"It produces a spermicidal intrauterine environment." Intrauterine devices produce a spermicidal intrauterine environment. A copper IUD (ParaGard T380A) inflames the endometrium, damaging or killing sperm and preventing fertilization and/or implantation; a Mirena IUD (LNG-IUS) releases levonorgestrel, damaging sperm and causing the endometrium to atrophy, thus preventing fertilization and/implantation. A diaphragm blocks the cervical os. The IUD does not act by blocking the openings to the fallopian tubes. Preventing sperm from reaching the vagina is the function of a condom.

The nurse is providing care to a client who is being treated for bacterial cystitis. Before discharge, it is most important for the client to: Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration Be able to identify dietary restrictions and plan menus Achieve relief of symptoms and to maintain kidney function Recognize signs of bleeding, a complication associated with this type of procedure

Achieve relief of symptoms and to maintain kidney function To have relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 L a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.

A client has had a total gastrectomy. What should the nurse include in the discharge teaching? Daily use of a stool softener. Injections of vitamin B 12 for life. Monthly injections of iron dextran. Replacement of pancreatic enzymes.

Injections of vitamin B 12 for life. Intrinsic factor is lost with removal of the stomach, and vitamin B 12 is needed to maintain the hemoglobin level and prevent pernicious anemia. Adequate diet, fluid intake, and exercise should prevent constipation. Iron deficiency anemia is not expected. Secretion of pancreatic enzymes should not be affected because this surgery does not alter this function.

An infant is receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age. What instructions should the nurse give the parents? Give a baby aspirin if there is pain. Call the clinic if marked drowsiness occurs. Apply ice to the injection site if there is swelling. Provide heat at the injection site if redness occurs.

Call the clinic if marked drowsiness occurs. Altered level of consciousness and seizures are rare but serious complications of the pertussis vaccine. Aspirin should not be given to infants and children because it is associated with Reye syndrome, and the nurse is not legally allowed to prescribe medications anyway. Infants are sensitive to the application of ice. Heat will cause an extension of the inflammatory response and should be avoided.

A breastfeeding mother asks the nurse how human milk compares with cow's milk. How should the nurse respond? Lactose content is higher in cow's milk than in human milk. Protein content in human milk is higher than that in cow's milk. Fat in human milk is easier to digest and absorb than the fat in cow's milk. Immunological and antiallergenic factors found in human milk are now added to cow's milk.

Fat in human milk is easier to digest and absorb than the fat in cow's milk. Fat in human milk is easier to digest because of the arrangement of fatty acids on the glycerol molecule. Also, human milk is not heat-treated as is cow's milk when it is pasteurized. The lactose content is higher in human milk. There is less protein in human milk than in cow's milk; however, it is easier for human beings to digest. Human immunological and antiallergenic factors are found only in human milk, not in cow's milk.

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: Increase oral fluid intake to 2 to 3 L per day. Maintain bed rest after discharge. Limit fluid intake to 1 L/day. Void at least every hour.

Increase oral fluid intake to 2 to 3 L per day. Increasing oral fluid intake to 2 to 3 L per day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

A mother tells the nurse that her 7-month-old infant has just started sitting without support. The nurse teaches the mother that this: Is expected developmental behavior at this age Is an indication that walking will begin within 2 months Reflects infants in the upper 10% of physical development Indicates a possible developmental delay requiring further evaluation

Is expected developmental behavior at this age This behavior is within the expected range; a 7-month-old can sit without assistance by extending the legs to the side and leaning forward on the hands. By 8 months an infant should sit steadily unsupported. Sitting alone is not a predictor of when the infant will walk. Most infants can sit without assistance by 7 to 8 months of age.

A 3-year-old child has a tentative diagnosis of pinworm infestation. What should the nurse teach the parents about obtaining a specimen to confirm the diagnosis? Save the returns from a tapwater enema. Tape a gauze pad over the child's anus before bedtime. Make an anal impression on cellophane tape when the child awakens. Collect the stool specimen by inserting a cotton-tipped swab into the anus.

