adv med surg final set 3

A client with the diagnosis of Parkinson disease asks the nurse, "Why do I drool so much?" Which is the nurse's best response?

"You have a loss of involuntary movements." (The client with this disease cannot execute automatic involuntary movements and has difficulty swallowing saliva. It is known that bradykinesia and muscular weakness cause difficulty in swallowing saliva).

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation? 1. place in a sitting position 2. give nifedipine as prescribed 3. examine for symptoms of pressure ulcers 4. monitor blood pressure every 10-15 minutes

1 rationale: Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high blood pressure. The first step in this situation is to assist the client into a sitting position because it naturally reduces blood pressure. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure ulcers after stabilizing the client. The nurse should monitor client's blood pressure every 10 to 15 minutes after stabilizing the client.

Arrange the order of airway management in a client with burns.

1. intubation within 1 to 2 hours after injury 2. placed on ventilatory support, providing oxygen concentration based on arterial blood gas values 3. extubation may be indicated when edema resolves, usually 3 to 6 days after initial injury, unless severe inhalation injury is involved 4. escharotomies of the chest wall may be necessary to relieve respiratory distress

In what order should the tasks be performed by the nurse leader when implementing evidence-based practice?

1. search for most relevant evidence 2. appraise the evidence 3. integrate the best evidence with one's clinical expertise 4. evaluate outcomes of the practice design 5. disseminate the outcomes of the decision

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority? 1.Checking for a patent airway 2.Maintaining effective circulation 3.Performing adequate fluid replacement 4.Caring for the burn wound

1.Checking for a patent airway 2.Maintaining effective circulation 3.Performing adequate fluid replacement 4.Caring for the burn wound The priority nursing intervention for a client with severe burn wounds is checking for a patent airway. The next priority is to maintain effective circulation. Then, adequate fluid replacement is established. Once a patent airway, effective circulation, and adequate fluid replacement have been established, priority is given to care of the burn wound.

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the rule of nines. Record your answer using one decimal place. _______%

13.5

Functions of the skin include:

1st line defense against infection Regulates body temperature Able to sense heat, cold, touch, pressure, pain Helps regulate fluids in the body Barrier

A toddler with a puncture wound to the sole is brought to the emergency department. Because of a language barrier the caregiver cannot provide a clear history of previous tetanus immunizations. Tetanus immunoglobulin (TIG) is prescribed by the healthcare provider. The nurse explains to the caregiver that this medication is given because it has what action? 1 Produces lifelong passive immunity to tetanus 2 Confers short-term passive defense against tetanus 3 Induces long-lasting active protection from tetanus 4 Stimulates the production of antibodies to fight tetanus

2 Tetanus immunoglobulin contains antibodies, not the live or attenuated virus; it confers short-term passive immunity that is temporary. Tetanus toxoid, not TIG, stimulates the production of antibodies.

Antimicrobials

Systemic infection is leading cause of death in burns

A patient has just undergone a spinal fusion and a laminectomy and has returned from the operating room, which assessments are done in the first 24 hours

Take vital signs every 4 hours and assess for fever and hypotension, perform neuro assessment every 4 hours with attention to movement and sensation, monitor intake and output and assess for urinary retention, observe for clear fluid on or around the dressing and test for glucose

A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what? 1. 2100 mL 2. 4200 mL 3. 6300 mL 4. 8400 mL

2. 4200 mL In the first 8 hours 4200 mL should be infused. According to the Parkland (Baxter) formula, one half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?

Tea- is low in K

General management for all types of burns

The administration of tetanus toxoid for prophylaxis

The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? The scar is firm and inelastic on palpation. Fibrin strands form a scaffold or framework. White blood cells migrate into the wound. Epithelial cells are grown over the granulation tissue bed.

The scar is firm and inelastic on palpation.

A nurse in a rehab center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction

They usually will never walk

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. For which clinical indicators associated with unresolved severe peripheral edema should the nurse assess the client?

Tissue ischemia

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics?

Topical

A client is admitted to the emergency department with allergic rhinitis and asthma. The laboratory report shows histamines and prostaglandins. Which type of hypersensitivity reaction may have occurred?

Type I

A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. About which contributing factor should the nurse question the client when collecting a health history?

Ultraviolet radiation exposure

A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, what are delusions?

a defense against anxiety

A student nurse is learning about the social milestones reached by children at different stages of development. Which statement made by the student nurse demonstrates adequate knowledge on the topic?

an 8 yo child begins to get interested in boy-girl relationships

The leader nurse is calculating the average daily census (ADC) in a 40-bed medical surgical unit, which accrued 679 client days in the month of July. What is the ADC on this unit? Record your answer using a whole number. ____________

22

popping, discontinuous sounds caused by air moving into previously deflated airways? what sound is this?

answer: Crackles

A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide?

answer=To treat Helicobacter pylori infection rationale=Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function

Which characteristic does the nurse anticipate in an infant born at 32 weeks' gestation?

barely visible areolae and nipples

Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving warfarin therapy after a myocardial infarction?

blood clotting function of vitamin k

What would the nurse describe as a similarity between the growth and development of preschoolers and that of toddlers?

both gain 5 to 7 pounds per year

A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. What food will the nurse encourage the client to eat?

broccoli

A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy?

culture and sensitivity tests

A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula?

has many visitors while sitting in a chair

Listening to a client's heart sounds using a stethoscope, a nurse hears these sounds. What should the nurse document on the client's report?

pericardial friction rubs

A client is admitted with the diagnosis of borderline personality disorder and possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client?

potential for suicide

A nurse is caring for an adult client with acromegaly. What clinical manifestation does the nurse expect the client to exhibit?

prominent jaw

Which relationship does the nurse consider reflective of the relationship of naloxone to morphine sulfate?

protamine sulfate to heparin

The oxygen saturation value of an African client measured through a pulse oximeter is 93%. What does the nurse infer from this reading?

the client has a normal SPo2

The nurse is assessing clients on the postpartum unit for pain. Which client will have more severe afterbirth pains?

the client who is a grand multipara

A nursing student analyzes drug information on a chart. Which statement by the nursing student indicates a need for further teaching?

the temporal relation between the onset of action and elimination half-life of uterine stimulants is proportional

Which lobe of the cerebrum includes the client's Broca's speech center? A. Frontal lobe B. Parietal lobe C. Occipital lobe D. Temporal lobe

A- Broca's speech center is located in the frontal lobe and is responsible for the formation of words into speech. The parietal lobe aids in processing of spatial awareness and receiving and processing information about temperature, taste, and touch. The primary visual center is in the occipital lobe. The auditory center for interpreting sound is present in the temporal lobe.

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1. flaccid paralysis and numbness 2. absence of sweating and pyrexia 3. escalating tachycardia and shock 4. paroxysmal hypertension and bradycardia

4 rationale: When autonomic dysreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Bradycardia occurs. These clinical findings occur as a result of exaggerated autonomic responses.

What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply.

-pruritus -wheezing -bronchospasms

A client is admitted with the diagnosis of tetanus. Which clinical indicators should the nurse assess in the client? Select all that apply.

-restlessness -muscular rigidity -respiratory tract spasms -spastic voluntary muscle contractions

A client diagnosed with Paget's disease is prescribed zoledronic acid. Which assessments should be performed before initiating therapy? Select all that apply.

-serum creatinine -dental examination

Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply.

-turgor of tissue -texture of mucous membranes

A client is admitted with a diagnosis of Cushing syndrome. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.

-weakness -hypertension -truncal obesity

Which statement by the nurse is true regarding the disaster triage tag system? 1 Class IV clients are issued a red tag. 2 Class III clients are given a black tag. 3 Class II clients are marked with a yellow tag. 4 Class I clients are identified with a green tag.

3 Class II clients who can wait for a short time for care are marked with a yellow tag. Class IV clients who are expected to die or are dead are issued a black tag. Class III clients who require nonurgent care or "walking wounded" are given a green tag. Class I clients who require emergency care are identified with a red tag.

A nurse is assessing the laboratory findings of cerebrospinal fluids of four different clients. Which finding is consistent with meningitis?

Client A

The nurse is caring for four clients who have survived burn injuries from a chemical plant explosion. Which client requires immediate surgical intervention based on priority?

Client with visible thrombosed vessels

The health care provider prescribes an oral hypoglycemic for the client with type 2 diabetes. What will the nurse need to consider when developing the teaching plan?

clients taking oral hypoglycemics may subconsciously relax dietary rules to gain a sense of control

The primary healthcare provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question is priority that the nurse should ask the client?

do you take antidepressants

What should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel?

epistaxis

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn?

esophagela atresia

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing?

hypothermia

segmented neutrophils

mature neutrophils

Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? (thrombolytic agent)

signs of bleeding (risk of hemorrhage)

Third degree burn (full thickness)

skin is waxy white, dark brown in appearance skin is dry, leathery eschar and there is absence of pain

The nurse is assessing a newborn with exstrophy of the bladder. What other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?

the nurse recommends the client's pharmacy to relabel the medication in large letters

The nursing instructor asks the nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct?

"Choking, coughing, or eructation may occur in both disorders." (Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects swallowing, chewing, and biting).

The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions?

"I must report any chest pain right away." (Chest pain must be reported immediately with the use of sumatriptan).

The client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse?

"Narcotics will be needed for pain relief." ( Mild analgesics, not narcotics, are used for pain associated with Bell's palsy).

An adolescent girl who has sustained deep partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only four weeks away. I'll never be healed!" What is the nurse's best response?

"Recovery will take approximately three weeks."

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?

"There are some tetrahydrocannabinol (THC)-based medications that contain marijuana that control chemotherapy-induced nausea and vomiting in some people."

A nurse in the child life center is evaluating a 15-month-old toddler's ability to perform physical tasks. What behavior indicates to the nurse that the child's development is age appropriate? Select all that apply.

-drinking from a cup -walking with a wide-based gait -throwing toys around the room

A nurse is collecting information about a client with type 1 diabetes who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Select all that apply.

-excessive emotional stess -running a fever with the flu

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine. The nurse should monitor the client for which common side effects? Select all that apply.

-hypoglycemia -decreased blood pressure

What manifestations does the nurse expect to identify when taking a health history from a client with moderate dementia? Select all that apply.

-sundowning -exaggeration of premorbid traits

A patient has a long history if chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending surgical procedure for spine stabilization, which procedure does the nurse anticipate this patient will need

Spinal fusion

S/S carbon monoxide poisoning

Headache Cherry red colored skin Nausea Dizziness Coma Death

The nurse uses the rule of nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the left leg. The nurse estimates the surface area to be?

55

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what? 1. Serum sodium 2. Urinary output 3. Hematocrit level 4. Serum potassium

2. Urinary output As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

The nurse is preparing to physically assess a patients subjective report of parathesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the nurse use

Ask the patient to identify sharp and dull sensation by using a paper clip and cotton ball

The nurse is performing a physical assessment of a newly admitted client. Identify the area of the chest on the illustration that produces resonance when percussed.

B

S/S of full thickness burn

NO capillary refill Hair follicles NOT intact- pt will not know pulling hair out No sensation of pain or light touch at site due to destroyed pain/touch receptors

Hyperkalemia

Na is entering cells= K is leaving cells

Which hormone is crucial in maintaining the implanted egg at its site? Inhibin. Estrogen Progesterone Testosterone

Progesterone. Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

The leader nurse noticed that a staff nurse is unable to meet the responsibilities assigned, though the staff nurse is aware of the working requirements. What is the staff nurse experiencing?

Role conflict

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client three days after admission?

Severe pain

Blackwater fever occurs in some clients with malaria. Which response should the nurse assess in this client?

dark red urine

subacute inflammation

has the features of the acute process but lasts longer. -ex: infective endocarditis is a smoldering infection w acute features but lasts longer up to weeks or months

A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client?

neuroleptic malignant syndrome

Assessment of a newborn reveals congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

rubella

What nursing intervention is anticipated for a client with Guillain-Barré syndrome? a. Providing a straw to stimulate the facial muscles b. Maintaining ventilator settings to support respiration c. Encouraging aerobic exercises to avoid muscle atrophy d. Administering antibiotic medication to prevent pneumonia

B

A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply.

- increased heart rate -increased temperature

After reviewing the urinalysis reports of a client with a renal disorder, the nurse concludes that the client may have a urinary tract infection. Which urinary laboratory findings enabled the nurse to make this conclusion? Select all that apply.

- ph 8.5 -white blood cells 6/hpf

A nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations should the nurse assess in the client? Select all that apply.

-Ascites -Pruritus -Jaundice

The nurse is preparing to educate a group of clients about health promotion to prevent head and neck cancer. Which clients are of highest priority for education? Select all that apply.

-a client who chews tobacco -a client who has sex with multiple partners - a client with a history of alcohol abuse for 5 years

Which priority interventions should be followed by the nurse when caring for a client with malignant hyperthermia? Select all that apply.

-administer 100% o2 -intubate withan endotracheal tube - stop all inhilation anesthetic agents

A client with end-stage renal disease is hospitalized. For which complications should the nurse monitor the client? Select all that apply.

-anemia -dyspnea

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply.

-anorexia -hemiplegia -history of diabetes -urinary incontinence

infection can also be caused by ________

-heat, radiation, trauma, chemicals, allergens, and autoimmune reaction.

cellular response

-neutrophils and monocytes move from circulation to the site of injury.

Which nurses should be reassigned to assist with acute care of trauma victims coming through the emergency department? Select all that apply.

-nurse who works in ICU -Nurse who works in PACU

A healthcare provider prescribes a medication to be administered via a metered-dose inhaler (MDI) for a young adult with asthma. List in order the steps the nurse teaches the client to follow when using the inhaler. 1. Hold the inhaler upright in the mouth. 2. Shake the inhaler for 30 seconds. 3. Start breathing in and press down on the inhaler once. 4. Exhale slowly and deeply to empty the air from the lungs.

2. Shake the inhaler for 30 seconds. 4. Exhale slowly and deeply to empty the air from the lungs. 1. Hold the inhaler upright in the mouth. 3. Start breathing in and press down on the inhaler once.

Which medications are associated commonly with upper gastrointestinal (GI) bleeding? Select all that apply. A. Aspirin B. Ibuprofen C. Ciprofloxacin D. Acetaminophen E. Methylprednisolone

A. Aspirin B. Ibuprofen E. Methylprednisolone

Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit?

Nystagmus, Scanning Speech, and Intention Tremors. This group of signs is known as Charcot's triad.

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses?

inflammation in myocardium causes a rise in the systemic body temperature

infection

involves invasion of tissues or cells by microorganisms such as bacteria,fungi, and viruses.

Atopic dermatitis

is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.

A client reports fever, cough, muscle aches, night sweats, and chest pain. The laboratory reports of the client indicate the presence of Coccidioides organisms in the respiratory tract. Which drug is beneficial for the client?

Flucanazole

A multigravida client has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time?

Halfway between the symphysis pubis and the umbilicus

Which age-related effects on the immune system are seen in the older client? Increased autoantibodies. Increased expression of IL-2 receptors. Increased delayed hypersensitivity reaction. Increased primary and secondary antibody responses.

Increased autoantibodies.

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for which finding?

Nasal discharge containing carbon particles

A client is prescribed apomorphine. Which concern would be a priority while addressing patient needs?

Operating heavy machinery or driving

The client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention will the nurse perform first?

Raises the head of the bed to 45 degrees

Radiation burns

Sunburn, X rays, radiation therapy for cancer patients

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?

Aspiration. (Dysphagia may lead to aspiration, which can cause pneumonia, interfering with gas exchange and posing a threat to life.).

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects which procedure will be considered as a treatment option? a. Hemodialysis b. Plasmapheresis c. Thrombolytic therapy d. Immunosuppression therapy

B

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? A. Decreased physical mobility related to stooped posture B. Risk for injury related to gait disturbances C. Impaired skin related to drooling D. Pain related to headache

B- The client with Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson disease.

Patient has had an anterior cervical diskectomy with fusion and has returned from the recovery room. What is the priority assessment

Assess for patency of airway and respiratory effort

What nursing intervention is anticipated for a client with Guillain-Barré syndrome?

Maintaining ventilator settings to support respiration (this is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected.)

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position?

On the right side

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission?

Swimming. (Swimming helps keep the muscles supple, without requiring fine motor activity.)

Before a femoral arteriogram is started, the nurse plans to teach the client that: 1 Radioactive dye will be injected into the femoral vein 2 Local anesthesia will be used to lessen pain at the site 3 Contrast media will be injected into a small vessel of the foot 4 Medication will be administered intravenously to induce sleep

Correct2 Local anesthesia will be used to lessen pain at the site Teaching the client that local anesthesia will be used to lessen any pain at the site reassures the client and allays fears of pain. The contrast medium used is not radioactive. The femoral artery is used for contrast media. The client will be awake during the procedure.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis

Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

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 which information? a. Plan activities for later in the day. b. Eat meals in a semirecumbent position. c. Avoid people with respiratory infections. d. Take muscle relaxants when under stress

C

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification?

"I should obtain a pneumococcal vaccination each year."

Which clients should the medical-surgical nurse identify as appropriate for transfer or discharge to make room for admission of victims of a disaster? Select all that apply.

68-year-old client third post-operative day total knee replacement

Gastrointestinal system complications with burn injuries

>20% TBSA burn= decreased peristalsis Paralytic ileus- obstruction of intestine due to paralysis of intestinal muscles Stress ulcers

A client is admitted to the ambulatory health clinic with a diagnosis of Bell palsy. What is most appropriate for the nurse to do? a. Teach facial exercises. b. Prepare the client for surgery. c. Tape the client's affected eyelid open. d. Record symmetrical progression of the paralysis.

A

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? a. Aspiration b. Dehydration c. Nutritional imbalance d. Impaired communication

A

Which nursing action is specific to the plan of care for a client with trigeminal neuralgia? a. Be alert to prevent dehydration or starvation. b. Initiate exercises of the jaw and facial muscles. c. Apply ice compresses to the affected body area. d. Emphasize the importance of brushing the teeth.

A

While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record?

Answer: Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing

The student nurse is learning about proportional changes exhibited by children during infancy. Which statement made by the student nurse indicates effective learning? Select all that apply.

-breastfed infants gain less weight than bottle-fed infants -The head circumference of breastfed infants is not inadequate.

When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which functions will the nurse assess? Select all that apply.

-breathing -pulse rate

A 12-year-old child with Down syndrome is admitted to the hospital for intravenous antibiotics for pneumonia. Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply.

