1460C - Module 1 & 2

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau's sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

a. Test for skin tenting. b. Measure rate and character of pulse. f. Observe for flatness of neck veins when supine. ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.

A patient complains of insomnia while in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective Coping related to hospitalization c. Denial related to hospitalization d. High Risk for Insomnia related to hospitalization

A Anxiety related to hospitalization The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient's data do not support Defensive Coping, Ineffective Denial, or Risk-Prone Health Behavior as problems for this patient.

A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. "What kinds of things do you do to reduce or cope with your stress?" b. "Tell me about your family history—do any relatives have problems with stress?" c. "Tell me about exercise—how far do you typically run when you go jogging?" d. "Stress can interfere with sleep. How much did you sleep last night?"

a. "What kinds of things do you do to reduce or cope with your stress?" The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member's home. d. Ask social services to assess what the patient's needs will be after discharge to home.

a. Ask if there is another family member who can help at home while the patient is in the hospital. The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person.

The nurse knows that which of the following medical conditions are most commonly associated with anxiety? Select all that apply: a. Cancer b. Chronic obstructive pulmonary disease c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism

a. Cancer b. Chronic obstructive pulmonary disease d. Dysrhythmias e. Encephalitis f. Hyperthyroidism A, B, D, E, and F are all associated with anxiety. Hypothyroidism is not associated with anxiety.

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.) a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes d. Age and height e. Temperature

a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes Stressors are subjective based on patient perception and assessment of stressors as part of a patient history. Stressors trigger coping behaviors that can include negative uses of drugs and alcohol and appetite changes that affect weight. Age, height, and temperature are not typically altered with coping, although pulse, respiratory rate, and blood pressure may be affected.

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is which of the following? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

a. Identifying the cause of fear Identifying the cause of a negative perception is the first step in restructuring how a patient perceives a stressor, also called cognitive restructuring. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day

a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.

A patient tells the nurse "My doctor thinks my problems with stress relate to the negative way I think about things, and he wants me to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts Cognitive reframing focuses on recognizing and correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of thinking.

The nurse is making a home visit to a child who has a chronic disease. Which finding has the greatest implication for acid-base aspects of this patient's care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

a. Urine output is very small today. Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

When planning to evaluate a patient's satisfaction with a teaching activity, the most appropriate strategy would be to a. include a survey instrument. b. observe for level of skill mastery. c. present information more than one time. d. provide for a return demonstration.

a. include a survey instrument. A survey or questionnaires can be used to measure affective behavior change as well as patient satisfaction with the teaching experience. Observing for level of skill mastery would evaluate achievement of a psychomotor goal rather than satisfaction with the experience. Repeating information more than one time or in more than one way may be appropriate strategies to include in the teaching plan but would provide no evaluation data. Providing for a return demonstration would help in evaluating achievement of a psychomotor goal, not satisfaction with the activity.

Understanding cultural differences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care.

a. put himself first. In independent cultures, an individual will put himself first in the case of a life-threatening illness, whereas even in dire circumstances, members of collectivist cultures may still consult other family members for the best course of action. In independent cultures, an individual will not consult with other family members, ask for a second opinion, or travel great distances to receive the best care.

Mr. Giuseppe is a 60-year-old Italian immigrant who presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is "If it ain't broke, don't try to fix it." Understanding that respect for traditions and fulfilling obligations is important in developing a nursing plan of care. Mr. Giuseppe's cultural orientation is towards a. short term. b. long term. c. leisurely term. d. noncommittal.

a. short term. Short-term cultural orientation is towards the present or past and emphasizes quick results. Long-term cultural orientation is towards the future and long-term rewards. Long-term-oriented cultures favor thrift, perseverance, and adopting to changing circumstances. Leisurely term and noncommittal are undefined in cultural orientation.

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to a. switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. alter the internal state by modifying electronic signals related to physiologic processes. c. replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. reduce catecholamine production and promote the production of additional beta-endorphins.

a. switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. When the sympathetic nervous system is operative, the individual experiences muscular tension and an elevated pulse, blood pressure, and respiratory rate. Relaxation is achieved when the sympathetic nervous system is quieted and the parasympathetic nervous system is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery's effectiveness.