Make an anal impression on cellophane tape when the child awakens. The impression is made on the sticky side of the tape; the specimen is collected before toileting so the ova deposited in the perianal area during the night may be removed. An enema will wash away the eggs; they must be collected directly from the perianal area. Placing a pad over the anus will prevent the female worm from migrating to the perianal area and laying her eggs. The eggs are deposited in the perianal area, not in the stool. Inserting a cotton-tipped swab into the anus is unsafe.

A nurse identifies that the client understands information about vitamin K when the client states, "Vitamin K is: Found in a variety of foods, so there is no danger of deficiency." Easily absorbed without assistance, so everything eaten is absorbed." Rarely found in dietary foods, so a natural deficiency can easily occur." Produced in sufficient amounts by intestinal bacteria, so metabolic needs are met."

Produced in sufficient amounts by intestinal bacteria, so metabolic needs are met." Vitamin K is synthesized by intestinal bacteria but also is found in large quantities in green leafy vegetables. Vitamin K is found only in specific foods, not a wide variety. Vitamin K is not easily absorbed; it is fat-soluble and requires bile salts for its absorption. It is synthesized by intestinal bacteria, so a natural deficiency does not occur.

A client newly diagnosed with type 2 diabetes is receiving glyburide (Micronase) and asks the nurse how this drug works. The nurse explains that glyburide: Stimulates the pancreas to produce insulin Accelerates the liver's release of stored glycogen Increases glucose transport across the cell membrane Lowers blood glucose in the absence of pancreatic function

Stimulates the pancreas to produce insulin Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.

A client who had a transurethral resection of the prostate is to be discharged from the outpatient surgical department. Which client statement indicates to the nurse that discharge teaching about self-care is understood? "I am going to drive myself home today." "I am looking forward to a bowl of hot chili for supper." "I will drink four to five glasses of water during the day." "I will notify my health care provider if persistent bleeding occurs."

"I will notify my health care provider if persistent bleeding occurs." Intermittent bleeding is expected; however, the health care provider should be notified if bleeding persists. The client driving themselves home after the surgery is unsafe; immediately after surgery, the client should avoid strenuous activities to prevent injury. The client should avoid spicy food or should use spices in moderation to prevent irritation of remaining prostatic tissue. Four to five glasses of water will not provide sufficient fluid; 3 to 4 L of fluid are needed to keep urine flowing freely and to prevent formation of clots.

A nurse is conducting a health class for adolescents. What modifiable risk factor, most closely associated with the development of coronary heart disease (CHD) in both men and women, should the nurse discuss? Opioid use Cigarette smoking Judicious alcohol intake Moderate exercise program

Cigarette smoking Nicotine in cigarette smoke constricts blood vessels, including coronary arteries, which contributes to the occurrence of angina and CHD. Opioid use is not a risk factor for CHD. Judicious alcohol intake may promote relaxation, decreasing stress and limiting the development of CHD. Inactivity, not moderate exercise, is a risk factor for coronary heart disease. Exercise decreases hypertension, blood clotting, and heart rate. Exercise also increases metabolism, the plasma level of high-density lipoprotein cholesterol, and cardiac capillary blood flow.

A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine (Mestinon) is prescribed. When teaching the client about this medication, the nurse explains that the desired effect is to increase: Intestinal peristalsis Salivary and gastric secretions Contraction of skeletal muscles Secretion and discharge of tears

Contraction of skeletal muscles Anticholinesterase drugs inactivate cholinesterase, allowing sufficient acetylcholine to mediate stronger muscle responses. Increasing intestinal peristalsis is not a therapeutic response to pyridostigmine. Increasing salivary and gastric secretions are side effects of, not therapeutic responses to, pyridostigmine. Secretion and discharge of tears are side effects of, not therapeutic responses to, pyridostigmine.

A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk for spreading the disease when the client states, "I should: Wash my hands frequently." Launder my clothes separately." Put used tissues in the garbage." Wear a mask when leaving the house."