-saddle nose -inner epicanthic folds

Which gastrointestinal (GI) change may be found in the client with burn injuries?

1) Abdominal distention. Rationale: The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?

Nausea

A client is admitted with a diagnosis of gastric ulcer. Which location is most commonly indicated by the client as being painful when the nurse assesses for the presence of pain?

B

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? a. A genetic defect in the production of acetylcholine (ACh) b. An inefficient use of the neurotransmitter acetylcholine c. A decreased number of functioning acetylcholine receptor (AChR) sites d. An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C

Utricaria

an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis.

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention?

Manage pain with oral pain medication.

After assessing the skin of a client, the primary healthcare provider concludes it is allergic contact dermatitis. Which clinical manifestation made by the primary healthcare provider helped reach that conclusion?

appearance of red papules and plaques

macrophages

assist in phagocytosis of the inflammatory debris. -cleaning of the area before healing can begin. -have long life span. they can multiply and may stay in the damaged tissues for weeks.

The nurse assesses a male client with a preliminary diagnosis of cancer of the urinary bladder. Which clinical manifestation will indicate to the nurse the cancer is in the early stage?

hematuria

A client is diagnosed with pulmonary tuberculosis, and the healthcare provider prescribes a combination of rifampin and isoniazid. The nurse evaluates that the teaching regarding the drug is effective when the client reports which action as most important?

"continue taking the medicine even after i feel better"

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously which lasted for ten weeks. What other symptoms may be manifested by the client? Select all that apply.

-Rhinorrhea -Lacrimation - Pupillary constriction

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply.

-acetone breath -decreased arterial carbon dioxide

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

-dependent edema -swollen hands and fingers -right upper quadrant discomfort

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply.

-nasal falaring -sternal retractions -grunting respirations

A client reports dry mouth, difficulty swallowing, vomiting, and blurred vision. During an assessment, the client reveals that he or she usually eats contaminated food. The nurse observes that the client has drooping eyelids. The client's laboratory reports indicate the presence of an infection. Which findings are expected in the client in the later stage of the disease indicated by these symptoms? Select all that apply.

-paralysis -bilateral cranial nerve impairment

Which toys should the nurse identify as most appropriate for a 3-year-old child? Select all that apply.

-pounding toy -play telephone -box filled with plastic figures

monocytes

-second type of phagocytic cells that migrate from circulating blood. -they usually arrive at the site within 3-7 days after the onset of inflammation. -monocytes transform into macrophages when entering tissue spaces.

The registered nurse has instructed the client about effective ways of reducing burn injury. Which statement made by the client shows ineffective learning?

2) "Iwill set the bathing water temperature below 160 degrees F." Rationale: The water tank should be set below 140° F; higher temperatures may result in scald burns. Smoking in bed should be avoided to prevent injury due to fire. Potholders should be used while taking food from the oven to prevent thermal burn injuries. For preventing flame burn injuries, the screens and the doors should be kept closed on the front of fireplaces.

Which wound care is given to a client with severe burn injuries during the acute phase? 1. Assess extent and depth of burns 2. Provide daily shower and wound care 3. Remove dead and contaminated tissue 4. Assess the wound daily and adjust the dressing

4. Assess the wound daily and adjust the dressing In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase.

A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client? 1. Stupor 2. Vertigo 3. Convulsions 4. Slight breathlessness

4. Slight breathlessness Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur.

The healthcare provider prescribes 1 liter of intravenous (IV) fluid to infuse over 4 hours for a client admitted for a urinary tract infection and hyponatremia. The tubing drop factor is 10 drops/mL. At what rate will the nurse infuse the medications?

42 gtts/min

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful according to the client and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, the nurse should administer the medication:

60 minutes before the dressing change.

A client with a partial occlusion of the left common carotid artery is to be discharged while still receiving warfarin. Which clinical adverse effect should the nurse identify as a reason for the client to seek medical consultation? Select all that apply. A. Presence of blood in urine (hematuria). B. Bruising noted at various stages of healing. C. Delayed clotting from minor cuts and scrapes. D. Bleeding from gums when brushing teeth. E. Vomiting coffee-ground emesis.

A. Presence of blood in urine (hematuria). E. Vomiting coffee-ground emesis.

An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action?

Assessing the infant for signs of pneumonia

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?

Beginning realization of implications for the future

Which part of the respiratory system is referred to as Angle of Louis? Hilum. Carina. Alveoli. Epiglottis.

Carina. Located at the level of the manubriosternal junction, the carina is also referred to as the Angle of Louis.

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia?

Chew on the unaffected side.

For which illness should airborne precautions be implemented?

Chickenpox Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

Risk factors for burns

Children under 4- don't understand dangers, lack ability to react appropriately Older adults- slower reaction time, impaired mobility, sensory impairment Pre existing medical conditions- COPD, HF

A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action?

Determine the client's blood glucose level.

A nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse has observed the dressing change procedure. What initial action should the observing nurse take?

Discuss the incident with the nurse.

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply.

Dry cough Singed nasal hair Hoarse quality to the voice

The nurse is providing discharge teaching for a patient with a spin , cord injury who will be performing intermittent self catheterization at home, which signs and symptoms will the nurse instruct the patient to report immediately to the primary health care provider

Fever, foul smelling urine

A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity 1.015, urine output 50 mL/hr, hematocrit 32, albumin 3.6 g/dL, and pulmonary arterial wedge pressure 10 mm Hg. The nurse concludes that the data indicate that the:

Fluid therapy is successful

Deep partial thickness burn

Involves the dermis and extends to reticular layer of dermis Ex- hot liquids/solids, flash flame, direct flame, intense radiant exposure, chemical agents Pale, waxy, moist or dry blisters Scarring, contractures are possible Usually require more than 21 days to heal

A nurse is caring for a client during the first few hours after admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of a burn injury?

Leukopenia

A patient has just undergone spinal fusion surgery and returned from the operating room 12 hours ago, which task is best to delegate to the nursing assistant

Log roll the patient every 12 hours

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?

Metabolic Acidosis

The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. The principle underlying the function of a portable drainage system is:

Negative pressure

The nurse is assessing the Apgar scores of four different newborns in a pediatric ward. Which child does the nurse anticipate is experiencing severe distress?

Newborn A

what is osteomalacia?

Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency.

what is osteomylitis?

Osteomyelitis is infection of bone or bone marrow

A preschooler with partial-thickness burns on 21% of the total body surface area progresses from the emergency phase to the acute phase of burn care. What is the most important nursing intervention at this time?

Pain management plan

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention?

Suction the client's oropharynx (A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway.)

The nurse is caring for a client who is suspected of having a brain tumor and is scheduled for a computed tomography (CT) scan. The nurse expects that the preprocedure plan of care will include which component? A. Withholding routine medications B. Administering the prescribed sedative C. Explaining that all metal must be removed D. Telling the client about what to expect during the examination

D- Knowing what to expect decreases anxiety. Routine medications are not withheld. A sedative is not necessary for a CT scan. Removing metal is for a magnetic resonance imaging (MRI) test.

A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? A. Disintegration of the myelin sheath B. Breakdown of upper and lower neurons C. Reduced acetylcholine receptors at synapses D. Degeneration of the neurons of the basal ganglia

D- Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is:

36

Nutritional support

4-6 thousand kcal/day Enteral feedings with feeding tube Central venous catheter if enteral feeding contraindicated

Carbon monoxide poisoning interventions

Administer 100% O2 high flow immediately via non rebreather

What does the nurse do for a client with a cervical laminectomy that differs from nursing care for a client with a lumbar lami?

Assist with the removal of oral secretions

Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. The nurse determines that this most likely indicates that the client is developing:

Cerebral hypoxia

The nurse is assessing four clients with musculoskeletal injuries. Which client is advised to have thermotherapy?

Client C

Which client is at a high risk for a rise in blood pressure based on the given data?

Client C

The nurse is caring for four different clients in a healthcare facility. Which client should be provided with immediate care?

Client with 85% oxygen saturation

A nurse is caring for two clients. One has Parkinson disease and the other has myasthenia gravis. For what common complication associated with both disorders should the nurse assess these clients?

Difficulty Swallowing.

Chemical burn

Direct contact between skin and acid/alkaline agents, organic compounds Severity is based on chemical agent, mechanism of action, duration, contact, and amount of BSA exposed

Treatment of severe burns

Emergent/resuscitative stage- lasts from onset of burn through successful fluid resuscitation 1. assess airway patency 2. administer O2 as prescribed 3. obtain VS 4. administer IV fluids as ordered 5. elevate extremity above heart unless contraindicated 6. keep warm and make NPO

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect?

High in fluids

When a nurse is evaluating the condition of a client with burns of the upper body, a sign that indicates potential respiratory obstruction is:

Hoarse quality to the voice

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?

My incision will probably be painful.

After suffering a SCI a patient develops autonomic dysreflexia, including a neurogenic bladder. What is the priority patient problem for this condition

Risk for urinary tract infection

Fluid goes into tissues =

Third spacing

Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to?

Urticaria

A nurse is collecting a health history from a client with thromboangiitis obliterans (Buerger disease). What symptoms are most likely to be associated with this disorder?

burning pain after exposure to cold

During a diabetes mellitus campaign, the community nurse is assessing different clients. Which client should be treated first?

b

A nurse is caring for a client admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?

hypoglycemi and hypotension

During a physical examination in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. Which sign should the nurse document in the client's clinical record?

chadwick

A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery?

toes for mobility

A client presents with extensive lesions due to psoriasis. Which intervention does the nurse anticipate from the healthcare provider?

topical application of steroids

A school-aged child scores between 55 and 68 on a standardized intelligent quotient (IQ) assessment test. What degree of intellectual impairment should the nurse consider this to represent?

mild

Which clinical manifestation is associated with the skin disorder present in the client?

nodular lesion topped with a crust or central area of ulceration

When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.

-diarrhea -seizures

A nurse is using the rule of nines to estimate burn injury in a client. The client has burns on the front chest, front abdomen, both sides of both upper extremities, and entire head. Calculate the percentage of body surface burned. Record your answer as a whole number. ______%

45% Rationale: The chest is 9%, the front abdomen is 9%, each upper extremity is 9% (for a total of 18% for both), and the entire head and neck are 9%. 9 + 9 + 18 + 9 = 45.

A nurse is using the rule of nines to estimate burn injury in a client. The client has burns on the front chest, front abdomen, both sides of both upper extremities, and entire head. Calculate the percentage of body surface burned. Record your answer as a whole number. ______%

45% The chest is 9%, the front abdomen is 9%, each upper extremity is 9% (for a total of 18% for both), and the entire head and neck are 9%. 9 + 9 + 18 + 9 = 45.

A client is receiving furosemide to relieve edema. The nurse will monitor the client for which responses? Select all that apply. A. Weight loss B. Negative nitrogen balance C. Increased urine specific gravity D. Excessive loss of potassium ions E. Pronounced retention of sodium ions

A. Weight loss D. Excessive loss of potassium ions

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine isethionate intravenously (IV) once daily. The nurse should monitor the client for what adverse effect? A. Hypertension B. Hypokalemia C. Hypoglycemia D. Hypercalcemia

C. Hypoglycemia

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply. A. Oliguria B. Anorexia C. Weakness D. Moon face E. Weight gain F. Nervousness

C. Weakness D. Moon face E. Weight gain

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns?

Deep partial-thickness

A patient with a SCI has paraplegia and paraparesis, the nurse had identified a priority patient problem of inability to ambulate, the nurse assesses the calf area of both legs for swelling, tenderness, redness or possible complaints of pain. This assessment is specific to the increase risk for which condition

Deep vein thrombosis

What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving

Directive The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

1st 24 hours

FLUIDS is most important in stabilizing pt especially with fluid shift the pt will have

A nurse in the clinic is assessing a teenager with a tentative diagnosis of primary syphilis. What is an early sign of this infection?

genital lesion

A client with burns caused by flames is hospitalized. Which specific emergency burn management would be appropriate for this client?

First remove all smoldering clothing and metal objects

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin

Globulin The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen. The 3 major plasma proteins are? albumin, globulins, fibrinogen What is the function of albumin? to maintain osmotic pressure which prevents plasma from leaking into tissues What is the function of globulins? to transport substances such as antibodies which protects the body against infection What is the function of fibrinogen? to be converted to fibrin What is the function of fibrin? to assemble together to form structures (threads) that are important in blood clotting

Radiation burns management

Help to bathe or shower

The patient is an adolescent who is quadriplegic as a result of a diving accident. The nursing assistant reports that the patient started yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating nobody is going to do anything else to me I'm going to get out of this place. What is the priority patient problem

Inability to cope with the situation

A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is what? A. Electromyography B. Pyridostigmine test C. History of physical deterioration D. Edrophonium chloride test

D. Edrophonium chloride test Rationale: Edrophonium chloride test uses a drug that is a cholinergic and an anticholinesterase; it blocks the action of cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine. Its action of increasing muscle strength is immediate for a short time. The results of an electromyography will be added to the database, but they are nonspecific. Pyridostigmine is a slower-acting anticholinesterase drug that is prescribed commonly to treat myasthenia gravis; edrophonium chloride is used instead of pyridostigmine to diagnose myasthenia gravis because, when injected intravenously, it immediately increases muscle strength for a short time. The results of a history and physical are added to the database, but the data collected are not as definitive as another specific test for the diagnosis of myasthenia gravis.

Burns involving 40% or more of TBSA

Increase in microvascular permeability at burn wound site Generalized impairment of cell wall function resulting in intracellular edema Increase in osmotic pressure of burned tissue leading to extensive fluid accumulation

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? A. Recognize that depression often occurs after surgery B. Ask the primary healthcare provider to arrange for a psychologic consultation C. Reassure the client that things will feel better after the discharge date has been set D. Talk with the client about the prognosis and emphasize activities the client is still able to perform

D. Talk with the client about the prognosis and emphasize activities the client is still able to perform Rationale: Honest discussion with emphasis on functional and psychologic abilities helps promote adjustment. Postoperative depression is not a characteristic feature of thymectomy. Asking the client's practitioner to arrange for a psychologic consultation is too soon; it may eventually be necessary if the client has difficulty adjusting to the chronicity of this condition. Reassuring the client that things will feel better when the discharge date is set provides false reassurance; there is no guarantee the client will feel better on discharge.

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, the nurse expects that the client will manifest:

Increased muscular weakness (Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated).

Parkland formula for burns

LR 4 mL X kg body weight X percentage burn TBSA (1/2 volume in first 8 hours and remaining delivered over next 16 hours)

The nurse is caring for several patients with SCIs, which task is best to delegate to the nursing assistant

Log roll the patient, maintain proper body alignment and place a bedpan for toileting

After a client is treated for a spinal cord injury the health care provider informs the family that the client is a paraplegic. The family asks what this means, what explanation should the nurse provide

Lower extremities are paralyzed

Urinary system complications with burns

Monitor urine output Dead erythrocytes

A client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit? Select all that apply.

Obtaining vital signs and inspecting the bandages for bleeding are interventions that must be performed in this situation; physiologic stability must be maintained. Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid emotional recovery. Telling the patient that their life isn't that bad and that they have much to live for does not promote therapeutic communication and is not appropriate.

Assessment of. Patient with lower spinal cord injury confirms that the patient has paralysis of bilateral lower extremities. How does the nurse document the findings

Paraplegia

A client injures an amphiarthrodial joint. Which joint did the client injure? Knee joint Pelvic joint Elbow joint Cranial joint

Pelvic joint

Rules of nine for burns

Head and Neck= 9% Each upper ext= 9%- 18% Each lower ext= 18%- 36% Anterior trunk= 18% Posterior trunk= 18% Genitalia/perineum= 1%

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Crackles in the lungs

Which assessment question will provide the best information regarding a client's risk for waking in the night and interrupted sleep related to lifestyle choices?

"Do you smoke cigarettes, cigars, or a pipe?"

A client with migraine headaches is admitted for encephalogram (EEG). The nurse knows teaching is effective when the client makes the following statement?

"I will need to avoid caffeine."

A client is burned on the anterior part of both legs, from the knees to the feet. The nurse uses the Rule of Nines to assess the percentage of total body surface area (TBSA) burned. What percentage should the nurse document in the client's hospital record?

9%

Usually takes 24-36 hours after injury for

Capillary integrity to be restored

A patient with an upper spinal cord injury is at risk for Autonomic Dysreflexia. What is the priority problem for this patient

Decreased cerebral tissue perfusion

The beginning of the acute phase of burn recovery (36 to 48 hours after the injury) is evident by hemodynamic instability

Expect to see unstable vital signs

When caring for a client who has a burn in the emergent stage, which has the highest priority as part of an accurate burn assessment?

Extent of burn

Which statement about spinal shock are accurate

It lasts <48 hours up to a few weeks, there is temporary loss of motor and sensory function, there is temporary loss of reflex and autonomic function

Which medication will cause the nurse to monitor the client closely for hemolytic anemia?

Methyldopa

Hyponatremia

Na is leaving blood stream and going into the cells

Which key feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence

Presence of nonintact skin

Which assessment finding is characteristic of a client with hypoparathyroidism?

Serum phosphorus of 5 mg/dL (1.61 mmol/L); serum magnesium of 0.9 mEq/L (0.9 mmol/L)

Inhalation burn

Sooty-colored sputum

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances?

Spinach and mangoes

How should a nurse expect a client's anxiety to be manifested physiologically?

increased blood glucose level

What intrauterine medication exposure may lead to the child being born with a cleft lip?

The mother was on nitrofurantoin therapy.

During a cardiovascular assessment, a nurse auscultates a client's heart and hears these sounds. How does the nurse document these sounds on the client's assessment report?

Third heart sound (S3)

histamine

-stored in granules of basophils, mast cells, platelets -causes vasodilation and increased capillary permeability

The nurse uses the Rule of Nines to estimate the percentage of the burn surface area on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client? Record your answer as a whole number. ________%

55 The Rule of Nines is used to determine the body surface area (BSA) of a burn injury. How the Rule of Nines estimates percent burn injury: 9% for the entire surface of one arm (a total of 9% x 2 for both arms); 18% for the posterior trunk, 1% for the genitals, and 18% for the entire left leg. Therefore, the percentage of body surface area sustaining a burn injury according to the Rule of Nines is: 9 + 9 + 18 + 1 + 18 = 55%.