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client's teaching? a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

a. "Avoid carrying your grandchild with the arm that has the central catheter." A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client considerable freedom of movement. Clients can participate in most activities of daily living; however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is important to keep the insertion site and tubing dry, the client can shower. The device is flushed with heparin.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

a. A 34-year-old on NPO status who is receiving intravenous D5W Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes e. A 76-year-old who is prescribed antacids Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxide-based or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 - 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client's nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

a. Apply oxygen by mask or nasal cannula. The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag over the client's nose and mouth would worsen the acidosis. Sodium bicarbonate should not be administered because the client's arterial bicarbonate level is normal. Glucose and insulin are administered together to decrease serum potassium levels. This action is not appropriate based on the information provided.

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 - 16 mEq/L. What action should the nurse take next? a. Assess client's rate, rhythm, and depth of respiration. b. Measure the client's pulse and blood pressure. c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.

a. Assess client's rate, rhythm, and depth of respiration. Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 - 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway. b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

a. Assess the airway. All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

a. Assess the client's respiratory rate, rhythm, and depth. In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg ACE inhibitors will disrupt the renin-angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client's blood pressure.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 - 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation

a. Cardiac rate and rhythm Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

a. Client with pancreatitis who has continuous nasogastric suctioning A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

a. Depth of respirations A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the client's respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.

b. The medication may take up to 12 weeks to become effective. Efficacy may take at least 8 to 12 weeks. The other options are not realistic.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

a. Electrocardiogram changes d. Paralytic ileus e. Skeletal muscle weakness Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia - Flaccid paralysis with respiratory depression b. Hyperphosphatemia - Paresthesia with sensations of tingling and numbness c. Hyponatremia - Decreased level of consciousness d. Hypercalcemia - Positive Trousseau's and Chvostek's signs e. Hypomagnesemia - Bradycardia, peripheral vasodilation, and hypotension

a. Hypokalemia - Flaccid paralysis with respiratory depression c. Hyponatremia - Decreased level of consciousness Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseau's and Chvostek's signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia.

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness

a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 - 18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

a. Increased rate and depth of respirations This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.

A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases pH = 7.28 PaO2 = 85 mm Hg PaCO2 = 55 mm Hg HCO3 - = 26 mEq/L Vital Signs: Pulse rate = 96 beats/min Blood pressure = 135/45 Respiratory rate = 6 breaths/min O2 saturation = 88% Which action should the nurse take first? a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a mask and reassess in 10 minutes. c. Place the client in Fowler's position if he or she is able to tolerate it. d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

a. Notify the Rapid Response Team and provide ventilation support. The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the client's respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the client's hypoxic drive, nor would it address the client's most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety.

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related to an acid-base imbalance should the nurse assess? (Select all that apply.) a. Positive Chvostek's sign b. Elevated blood pressure c. Bradycardia d. Increased muscle strength e. Anxiety and irritability

a. Positive Chvostek's sign e. Anxiety and irritability A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic alkalosis include positive Chvostek's sign, normal or low blood pressure, increased heart rate, skeletal muscle weakness, and anxiety and irritability.

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 - 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau's sign

a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive Trousseau's sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic acidosis.

A nurse is planning interventions that regulate acid-base balance to ensure the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) a. Reduction in the function of hormones b. Fluid and electrolyte imbalances c. Increase in the function of selected enzymes d. Excitable cardiac muscle membranes e. Increase in the effectiveness of many drugs

a. Reduction in the function of hormones b. Fluid and electrolyte imbalances e. Increase in the effectiveness of many drugs Acid-base imbalances interfere with normal physiology, including reducing the function of hormones and enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and decreasing the effectiveness of many drugs.

The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. "How do you feel about what happened to you as a child? b. "How do you feel about what is going on right now?" c. "Remember a time when you were calm." d. "Tap your hands until the feeling goes away."

b. "How do you feel about what is going on right now?" Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. "Baking soda is an effective inexpensive antacid." b. "I shall take my insulin on time every day." c. "My aspirin is on a high shelf away from children." d. "I have reliable transportation to dialysis sessions." e. "Fasting is a great way to lose weight rapidly."

b. "I shall take my insulin on time every day." c. "My aspirin is on a high shelf away from children." d. "I have reliable transportation to dialysis sessions." Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? a. "To prevent another problem, I should eat less sodium during diarrhea." b. "My blood became too acid because I lost some base in the diarrhea fluid." c. "Diarrhea removes fluid from the body, so I should drink more ice water." d. "I should try to slow my breathing so my acids and bases will be balanced."

b. "My blood became too acid because I lost some base in the diarrhea fluid." Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced. Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.

A diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up." Which response by the nurse is appropriate? a. "It is probably just coincidental that your blood sugar is high when you are ill." b. "Stressors such as illness cause the release of hormones that increase blood sugar." c. "Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times." d. "Your diet is different here in the hospital than at home, and that is the most likely cause of the increased glucose level."

b. "Stressors such as illness cause the release of hormones that increase blood sugar." The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels. The increase in blood sugar is not coincidental. The kidneys do not control blood glucose. A diabetic patient who is hospitalized will be on an appropriate diet to help control blood glucose.

The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

b. Discuss how divorce support groups could increase coping and social support. High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships are known to affect a person's coping effectiveness negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases

b. Level of consciousness Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek's sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer

b. Positive Chvostek's sign in patient with acute pancreatitis Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet

b. Tingling of fingertips d. Numbness around mouth e. Cramping in feet Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland

b. Tumor that secretes excessive antidiuretic hormone (ADH) ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.

The home health nurse has an acute immunodeficiency syndrome (AIDS) patient who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau's sign e. Flat neck veins when upright f. Decreased patellar reflexes

b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau's sign Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.

Strategies to include in a teaching plan for an adult who has repeatedly not followed the written discharge instructions would include a. individualized handout. b. instructional videos. c. Internet resources. d. self-help books.

b. instructional videos. An instructional video would provide a visual/auditory approach for discharge instructions. Repeatedly not following written instructions is a clue that the patient may not be able to read or understand the information. While assessing the literacy level of an adult patient can be challenging, the information that they have not been able to follow previous written instructions would suggest that the nurse use an alternate strategy that does not require a high degree of literacy. An individualized handout would be written, very similar to previous instructions, and would not address a concern about literacy. Internet resources generally require an individual to be able to read, and although videos are available through the Internet, this is not the best response. Self-help books would be appropriate for an individual who reads. There is a question about whether this patient is literate, so these would not be the best choice.

When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. d. call the oldest male relative for help with decision making.

b. prompt further to elicit additional questions or concerns. When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns.

After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis? a. "I will drink at least three glasses of milk each day." b. "I will eat three well-balanced meals and a snack daily." c. "I will not take pain medication and antihistamines together." d. "I will avoid salting my food when cooking or during meals."

b. "I will eat three well-balanced meals and a snack daily." Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates the client correctly understood the teaching? a. "I must drink a quart of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 PM so I won't have to get up at night."

b. "I will weigh myself each morning before I eat or drink." One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek's sign

b. Kussmaul respirations The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek's sign are manifestations of the electrolyte imbalances that accompany alkalosis.

A nurse is planning care for a client who is anxious and irritable. The client's arterial blood gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 - 19 mEq/L. Which questions should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) a. "Are you taking any antacid medications?" b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" d. "Have you been experiencing any vomiting?" e. "Are you experiencing any shortness of breath?"

b. "Is your spouse's current behavior typical?" c. "Do you drink any alcoholic beverages?" This client's symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse should ask the client's spouse or family members if the client's behavior is typical for him or her, and establish a baseline for comparison with later assessment findings. The nurse should also assess for alcohol intake because alcohol can change a client's personality and cause metabolic acidosis. The other options are not causes of metabolic acidosis.

A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 - 26 mEq/L. Which question should the nurse ask when developing this client's plan of care? a. "Do you take any over-the-counter medications?" b. "You appear anxious. What is causing your distress?" c. "Do you have a history of anxiety attacks?" d. "You are breathing fast. Is this causing you to feel light-headed?

b. "You appear anxious. What is causing your distress?" The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 - 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

b. Anxiety-induced hyperventilation The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) b. Anxious client who has tachypnea c. Client who is on fluid restrictions d. Client who is constipated with abdominal pain

b. Anxious client who has tachypnea Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler's position

b. Apply oxygen by mask or nasal cannula. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler's position will not address the client's problem.