Wash my hands frequently." Hepatitis A microorganisms are transmitted via the anal-oral route; handwashing, particularly after toileting, is the most important precaution. The response "launder my clothes separately" will not deter the spread of the virus; handwashing is necessary. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

A 28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile because she has been trying to become pregnant for 2 years. While collecting the health history the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The health care provider diagnoses polycystic ovarian syndrome (PCOS). Which of the following interventions is the most important? Consoling the client over her inability to have children Discussing weight loss, exercise, and a balanced low-fat diet Providing information to the client on how to prepare for surgery Informing client that there are no long-term complications of PCOS

Discussing weight loss, exercise, and a balanced low-fat diet Weight loss, exercise, and a balanced low-fat diet can reduce insulin and androgen levels related to PCOS. Meeting with a dietitian may be helpful. Surgery is not necessary at this time. The health care provider would most likely prescribe hormones, other medications, or both. If pregnancy does not occur, surgery is an option. Pregnancy may be possible with hormones, other medications, or both. Early detection of PCOS is important because the condition can lead to type 2 diabetes, hypertension, cardiovascular disease, and ovarian, breast, and endometrial cancers. Encourage treatment compliance, and encourage positive lifestyle changes.

What is the best nursing intervention to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination? Distracting the client by asking her preference regarding the infant's sex Assisting the practitioner so the client's examination can be completed quickly Explaining the procedure and maintaining eye contact while touching the client gently Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath

Explaining the procedure and maintaining eye contact while touching the client gently Explaining the and maintaining eye contact while touching the client gently will help the client relax and will lessen discomfort. Distracting the client by asking her preference regarding the sex of her infant may distract the client but will not produce relaxation. The client may become more anxious if the procedure is hurried. Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath may make the client more anxious; holding the breath causes tightening of the perineum.

After 2 weeks of radiation therapy for cancer of the breast a client experiences some erythema over the area being radiated. The area is sensitive but not painful. She states that she has been using tepid water and a soft washcloth when cleansing the area and applying an ice pack three times a day. What does the nurse conclude from this information? Further teaching on skin care is necessary. No other intervention is needed at this time. The radiation team should be notified of this problem. Health teaching on the side effects of radiation is needed.

Further teaching on skin care is necessary. Further teaching is needed because extremes of temperature should be avoided; ice constricts blood vessels, interfering with circulation. Continued application of cold is contraindicated because it may cause tissue damage. Erythema is an expected reaction; however, pain, vesicle formation, or sloughing of tissue requires intervention. The knowledge deficit is related to skin care, not the side effects of radiation therapy.

A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent? Keep the infant in an upright position after feedings. Prevent the infant from crying for prolonged periods. Keep the infant in the prone position after each feeding. Ensure that the infant drinks a full bottle of formula at each feeding.

Keep the infant in an upright position after feedings. Chalasia allows reflux of gastric contents into the esophagus and eventual regurgitation. Placing the infant in an upright position keeps the gastric contents in the stomach by means of gravity and limits the pressure against the cardiac sphincter. Preventing the infant from crying for prolonged periods will probably have little effect on chalasia. Keeping the infant in the prone position after feedings will promote regurgitation; it is also unsafe because of the danger of sudden infant death syndrome. Ensuring that the infant drinks a full bottle of formula at each feeding will promote vomiting; the infant should be allowed to stop feeding when satiated, not when the bottle is empty.

On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question? Use of disposable diapers Prolonged contact with an irritant Decreased pH of the infant's urine Too-early introduction of solid foods

Prolonged contact with an irritant Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Both cloth and disposable diapers can cause diaper dermatitis if they are not changed frequently. An increased pH (i.e., alkaline) of the urine can contribute to diaper dermatitis. A change in diet may contribute, but there is no evidence that this is directly related.

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Poached eggs Spinach salad Sweet potatoes Cheese sandwich

Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.