Superficial partial thickness burn

Extends from skin's surface into papillary layer of dermis Ex- contact of hot surface, dilute chemical agents Bright red, moist, glistening, blisters Usually heals within 21 days

During the implementation of evidence-based practice, a nurse researcher using MEDLINE databases collects published scientific studies and uses PICOT questions when conducting the search for evidence. What would be the next step performed by the nurse researcher?

critically appraise the evidence

A client is suffering from the contagious skin infection depicted in the image. Which drug does the nurse expect to be in the client's prescription?

lindane

A client at 28 weeks' gestation visits the clinic for a routine examination. Which finding is of greatest concern to the nurse?

puffy fingers

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis?

answer:redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.)

Tachypnea and Hypotension

Which statement by the nursing student illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)?

The client's respiratory status and muscle function are affected by both diseases.

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. A nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%

The entire right lower extremity is 18%; the anterior portion of the right upper extremity is 4.5%. 18 + 4.5 = 22.5.

The nurse and the nursing student are working together to bathe and reposition a patient who is in a halo fixator device. Which action by the nursing student causes the nurse to intervene

Turns the patient by pulling on the top of the halo device

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?

Urinary output every hour

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. During the first two to three days after the burn to monitor fluid balance, it is important for the nurse to assess the:

Urinary output every hour

What problem is the nurse primarily attempting to prevent when encouraging the client with spinal cord injury to increase oral fluid intake

Urinary tract infection

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.)

Urinary urgency, loss of skin elasticity, swallowing difficulties, elevated blood pressure.

Necrotic tissue management

Wound debridement Hydrotherapy Enzymatic debridement- breaks down necrotic tissue

A nursing instructor is teaching student nurses about the adaptive behaviors exhibited by children at different stages of development. Which statement made by a student nurse indicates that the student nurse needs further teaching?

a 5 year old can brush and comb his or her own hair acceptably without help

A nurse is caring for a client who had a gastroscopy. What response indicates a major complication associated with this surgery?

abdominal distention

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin?

acetylsalicylic acid

A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1.Cloudy wound drainage 2.Absence of the gag reflex 3.Decreased urinary output 4.Restlessness with dyspnea

answer: Restlessness with dyspnea rationale:The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication Decreased urinary output needs to be monitored but does not take priority.

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? A. Serous B. Purulent C. Fibrinous D. Catarrhal

answer: B rationale= Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

is a lower-pitched, coarse, continuous snoring sound that arises from the large airways? what sound is this?

answer: Rhonchus

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

answer= discontinue iv infusion rationale=The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis

A client is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client was diagnosed recently with early dementia. The client appears oriented and alert and responds appropriately when interviewed. When the nurse is providing preoperative teaching, the client says, "I don't want to have that surgery." The client's spouse voices a desire to proceed with the surgery to provide relief for the client. How should the nurse respond?

ask the client if a power of attorney for health care has been established

What does a shift to the left indicate in the white blood cell count differential?

immature neutrophils in the blood

Allergic contact dermatitis

is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens.

chemotaxis

is directional is the migration of WBCs to the site of injury, resulting in an accumulation of neutrophils and monocytes at the site.

inflammatory response

is sequential reaction to cell injury -it neutralized and dilutes the inflammatory agent, removes necrotic materials, and establishes an environment suitable for healing and repair.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear?

moist rumbling sounds that clear after coughing

A nurse is caring for a preschooler on the pediatric unit. What does the nurse identify as the child's greatest fear at this age?

mutilation

The nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect?

rectal pressure during contractions

A 1-year-old infant is brought to the pediatric clinic for the first time. During the assessment the nurse suspects a developmental delay. What developmental milestone should have been achieved by this age?

responding to peek-a-boo

First degree burn (superficial)

skin is red in color with minimal edema and pain

Which nurse could be safely reassigned to assist in the operating room for emergency surgeries being performed on trauma victims?

surgical suite staff development trainer

Which individual is coping with issues concerning dependence versus independence?

toddler

The client is admitted with trigeminal neuralgia for a percutaneous sterotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next?

Administers pain medication as requested

Biological and biosynthetic dressings

Homograft- allograft- biological Heterograft- xenograft- biosynthetic

A client who is to receive external radiation therapy says to the nurse, "My family said that I will get a radiation burn." What is the nurse's best response?

"A localized skin reaction usually occurs."

The client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response?

"Contact the Guillain-Barré Foundation International for resources."

The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis (ALS) who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions?

"I will need frequent checks of my liver enzymes." (May cause liver toxicity. This must also be taken on an empty stomach, twice a day, and may cause tachycardia).

A client who has been taking ibuprofen (Advil) for rheumatoid arthritis asks the nurse if acetaminophen (Tylenol) can be substituted instead. An appropriate nursing response is: 1 "Acetaminophen is the preferred treatment for rheumatoid arthritis." 2 "Acetaminophen irritates the stomach more than ibuprofen does." Correct3 "Ibuprofen is an antiinflammatory and acetaminophen is not." 4 "Both are antipyretics and have the same effect."

"Ibuprofen is an antiinflammatory and acetaminophen is not." Ibuprofen has an antiinflammatory action that relieves the inflammation and pain associated with arthritis. Acetaminophen is not an NSAID. NSAIDs are preferred for treatment of rheumatoid arthritis. Acetaminophen does not cause gastritis; this is an effect of aspirin. Ibuprofen is not an antipyretic.

vitals signs (fever) moderate fevers

-(up to 103F) usually produce few problems in most pts. if pts is very young or very old it is extremely uncomfortable -the use of antipyretics should be considered. -FEVER w immunosuppressed patient should be treated immediately w antibiotic therapy because infections can rapidly progress to septicemia. -FEVER greater than 104F can damage body cells and delirium and seizures can occur. -FEVER temperatures greater than 105.8F regulation by the hypothalamic temperature control center becomes impaired. Damage to the cells can occurs and to the brain.

A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on:

... covering up the victim with one of those tablecloths."

A nurse is caring for a client with a spinal cord injury. What is the specific reason fluid intake should be increased for this client? 1. to prevent dehydration 2. to maintain electrolyte balance 3. to prevent a urinary tract infection 4. to limit an increase in temperature

3 rationale: Lack of or reduced movement predisposes the client with paraplegia or quadriplegia to urinary stasis, which may result in a urinary tract infection and calculus formation. All individuals require fluid to prevent dehydration; this is not why fluids are encouraged for this client. Administration of fluids does not maintain electrolyte balance. Fluids do not prevent an increase in temperature.

The nurse is examining four different clients who present with thermal burns. Which client does the nurse diagnose as having second-degree burns? 1. Client A 2. Client B 3. Client C 4. Client D

3. Client C Client C has second-degree burns. The client is experiencing severe pain and the skin shows moist blebs and blisters. Client A may have third- and fourth-degree burns, in which the skin is waxy white, dark brown in appearance. Client B may have first-degree burns, in which the skin is red in color with minimal edema and pain. Client D may have third- and fourth-degree burns as the skin is dry, leathery eschar and there is absence of pain.

A client is admitted with severe burns, is obese, and has pre-existing respiratory problems. Which complication should the nurse anticipate? 1 Necrosis 2 Pneumonia 3 Dysrhythmias 4 Venous thromboembolism

4 Venous thromboembolism is the complication of the client with severe burns, who is obese and has pre-existing respiratory problems. Necrosis is an untreated complication of the cardiovascular system. Pneumonia is a complication for the client with pre-existing respiratory problems. Dysrhythmias are a complication of the cardiovascular system.

The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately? 1. monitoring urinary output 2. assessing for other injuries 3. infusing lactated Ringer solution 4. immobilizing and stabilizing cervical spine

4 rationale: A client with a spinal cord injury should first have the cervical spine immobilized and stabilized. Monitoring urinary output should be performed during ongoing assessments, after providing initial treatment. The client should be assessed for other injuries after immediate interventions are performed. Ringer solution should be infused after stabilizing oxygen levels and cervical spine.

Which image represents a deep full-thickness burn injury?

4. Rationale: Image 4 represents the typical appearance of a full-thickness burn injury. This injury has a hard, dry, leathery eschar formed from the coagulated particles of destroyed skin. Image 1 signifies a superficial partial-thickness burn injury. Image 2 also represents a superficial partial-thickness burn injury. Image 3 signifies the typical appearance of a deep partial-thickness burn injury.

The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which blood glucose levels should the nurse identify as hypoglycemia? 68 mg/dL (3.8 mmol/L) 78 mg/dL (4.3 mmol/L) 88 mg/dL (4.9 mmol/L) 98 mg/dL (5.4 mmol/L)

68 mg/dL (3.8 mmol/L)

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000 mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ______ mL

950mL

After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide? 1. lower extremities are paralyzed 2. upper extremities are paralyzed 3. one side of the body is paralyzed 4. both lower and upper extremities are paralyzed

1 rationale: Both legs and generally the lower part of the body are paralyzed in paraplegia. There is no term to describe only upper extremities affected; all parts below an injury are affected. One side of the body paralyzed describes hemiplegia. The paralysis of both lower and upper extremities describes quadriplegia.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1. bradycardia 2. hypotension 3. spastic paralysis 4. bladder dysfunction 5. increased pulse pressure

1, 2, 4 rationale: Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

A client is transferred to the postpartum care unit 1 hour after a spontaneous vaginal delivery. On assessment the nurse finds the fundus at U-1 and firm and the pad saturated with blood. The pad is changed and reassessed 15 minutes later, and again found saturated with blood. The fundus remains at U-1, midline and firm. Place the interventions in order of priority.

1. Assessing the episiotomy 2. weighing pads to measure blood loss 3. taking vital signs 4. assessing the client for a vaginal laceration 5. calling the primary health care provider

Arrange the order of steps involved in a type one allergic reaction in its correct sequence.

1. exposure to the allergen 2. activation of b lympocytes 3. sensitization of igE antibodies 4. Attachement to mast cells 5. release of chemical mediators

The nurse is caring for a client with burns receiving opioid analgesics and who is sedated. Which medications should the nurse anticipate to be prescribed by the primary healthcare provider to overcome this side effect of the opioid analgesics? Select all that apply. 1 Morphine 2 Pregabalin 3 Lorazepam 4 Midazolam 5 Gabapentin

2 5 Pregabalin and gabapentin are adjuvant analgesics used to overcome the side effects caused by opioid analgesics. Morphine is an opioid analgesic used in the treatment of pain that can cause sedation. Lorazepam and midazolam are anxiolytic agents used to inhibit anxiety.

Before administering preoperative medication to a client, the nurse plans to:

Verify the consent

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine for pain. What side effects or adverse reactions does the nurse anticipate after administering this medication? Select all that apply. A. Nausea B. Oliguria C. Sedation D. Dry mouth E. Flushed skin F. Orthostatic hypotension

A. Nausea C. Sedation D. Dry mouth F. Orthostatic hypotension

A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. A. Obtain the client's vital signs. B. Monitor hemoglobin and hematocrit levels. C. Allow the blood to reach room temperature. D. Determine typing and crossmatching of blood. E. Use a Y-type infusion set to initiate 0.9% normal saline.

A. Obtain the client's vital signs. D. Determine typing and crossmatching of blood. E. Use a Y-type infusion set to initiate 0.9% normal saline.

What dietary choices should the nurse instruct the client taking spironolactone to avoid increasing? Select all that apply. A. Potatoes B. Red meat C. Cantaloupe D. Wheat bread E. Flavored yogurt

A. Potatoes C. Cantaloupe

A client is scheduled to receive an intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? Select all that apply. A. Urinary output B. Deep tendon reflexes C. Last bowel movement D. Arterial blood gas results E. Last serum potassium level F. Patency of the intravenous access

A. Urinary output E. Last serum potassium level F. Patency of the intravenous access

The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." The nurse recalls that rabies can be described as:

An acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system

Treatment of deep partial thickness burn

Analgesics Cleaning Gentle AROM and PROM Grafting

Treatment of superficial partial thickness burn

Analgesics Skin substitutes may be used Cleaning

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply.

Anorexia Hemiplegia History of diabetes Urinary incontinence

A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis?

Appearing composed

Second degree burn (superficial partial thickness)

painful, reddened, and have blisters pink to cherry red skin with blisters Spontaneous epithelial regeneration occurs within several weeks

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?

answer=Salicylate toxicity rationale=Excessive aspirin ingestion can influence the vestibulocochlear nerve (cranial nerve VIII), causing tinnitus and dizziness The client is experiencing symptoms of toxicity

A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Assess the clients lungs

A patient involved in a high speed motor vehicle accident with sustained multipul injuries and active bleeding is transported to the ER with immobilization devices in place. There is a high probability of cervical spine fracture, the patient has altered mental status and extremities are flaccid. What is the priority nursing assessment

Assess the respiratory pattern and ensure a patent airway

A client with heart failure is digitalized (given a loading dose of digoxin) and placed on a maintenance dose of digoxin 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? A. Diuresis and decreased pulse rate B. Increased blood pressure and weight loss C. Regular pulse rhythm and stable fluid balance D. Corrected heart murmur and decreased pulse pressure

A. Diuresis and decreased pulse rate

During auscultation of the heart, where does the nurse expect the first heart sound (S1) to be the loudest?

Apex of the heart

The client with advanced Guillain-Barré syndrome (GBS) is no longer able to perform ADLs independently. Which priority problem best identifies measures to prevent pressure ulcers?

Impaired Physical Mobility related to weakness, paralysis, and ataxia

The primary healthcare provider suspects agranulocytosis in a client with a history of bipolar disorder (BPD). Which drug used to treat BPD is responsible for this condition?

Clozapine

The healthcare provider prescribes finasteride for a client with benign prostatic hyperplasia. What information does the nurse provide to the client? A. Male pattern baldness can occur. B. Results can be expected in 4 to 6 weeks. C. The medication relaxes the muscles in the bladder neck, making it easier to urinate. D. Protection should be worn during intercourse with a pregnant female.

D. Protection should be worn during intercourse with a pregnant female.

A nurse caring for a pregnant client at 28 weeks' gestation and her partner suspects intimate partner violence. Which assessments support this suspicion? Select all that apply.

- the woman has injuries to the breast and abdomen -the partner answers questions that are asked of the woman -the woman has visited the clinic several times in the last month

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply.

-resting tremors -flattened affect -slow voluntary movements

A 5-year-old child is admitted with burns covering the face and anterior arms and hands. Using the total body surface area (TBSA) percentages shown in the diagram, determine what percentage of the child's body has been burned. Record your answer using a whole number. ____%

15%

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours?

2) pulmonary distress. Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs. Although wound sepsis is a possible complication, it will not be evident until the third to fifth day. Although the child is probably fearful, maintaining a patent airway is the priority. This child is too old for separation anxiety; however, complications related to stress may occur later. Fluid losses may be extremely high but reach their maximum about the fourth day; the initial priority is maintaining a patent airway.

Proliferation phase

2-3 days post burn Granulated tissue begins to form Epithelial cells begin to cover wound as each cell stretches across wound surface Lasts until complete re epithelialization occurs

A 10-year-old child sustains partial-thickness burns of the entire right arm and hand, upper anterior left arm, and anterior chest. The nurse calculates the percent of total body surface area (TBSA) burned with the use of the modified "rule of nines." What percentage of the child's body is burned?

24.5%

After providing epinephrine to a client experiencing an anaphylactic reaction, which second-line drugs should the nurse prepare to provide? Select all that apply. 1 Dopamine 2 Norepinephrine 3 Dexamethasone 4 Diphenhydramine hydrochloride 5 Hydrocortisone sodium succinate

3 4 5 Dexamethasone is a corticosteroid that is a second-line drug used in the treatment of anaphylaxis. Diphenhydramine hydrochloride is an antihistamine that is a second-line drug used in the treatment of anaphylaxis. Hydrocortisone sodium succinate is a corticosteroid that is a second-line drug used in the treatment of anaphylaxis. Dopamine and norepinephrine are vasopressor medications and are considered support drugs in the treatment of anaphylaxis.

S/S of deep partial thickness burn

Capillary refill decreased Intact hair follicles Decreased sensation at site

A severely burned client has been hospitalized for two days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does the nurse conclude the client is most likely developing?

Cerebral hypoxia

A nurse is assessing clients with gastrointestinal problems. Which client does the nurse suspect to have shigellosis?

Client 2

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water seal chamber

The client has Guillain-Barré syndrome. Which interdisciplinary health care team members will the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in the client with Guillain-Barré syndrome?

Family, dietician, and Occupational therapist (OT).

What change in blood pressure (BP) should the nurse anticipate after a client has an aldosteronoma surgically removed?

Gradually return to expected levels for an adult

S/S of superficial burn

HA N/V Chills

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist:

Helps health care providers to control infections

Partial thickness (second degree) burn

Involves both epidermis and PART of the dermis Two categories- superficial partial and deep partial

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall.

Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention.

A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply. 1 Corn 2 Cheese 3 Oatmeal 4 Rye bread 5 Fruit juice

Oatmeal

The nurse is caring for a client that had a colostomy three days ago. The primary nursing intervention for this client is to:

Observe drainage and the condition of the abdominal incision

Which complication may be caused by sepsis in burns? Diarrhea Constipation Paralytic ileus Curling's ulcer

Paralytic ileus Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointestinal tract in clients with burns.

Which is the definition of photophobia? Double vision Foreign body sensation Persistent abnormal intolerance to light Gradual or sudden inability to see clearly

Persistent abnormal intolerance to light

A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority?

Potential for aspiration related to difficulty with swallowing

A client with a partial-thickness burn reports feeling chilled. What should the nurse do to limit this response?

Prevent drafts in the client's room

Which benign condition shows silver scaly plaques on the skin?

Psoriasis

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy

Reposition the client by log rolling

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention?

Starting an intravenous line with a large-bore catheter

Initial wound care

Stop burning- tepid (Luke warm) water Remove all clothing and jewelry Cover with clean dry sheets to avoid hypothermia Elevate extremities to reduce swelling NO ointments unless directed by burn unit NO ice or other home remedies

A patient has just undergone a laminectomy and returned from surgery at 1300 hours, at 1530 the nurse is performing the change of shift assessment. Which postoperative finding is reported to the surgeon immediately

Swelling or bulging at the operative site, moderate clear drainage on the postoperative dressing

The nurse cares for a client who develops pyrexia three days after surgery. The nurse should monitor the client for which signs and symptoms commonly associated with pyrexia? (Select all that apply.)

Tachypnea Increased pulse rate

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the rule of nines. Record your answer using one decimal place. _______%

The front of the head is 4.5%, and the anterior torso is 9%, for a total of 13.5%.