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 - 22 mEq/L. Which clinical situation should the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema b. Bronchial obstruction related to aspiration of a hot dog c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

b. Bronchial obstruction related to aspiration of a hot dog Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin (Calcimar).

b. Connect the client to a cardiac monitor. This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure the solution is appropriate for a central line.

b. Ensure an x-ray is completed to confirm placement. A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid-base imbalance? (Select all that apply.) a. Metabolic alkalosis - Young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis - Postoperative client who received 6 units of packed red blood cells e. Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease

b. Metabolic acidosis - Older adult who is following a carbohydrate-free diet c. Respiratory alkalosis - Client on mechanical ventilation at a rate of 28 breaths/min e. Metabolic alkalosis - Older client prescribed antacids for gastroesophageal reflux disease Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next? a. Administer a sublingual nitroglycerin tablet. b. Prepare to assist with chest tube insertion. c. Place a sterile dressing over the IV site. d. Re-position the client into the Trendelenburg position.

b. Prepare to assist with chest tube insertion. An insertion-related complication of central venous catheters is a pneumothorax. Signs and symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing the catheter, administering oxygen, and placing a chest tube. Pain is caused by the pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile dressing and placement of the client in a Trendelenburg position are not indicated for the primary problem of a pneumothorax.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L

b. Serum potassium level of 5.4 mEq/L e. Blood osmolality of 250 mOsm/L Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 - 16 mEq/L. Which provider order should the nurse expect to receive? a. Furosemide (Lasix) 40 mg intravenous push b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W c. Mechanical ventilation d. Indwelling urinary catheter

b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W This client's arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate should be replaced to help restore this client's acid-base balance. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the client's pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for this client.

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this client's care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed. Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

c. Have training sessions to help the staff understand their new responsibilities. Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice.

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

c. Identifying a confidant to share feelings Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

c. Increased risk for suicide Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

c. Oliguric renal disease When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30 to 60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

c. Slow and deepen breathing via use of a positive, repeated word. The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous system's arousal, normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58

c. Urine output 8 mL/hr Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. Only an overnight weight gain indicates a fluid gain.

The nurse is triaging a hysterical patient in the ER. The patient is crying, with uncontrollable spasms, trembling, and shouting. It is important to identify manifestation of illness in order to effectively treat a patient. The nurse identifies this as a culture-bound syndrome called a. shenjing sharo. b. loco de la cabeza. c. ataque de nervios. d. neuroasthenia.

c. ataque de nervios. Ataque de nervios is a Latin-Caribbean culture-bound syndrome that usually occurs in response to a specific stressor and is characterized by dissociation or trance-like states, crying, uncontrollable spasms, trembling, or shouting. Shenjeng sharo refers to "weakness of nerves" in Chinese culture; it is caused by a decrease in vital energy that reduces the function of the internal organ systems and lowers resistance to disease. Loco de la cabeza is a Spanish phrase meaning crazy in the mind and not necessarily manifested by physical symptoms. Neuroasthenia is an Asian term characterized by extreme fatigue after mental effort and bodily weakness of persistent duration.

Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality.

c. fixed gender roles. In cultures with more fixed gender roles, women are usually given the role of caretaker for aging relatives and may suffer the stresses of caregiver strain. Feminine attributes refers to harmonious relationships, modesty, and taking care of others. Unequal gender refers to roles of males and females being unevenly distributed. Female inequality refers to female gender and roles being less than or unequal to male roles.

Barriers to patient education the nurse considers in implementing a teaching plan include a. family resources. b. high school education. c. hunger and pain. d. need perceived by patient.

c. hunger and pain. A patient who is hungry or in pain has limited ability to concentrate or learn. Family resources would be considered in developing a plan of care and could be an asset or a barrier to patient education. The patient's educational level would be considered in planning teaching strategies but would not be a barrier to education. A need perceived by a patient would provide motivation for learning and would not be a barrier.

The emphasis on understanding cultural influence on health care is important because of a. disability entitlements. b. HIPAA requirements. c. increasing global diversity. d. litigious society.

c. increasing global diversity. Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit.