A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain most likely will remain contaminated with the hepatitis A virus after being cooked? Canned tuna Broiled shrimp Baked haddock Steamed lobster

Steamed lobster The temperature during steaming is never high enough or sustained long enough to kill microorganisms. Processing destroys the virus. Because of the extremely high temperature, broiling sufficiently destroys the virus. Baking will destroy the virus.

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)? "Increase your intake of fiber and fluid." "Take the medication before you go to bed." "Check your pulse before taking the medication." "Contact your health care provider if your skin or sclera turn yellow."

"Increase your intake of fiber and fluid." Fiber and fluids help prevent the most common adverse effect of constipation and its complication, fecal impaction. The medication should be taken with meals. The pulse is not affected. Cholestyramine binds bile in the intestine; therefore, it reduces the incidence of jaundice.

A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: Eat a low fat, low protein diet Avoid foods high in carbohydrates Avoid ingesting alcoholic beverages Eat a bland diet of six small meals a day

Avoid ingesting alcoholic beverages Alcohol increases pancreatic secretions, which cause pancreatic cell destruction. Although the diet should be low in fat, it should be high in protein; also, it should be high in carbohydrates. The client should be consuming a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet is not necessary, but large, heavy meals should be avoided.

What feeding instruction should a nurse give the mother of a 2-month-old infant with the diagnosis of heart failure? Use double-strength formula. Avoid using a preemie nipple. Refrain from feeding until crying from hunger begins. Feed slowly while allowing time for adequate periods of rest.

Feed slowly while allowing time for adequate periods of rest. Because of limited exercise tolerance and fatigue, infants with heart failure become too tired to feed; allowing rest and feeding slowly limits the fatigue associated with feeding. Although the infant may be given a formula with a higher caloric value (30 kcal/oz rather than 20 kcal/oz), double-strength formula is too high an osmotic load for the infant. A soft nipple used for preterm infants or a regular nipple with an enlarged opening is preferred to conserve the energy required for sucking. Crying consumes energy and is exhausting. The infant should be fed when exhibiting signs of hunger, such as sucking on a fist.

A pale, lethargic 1-year-old infant weighs 28 lb (12.6 kg) and has a hemoglobin level of 9 g/dL. The parent tells the nurse that the infant refuses solid food when it is offered by spoon and drinks between four and six full bottles of milk per day. What should the nurse recommend? Beginning the weaning process immediately Taking the infant to the metabolic clinic for an examination Giving the infant finger foods such as dry cereal and chopped meat Poking a large hole in the nipple of the bottle and add puréed baby foods to the milk

Giving the infant finger foods such as dry cereal and chopped meat A diet of only milk is not sufficient to meet the infant's iron needs. Meat and fortified cereals are high in iron. Finger foods are appropriate for older infants. At this age, weaning from the bottle is not the issue; supplementary iron intake is. Although health care and monitoring will be required, the metabolic clinic is not the appropriate referral. Although giving finger foods such as dry cereal and meat will increase iron intake, this is not appropriate for a 1-year-old infant, nor is it desirable. Although adding pureed baby foods to the milk would increase iron intake, a large hole in the nipple of the bottle is not desirable at this point.

A pregnant client with an infection tells the nurse that she has taken tetracycline (Tetracyn) for infections on other occasions and prefers to take it now. The nurse tells the client that tetracycline is avoided in the treatment of infections in pregnant women because it: Affects breastfeeding adversely Influences the fetus's teeth buds Causes fetal allergies to the medication Increases the fetus's tolerance to the medication

Influences the fetus's teeth buds Tetracycline (Tetracyn) has an affinity for calcium; if used during tooth bud development it may cause discoloration of teeth. Tetracycline does not adversely affect breastfeeding, cause fetal allergies to the medication, or increase the fetus's tolerance of the medication.

What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs because of cerebral palsy? Test the temperature of the water before a bath. Tighten brace straps securely before ambulating. Set the clock twice during the night to change position. Look down at the legs when crutch walking to check how they are positioned.