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurological assessment, the nurse applies a painful stimulus to the client's left lower leg. An expected response in a healthy adult is: Correct1 Withdrawing the leg 2 Making no movement 3 Plantar flexing the left foot 4 Flexing the upper extremities

Withdrawing the leg Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.

The nurse is evaluating the client's cardiac rhythm and measures a PR interval of 0.08 seconds (two small boxes). How should the nurse interpret this finding?

abnormally fast conduciton

The priority nursing intervention when the membranes rupture spontaneously is an assessment of what?

variable decelerations or fetal bradycardia

The client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching?

"I can continue to take over-the-counter drugs."

A client with burns tells the nurse that the primary health care provider stated that skin grafts would be required. The client asks when the procedure will be performed. The most appropriate nursing response is:

"Tell me what your primary health care provider said about the graft procedure."

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction?

A brassy cough is indicative of possible pulmonary damage caused by an inhalation burn Singed nasal hair indicates possible pulmonary damage Dark mucous membranes are a sign of potential respiratory insufficiency that results from inhalation burns

A client is receiving total parenteral nutrition via a central venous access catheter. When providing care to the site, the nurse should wear:

A mask and sterile gloves

A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client?

A tracheostomy tray

A spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test. The nurse reads the test and identifies an area of induration greater than 10 mm. What does this result indicate to the nurse? No further action is required. Additional tests are necessary. Repeating the skin test is indicated. Results are positive, including infection.

Additional tests are necessary.

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

Administer the prescribed intravenous fluid with the added vitamin C. Vit C is ESSENTIAL for wound healing

The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next?

Allow the client to remain undisturbed

A client reports an absence of menstruation to the nurse. Which condition does the nurse suspect? Gonorrhea Amenorrhea Dysmenorrhea Ectopic pregnancy

Amenorrhea

Pharm therapy for burns

Anxiety and pain control- IV narcotics, anti anxiety agents, alternative therapies Antimicrobials- diagnose infection through wound biopsy, broad spectrum/topical/prophylactic abx Antacids- gastric aspirant through NG tube

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN) 30 mg/dL, creatinine 2.4 mg/dL, serum potassium 6.3 mEq/L, pH 7.1, Po2 90 mm Hg, and Hgb 7.4 g/dL. The nurse concludes that these findings indicate:

Azotemia

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? a. Auscultate for breath sounds. b. Suction the client's oropharynx. c. Administer and continue to monitor oxygen via nasal cannula. d. Place the client in the orthopneic position.

B

A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding? A. Rapid delivery of the infusion B. Chemical irritation to the tissues C. Allergic response to the infusion D. Catheter infiltration into the tissues

B. Chemical irritation to the tissues

Inflammation phase

Begins immediately Platelets aggregate at damaged tissue Thrombus forms Local vasoconstriction causes hemostasis Neutrophils, monocytes, macrophages Secrete growth factors to stimulate deposit of a wound matrix

Blood stream becomes concentrated

Blood becomes thick because Na and albumin leave blood stream to go into cells

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for:

Blood production

A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information should the nurse share with the client? a. Cool compresses decrease facial involvement. b. Pain occurs with transient ischemic attacks (TIAs). c. Most clients recover from the effects in several weeks. d. Body changes should be expected with residual effects.

C

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about what the client can anticipate should be incorporated into the nurse's response? a. High cure rate with proper treatment b. Slowly progressive course without remissions c. Chronic illness with exacerbations and remissions d. Poor prognosis, with death occurring in a few months

C

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? a. Cogwheel gait b. Impaired cognition c. Difficulty swallowing d. Nonintention tremors

C

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? 1. Using Credé maneuver 2. Using an indwelling catheter 3. Using anticholinergic medications 4. Monitoring and restricting fluid intake to 800 mL daily 5. Monitoring for and reporting signs of urinary tract infection a. 1, 3, 5 b. 1, 4 c. 1, 5 d. 2, 3, 5

C

A- Closed Femur fracture- Green B- Airway Obstruction- Red C- Closed Tibial Fracture-Black D- Open minor fracture with distal pulse- Yellow Triage officers are tagging clients with disaster triage tags at the site of an earthquake. Which client's tag requires replacement? A B C D

C Clients with closed fractures may be given green disaster triage tags. Therefore the black tag on client with a closed tibial fracture should be replaced with a green tag. The client with a closed femur fracture has correctly been given a green tag. Clients with life-threatening conditions such as airway obstruction or shock are applied with red disaster triage tags. Therefore, the client B is correctly given a red tag. Clients with open fractures with a distal pulse are given yellow tags. Therefore the client D is correctly tagged.

A nurse is performing a neurologic assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of the client? A. Tuning fork B. Ophthalmoscope C. Tongue depressor D. Cotton and a straight pin

C- A tongue depressor is used to depress the tongue to observe the pharynx and larynx, and to assess soft palate symmetry and the presence of the gag reflex. The information obtained provides data about cranial nerve X (vagus). A tuning fork is used to assess cranial nerve VIII (auditory). An ophthalmoscope is used to assess cranial nerve II (optic). Cotton and a straight pin are used to assess sensory function: light touch and pain.

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? A. Hemodynamic changes related to tilt table positioning B. Deteriorating myelin sheath C. Distended large intestine D. Crushed spinal cord

C- Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury. Here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. The client being upright on a tilt table is not involved in the autonomic hyperreflexia nerve impulses [1] phenomenon. The myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the autonomic hyperreflexia phenomenon

A client who takes high-dose aspirin for arthritis has an acute episode of right ventricular heart failure. The healthcare provider prescribes furosemide and lowers the client's usual dosage of aspirin. The client asks the nurse the reason for the lower dose. On what principle does the nurse base a response? A. Aspirin accelerates metabolism of furosemide and decreases the diuretic effect. B. Aspirin in large doses after an acute stress episode increases the bleeding potential. C. Competition for renal excretion sites by the drugs causes increased serum levels of aspirin. D. Use of furosemide and aspirin concomitantly increases formation of uric acid crystals in the nephron.

C. Competition for renal excretion sites by the drugs causes increased serum levels of aspirin.

A client is diagnosed with trigeminal neuralgia. Which medications should the nurse anticipate will be prescribed for this client?

Carbamazepine (Tegretol) and Baclofen (Lioresal). (Carbamazepine is an anticonvulsant, antineuraligic drug used to control pain in trigeminal neuralgia and to prevent future attacks. Baclofen is an antispasmodic that may be used alone or in conjunction with Tegretol.)

Electrical burn

Cardiac arrest

Electrical burn management

Cardiopulmonary resuscitation

Full thickness (3rd degree) burn

Caused by prolonged contact with flames, chemicals, high voltage electric current Involves all layers of skin- may extend into SQ fat, connective tissue, muscle, and bone Pale, waxy, yellow-brown, mottled, charred, non blanching red Wound surface is dry, leathery, firm to touch

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.)

Contact, Standard, and Airborne

Wound management

Control microbial colonization Prevent wound progression Achieve wound coverage as early as possible Promote function of healing skin

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure that a nurse should instruct the person to apply before seeking health care?

Cool, moist towels

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list? Select all that apply. 1 Eggs 2 Liver 3 Cheese 4 Squash 5 Chicken

Correct 1 Eggs Correct 2 Liver Correct 3 Cheese Vitamin K decreases clotting time. Egg yolks are high in vitamin K and should be avoided. Liver, an organ meat, is high in vitamin K, as are all organ meats, and should be avoided. Cheese, a dairy product, is high in vitamin K, as are all dairy products, and should be eaten sparingly. Squash is low in vitamin K and is not limited in the diet of clients who are taking anticoagulants. Chicken contains about half the vitamin K that green, leafy vegetables contain and is permitted in the diet.

1. A nurse is caring for a female client who is receiving rifampin (Rifadin) for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply. 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." 2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." 3 "I cannot take an antacid within two hours before taking my medicine." 4 "My health care provider must be called immediately if my eyes and skin become yellow." 5 "If I can't swallow the pill, I can't open the capsule and mix the powder with applesauce." 00:00:43 Question Answer Confidence Buttons

Correct 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." Correct2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." Correct 4 "My health care provider must be called immediately if my eyes and skin become yellow." Alcohol may increase the risk of hepatotoxicity. Rifampin has teratogenic properties and also may reduce the effectiveness of oral contraceptives. Yellowing of the eyes and skin are signs of hepatitis and should be reported immediately. An antacid may be taken one hour before taking the medication. The capsule may be opened and the powder mixed with applesauce. 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." Correct2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." Incorrect 3 "I cannot take an antacid within two hours before taking my medicine." Correct 4 "My health care provider must be called immediately if my eyes and skin become yellow." 5 "If I can't swallow the pill, I can't open the capsule and mix the powder with applesauce." Alcohol may increase the risk of hepatotoxicity. Rifampin has teratogenic properties and also may reduce the effectiveness of oral contraceptives. Yellowing of the eyes and skin are signs of hepatitis and should be reported immediately. An antacid may be taken one hour before taking the medication. The capsule may be opened and the powder mixed with applesauce.

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? a. Localized seizures b. Skin desquamation c. Hyperactive reflexes d. Ascending weakness

D

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? a. Offer three large meals a day. b. Assess the client's respiratory status before and after meals. c. Seek a change in the diet prescription from soft foods to clear liquids. d. Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

D

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis? A. Sees best in dim light B. Sees halos around lights C. Cannot see objects in the periphery D. Cannot see objects in the center of the visual field

D- The macula is the central vision area of the retina. Therefore, macular degeneration affects central vision and makes it difficult to see objects within direct, central vision. Dim light will make vision more difficult for this client. Seeing halos around lights is related to glaucoma rather than to macular degeneration. An inability to see objects in the periphery is related to glaucoma rather than to macular degeneration.

Thermal burn

Direct exposure to dry (flames) or moist heat (steam, hot liquids) Most common Usually affect children and adults over 65 Causes cellular destruction- may result in charring of vascular, bony, muscle, and nervous tissue

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next?

Document the incident

Respiratory interventions for burns

Elevate HOB 30 degrees Humidify room air or O2 Intubation if necessary Suction frequently Meds to dilate constricted bronchial passages ART line to monitor ABGs

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should:

Elevate the affected leg above the level of the heart

Carbon monoxide safety alert

False normal pulse ox reading because Pulse ox can't distinguish O2 from hemoglobin Carbon monoxide binds to hemoglobin Pt will stat normal, but actually have hypoxia

Hyperkalemia clinical manifestations

Fatigue, paresthesias, and cardiac dysrhythmias

A client has a functional transection of the spinal cord at C7-8 resulting I spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury

Flaccid paralysis, lack of reflexes below the injury

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving immunoglobulin (IVIG). Which client finding warrants immediate evaluation?

Headache with stiff neck (This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy).

Autografting

Healthy skin from pt to applied burn wound Cultured epithelial autografting 3-4 weeks process of skin growth

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss?

Hematocrit

The nurse is caring for a client four days after the client was admitted to the hospital with burns on the trunk and arms. The nurse provides a dietary plan for the following day and includes:

High caloric intake, liberal potassium intake, and 3 grams of protein/kg/day

Inhalation burn

Hoarseness

Integumentary system complications with burn injuries

Infection secondary to loss of integrity Difficulty maintaining body temperature Eschar formation during acute stage

3 phases of burn healing

Inflammation Proliferation Remodeling

Respiratory complications with burns

Inhaltion injury- often lethal ARDS Pulmonary edema Atelectasis Airway edema peaks 24-48 hours- assess for singed facial, scalp, nasal hair Smoke poisoning Carbon monoxide is colorless, odorless, tasteless and has 200 times greater binding to hemoglobin than oxygen

Which information should be included in the teaching plan for the client who is prescribed sumatriptan (Imitrex) for migraine headache?

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 client with burns over 35% of the body complains of chilling. To promote client comfort, the nurse should:

Limit room drafts

The nurse is caring for a client who has been admitted with partial- and full-thickness burns over 25% of the total body surface area. Lactated Ringer solution and 5% dextrose have been prescribed. What is the purpose of these fluids?

Maintain blood volume Lactated Ringer solution and 5% dextrose in saline are not plasma expanders, as is albumin.

After surgery, a client has a portable wound drainage system in place. What nursing intervention promotes drainage?

Maintaining compression of the drainage system.

The nurse should wear what personal protective equipment when providing central venous access device site care?

Mask and sterile gloves

Dressing the wound

Open/closed methods Contractures a common problem- tightening of skin ROM Q2 hours Uniform pressure

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?

Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disc.

Pain radiating to the hip and leg

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves.

The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase inhibitor (ChE). The nurse plans to contact the physician if the client is taking which medication?

Procainamide (Pronestyl) . (Procainamide (Pronestyl) should be avoided because it may increase the client's weakness)

Water follows

Protein

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours?

Pulmonary distress The immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs

The laboratory test reports of a client reveal the presence of human leukocyte antigen (HLA-B27). Which diagnosis will the nurse most likely observe written in the client's electronic medical record?

Reiter's syndrome

Escharotomy

Removal of eschar to prevent circumferential constriction

Surgical debridement

Removal of wound to level of viable tissue

A client with myasthenia gravis continues to become weaker despite treatment with neostigmine (Prostigmin). What reason should the nurse identify for the health care provider's prescription for edrophonium (Enlon)?

Rule out cholinergic crisis (Edrophonium improves muscle strength in myasthenic crisis; weakness persists if symptoms are caused by cholinergic crisis, which can result from toxic levels of neostigmine).

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.

Scaly lesions Pruritic lesions Reddened papules

What is a clinical manifestation of hypernatremia in burns? Fatigue Seizures Paresthesias Cardiac dysrhythmias

Seizures. Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

Which position is therapeutic and comfortable for a patient with lower back pain

Semi fowlers position with a pillow under the knees to keep them flexed

For which clinical indicator should the nurse assess a client who just had a microdiskectomy for a herniated lumbar disk

Sensory loss in legs

A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? Decrease in urine output Increase in pulse strength Shrinkage of the tumor on scanning Increase in the quantity of white blood cells (WBCs)

Shrinkage of the tumor on scanning

A nurse is caring for a group of clients who are being considered for treatment with a negative pressure wound treatment device. The nurse should discuss this prescription with the primary health care provider when the client has which condition?

Stage IV pressure ulcer with eschar

The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client? 1. Establish airway by positioning, suctioning, and oxygen as needed. 2. Assess breath sounds and respiratory effort. 3. Prepare for chest decompression if needed. 4. Maintain vascular access using a large-bore catheter. 5. Use direct pressure for external bleeding.

The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse should establish airway patency by positioning, suctioning, and providing oxygen as needed. Assess breath sounds and respiratory effort and provide chest decompression if needed in order to assess breathing. Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? 1 Pulse rate 2 Tissue turgor 3 Specific gravity 4 Body temperature

Tissue turgor Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.

A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?

Topical application of steroids

Which neurologic assessment technique does the nurse use to test a patient for sensory function

Touch the skin with a clean paper clip and ask whether it is a dull or sharp sensation

The nurse is providing postoperative care for a client that had choledocholithotomy. After identifying that the skin around the client's T-tube is raw and excoriated, the nurse plans to:

Use a skin barrier around the tube's exit site

Optimal teaching for the client with multiple sclerosis (MS) who is experiencing urinary retention includes:

Using Crede's maneuver, and Monitoring for and reporting signs of urinary tract infection.

When planning care to prevent deformities and contractures in a client with burns, the nurse expects to begin range-of-motion (ROM) exercises when the client's:

Vital signs are stable

A client had a colostomy surgery and is learning how to care for the skin around the stoma. What should the nurse include in the teaching plan for this client?

Wash the area gently with soap and water before applying an appliance

What is the similarity between evidence-based practice (EBP) and quality improvement (QI)?

both receive funding from internal sources

Which of these features would the nurse state are exhibited by a preschooler?

eagerness for formal education

A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present?

increased protein

What will the nurse do to assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver?

obtain the client's weight at least once every day

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?

oliguria

The nurse is preparing to administer a subcutaneous dose of 15 units of lispro insulin to a client. Choose the proper syringe for this injection.

option 2 says units on syringe

A nursing instructor asks a student to describe the moral developmental theory. Which statement made by the student indicates a need for further teaching?

the fifth stage defines 'right' by the decision of conscience in accordance with self-chosed ethical principles

Which gastrointestinal (GI) change may be found in the client with burn injuries? 1. Abdominal distention 2. Increased peristalsis 3. Activation of GI motility 4. Increased blood flow to the GI area

1. Abdominal distention The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.

S/S of superficial partial thickness burn

Severe pain related to temperature and air exposure

which disease is caused by E coli?

answer= peritonitis Peritonitis is usually infectious and often life-threatening. It's caused by leakage or a hole in the intestines, such as from a burst appendix.

A healthcare provider prescribes selegiline 5 mg twice a day for a client with a diagnosis of Parkinson disease. What is most important for the nurse to teach the client? A. Eat food high in tyramine. B. Ensure that an opioid is not taken currently. C. Take the medication in the morning and evening. D. Monitor for signs of hypoglycemia and hyperglycemia.

B. Ensure that an opioid is not taken currently.

A client is receiving furosemide. For which sign of hypokalemia should the nurse monitor the client? A. Chvostek sign B. Flabby muscles C. Anxious behavior D. Abdominal cramping

B. Flabby muscles

A nurse is caring for a client with a spinal cord injury during the immediate post injury period. What is the primary focus of nursing care during this immediate phase

Avoid flexion or hyper extension of the spine

The nurse is assessing a client for recall memory. Which statements made by the client indicate that the client's recall memory is intact? A. "I was born in New York city." B. "I came to the hospital in a car." C. "You asked me to repeat the words apple, street, and chair." D. "I was admitted on the 24 th of September at 5 in the evening." E. "I had an appointment with a neurophysician last month."

B, C, D, E- Recall memory can be tested by asking questions related to the recent past, such as mode of transportation to the hospital, time and date of admission, and history of appointments with healthcare providers. Asking the client to repeat words tests recall memory. Remote memory is tested by asking the client about the city of birth or birth date.

A client reports a cold and severe cough lasting for several minutes accompanied by frequent exhaustion. The nurse observes a "whooping" sound at the end of the cough. Which organism may responsible for this condition in the client?

Bordatella pertussis

A client is admitted to the hospital due to electrical burns

Burn odor Leathery skin Cardiac arrest

bands

-immature neutrophils released by the bone marrow into the circulation. (because of the demand)

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional

How should a nurse prepare a client for cranial surgery?