The most appropriate resources to include when planning to provide patient education related to a goal in the psychomotor domain would be a. diagnosis-related support groups. b. Internet resources. c. manikin practice sessions. d. self-directed learning modules.

c. manikin practice sessions. A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain.

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO2 high, HCO3- high b. pH low, PaCO2 low, HCO3- low c. pH low, PaCO2 high, HCO3- high d. pH low, PaCO2 high, HCO3- normal

c. pH low, PaCO2 high, HCO3- high Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3-. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis.

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond? a. "Potatoes and avocados can be substituted for fruit." b. "If you cook the fruit, the amount of potassium will be lower." c. "Berries, cherries, apples, and peaches are low in potassium." d. "You are correct. Fruit is very high in potassium."

c. "Berries, cherries, apples, and peaches are low in potassium." Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? a. "I don't drink milk because it gives me gas and diarrhea." b. "I have been taking digoxin every day for the last 15 years." c. "I take sodium bicarbonate after every meal to prevent heartburn." d. "In hot weather, I sweat so much that I drink six glasses of water each day."

c. "I take sodium bicarbonate after every meal to prevent heartburn." Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching? a. "Weigh yourself every morning and every night." b. "Check your radial pulse twice a day." c. "Read food labels to determine sodium content." d. "Bake or grill the meat rather than frying it."

c. "Read food labels to determine sodium content." Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure

c. A 76-year-old who is cognitively impaired Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill

d. Cultural desire, self-awareness, cultural knowledge, and cultural skill The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members.

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. b. Provide a heart healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

After administering 40 mEq of potassium chloride, a nurse evaluates the client's response. Which manifestations indicate that treatment is improving the client's hypokalemia? (Select all that apply. a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

c. Strong productive cough d. Active bowel sounds A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. "Is there a place that I can dispose of my unused morphine pills?" b. "I want to lose at least 20 pounds without getting sick this time." c. "I think I have asthma because I cough when dogs are near." d. "I ran out of money and am cutting my insulin dose in half."

d. "I ran out of money and am cutting my insulin dose in half." Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response? a. "Why not start by learning to meditate? That technique will cover everything." b. "In cases like yours, physical exercise works to elevate mood and reduce anxiety." c. "Reading about stress and how to manage it might be a good place to start." d. "Let's talk about what is going on in your life and then look at possible options."

d. "Let's talk about what is going on in your life and then look at possible options." In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. "This tool will let us compare your stress to other patients in the hospital." b. "This tool is short because it only measures the negative stressors you are experiencing." c. "You will need to ask your parents about stressors you had as a child to complete this tool." d. "This tool will help assess recent positive and negative events you are experiencing."

d. "This tool will help assess recent positive and negative events you are experiencing." Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness

d. Decreased level of consciousness Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient's heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

d. Institute fall precautions due to potential postural hypotension and weak leg muscles. Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about diabetes management.

d. Plan to reinforce and repeat teaching about diabetes management. Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.

A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery d. Relaxation breathing

d. Relaxation breathing Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient's daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

d. The patient has recently lost her spouse and needed to move in with her daughter. The stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient's sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient's daughter may have added stress due to working, but this should not directly affect the patient.

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. addresses group needs. b. follows formalized plans. c. has standardized content. d. often occurs one-to-one.

d. often occurs one-to-one. Informal teaching is individualized one-on-one teaching which represents the majority of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content.

The nurse educator would identify a need for further teaching when the student lists the types of learning as a. affective. b. cognitive. c. psychomotor. d. self-directed.

d. self-directed. Self-directed is one approach to learning but is not considered a type or domain of learning. Self-directed would be a cognitive way of learning. Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) are the main domains of learning.

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include a. adherence. b. developmental level. c. motivation. d. technology.

d. technology. The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

d. Dangle the client on the bedside before ambulating. An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness

d. Decreased orthostatic light-headedness and dizziness The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole wheat crackers d. Grilled chicken breast with glazed carrots

d. Grilled chicken breast with glazed carrots Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are often high in sodium.

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

d. Metabolic alkalosis Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse

d. Presence of an ulnar pulse An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously. c. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

d. Teach the client fall prevention measures. The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.