Test the temperature of the water before a bath. Individuals whose thermoreceptive senses are impaired are unable to detect changes or degrees of temperature. They must be taught to first test the temperature in any water-related activity to prevent scalding and burning. Overtightening of brace straps may lead to circulatory impairment or skin breakdown. The child with cerebral palsy has uncontrolled movement of voluntary muscles and does not need to change positions at night to prevent skin breakdown. Looking down at the legs when crutch walking is dangerous because this action alters the center of gravity; with practice the child will be able to place the legs in the appropriate position for walking without looking down.

An 11-month-old infant with iron-deficiency anemia is started on an oral iron supplement. What information should the nurse include when teaching the parents about the side effects of iron supplements? The urine may turn red. The skin will turn yellow. The teeth may become stained. The stools will take on a clay color.

The teeth may become stained. Liquid oral iron supplements may stain the teeth; brushing the teeth after administration may limit the discoloration. There should be no change in the color of the urine. Yellowing of the skin is a sign of jaundice; it is not a side effect of an iron supplement. The stools will become black-green; clay-colored stools are a sign of biliary obstruction.

While teaching a prenatal class about infant feeding, the nurse is asked about the relationship between breast size and ease of breastfeeding. How should the nurse respond? "Breast size is not related to milk production." "Motivated women tend to breastfeed successfully." "You seem to have some concerns about breastfeeding." "Glandular tissue in the breasts determines the amount of milk you'll produce."

"Breast size is not related to milk production." The question should be answered directly in the class. However, the mother's statement indicates some concerns about breastfeeding that should be explored privately later. Stating that motivated women tend to breastfeed successfully constitutes false reassurance; successful breastfeeding requires mastery, and some women have difficulty. Although noting that the client seems to have concerns about breastfeeding indicates that the nurse perceives the client's concerns, this response is inappropriate in a class setting; the nurse should elicit more information privately later. The infant's suckling and emptying of the breasts determine the amount of milk produced.

Electrocardiography (ECG) is scheduled for an infant who has tetralogy of Fallot. The mother asks the nurse what type of test this is and why it is done. What is the best response by the nurse? "It's a type of x-ray that shows us the size of the baby's heart." "Electrical activity in the baby's heart is recorded, then printed on graph paper." "It's an ultrasound procedure that produces images of the structures in the baby's heart." "Contrast material is injected into the baby's vein to visualize the flow of blood through the heart."

"Electrical activity in the baby's heart is recorded, then printed on graph paper." An ECG not only records electrical impulses in the heart but can also reveal atrial and ventricular hypertrophy. The x-ray procedure that shows the size of a baby's heart is a chest x-ray. The ultrasound procedure that would be used to produce images of the structures in a baby's heart is the echocardiogram. The intravenous injection of contrast material to visualize the flow of blood through the heart is an angiogram.

A nurse gives a teenager discharge instructions regarding cast care. The nurse concludes that the instructions have been understood when the teenager says: "If I get itchy around the cast, I'll rub the itchy area gently." "If I get itchy around the cast, I'll pat the area with an alcohol swab." "If I get itchy around the cast, I'll ask my doctor for a prednisone prescription." "If I get itchy around the cast, I'll sprinkle a layer of powder around the itchy spots."

"If I get itchy around the cast, I'll rub the itchy area gently." Gentle rubbing may soothe the skin; stimulation of sensory neurons by rubbing may decrease the itching sensation. Alcohol is a drying agent and should not be used. Steroids such as prednisone are not routinely given for itching caused by a cast. Powder may become caked, slip under the cast, and cause additional discomfort. Also, powder, which is a respiratory irritant, may be inhaled.

A nurse is teaching a young adolescent with type 2 diabetes about nutritional needs. Which statement demonstrates that the adolescent understands what was taught? "I can have low fat, low cal candy bars." "Regular soft drinks are better than diet ones." "It's OK for me to eat one slice of pizza at a party." "My fasting blood sugar should be no higher than 150."