Obtain the client's consent to shave the head

The nurse should expect a client with a spinal cord injury to have some spasticity of the lower extremities, what should the nurse include in the plan of care for the client to prevent the development of lower extremity contractures

Proper positioning

What is the application of Roger's diffusion theory?

engages key leaders in a change to infuse the energy from early adopters

Second degree burn (deep partial thickness)

painful, red to white color

Which complication should the nurse assess in a client who had a bilateral herniorrhaphy?

urinary retention

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. 1. spasticity 2. incontinence 3. flaccid paralysis 4. respiratory failure 5. lack of reflexes below the injury

3, 5 rationale: Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected.

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

Raise the head of the bed. (Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration).

A healthcare provider prescribes ampicillin for a client with an infection. What information should the nurse include in the teaching plan about this medication? A. Take the ampicillin with meals. B. Store the ampicillin in a light-resistant container. C. Notify the healthcare provider if diarrhea develops. D. Continue the drug until a negative culture is obtained.

C. Notify the healthcare provider if diarrhea develops.

Which medication requires the nurse to monitor the client for signs of hyperkalemia? A. Furosemide B. Metolazone C. Spironolactone D. Hydrochlorothiazide

C. Spironolactone

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. What would be the possible diagnosis?

HIV infection

S/S of airway obstruction due to edema

Hoarseness Labored breathing Stridor

What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS) share in common?

Increased risk for respiratory complications.

An obese client must self-administer insulin at home. The nurse will teach the client to inject insulin at which angle? A. 30-degree angle B. 60-degree angle C. 45-degree angle D. 90-degree angle

D. 90-degree angle

A client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the health care provider will prescribe to decrease the size and vascularity of the thyroid gland before surgery? A. Vasopressin B. Levothyroxine C. Propylthiouracil D. Potassium iodide

D. Potassium iodide

Hypovolemic shock s/s

Decreased CO Hypotension Tachycardia Tachypnea Vasoconstriction

The nurse is talking a history on an older adult patient who reports chronic back pain. The nurse seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting this information

Do you have a history of osteoarthritis

A nurse is teaching an adult health and wellness class about bladder cancer. The nurse informs the class participants that which activities put a person at risk for bladder cancer? Select all that apply. 1 Jogging three miles a day Incorrect 2 Drinking three cans of cola a day Correct 3 Smoking two packs of cigarettes a day Correct 4 Working with dyes and ink every day 5 Using a jackhammer and chainsaw every day

Drinking three cans of cola a day Correct 3 Smoking two packs of cigarettes a day Correct 4 Working with dyes and ink every da Using a jackhammer and chainsaw every day The occurrence of bladder cancer is related to smoking. Dyes and ink are environmental carcinogens; working with them daily increases an individual's risk of bladder cancer. Jogging is unrelated to the development of cancer of the bladder. Ingestion of cola has not been linked to cancer of the bladder. Vibrations may result in musculoskeletal or kidney problems but are unrelated to cancer of the bladder.

As part of the teaching plan for a client with scleroderma, the nurse addresses the need for special skin care and advises the client to:

Keep the skin well lubricated

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is:

Negligent and can be sued for malpractice

Hyperpigmented areas that vary in form and color ?

Nevi

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? Notify the primary healthcare provider immediately. Apply a warm, moist compress to the incision site. Increase the intravenous fluid rate by 20 mL/hr. Monitor vital signs more frequently.

Notify the primary healthcare provider immediately. The primary healthcare provider must be notified immediately so that anticoagulation therapy can be instituted.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.)

Pain history including location, intensity and quality of pain, and Pain pattern including precipitating and alleviating factors

What changes in family status are required for developmental changes in an adolescent to occur? Select all that apply.

-a refocusing on midlife material and career issues - permitting adolescents to move in and out of the family system

The nurse is planning the care for a client with a body surface burn injury of 55%. The nurse understands that clients with burn injuries:

Are prone to poor healing because of a hypermetabolic state.

The nurse reviews the discharge and hike care instructions with a patient who had back surgery. Which statement by the patient indicates further teaching is needed

I will drive myself to the doctors office next week

Which diseases can be transmitted from client to client by droplet infection? Select all that apply.

Pertussis Diphtheria Pertussis and diphtheria are infectious diseases that are known to be transmitted by droplet infection. Shingles and measles are infectious diseases that are known to be transmitted by air. Scabies is an infectious disease that is transmitted by direct contact.

Electrical burn

Severity depends on type, duration, voltage Electricity follows path of least resistance- usually muscles, bones, blood vessels, and nerves Depth of injury may not be evident until weeks after initial burn event May cause seizures, cardiopulmonary arrest

A newborn's Apgar score at 5 minutes is 5. Which condition correlates with this low Apgar score?

neonatla morbidity

The primary healthcare provider has prescribed different drugs for four clients with tuberculosis. Which client is at a risk of sunburn?

Client 4

The nurse is assessing a patient with spinal cord injury and recognizes that the patient is experiencing autonomic dysreflexia. What is the nurses priority action

Raise the head of the bed

After assessing a client's reports, the nurse confirms that the client has moderate hypothermia. What should be the nurse's immediate intervention? Select all that apply.

-administering heated o2 - positioning the client in supine position -applying external heat with blankets

adequate nutrition

-is essential so that the body has necessary factors to promote healing when injury occurs. -high fluid intake is needed to replace fluid loss from perspiration.

A nurse spends time in individual sessions helping a depressed, suicidal client verbalize feelings. For what themes should the nurse particularly listen? Select all that apply.

-isolation -hopelessness

What clinical manifestations does a nurse expect a client with systemic lupus erythematosus (SLE) most likely to exhibit? Select all that apply.

-joint pain -facial rash -percarditis

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.

-pallor -agitation -tachycardia -narrow pulse pressure

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?

Restore fluid volume

Pulse Pressure (PP)

SBP-DBP The force the heart generates each time it contacts <40 is low Early indicator to see if pt is having a problem

Treatment of full thickness burn

Skin grafting to heal Excision of eschar Topical agents

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

Slowing of a previously rapid pulse

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?

Smoke inhalation can cause edema of the respiratory lumen, interfering with oxygenation; evaluation of respiratory status is the first

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day. (Spacing activities will encourage maximum functioning within the limits of strength and fatigue.)

A woman who is infertile is diagnosed with primary ovarian failure. Which fertility drug regimen may be prescribed to treat infertility?

estrogen and progestins

Which data collected during a developmental assessment for a 5-year-old client would indicate the need for further intervention?

has a vocabulary of 1500 words

After a spontaneous pneumothorax, the client becomes extremely drowsy, and the pulse and respirations increase. What do these client responses indicate to the nurse?

hypercapnia

At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing?

hypoglycemia

A client with type 1 diabetes receives 30 units of NPH insulin at 7 am. At 3:30 pm the client becomes diaphoretic, weak, and pale. What does the nurse determine that these physiologic responses are associated with?

hypoglycemic reaction

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

increased serum lipids

The nurse is assessing a newborn with exstrophy of the bladder. What other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?

pubic bone malformation

A client is scheduled for a computed tomography (CT) scan of the chest with intravenous (IV) contrast. Which assessment is the priority before the test is performed?

serum creatinine levels

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should the nurse report to the primary healthcare provider immediately?

small amount of yellowish green oozing

shift to left

the finding of increased number of band neutrophils in circulation. -commonly found in pts w acute bacterial infections

acute inflammation

the healing that occurs in 2 to 3 weeks and usually leaves no residual drainage . -neutrophils are predominant cell type at the site

A nurse is learning about the maturation of systems in a school-age child. Which statement made by the nurse indicates effective learning?

the heart grows slower in the school-aged child than any other period of life

A nurse is admitting a client with the diagnosis of severe procidentia (prolapse of the uterus). What complication would the nurse anticipate finding during the assessment?

ulcerations

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the primary healthcare provider?

urine output of 20 to 30 mL/hr

inflammatory response can be divided into______

vascular response,cellular response, formation of exudate, and healing

The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L (2.3 mmol/L). What does the nurse expect when assessing this client?

vomiting, diarrhea, and decreased coordination

A nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6-month-old infant in which instance?

was born during the 32nd week of gestation

An orthopedic surgeon plans to have a school-aged child with cerebral palsy walk with crutches. What should the nurse determine before preparing this child for crutch-walking?

weight bearing ability of the child's four extremities

A nurse is assessing a wound that is healing by secondary intention. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

yellow

neutrophils

are the first leukocytes to arrive at the injury site (usually within 6-12 hrs. - they phagocytize (engulf) bacteria, other foreign material and damaged cells. -short life span of (24-48hrs) dead neutrophils accumulate.

Which statement by a client with multiple sclerosis indicates to the nurse that the client needs further teaching?

"I will take a hot bath to help relax my muscles." (Hot baths tend to increase symptoms and may result in burns because of decreased sensation.)

A nurse is performing a physical assessment of a client with gout. Which parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply.

-feet -ears

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply.

-flaccid paralysis -lack of reflexes below the injury

After assessing a client's condition, the nurse suspects that the client has diabetes mellitus. Which statement made by the client would be most appropriate in helping the nurse reach this conclusion? Select all that apply.

-i am 55 yo -i quite often feel thirsty -i eat food every 2 hours

The registered nurse is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? Select all that apply.

-i should keep the teaching sessions short -i should involve the client in any discussion or activity

systemic manifestations of inflammation

-increased WBC count w shift to left,malaise, nausea, and anorexia, increased pulse and resp rate and fever.

A client has a hysterectomy, salpingo-oophorectomy, tumor removal, and multiple abdominal biopsies for ovarian cancer. For which clinical manifestations indicating that the client may be experiencing a pulmonary embolus should the nurse assess the client? Select all that apply.

-increased temperature - decreased oxygen saturation level -sudden onset of SOB

Which drugs can be used as preanesthetic agents? Select all that apply.

-barbituates -benzodiazepines

The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring?

A classic migraine

The laboratory reports of a client reveal selective hypopituitarism related to growth hormone (GH). What other findings does the nurse anticipate in the client? Select all that apply.

-decreased muscle strength -increased serum cholesterol

The client with Parkinson disease is being discharged home with his wife. To ensure compliance with the management plan, which discharge action is most effective?

Involving the client and his wife in developing a plan of care

The registered nurse raises a concern about preparedness after the community healthcare provider explains the disaster plan schedule. Which statement made by the provider is the registered nurse concerned about?

"we should improvise the plan structure for handling the risks associated with the disaster

A client comes to the clinic reporting weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. Which question is most appropriate for the nurse to ask initially?

"when did it first become evident to you that you had a fever?"

What are the similarities between a preschooler and a toddler? Select all that apply.

-both preschoolers and toddlers have similar dietary requirements. -both preschoolers and toddlers are unable to recall explanations about pain.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

-bradycardia -hypotension -bladder dysfunction

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.

-capillary refill -pulse and skin temperature -movement and sensation

Upon assessment, the primary healthcare provider finds that the client is experiencing weight gain as well as elevated lipid and blood glucose levels. Which drugs in the client's prescription list are most likely to cause these metabolic side effects? Select all that apply.

-clozapine -olanzapine

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the physician will request which medication to aid in the diagnosis of MG?

*Edrophonium chloride (Tensilon)* Edrophonium chloride (Tensilon) is used most often for testing for MG because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors

A nurse is teaching a parent about promoting safety in adolescents. Which statements made by the parent indicate the need of further teaching? Select all that apply.

- "i should limit my child's interaction with adults" -"I should allow my child to play freely with peers"

A registered nurse teaches a nursing student about antipsychotic drugs. Which statements made by the nursing student need a correction? Select all that apply.

-"Antipsychotic drugs only benefits clients with psychotic symptoms" -"Antipsychotic drugs are always used in combination with lithium and valproate"

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply.

-Fat cells in the urine -PaO2 value of 58 mm Hg -Hematocrit value of 30%

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? A. Encourage the client to rest for short periods. B. Continue the bath while supporting the client's arms. C. Gradually increase the client's activity level each day. D. Administer a dose of pyridostigmine bromide.

A. Encourage the client to rest for short periods. Rationale: Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins. Continuing the bath while supporting the client's arms and gradually increasing the client's activity level each day will aggravate the fatigue; activity and rest should be delicately balanced to prevent fatigue. Administering a dose of pyridostigmine bromide cannot be done without a healthcare provider's prescription; rest usually will alleviate the fatigue.

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? 1 Accept the client's behavior. 2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions.

Accept the client's behavior. At this time the client is using this behavior as a defense mechanism. Acceptance can be an effective interpersonal technique because it is nonjudgmental. Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies non-acceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history? Any rectal cancer in the family. All foods eaten in the past 24 hours. Any recent extreme emotional stress. An upper respiratory infection in the past 10 days.

All foods eaten in the past 24 hours.

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas?

Ammonia level

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse. 1. Don a pair of clean gloves. 2. Run the transfusion slowly. 3. Determine the client's vital signs. 4. Ensure that the client signed a consent for the transfusion. 5. Compare the number on the blood product and laboratory record.

Compare the number on the blood product and laboratory record. Incorrect 3. Determine the client's vital signs. A client must sign a consent for the transfusion before the procedure; clients have the right to refuse. Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected. Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize risk of transfusion reactions. Clean gloves must be worn before inserting the spike of the blood administration set. The transfusion is run slowly for the first 15 to 20 minutes, but only after other steps have been completed.

What could be the possible cause of a scald injury? Contact with grease. Contact with hot liquids or steam. Contact with alkali in oven cleaners. Contact with open flame in house fires.

Contact with hot liquids or steam.

A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route?

Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury The medication begins to work in minutes; doses can be controlled Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue Impaired peripheral circulation is bypassed

Tissue damage is determined by

Depth- how many layers of tissue is affected Extent of burn- % of BSA involved

The nurse is caring for a patient with a recent spinal cord injury, which intervention does the nurse use to target and prevent the potential SCI complication o autonomic dysreflexia

Keep the room warm and control environmental stimuli, monitor stool output and maintain a bowel program, monitor urinary output and check for bladder distention

A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. When teaching skin care to the client, the nurse emphasizes:

Keeping the skin dry to protect it from excoriation

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when? 1 First 2 Second 3 Third 4 Last

Last The nurse should systematically assess the abdomen concluding with the symptomatic area. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere with the assessment.

Burn shock

Massive fluid shifts of plasma, electrolytes, and proteins into the burn wound causing edema Usually occurs within first 24 hours of injury Inability to maintain fluid in cells within vascular space

Remodeling phase

May lasts for years Collagen fibers reorganize into more compact areas Scars contract and fade in color

The client has Parkinson disease (PD). Which nursing intervention best protects the client from injury?

Monitoring the client's sleep patterns (Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).

Urine output is

Most reliable and sensitive non invasive assessment for CO and tissue perfusion

A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when recording on the client's progress report? Incorrect1 Spastic 2 Steppage Correct3 Shuffling 4 Scissoring

Shuffling Steps are short and dragging; this is seen with defects of the basal ganglia. Spastic gait is associated with unilateral upper motor neuron disease. Steppage gait is when the foot is lifted high to clear the toes; there is no heel strike, and the ground is hit first with the toes. It is associated with advanced diabetic neuropathy and peripheral neuritis. Scissoring gait is associated with bilateral spastic paresis of the legs.

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately?

Small amount of yellowish green oozing

Which drugs are used for the treatment of clients with rheumatoid arthritis that inhibit tumor necrosis factor-A? Select all that apply.

-Infliximab -etanercept - golimumab

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of:

Hypokalemia

Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment? a. A raised toilet seat b. Side rails for the bed c. A trapeze above the bed d. Crutches for ambulation

A

Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, and the other is stacking blocks. Which type of play are these children participating in based on this scenario?

Associative play

A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the healthcare provider should the nurse question? A. Colloids B. Potassium C. Hypertonic saline D. Lactated Ringer solution

B. Potassium

A nurse is preparing to change a client's dressing. The nurse recalls that the basis of surgical asepsis that is needed for this procedure is to:

Keep the area free of microorganisms

Chemical burn

Paralysis is most likely due to chemical burns caused by chemical fumes

Prednisone is prescribed for a client with an exacerbation of colitis. What does the nurse teach the client before administering the first dose?

although the medication decreases inflammation it will not cure colitis

what bacteria causes food poisoning?

answer=Clostridium botulinum causes food poisoning

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? A. Aspiration B. Dehydration C. Nutritional imbalance D. Impaired communication

A. Aspiration Rationale: Dysphagia may lead to aspiration, which can cause pneumonia, interfering with gas exchange and posing a threat to life. While nutrition and fluid intake will be adversely affected by dysphagia, dehydration and nutritional imbalance are not the priority. Dysphagia is difficulty swallowing and does not affect communication.

A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply. A. Respiratory depression B. Distention of the bladder C. Decreased blood pressure D. Fine tremor of the fingers E. High-pitched gurgling bowel sounds

A. Respiratory depression C. Decreased blood pressure E. High-pitched gurgling bowel sounds

A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiologic changes does the nurse expect the parents to report? Select all that apply.

-pale skin -eating less food -purplish spots on the skin

After assessing a client, a nurse concludes that the client may be experiencing hyperglycemia. Which clinical findings commonly associated with hyperglycemia support the nurse's conclusion? Select all that apply.

-polyuria -polydypsia -polyphagia

A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply.

-postural instability -incrased gait disturbances

The client arrives to the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease?

Myasthenia gravis (MG)

A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period?

dysrhythmias, especially atrial fibrillation

Diagnostic tests for burns

Pulse ox Carboxyhemoglobin measurement- for carbon monoxide poisoning ABGs 12 lead ECG Serial CXR studies UA CBC- decreased RBC, increased WBC Serum electrolytes Renal function test- decreased GFR, increased BUN, creatinine, urine specific gravity, uric acid Total protein Albumin C reactive protein- shows inflammation Blood glucose- increased

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. What is the best nursing intervention when providing wound care?

Use a consistent approach to care and encourage participation.

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess?

tissue ischemia

Lithium therapy is initiated for a client diagnosed with manic episodes. Laboratory testing shows that the client's lithium level is 1.2 mEq/L (1.2 mmol/L). Why would the healthcare provider reduce the client's lithium dosage?

to maintain serum drug level

A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective? "I should massage my feet and legs with oil or lotion." "I should apply heat intermittently to my feet and legs." "I should eat foods high in protein and carbohydrate kilocalories." "I should control my blood glucose with diet, exercise, and medication."

"I should control my blood glucose with diet, exercise, and medication." Controlling the diabetes decreases the risk of infection; this is the best prevention.

A client develops hydrocephalus two weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response?

blocked absorption of fluid from the arachnoid space

A client with myasthenia gravis has been receiving neostigmine and asks about its action. What information about its action should the nurse consider when formulating a response?

blocks the action of cholinesterase

A client with arthritis is taking large doses of aspirin. What symptom does the nurse include when teaching the client about the clinical manifestations of aspirin toxicity?

hearing disturbances (ringing in the ears, ottotoxicity, tinnitus).

A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. Which hemodynamic change of pregnancy is likely to affect the client at this time?

heart rate acceleration in the last half of pregnancy

A nurse is performing an admission health history and physical assessment of a client. The client's face is pictured below. Which information is most important to obtain?

heart rate and rhythm

The nurse is caring for a client diagnosed with Cushing syndrome. What symptoms does the nurse expect the client to exhibit?

lability of mood

The nurse is comparing Meso-2,3-dimercaptosuccinic acid (DMSA) and British antilewisite (BAL) as chelating agents to be used as treatment for lead poisoning. Which statements indicate correct knowledge regarding chelating agents? Select all that apply.

-"DMSA is given orally while BAL is given intramuscualrly - "Both DMSA and BAL are given in repeated doses over several days"

The nurse suspects stage I seminoma in a client with Klinefelter syndrome. Which diagnostic tests would be helpful in further evaluating the mass? Select all that apply.

-alpha fetoprotein -lactase dehydrogenase -beta human chorionic gonadotrophin

Which physiologic responses should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

-blurred vision -increased appetite -widened pulse pressure

A client who has been immobile for a prolonged time develops hypercalcemia. Which findings are consistent with this condition? Select all that apply.

-bone pain -depressed deep tendon reflexes

Which statements are related to nursing roles and function changes in the health care organization? Select all that apply.

-conflict management technique is beneficial -society needs nurses who can engage in political policy development

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply. 1

-decreased pulse -weak pulse -difficulty swallowing -loss of bladder control

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply.

-rapid pulse -decreased urinary output

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply.

oral temperature of 98.2 -apical pulse of 88 bmp -bp 116/78

During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action?

palpate the suprapubic area of the abdomen

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply.

-headache -abdominal pain -visual disturbances

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.

-hirsutism -buffalo hump

Which questions should the nurse ask to elicit psychosocial issues in a client with cancer? Select all that apply.

-how is your family dealing with your condition -how do you rate your distress on a scale of 0 to 10

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply.

-i should use pressure relieving pads -i should place pillows between two bony surfaces

The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan?

"I must not miss a meal!" (Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified).

Which complication may be caused by sepsis in burns?

Paralytic ileus

A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response?

"It relieves pain while promoting rapid healing."

The nurse is teaching the client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates correct understanding of the pathophysiology of the disease?

"Parts of my nervous system have plaques." (MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system).

Which action demonstrates the "analyticity" concept of a critical thinker? Select all that apply.

- The nurse uses evidence-based knowledge for clinical decision-making - the nurse anticipates possible results or a consequence in a given situation.

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1 Determining drug allergies 2 Noting the general appearance 3 Examining the neck for stiffness 4 Auscultating for heart and lung sounds

1 The priority nursing action during the health history portion of the assessment is to determine drug allergies. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history.

The nurse is conducting a primary survey during an emergency assessment. Which are the priority nursing actions related to breathing in response to this assessment? Select all that apply. 1 Having suction available 2 Giving supplemental oxygen 3 Assessing pupil size and reactivity 4 Immobilizing any obvious deformities 5 Obtaining blood samples for type and crossmatch

1 2 The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen. Assessing pupil size and reactivity is an appropriate nursing action during the brief neurologic assessment. Immobilization of any obvious deformities is a nursing action appropriate in response to data obtained during the disability portion of the assessment. Obtaining blood samples for a type and crossmatch is a nursing action appropriate in response to data obtained during the circulation portion of the assessment.

A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation?

1. A jaw-thrust maneuver helps to establish an airway and breathing 2. bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. 3. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. 4. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. 5. The clothes of the client are removed with scissors to prevent fabric melting into the skin.

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.

1. Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist 2. Apply either a surgical mask or a respirator around the mouth and nose 3. Apply eyewear or goggles snugly around the face and eyes 4.Apply clean gloves within the gown 5. Bring the glove cuffs over the edge of the gown sleeves

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1. Arrangements will be made by the client and the client's family. 2. The plan is formulated and implemented early in the client's care. 3. The rehabilitation is minimal and short term, because the client will return to former activities. 4. Arrangements will be made for long-term care, because the client is no longer capable of self-care.

2 rationale: To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the healthcare system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.

The primary healthcare provider instructs the nurse to place a client with burns in the supine position with the affected arm over the head to reduce the risk of contractures. Which part of the client is affected due to burns? 1 Wrist 2 Lateral trunk 3 Anterior shoulder 4 Posterior shoulder

2 A client whose lateral trunk is affected due to burns should be placed in supine position with the affected arm over the head to reduce the risk of contractures. A client whose wrist is affected should use a splint. The nurse should maintain the upper arm at 90 degrees of abduction from the lateral aspect of the trunk of a client whose anterior shoulder is affected. The nurse should keep the arm slightly behind the midline of a client whose posterior shoulder is affected.

A 15-year-old adolescent is admitted with partial- and full-thickness burns of the arms and upper torso. What are the purposes of administering pain medication by way of the intravenous route rather than the intramuscular route? Select all that apply. 1 Adolescents are afraid of injections. 2 It decreases the risk of tissue irritation. 3 Severe pain is reduced more effectively. 4 Impaired peripheral circulation is bypassed. 5 It provides for more prolonged relief of pain.

2 3 4 Decreasing the risk for tissue irritation can reduce the risk of infection, which is also one of the top care priorities after a burn injury. The medication begins to work in minutes; doses can be controlled. Intramuscular medications are avoided when possible to prevent inadequate absorption of the medication because of damaged tissue. Stating that adolescents are afraid of injections is a generalization that is not necessarily true. The duration of effectiveness of an analgesic is based on its therapeutic level in the body, regardless of what route is used.

The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process? 1. Removing the cervical spine collar 2. Monitoring for autonomic dysreflexia 3. Implementing the logrolling technique 4. Administering the prescribed pain medication

3 rationale: The priority when moving a client who presents with a neck and a spinal cord injury is to logroll the client whenever a transfer must occur. The nurse would not remove the cervical spine collar because this can exacerbate the original injury. The nurse would not monitor for autonomic dysreflexia during the acute phase of the injury. While monitoring and addressing pain is important, this is not the priority when transferring this client.

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained?

3) Electrical burn. Rationale: In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

A preschool child with a spinal cord injury will be on prolonged bed rest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan? 1. fish 2. fruit 3. beef 4. cheese

4 rationale: Cheese contains calcium, which is excreted by the kidneys and may contribute to the formation of kidney stones; it adds to the child's risk because immobility causes bone decalcification. Fish contains protein, which is needed for wound healing and growth. Fruit contains some fiber, which will help decrease the risk of constipation. Beef contains protein, which is needed for wound healing and growth.

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? 1. dehydration 2. skin breakdown 3. electrolyte imbalances 4. urinary tract infections

4 rationale: Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer? 1. A 2. B 3. C 4. D

4 rationale: The sacrum, letter D, bears the most pressure because it is the focal point of the weight of the body when in the low Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low Fowler position.

Which wound care is given to a client with severe burn injuries during the acute phase?

4) Assess the wound daily and adjust dressing. Rationale: In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase.

What are the steps of performing a primary survey according to priority to assess a client with severe injuries from a bomb blast? Correct 1. Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure

ABCDE The initial assessment of a client with severe injuries in a bomb blast is called the primary survey. It is based on a standard "ABC" mnemonic plus a "D" and "E." Here, A stands for airway/cervical spine, B for breathing, C for circulation, D for disability, and E for exposure.

In full thickness burns dead tissue can

Act as a rubber band if it's all the way around the extremity

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? 1 Moro 2 Babinski 3 Stepping 4 Cremasteric

Babinski This is the description of how to elicit the Babinski reflex. If it is present in adults it may indicate a lesion of the pyramidal tract. The Babinski reflex is expected in newborns and disappears after one year. The Moro (startle) reflex is expected in newborns. It disappears between the third and fourth months; if present after four months, neurological disease is suspected. The stepping reflex is expected in newborns. It disappears at about three to four weeks after birth and is replaced by more deliberate action. The cremasteric is a superficial reflex that tests lumbar segments 1 and 2. Stimulation of this reflex is useful in initiating reflex emptying of the spastic bladder after a spinal cord disruption above the second, third, or fourth sacral segment.

A client with a spinal cord injury has paraplegia. The nurse assesses for which major problem the client ,y's experience in the recovery period

Bladder control

The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?

Blistered and wet

A client is recovering from full-thickness burns and the nurse provides counseling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching?

Cheeseburger and a malted milkshake

The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? A. Diazepam B. Meperidine C. Flurazepam D. Morphine sulfate

D. Morphine sulfate

A client, admitted to the cardiac care unit with a myocardial infarction, complains of chest pain. What intervention will be most effective in relieving the client's pain? A. Nitroglycerin sublingually B. Oxygen per nasal cannula C. Lidocaine hydrochloride 50 mg IV bolus D. Morphine sulfate 2 mg intravenously (IV)

D. Morphine sulfate 2 mg intravenously (IV)

The ER nurse is Assessing and monitoring a patient with a gunshot wound to the middle of the back. Because the patient is at risk for spinal shock what does the nurse monitor for

Decreased BP, bradycardia and flaccid paralysis

On the second day after sustaining extensive severe burns a 6-year-old child exhibits edema and decreased urine output. For which additional adverse response should the nurse assess the child in this early stage of burn injury?

Disorientation may be an initial indication of dehydration or an early sign of hypoxia resulting from respiratory complications Tachycardia

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?

Disorientation with twitching

A client is admitted for the repair and revision of a residual limb after a traumatic amputation of the hand. A week after surgery the client complains of constant throbbing in the affected limb. Which is the most appropriate nursing intervention? 1 Apply cool compresses to the limb 2 Secure a prescription for pain medication 3 Elevate the extremity on two pillows 4 Loosen the bandage around the limb

Elevate the extremity on two pillows Elevation of the extremity promotes venous return, which limits edema and the related pressure on nerve endings that causes pain. Cool compresses limit venous return; vasoconstriction interferes with wound healing. A week after surgery the discomfort probably is caused by venous congestion related to the limb's dependent position rather than incisional pain. Loosening the bandage around the limb is contraindicated because the bandage prevents bleeding and edema and promotes shrinkage of the residual limb. Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.

A patient comes to the ER department with back pain, but is alert and oriented and is not having any problems breathing. Her husband is very distraught and when the nurse tries to find out what has happened he yells, just help her now, stop asking ,e these stupid questions, why is it important for the nurse to continue trying to obtain information from the husband

Engaging the husband will help him to calm down and give him and active role

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms?

Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies that which factor may have contributed to the development of the calculi?

History of hyperparathyroidism

Cardiac complications with burns

Hypovolemic shock/burn shock- within minutes after major burn Dysrhythmias- pts with electrical burns, hyperkalemia Peripheral vascular compromise- circumferential burns encircles an extremity, compartment syndrome

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply

Identifying the causative agent for neutropenia is important for starting treatment. Therefore the priority nursing intervention is to obtain blood cultures immediately and administer antibiotic STAT as prescribed to the client. The nurse can monitor for rashes and pruritus after administering the medication. The nurse can prepare a diet plan and teach hygiene measures after stabilizing the client.

Which image represents a deep full-thickness burn injury?

Image 4 represents the typical appearance of a full-thickness burn injury. This injury has a hard, dry, leathery eschar formed from the coagulated particles of destroyed skin. Image 1 signifies a superficial partial-thickness burn injury. Image 2 also represents a superficial partial-thickness burn injury. Image 3 signifies the typical appearance of a deep partial-thickness burn injury.

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? 1 Inflating the cuff too slowly 2 Wrapping the cuff too loosely 3 Applying the stethoscope too firmly 4 Repeating the assessment too quickly

Inflating the cuff too slowly Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.

A client had surgery for a strangulated hernia. One hour after surgery the client's blood pressure drops from 134/80 to 114/76 mm Hg. Assessment reveals that the client does not have postoperative bleeding. What action should the nurse take? 1 Place the client in the left side-lying position. Correct2 Instruct the client to move both legs. Incorrect3 Notify the primary health care provider immediately. 4 Administer the prescribed pain medication.

Instruct the client to move both legs. The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return. Turning the client onto the left side will not increase the blood pressure; this intervention is used for pregnant women to move the gravid uterus off the vena cava, which increases placental perfusion. Calling the health care provider eventually may be done after performing the initial interventions and evaluating results. Opioid analgesics may decrease the blood pressure further.

A nurse finds a victim under the wreckage of a collapsed building, the individual is conscious, supine, breathing satisfactorily and reporting back pain and the inability to move the legs, what action should the nurse take first

Leave the individual lying on the back with instructions not to move and seek additional help

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.

Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

Which diagnostic test may be used to distinguish vascular from nonvascular structures? Chest X-ray Pulmonary angiogram Computed tomography Magnetic resonance imaging

Magnetic resonance imaging. Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.

The nurse is caring for a client that has been admitted with partial- and full-thickness burns over 25% of the total body surface area (TBSA). Lactated Ringers and 5% dextrose have been prescribed to be rapidly infused to:

Maintain blood volume

A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take?

Notify the primary healthcare provider of the result, which is critically low.

Bed rest is prescribed after a client's cerebrovascular accident (also known as "brain attack") results in hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? Correct1 Passive range-of-motion exercises 2 Active exercises of the extremities 3 Light weight-lifting exercises of the right side 4 Isotonic exercises that will capitalize on returning muscle function

Passive range-of-motion exercises Passive range-of-motion exercises prevent the development of deformities (e.g., contractures) and do not require any energy expenditure by the client. Instituting range-of-motion exercises is an independent nursing function. Bed rest is prescribed to decrease oxygen demands; active exercises markedly increase oxygen consumption.

A client had a cerebrovascular accident (also known as a "brain attack") and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client? 1 Splints 2 Blocks 3 Cradles 4 Sandbags Splints

Splints Various types of splints or boots are available to keep the foot in a position of functional alignment. Blocks elevate the frame of the bed and have no effect on the position of the feet. Although a cradle will keep the pressure of the linen off the client's feet, which otherwise may promote footdrop, the cradle does not maintain functional alignment of the ankle. Sandbags help prevent rotation of an extremity or the head; they are not used to prevent footdrop.

How is stage 2 of Kohlberg's theory different from stage 1?

Stage 2 is about recognizing another's point of view

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority?

Take the medication according to a specific schedule (A priority of care for a client with myasthenia gravis is to take medication according to a specific schedule; for example, the anticholinergic medication should be taken before meals because it enhances chewing and swallowing).

A patient has been talking to his physician about drugs that could potentially be used in the treatment of his chronic low back pain. Which statement by the patient indicates a need for additional teaching

The doctor may prescribe hydromorphone and it may cause drowsiness, I should not drive or drink alcohol when I take it

The nurse is preparing a quad patient for discharge and has taught the patients spouse to assist the patient with a quad cough to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught

The spouse places her hands below the diaphragm and pushes upward as the patient exhales

what is thermography??

Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface. Therefore it is used to investigate the cause of an inflamed joint and in determining the client's response to antiinflammatory drug therapy.

Why is Phalen's test performed in a client? To diagnose atrophy To diagnose bone tumor To detect rotator cuff injuries To detect carpal tunnel syndrome

To detect carpal tunnel syndrome

The nurse is providing education about care of the residual limb to a client that had a below-the-elbow amputation. The teaching should include:

Washing and drying the residual limb at least once a day

A client who sustained serious burns now has a stress ulcer. When caring for this client, what clinical indicators of shock should the nurse immediately report to the health care provider? Select all that apply.

Weakness Diaphoresis Tachycardia Cold extremities

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person?

Wrap the person in a clean, dry sheet

The nurse is examining four different clients who present with thermal burns. Which client does the nurse diagnose as having second-degree burns?

c) Moist blebs, blisters, severe pain. Rationale: Client C has second-degree burns. The client is experiencing severe pain and the skin shows moist blebs and blisters. Client A may have third- and fourth-degree burns, in which the skin is waxy white, dark brown in appearance. Client B may have first-degree burns, in which the skin is red in color with minimal edema and pain. Client D may have third- and fourth-degree burns as the skin is dry, leathery eschar and there is absence of pain.

A nurse is evaluating the results of treatment with erythropoietin. Which assessment finding indicates an improvement in the underlying condition being treated?

decreased pallor

A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of drugs from which class? A. Steroids B. Diuretics C. Anticonvulsants D. Antihypertensives

A. Steroids

A nursing student is educating a client about the use of tampons. Which statement made by the nursing student indicates a need for correction?

"Use a superabsorbent tampon during the daytime." Organisms such as Staphylococcus aureus and Streptococcus pyogenes may cause toxic shock syndrome (TSS) due to tampon use. Therefore the client should not use a superabsorbent tampon. The client should wash his or her hands before inserting a tampon to maintain good hygiene. Limiting tampon use reduces TSS to a great extent; the client should use sanitary napkins at night. High temperatures, vomiting, and diarrhea are manifestations of TSS due to tampon use. These symptoms should be reported immediately to the primary healthcare provider.

A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what?

2) 4200 mL Rationale: In the first 8 hours 4200 mL should be infused. According to the Parkland (Baxter) formula, one half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication? 1. 15 minutes before the dressing change 2. 60 minutes before the dressing change 3. Along with a stool softener each time it is administered 4. Only if the client rates pain between 8 and 10 on the pain scale

2. 60 minutes before the dressing change Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change. Although pain medications can cause constipation, the nurse would not administer a stool softener each time the morphine is administered. If the client is experiencing pain and rates it anywhere on the pain scale, the client can receive pain medication if it is within the timeframe. It is important to premedicate a client before a painful procedure.