"It's OK for me to eat one slice of pizza at a party." Pizza contains complex carbohydrates and protein; the child with type 1 diabetes may include a slice in the diet on special occasions. Although candy bars can be low in fat and calories, they may still have a high simple sugar content, which is contraindicated. Diet, not regular, soft drinks are preferred for an individual with type 2 diabetes; regular soft drinks are high in simple sugars. The euglycemic fasting blood glucose should be 70 to 105 mg/dL.

A client asks the nurse what she should do if she forgets to take the pill one day. How should the nurse respond? "Take your pills as instructed." "Call your practitioner immediately." "Continue as usual, and there shouldn't be a problem." "On the next day take one pill in the morning and one before bedtime."

"On the next day take one pill in the morning and one before bedtime." The client should make up for the by taking two the next day; taking one in the morning and one in the evening lessens the chance of the client's becoming nauseated. Telling the client to take her pills as instructed does not explain what is to be done if a pill is missed; missing one pill can alter hormone levels and predispose the client to becoming pregnant. It is unnecessary to call the practitioner unless other problems are identified. Telling the client that there should be no problem if she continues as usual is incorrect advice; again, missing one pill can alter hormone levels and predispose a woman to pregnancy.

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? "It will keep your baby from going blind." "This ointment will protect your baby from bright lights." "There is a law that newborns must be given this medicine." "This antibiotic helps keep babies from contracting eye infections."

"This antibiotic helps keep babies from contracting eye infections." Erythromycin ophthalmic ointment is used to treats gonorrhea and chlamydia infections, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered.

Phenobarbital is prescribed for an infant who has had repeated seizures. One week later, at the follow-up visit, the infant is lethargic and the mother states that the infant is sleeping excessively. The infant's mother asks the nurse what is happening to her baby. What should the nurse tell the mother? "This is a response to the medication that will subside eventually." "The doctor will order another medication to counteract this side effect." "Your baby is getting too much medication, and the dosage will be reduced." "This is a common side effect, but the medication must be continued to prevent seizures."

"This is a response to the medication that will subside eventually." Lethargy and excessive sleeping are common side effects of therapy with barbiturates, which have sedative properties. Stating that the child is getting too much medication demonstrates inaccurate understanding of this anticonvulsant therapy; lethargy and excessive sleeping are usual responses to barbiturates. Stimulants are not administered routinely because they counteract the desired effect of seizure reduction. Although telling the mother that lethargy and excessive sleeping are common side effects and that the medication will be continued is important, the mother should also be informed that it is a temporary response.

Discharge instructions for the client diagnosed with cirrhosis with varices should include information about the importance of: (multiple) Adhering to a low carbohydrate diet Avoiding aspirin and aspirin containing products Limiting alcohol consumption to two drinks weekly Avoiding acetaminophen and products containing acetaminophen Avoiding coughing, sneezing, and straining to have a bowel movement

*Avoiding aspirin and aspirin containing products *Avoiding acetaminophen and products containing acetaminophen *Avoiding coughing, sneezing, and straining to have a bowel movement Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.

A nurse is asked to screen children in a third-grade class for head lice. In light of an 8-year-old's developmental level, how should the nurse first address the class? Describe what head lice are and how they look Teach the importance of daily hair washing and not to share combs Explain that every student must be checked because head lice are spread easily Tell them that if they have head lice the rest of the family will become infected

Describe what head lice are and how they look School-age children have reached the cognitive level of concrete operations that enables them to understand relationships between things and ideas. They can conceptualize what head lice look like, and if they see them they will recognize them by the description. Teaching to help them prevent head lice and how to prevent the spread of head lice should be presented after the students understand the basic information about head lice.

A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client: Contracts HIV-specific antibodies. Develops an acute retroviral syndrome. Is capable of transmitting the virus to others. Has a CD4 + T lymphocyte level of less than 200 cells/µL.

Has a CD4 + T lymphocyte level of less than 200 cells/µL. AIDS is diagnosed when an individual with HIV develops one of the following: a CD4 + T lymphocyte level of less than 200 cells/µL, wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flu-like syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain), one to three weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered? Telling the client that barbiturates and steroids will not be prescribed Warning the client not to eat cheese, fermented products, and chicken liver Monitoring the client for increased tolerance and reporting when the dosage is no longer effective Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma

Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma Glaucoma is one of the side effects of imipramine (Tofranil), and the client should be taught the symptoms. Tolerance is not an issue with tricyclic antidepressants such as imipramine. The other actions are true of monoamine oxidase inhibitors (MAOIs); imipramine is not an MAOI.

A client with acute kidney failure is to receive peritoneal dialysis and asks why the procedure is necessary. The nurse's best response is, "It: Prevents the development of serious heart problems." Helps perform some of the work usually done by the kidneys." Removes toxic chemicals from the body so you will not get worse." Speeds recovery because the kidneys are not responding to other therapy."

Helps perform some of the work usually done by the kidneys." Dialysis removes chemicals, wastes, and fluids usually removed from the body by the kidneys. The mention of heart problems is a threatening response and may cause increased fear or anxiety. Stating that peritoneal dialysis "removes toxic chemicals from the body so you will not get worse" is threatening and can cause an increase in anxiety. Dialysis helps maintain fluid and electrolyte balance; there are no data to indicate the cause of the acute kidney failure or previous therapy.

A client is recovering from a myocardial infarction. Before developing the client's teaching plan, it is important for the nurse to: Identify the learning needs of the client Determine the nursing goals for the client Evaluate the community resources available to the client Explore the use of group teaching for the client

Identify the learning needs of the client For teaching to be meaningful, the client must have a need to learn and a readiness to learn. These factors need to be identified before a teaching plan is formulated. Determining the nursing goals for the client eliminates the client from the goal-setting process; active participation by the client increases motivation and retention. Evaluating community resources is not the initial step; assessment of learning needs comes first. Exploring the use of group teaching for the client is not the initial step; learning needs must be determined first to see if group learning is appropriate; also, group learning must be available as an option.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: A loss of skin elasticity and a decrease in libido Impaired fat digestion and increased salivary secretions Increased blood pressure and decreased hormone production An increase in body warmth and some swallowing difficulties

Increased blood pressure and decreased hormone production With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? Promotes the formation of calculi in the cystic duct Stimulates the pancreas to secrete more insulin than it can immediately produce Alters the composition of enzymes so they are capable of damaging the pancreas Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas

Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic tissue. Although blockage of the bile duct with calculi may precipitate pancreatitis, this is not associated with alcohol. Alcohol does not deplete insulin stores; the demand for insulin is unrelated to pancreatitis. Although the volume of secretions increases, the composition remains unchanged.

A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication? Take the medication with breakfast. Have liver function tests every six months. Wear sunscreen to prevent photosensitivity reactions. Inform the health care provider if the client wishes to become pregnant.

Inform the health care provider if the client wishes to become pregnant. Simvastatin is contraindicated in pregnancy because it is capable of causing fetal damage (teratogenic). It is a Pregnancy Category X teratogen. Simvastatin should be taken in the evening because most cholesterol is synthesized between 12 midnight and 3:00 AM. Liver function tests should be done at 6 to 12 weeks initially and only then every 6 months. Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence; it is not as important as an action in another option.

A nurse is preparing a 5-year-old girl who has undergone a myringotomy for discharge. What should the parents be taught about their child's care at home? Insert ear plugs whenever a bath is given. Keep cotton in the ears until drainage subsides. Keep the child out of kindergarten until the ears are healed. Clean the child's ears with cotton-tipped swabs after each bath.

Insert ear plugs whenever a bath is given. Water in the ears after myringotomy supports the growth of pathogens and should be avoided. The ears should be kept open to the air and allowed to drain naturally. There is no reason to keep the child isolated. Cleaning the ears with cotton swabs is contraindicated because it may result in trauma.