A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? 1. Colitis 2. Gastritis 3. Stress ulcer 4. Metabolic acidosis

3. Stress ulcer An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H2 antagonists.

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing? 1 Bradypnea 2 Bradycardia 3 Hypotension 4 Hypothermia

4 After the removal of the burn client's clothing, the priority for the nurse is to monitor for hypothermia because burn trauma clients lose their ability to maintain body temperature due to the loss of skin which acts as an insulator. While the nurse will monitor for bradypnea, bradycardia, and hypotension, hypothermia is the priority.

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1 Urticaria 2 Tachycardia 3 Restlessness 4 Laryngeal edema

4 Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, cutaneous signs of urticaria, tachycardia, and increasing restlessness, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

495ml

How should a nurse prepare an intravenous piggyback (IVPB) medication for administration to a client receiving an IV infusion? Select all that apply. A. Wear clean gloves to check the IV site. B. Rotate the bag after adding the medication to mix. C. Use 100 mL of fluid to mix the medication. D. Flush the IV insertion site with 2 mL saline. E. Place the IVPB at a lower level than the existing IV. F. Use a sterile technique when preparing the medication.

A. Wear clean gloves to check the IV site. B. Rotate the bag after adding the medication to mix. F. Use a sterile technique when preparing the medication.

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client?

Avoid leaning forward. (The client with Parkinson disease often has a stooped posture because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.)

Complications of burns

AFFECTS ALL BODY SYSTEMS Respiratory function compromised CO decreased Tissue perfusion decreased Dysrhythmias, circulatory failure Third spacing Massive infection Fluid and electrolyte imbalance Skin loss Hypothermia

The client is being evaluated for signs associated with myasthenia crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis?

Abdominal cramps, blurred vision, facial muscle twitching (Abdominal cramps, blurred vision, and facial muscle twitching are signs of an acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs.).

A nurse is assessing a client eight hours after the creation of a colostomy. Which assessment finding should the nurse expect? 1 Presence of hyperactive bowel sounds 2 Absence of drainage from the colostomy 3 Dusky-colored, edematous-appearing stoma 4 Bright bloody drainage from the nasogastric tube

Absence of drainage from the colostomy A colostomy does not function for two to four days postoperatively because of the lack of peristalsis. Bowel sounds will be absent until peristaltic activity returns. A dusky-colored, edematous-appearing stoma indicates a problem with circulation to the stoma; it should be cherry red. Bright bloody drainage from the nasogastric tube indicates gastric bleeding, which is abnormal.

A client who works in the leather industry reports bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suspects a tumor of the nasal cavity and suggests the client consult a primary health care provider immediately. Which type of leadership does the nurse exhibit?

Adaptive leadership

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?

Administer 4 mL of phenytoin suspension containing 125 mg/5 mL.

The client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse?

Administer medications promptly on schedule to maintain therapeutic drug levels & Small frequent meals

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress

An unconscious means of reducing stress When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? a. The injury results in loss of the reflex arc. b. The injury is above the sixth thoracic vertebra. c. There has been a partial transection of the cord. d. There is a flaccid paralysis of the lower extremities.

B

During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? a. Diminished visual acuity b. Increased muscular weakness c. Pronounced muscular atrophy d. Impairment in cognitive reasoning

B

The family member of a client with newly diagnosed Guillain-Barré syndrome comes out to the nurse's station and informs the nurse that the client is having difficulty breathing. What is the first action the nurse should do? a. Notify the healthcare provider. b. Go with the family member to assess the client. c. Send the nursing assistive personnel to take vital signs. d. Assure the family member this is a normal response for this disease.

B

While assessing the client, the nurse observes abnormal eye movement. The client reports dizziness when standing or walking. Which structure of the auditory system might be affected in this client? A. tympanic membrane B. vestibular system C. auditory tube D. cochlea

B- Abnormal eye movement is seen in nystagmus. Dizziness when standing or walking may indicate vertigo in the client. These both are manifested due to problems with balance, which is maintained by the vestibular system marked by B. The structure represented as A is the tympanic membrane, a part of the middle ear. Conductive hearing loss may occur if the tympanic membrane is affected. The structure represented as C is the auditory tube, which helps to equalize atmospheric air pressure between the middle ear and throat and allows the tympanic membrane to move freely. Structure C is not associated with vertigo and nystagmus. The structure represented as D is the cochlea and is involved in the transmission of sounds. Hearing impairment may result if the cochlea is affected.

A client with myasthenia gravis improves and is discharged from the hospital. The discharge medications include pyridostigmine bromide 10 mg every 6 hours. The nurse evaluates that the drug regimen is understood when the client makes which statement? A. "I will take the medication on an empty stomach." B. "I need to set an alarm so I take the medication on time." C. "It will be important to check my heart rate before taking the medication." D. "I should monitor for an increase in blood pressure after taking the medication."

B. "I need to set an alarm so I take the medication on time."

A client newly diagnosed with myasthenia gravis is to begin taking pyridostigmine, a cholinesterase inhibitor. Two days later the client develops loose stools and increased salivation. What conclusion does the nurse make about these new developments? A. Indicative of a myasthenic crisis B. Cholinergic effects C. A temporary response D. Toxic effects of the medication

B. Cholinergic effects Rationale: Because this drug inhibits the destruction of acetylcholine, parasympathetic activity may be increased. The signs do not indicate a myasthenic crisis. Myasthenic crisis is characterized by difficulty breathing or speaking, morning headaches, feeling tired during the daytime, waking up frequently at night, not sleeping well, weak cough with increased secretions (mucus or saliva), an inability to clear secretions, a weak tongue, trouble swallowing or chewing, and weight loss. Side effects are not temporary; they continue as long as the drug is continued. The dosage may be adjusted or an anticholinergic given to limit side effects. Toxicity or cholinergic crisis is manifested by increased muscle weakness, including muscles of respiration.

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? A. Problems with cognition B. Difficulty swallowing saliva C. Intention tremors of the hands D. Nonintention tremors of the extremities

B. Difficulty swallowing saliva Rationale: Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

Potassium chloride effervescent tablets are prescribed for a client who is to be discharged from the emergency department. What information should the nurse include when teaching the client about this medication? A. Chew the tablet completely. B. Take the medication with food. C. Take the medication at bedtime. D. Use warm water to dissolve the tablet.

B. Take the medication with food.

1. A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen. 00:00:37

Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

Belonging Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1 Bradycardia 2 Hypotension 3 Spastic paralysis 4 Bladder dysfunction 5 Increased pulse pressure

Bradycardia 2 Hypotension Bladder dysfunction Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply.

Butterfly facial rash Inflammation of the joints

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. i. Spasticity ii. Incontinence iii. Flaccid paralysis iv. Respiratory failure v. Lack of reflexes below the injury a. i, ii b. iii, iv c. iii, v d. iv, v

C

Which clients belong to class I according to the disaster triage tag system? A Clients who can wait a short time for treatment B Clients who are dead or expected to die C Clients who need emergency treatment D Clients who have no urgent need for treatment

C Emergent clients are identified with red tags and belong to class I according to the disaster triage tag system. Clients who can wait a short time for treatment are identified by yellow tags and belong to class II according to the disaster triage tag system. Clients who are expected to die or are dead are given a black tag and belong to class IV in the disaster triage tag system. Clients who have no urgency for treatment are issued green tags and belong to class III.

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern? A. Flexing B. Localizing C. Extending D. Withdrawing

C- Abnormal upper arm extension receives a rate of 2 because it is characteristic of decerebrate (extension) posturing. Greater injury leads to less purposeful movement. Decerebrate posturing indicates severe brain injury; the only more serious response is total lack of response. Flexing, characteristic of decorticate (flexion) posturing associated with severe brain injury, receives a rate of 3. Localizing receives a rate of 5. The inability to withdraw from a painful stimulus indicates the greatest neurologic impairment. Withdrawing receives a rate of 4.

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? A. Pelvic warmth B. Feeling flushed C. Shortness of breath D. Salty taste in the mouth

C- An untoward response to the iodinated dye used as a contrast is anaphylaxis, a life-threatening allergic response. Anaphylaxis is manifested by respiratory distress, hypotension, and shock; counteractive measures must be instituted. A feeling of warmth or flushing is an expected minor side effect. A salty taste is an expected minor side effect.

During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action? A. Begin teaching self-catheterization. B. Develop a plan to ensure high fluid intake. C. Palpate the suprapubic area of the abdomen. D. Initiate a regimen to monitor urinary output.

C. Palpate the suprapubic area of the abdomen. Rationale: Assessment is the priority; the nurse should determine whether clinical manifestations are caused by a full bladder. Teaching self-catheterization may be necessary eventually, but it is not the initial action. Ensuring an increase in fluid intake may be done to reduce urinary bacterial count and stone formation, but it is not the initial action. Initiating a regimen to monitor urinary output should be done, but it is not the initial action.

A client is receiving penicillin G and probenecid for syphilis. What rationale should the nurse give for the need to take these two drugs? A. Each drug attacks the organism during different stages of cell multiplication. B. The penicillin treats the syphilis, whereas the probenecid relieves the severe urethritis. C. Probenecid delays excretion of penicillin, thus maintaining blood levels for longer periods. D. Probenecid decreases the potential for an allergic reaction to penicillin, which treats the syphilis.

C. Probenecid delays excretion of penicillin, thus maintaining blood levels for longer periods.

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response? A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of only the ptosis

C. Rapid but brief symptomatic improvement Rationale: Tensilon acts systemically to increase muscle strength; it lasts several minutes. Tensilon produces a brief increase in muscle strength; with a negative response the client will demonstrate no change in symptoms. Tensilon may intensify muscle weakness in a cholinergic crisis. Tensilon does not cause lasting effects. Tensilon acts systemically on all muscles, rather than selectively on the eyelids.

A client who is hospitalized after a myocardial infarction asks the nurse why morphine was prescribed. What will the nurse include in the reply? A. Decreases anxiety and promotes sleep B. Helps prevent development of atrial fibrillation C. Relieves pain and reduces cardiac oxygen demand D. Dilates coronary blood vessels to increase oxygen supply

C. Relieves pain and reduces cardiac oxygen demand

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? A. They contain little, if any, sodium. B. Absorption by the stomach mucosa is markedly enhanced. C. There is no direct effect on the systemic acid-base balance when taken as directed. D. Fewer side effects, such as diarrhea or constipation, are experienced when they are used properly.

C. There is no direct effect on the systemic acid-base balance when taken as directed.

A client receiving combination chemotherapy for treatment of metastatic carcinoma asks the nurse in the clinic why more than one type of drug is necessary. Which concept is most important to teach the client in relation to why drug cocktails are more effective than a single drug in cancer therapy?

Cellular growth cycle

A client, residing in an assisted living facility, is diagnosed with Parkinson disease and the health care provider prescribes selegiline (Eldepryl). What precaution should the nurse teach the client?

Change positions slowly (A common side effect of selegiline is dizziness. Safety precautions are necessary to prevent falls caused by orthostatic hypotension).

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?

Change the drainage bag at least once a week as needed.

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?

Chest tightness (Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing; the nurse should instruct the client to not take the medication until the nurse can talk with the prescribing health care provider).

Which is a primary glomerular disease? Diabetic glomerulopathy. Chronic glomerulonephritis. Hemolytic-uremic syndrome. Systemic lupus erythematosus (SLE).

Chronic glomerulonephritis. Diabetic glomerulopathy, hemolytic-uremic syndrome, and systemic lupus erythematosus (SLE) are secondary glomerular diseases.

The nurse is assessing four clients in the postoperative unit. Which client will be monitored for fluid volume overload as nursing safety priority?

Client A

A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide, and long-term steroid therapy has been initiated. What is especially important for the nurse to ensure? A. The client increases sodium intake. B. Protective isolation is established. C. Total daily fluid intake is decreased. D. The client is monitored for an exacerbation of symptoms.

D. The client is monitored for an exacerbation of symptoms. Rationale: Exacerbation of myasthenia gravis may occur temporarily at the beginning of steroid therapy, causing respiratory embarrassment and dysphagia. Increasing sodium intake is contraindicated because steroids increase sodium retention. Although clients should avoid contact with persons who have upper respiratory infections, protective isolation (neutropenic precautions) is not required. Decreasing total daily fluid intake is unnecessary; adequate fluid intake should be maintained.

A client is treated with lorazepam (Ativan) for status epilepticus. What effect of lorazepam does the nurse consider therapeutic? 1 Slows cardiac contractions. 2 Dilates tracheobronchial structures. Correct3 Depresses the central nervous system (CNS). 4 Provides amnesia for the convulsive episode.

Depresses the central nervous system (CNS). Lorazepam an anxiolytic and sedative, is used to treat status epilepticus because it depresses the CNS. Slower cardiac contractions are not an effect of lorazepam. Dilating tracheobronchial structures is not an effect of lorazepam. Providing amnesia for the convulsive episode is not an effect of lorazepam.

Nitrofuratoin used during the fifth week of pregnancy places the neonate at risk for which condition?

cleft lip

A nurse is assessing four clients. Which client would benefit from reality orientation?

client D

S/S of burn shock

Decrease in fluid volume within vascular space to interstitial compartment due to loss of cell wall integrity CO decreases- hypotension, urine output decreases, HR increases Body compensates with vasoconstriction, but only for so long Abnormal platelet aggregation and WBC accumulation result in ischemia in deep tissue Edematous body surfaces impair peripheral circulation- results in necrosis of underlying tissue Hyperkalemia- high risk for dysrhythmia due to potassium leaving intracellular compartment

Which drug can cause diabetes insipidus? Cabergoline Metyrapone Demeclocycline Aminoglutethimide

Demeclocycline. Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication?

Disorientation with twitching Excess extracellular fluid moves into cells (water intoxication) Intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include anorexia, nausea, vomiting, sleepiness, and convulsions

An ambulatory female client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a (Avonex). What adverse effects should the nurse explain may occur when taking this medication?

Depression, Flulike symptoms, constipation and Increased heart rate (Central nervous system effects include depression that may lead to suicide attempts. Gastrointestinal side effects include constipation, diarrhea, vomiting, and abdominal pain. Interferon immune modifier causes flulike symptoms, such as fever, muscle aches, and lethargy. Drugs for increased heart rate include side effects such as tachycardia, palpitations, and hypertension. An integumentary response to this drug is sweating, not lack of perspiration (anhidrosis)).

A client is admitted with cellulitis of the left leg and a temperature of 103° F. The primary health care provider prescribes intravenous (IV) antibiotics. Before instituting this therapy, the nurse should:

Determine the client's allergies

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (Select all that apply.)

Diarrhea, Weakness, Dysrhythmias

A dehydrated older adult is admitted to the hospital from a nursing home. The transfer form documents a history of liquid fecal incontinence. Which diagnostic intervention by the health care provider promotes identification of the cause of this incontinence? 1 Abdominal percussion 2 Digital rectal examination 3 Urine culture and sensitivity test 4 Pelvic and abdominal ultrasound

Digital rectal examination Fecal impaction is the primary cause of liquid fecal incontinence. A digital rectal examination will determine the presence of a fecal impaction. Abdominal percussion will not assist in the diagnosis of impaction. Urine culture and sensitivity test will identify urinary tract infection; urinary, not fecal, incontinence is associated with urinary tract infection. Pelvic and abdominal ultrasound might be done if earlier assessments are inconclusive and additional evaluations are required.

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiologic response to the radiation should the nurse assess the client during the return visit to the radiology department?

Dysphagia

What does the nurse do to implement bowel and bladder training for a patient with a SCI

Ensure the patient gets sufficient quantity of fluids each day, assist the patient in developing a schedule, teach the patient about high fiber foods, teach the patient to stimulate voiding by stroking the inner thigh, measure bladder residuals with a bladder ultrasound device

Two siblings who live in a camp for migrant workers have contracted measles. The nurse, trying to determine which individuals had contact with the children, identifies those with immunity and assesses the probability of containing the measles to the camp. What technique has the nurse used in managing this situation?

Epidemiological process

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program?

Explain ways to prevent physical trauma from occurring during a seizure The client may become injured in many ways during a seizure, and trauma prevention is a priority. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and should be taken with food. Seizures and seizure disorders are not similar; they vary greatly. Others should understand the condition and be taught how to help in case of a seizure.

The nurse notes that the client's rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. The nurse realizes that the client is in: Incorrect1 First degree atrioventricular (AV) block. 2 Second degree AV block Mobitz I (Wenckebach). Correct3 Second degree AV block Mobitz II. 4 Third degree AV block (complete heart block).

First degree atrioventricular (AV) block. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Also called Mobitz I or Wenckebach phenomenon, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? Ketoacidosis Somogyi phenomenon Hypoglycemic reaction Hyperosmolar nonketotic coma

Ketoacidosis. Ketoacidosis occurs when insulin is lacking and carbohydrates cannot be used for energy; this increases the breakdown of protein and fat, causing deep, rapid respirations (Kussmaul respirations), decreased alertness, decreased circulatory volume, metabolic acidosis, and an acetone breath. The Somogyi phenomenon is a rebound hyperglycemia induced by severe hypoglycemia; there are not enough data to determine whether this occurred. Hypoglycemia is manifested by cool, moist skin, not hot, dry skin; Kussmaul respirations do not occur with hypoglycemia. Hyperosmolar nonketotic coma usually occurs in clients with type 2 diabetes because available insulin prevents the breakdown of fat.

A nurse performs Leopold's maneuvers on a pregnant client and documents the following data: soft, firm mass in the fundus; several small parts on the right side; hard, round, movable object in pubic area; and cephalic prominence on right side. Applying these findings, which fetal position does the nurse identify?

Left occipitoanterior (LOA)

A client with a quadriplegia is placed on a tilt table daily. Each day the angle of the head of the table gradually is increased. what should the nurse identify as it's purpose when the client asks the reason for the tilt table.

Limit loss of calcium from the bones

Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis?

Monitoring respiratory status.

Which type of immunity is acquired through the transfer of colostrum from the mother to the child? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity

Natural passive immunity. Natural passive immunity is acquired through the transfer of colostrum from the mother to the child. Natural active immunity is acquired when there is a natural contact with an antigen through a clinical infection. Artificial active immunity is acquired through immunization with an antigen. Artificial passive immunity is acquired by injecting serum from an immune human.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has: 1 No spontaneous reflexes 2 Shallow and slow breathing Correct3 No cortical functioning with some reflex breathing Incorrect4 Deep tendon reflexes only and no independent breathing

No cortical functioning with some reflex breathing A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of brain dead.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily Give 1 L of 0.9% normal saline (NS) bolus over 4 hours Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr No prescription change

No prescription change. The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure).