The nurse explains to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is made based on: Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests Performance of high-risk sexual behaviors Evidence of extreme weight loss and high fever Identification of an associated opportunistic infection

Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Center for Disease Control surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? Maintaining sterility of the exposed bladder Measuring output from the exposed bladder Protecting the skin surrounding the exposed bladder Applying a pressure dressing to the exposed bladder

Protecting the skin surrounding the exposed bladder Constant drainage of urine on the skin promotes excoriation and Infection; so the skin must be protected. Sterility is impossible to maintain because of the leakage of urine. Output will be difficult to measure because of the constant leakage of urine. A pressure dressing is contraindicated because it will traumatize the exposed bladder.

Doxepin (Sinequan) is prescribed for a 74-year-old man for treatment of a depressive episode that has not responded to several other medications. The nurse in the outpatient clinic reviews with the client the side effects of doxepin. The identification of which side effects by the client as needing to be reported to the health care provider allows the nurse to conclude that the teaching has been effective? (multiple) Diarrhea Loss of appetite Photosensitivity Retention of urine Thoughts of suicide

Retention of urine Thoughts of suicide Doxepin (Sinequan), because of its significant anticholinergic properties, can lead to urine retention, particularly in older men. Doxepin may cause an increase in psychiatric symptoms and precipitate suicidal ideation. Doxepin may cause constipation, not diarrhea. Doxepin may cause an increase, not a decrease, in appetite. Although photosensitivity is a side effect of doxepin, it can be managed through nursing interventions such as avoiding the sun, wearing clothing, and using sunblock.

What is the first activity of daily living (ADL) that the nurse should help teach a developmentally disabled 8-year-old child? Dressing Toileting Self-feeding Combing hair

Self-feeding Self-feeding is an early step in the progression of growth and developmental skills. All the steps for acquiring the skills needed to fulfill ADLs should progress in the same order as they do for a child who is not mentally challenged. The difference is the age when the skill is acquired and the difficulty in learning to acquire the skill. Dressing is a more advanced skill than self-feeding; it requires mastery of gross and fine motor skills and hand-eye coordination Toileting is a more advanced skill than self-feeding; it requires control of the anal and urethral sphincters, readiness of psychophysiological factors, and motivation. Combing the hair is a more advanced skill than self-feeding. It requires control of gross and fine motor skills and muscle coordination.

A client's serum albumin value is 2.8 g/dL. Which food selected by the client indicates that the nurse's dietary teaching is successful? Beef broth Fruit salad Sliced turkey Spinach salad

Sliced turkey This client's serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL. White meat turkey (two slices 4 × 2 × 1/4 inch) contains approximately 28 g of protein. A 4 oz serving of beef broth contains approximately 2.4 g of protein. A 6 oz serving of mixed fruit contains approximately 0.5 g of protein. A 3 oz serving of spinach salad contains approximately 9 g of protein.

A nurse assesses a new mother who is breastfeeding. The client asks how to care for her nipples. What should the nurse recommend? Putting lanolin cream on the nipples after breastfeeding Applying vitamin E gel to the nipples before breastfeeding Using soap and water to clean the breasts and nipples at least once a day Spreading breast milk on the nipples after the feeding and allowing them to air dry

Spreading breast milk on the nipples after the feeding and allowing them to air dry Breast milk is a natural lubricant for the nipples and obviously is not toxic for the infant. Products containing lanolin or vitamin E are not advised because they may be ingested by the infant. Soap should not be used on the nipples because it has a drying effect, which may precipitate cracking of the nipples.

A nurse evaluates that a client with diabetes understands the teaching about the treatment of hypoglycemia when the client says, "If I become hypoglycemic I initially should eat: Fruit juice and a lollipop. Sugar and a slice of bread. Chocolate candy and a banana. Peanut butter crackers and a glass of milk.

Sugar and a slice of bread. The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); the simple sugar elevates the blood glucose level rapidly; the complex carbohydrates and protein produce a more sustained response. Fruit juice and a lollipop are fast-acting sugars, and neither of them will provide a sustained response. The fat content of chocolate candy decreases the rate of absorption of glucose. Neither peanut butter crackers or a glass of milk are a fast-acting sugar; peanut butter crackers and milk can be used to maintain the glucose level after it is raised.