Which retrograde procedure involves the examination of the ureters and the renal pelvises? Cystogram. Pyelogram. Urethrogram. Voiding cystourethrogram.

Pyelogram. A pyelogram is a retrograde examination of the ureters and the pelvis of both kidneys. A cystogram is a retrograde examination of the bladder. An urethrogram is a retrograde examination of the urethra. A voiding cystourethrogram is used to determine whether urine is flowing backward into the urethra.

An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply. 1 Increased high-density lipoprotein (HDL) 2 Taking an aspirin a day 3 Occasional cocaine use 4 Reduced hemoglobin level 5 African-American heritage

Occasional cocaine use African-American heritage Cocaine is a stimulant that causes tachycardia (up to 200 beats per minute) and hypertension. Hypertension is more prevalent in African Americans in the United States. Damage to target organs, such as kidneys and eyes, is more severe in African Americans than in whites or Hispanics; the reasons for this are unclear. Increased HDL reduces the risk for cardiovascular disease because it helps to remove excess cholesterol from the blood, thereby preventing atheromas. Aspirin decreases platelet aggregation, thus reducing the risk for cardiovascular disease. Lowered hemoglobin may increase the heart rate, not the blood pressure.

The nurse is assessing a patient who presented to the ED reporting acute onset of numbness and tingling in the right leg, how does the nurse document this subjective finding

Parathesia

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation?

Place in a sitting position Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high blood pressure. The first step in this situation is to assist the client into a sitting position because it naturally reduces blood pressure. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure ulcers after stabilizing the client. The nurse should monitor client's blood pressure every 10 to 15 minutes after stabilizing the client.

what is pneumonia??

Pneumonia is excess fluid in the lungs resulting from an inflammatory process.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning ther client every 1-2 hours

Prevent pressure ulcers

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? 1 Skin 2 Oral 3 Axilla 4 Rectal

Rectal Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.

After an earthquake, four groups of clients are given different tags in accordance with the disaster triage tag system. What is the correct order of treatment priority for each group? 1. Group given red tags 2. Group given yellow tags 3. Group given green tags 4. Group given black tags

Red-Yellow-Green-Black

local manifestations of inflammation

Redness-hyperemia from vasodilation heat- (calor) increased metabolism at the inflammatory site pain- (dolor) changed in pH. nerve stimulation by chemicals (e.g histamine,prostaglandings) pressure from fluid exudate swelling-(tumor) fluid shift to interstitial spaces. fluid exudate accumulation. loss of function-swelling and pain.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? Incorrect1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. Correct4 Stay nearby without initiating conversation.

Stay nearby without initiating conversation The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy. Crying, part of depression, usually ceases when the individual reaches acceptance. During acceptance the client may decide not to have visitors, preferring time for reflection. Detached from the environment, the client may find that the details of various procedures lose significance.

A client who has an above-the-knee amputation is fitted for a prosthesis. Two days after using the prosthesis, a small blister develops on the residual limb near the healed incision. The nurse anticipates that the client will be advised to:

Stop using the prosthesis until the blister heals

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation Correct3 Surgical asepsis Incorrect4 Medical asepsis Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

Surgical asepsis

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. What is an appropriate nursing response?

The epidermis is damaged

In response to a client's question, the nurse explains the difference between partial-thickness (second-degree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion?

They are painful, reddened, and have blisters

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain

Weight gain. The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

Yellow

A client with lymphosarcoma is receiving allopurinol and methotrexate. The nurse can help the client prevent complications related to uric acid nephropathy by administering which drug in relation to fluid intake?

allopurinol and increased fluid intake

A client reports sustaining an insect bite. The initial symptoms were edema and itching at the site of the bite. Which immunological reaction may have occurred?

anaphylaxis

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness

answer: B rationale= Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.

Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis? 1.Interleukin 2 2.Interleukin 11 3.Beta interferon 4.Alpha interferon

answer: Beta interferon Beta interferon is an immunomodulator that is administered in the treatment of multiple sclerosis

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes, and the other client has type 2 diabetes. When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes what clinical presentation about type 1?

complications are not present at the time of diagnosis

A nurse manager uses a participative leadership approach to change. List the steps in order of priority that the manager should follow to create effective change processes. 1. Provide opportunities for ventilation. 2. Be supportive. 3. Offer feedback. 4. Introduce new information.

The nurse manager first should create a supportive environment that will enable the personnel to be receptive to new information. Allowing time to ventilate about the new information received enhances the learning process. Feedback provides an opportunity for the nurse manager to evaluate the effectiveness of the learning experience.

Which health problem is most likely to precipitate acute hypoglycemia in a client?

liver disease

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply.

-exhibiting difficulty in showing concern for their child -procrastinating in obtaining treatment for their child's injuries

The school nurse is working with a child with a hearing deficit. The child arrives at school today without hearing aids. When the nurse talks with the child about the reasons for not wearing the aids, the nurse will need to ensure that the child hears what is being said. What actions by the nurse will promote effective communication? Select all that apply.

-facing the child directly when talking to the child -avoiding chewing gum while communicating with the child

A client who has hypofunction of the adrenal gland is prescribed oral hydrocortisone. Which clinical finding indicates the need for dosage adjustment in the client? Select all that apply.

-fluid retention -rapid weight gain

A registered nurse is evaluating the statements of a client after teaching the client measures to decrease the risk for antibiotic-resistant infections. Which statements made by the client indicate a need for more education? Select all that apply.

"I should skip doses when I am completely well." "I should save unfinished antibiotics for later emergency use." Antibiotics should not be stopped even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. Antibiotics should not be saved for later emergency use because old antibiotics can lose their effectiveness and in some cases can even be fatal if taken. Hand washing is necessary to prevent infections. Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. Antibiotics should be taken only after asking the physician.

Which drugs may lead to a prolongation of the QT interval in a client who is on drug therapy for schizophrenia? Select all that apply.

-haloperidol -thioridazine -chlorpromazine

A client with a full-thickness burn receives an allograft. Several days later the client points out that the graft is coming off at the edges. What is the nurse's best response?

"It is a temporary graft; it is expected to fall off."

An older client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse?

"You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply

- burn odor - leathery skin - cardiac arrest

The registered nurse is teaching the student nurse about care provided for clients according to the five level triage system of the Emergency Severity Index (ESI). Which statement made by the student nurse indicates effective learning? Select all that apply.

- clients who are in the ESI 4 category present with stable vital signs - clients with sever respiratory distress fall within the ESI 1 category

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply.

-headache -abdominal pain - flulike symptoms

Which clinical indicators does the nurse expect to identify when assessing a client with tic douloureux? Select all that apply.

-excruciating facial pain -twitching of the mouth

What clinical findings should lead a nurse to suspect that a toddler with a rash has rubella? Select all that apply.

-low grade fever -lymphaenopathy

The nurse is examining the nails of four different clients. Which client does the nurse anticipate having a myocardial infarction?

Client A

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is:

Exposure to radiation

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check?

Hct An increased Hct level indicates hemoconcentration secondary to fluid loss.

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?

In the preoperative period

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?

Ineffective Coughing.

Superficial (1st degree) burn

Involves epidermis only Burned skin remains intact Heals in 3-6 days Painful, red, slight edema, no blistering- sunburn, radiation

A client is scheduled for arthroscopy of the knee in the morning and asks the nurse about the procedure. Which statement by the nurse best describes the procedure? 1 "The procedure will determine the types of treatments that will be prescribed." 2 "It is a direct visualization of the joint to diagnose the extent of your knee injury." 3 "You will not remember anything about the procedure because you will be anesthetized." 4 "It is a radiologic procedure that will aid in the diagnosis of the extent of your knee injury."

"It is a direct visualization of the joint to diagnose the extent of your knee injury." The response "It is a direct visualization of the joint to diagnose the extent of your knee injury" describes an arthroscopy; a health care provider uses a scope to visualize knee structures to determine the extent of injury. Although the response "The procedure will determine the types of treatments that will be prescribed" is true, it evades the client's concern and does not describe the procedure. Although the response "You will not remember anything about the procedure because you will be anesthetized" is true, it evades the client's concern and does not describe the procedure. Arthroscopy is not a radiologic procedure.

A 20-year-old woman is known to be heterozygous for the cystic fibrosis (CF) gene. Her husband's genotype is unknown at present, and the couple is expecting their first child. What should the nurse tell the couple about the probability of their baby having CF?

25% or less

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? A. Adhesion B. Contractions C. Keloid formation D. Excess granulation tissue

Answer: D rationale=Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.

A nurse is reviewing the laboratory hormonal profile of four clients. Which client should be evaluated for ovarian cancer?

Client B

When caring for a client with a portable wound drainage system (Hemovac), the nurse takes into consideration that the physics principle underlying this drainage system is:

Fluids flow from an area of higher pressure to one of lower pressure

The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? Select all that apply. 1 Ripe bananas 2 Milk products 3 Green vegetables 4 Creamed potatoes 5 Whole grain bread

Green vegetables 4 5 Whole grain bread Green vegetables contain fiber, which promotes defecation. Whole grain bread contains fiber, which promotes defecation. Bananas have a binding effect and promote constipation. Milk and milk products have a binding effect and promote constipation. Creamed potatoes have a binding effect and promote constipation

A client with cellulitis of the leg asks why bed rest has been prescribed. The nurse explains that the primary purpose of bed rest for this client is to:

Limit muscle contractions that may force causative organisms into the bloodstream

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. 1 Lips 2 Sclera 3 Mouth 4 Sacrum 5 Nail beds 6 Shoulders

Lips Mouth Nail beds Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, while shoulders are assessed to confirm the condition of erythema.

Treatment of superficial burns

Mild analgesics, application of water -soluble lotions, regular cleaning Extensive superficial burns- IV fluids (elderly)

Full thickness burn

Minimal to absent pain

The nurse is caring for a client with severe preeclampsia. The nurse compares the client's current vital signs to the vital signs obtained on admission. In addition, the nurse performs a physical assessment. What is the nurse's initial action, in light of these assessments?

Stopping the infusion and notifying the primary healthcare provider

The nurse identifies silvery scales on a client's elbows and knees. To help identify the origin of this rash, the nurse should assess the client's history of:

Stress in recent months

The nurse identifies silvery scales on a client's elbows and knees. To help identify the origin of this rash, the nurse should assess the client's history of: 1 Using a harsh, irritating soap Correct2 Stress in recent months 3 Excursions into uncultivated, weedy areas 4 Infection with the human immunodeficiency virus (HIV)

Stress in recent months The client is exhibiting the clinical manifestations of psoriasis. Psoriasis is characterized by white scaly plaques on the scalp, knees, or elbows. The etiology is not known but it is thought to be a multifaceted disease that is related to stress and an immune response. Harsh soaps may cause dry, itchy, cracked skin, not silvery scales. However, too frequent washing may be irritating; tar-based soaps may be recommended. The client is exhibiting the signs of psoriasis, not Lyme disease. The lesions described are not associated with HIV.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections C. Assessment of the patient's circulation distal to the location of the dressing D. Assessment of the range of motion of the ankle and the patient's activity tolerance

answer: C rationale=A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? Frequent examination of the character and quantity of exudate Monitoring for signs and symptoms of local or systemic infections Assessment of the patient's circulation distal to the location of the dressing Correct Assessment of the range of motion of the ankle and the patient's activity tolerance

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? A. Increased platelet count Incorrect B. Increased blood urea nitrogen C. Increased number of band neutrophils Correct D. Increased number of segmented myelocytes

answer: C rationale=The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?

answer: Esophageal pain may imitate the symptoms of a heart attack. rationale=Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored. - Laboratory workups help differentiate these two diagnoses. Tests, such as cardiac enzymes, can help to reveal a myocardial infarction, thereby facilitating differentiation between these problems.

A client is receiving metoprolol. Which side effect should the nurse teach the client to expect?

dizziness with strenuous activity

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching?

cheeseburger and a milkshake have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair

The nurse is caring for four clients in an emergency department. Which client should be provided with immediate care based on priority?

client with bronchiolitis

A 20-year-old woman is admitted to the labor and delivery unit after reporting that she is experiencing severe contractions. She is 38 weeks +2 days' gestation. External fetal monitoring has been initiated. During the assessment the nurse notes that the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and continues to complain of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. What should the nurse suspect?

cocaine abuse

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators?

demonstrates use of metered dose inhaler

According to Freud's theory, which stage should the nurse include while educating the parents about a preschooler?

phallic stage

The nurse is providing care to a preschool-age client of Chinese descent diagnosed with lead toxicity. Which question is most appropriate for the nurse to include in the assessment process to determine the source of the lead?

do yo use ba-baw-san to treat your child's colic pain

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what?

full

Which charge-nurse remark would be expected in a care area that is using team nursing as a care delivery method?

have you discussed this client care issue with your team leader

A 2½-year-old child is admitted to the hospital with deep partial-thickness burns involving the face and chest. The nurse bases a plan of care on concerns related to the child's injury. Place the following concerns in their order of importance.

impaired gas exchange disturbed fluid balance presence of pain potential for infection compromised body image

A client with human immunodeficiency virus reports dyspnea on exertion, increased heart rate, a persistent dry cough, and a persistent low-grade fever. The nurse observes crackles during an auscultation of the breath sounds. Which organism is responsible for this condition in the client?

pneumocystis jiroveci

After fertilizer plant explosion, the nearest healthcare facility services were flooded with clients. The green-tagged clients who self-transported to the hospital from the site unknowingly carried toxins. Which emergency response plan devised by the emergency department (ED) does the registered nurse consider to be most suitable to reduce the risk of potentially disastrous consequences in the hospital?

providing appropriate decontamination measures at the facility

Which characteristic should the nurse predict will make an individual most likely to benefit from group therapy?

recognizing that she or he has a problem

A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?

reduces circulating blood volume (vasodilators relax smooth muscle)

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. What does the nurse identify as the drug's mechanism of action?

restores the dopamine levels in the brain

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infectious processes does the nurse conclude is impaired as a result of this disease?

stress response

During a status meeting for a research project, the project leader asks the team members for feedback. What leadership theory is represented by the action of the leader?

style theory

A client has a tentative diagnosis of primary biliary cirrhosis. What skin change does the nurse expect to observe when performing a physical assessment?

telangiectasia

Azotemia

the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? 1 "You need to receive the pneumococcal vaccine every other year." 2 "The pneumococcal vaccine should be received in early autumn every year." 3 "You should get the flu and pneumococcal vaccines at your annual physical examination." 4 "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose." The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 years or older with a single dose of the vaccine; if the pneumococcal vaccine was received before 65 years of age or if there is the highest risk of fatal pneumococcal infection, revaccination should occur 5 years after the initial vaccination. The pneumococcal vaccine should not be administered every 2 years. The pneumococcal vaccine should not be administered annually.

The nurse should refer a client to the pulmonary clinic for suspected tuberculosis based on which clinical indicators reported during the initial client interview? Select all that apply.

-hemoptysis -night sweats

A client with cancer has undergone treatment. The client's primary healthcare provider receives a record of the client's care from the oncologist. Which descriptions are given under the care summary received by the primary healthcare provider? Select all that apply.

-information about treatment institutions and key providers -identification of a key point of contact and coordinate of care

The nurse is admitting a client with a history of bipolar disorder. The nurse determines that the client is in the manic phase. Which signs and symptoms contribute to the nurse's conclusion? Select all that apply.

-irritability -grandiosity -pressured speech

Which medications will prevent the binding of human immunodeficiency virus (HIV) to a client's cells? Select all that apply

-maraviroc -enfuvirtide

Pus

-mixture of dead neutrophils, digested bacteria, and other cell debris accumulates as a creamy substance.

The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.

-observe for chest wall trauma -assess breath sounds and respiratory effort

An adolescent girl reports to her primary healthcare provider that she has missed periods. The provider insists on performing a pregnancy test. Which nursing care interventions are most appropriate if the test result is positive? Select all that apply.

-providing emotional support -assisting with parental notification

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply.

-pulsus paradoxus -mufffled heart sounds -jugular vein distention

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply.

-respiratory rate 14 bp 110/70 -o2 sat 96%

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply.

-respiratory rate of 14 bpm -blood pressure of 120/80 -o2 sat 95%

What observation caused the nurse to provide additional teaching to a client with AIDS during a home visit? Select all that apply.

-snacked on apple slices -picked a sandwich after petting the cat -rinsed dishes with cold water before using

vital signs (acute care) inflammation

-taking corticosteroids or receiving chemotherapy the manifestations of inflammation may be masked. -early symptoms of inflammation may be malaise or "just not feeling well" -with infection the temperature may rise, and pulse and resp rate may increase.

A mother comes to the clinic with her 7-month-old child for a routine checkup. Which assessment findings noted by the nurse suggest that the child is exhibiting appropriate fine motor development? Select all that apply.

-the child bangs objects together -the child pulls a string to obtain an object

The nurse manager is teaching the nursing team about funds allocated to health departments for personal health services by local, state, and federal governments. Which statement made by a member of the team would indicate effective learning? Select all that apply.

-the funds provide care for newbornds -the funds provide care for clients with tuberculosis -the funds provide care for children with birth defects

A nursing instructor asks a nursing student to explain the developmental changes in toddlers. Which statements made by the nurse indicate the need for further teaching? Select all that apply.

-toddlers have a concave-shaped abdomen -toddlers sleep approximately 12 hours a day

A client has a diagnosis of unruptured tubal pregnancy. Which assessment findings correlate with this diagnosis? Select all that apply.

-unilateral abdominal pain -history of a sexually transmitted infection

A client was treated with sex hormones during pregnancy. Which teratogenic effects may be seen in the newborn if the client gave birth to a baby girl? Select all that apply.

-vaginal carcinoma -masculinization of the female fetus -reproductive organ defecits

Which gross motor skills should the nurse assess for during a health maintenance visit for a toddler-age client? Select all that apply.

-walking up and down steps -standing on one foot for several seconds

A healthcare provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL

0.5

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is most appropriate? 1 The epidermis is damaged. 2 The dermis is damaged partially. 3 The structures beneath the skin are destroyed. 4 Both the epidermis and the dermis are destroyed.

1 A damaged epidermis describes a superficial partial-thickness burn. The dermis is not damaged in superficial partial-thickness burns. The entire epidermis and part of the dermis are affected with deep partial-thickness burns. A destroyed epidermis and dermis describes full-thickness burns. Destroyed structures beneath the skin is too vague a description of what is involved.

Which tag color according to the disaster triage tag system is assigned to a client who has an immediate threat to life? 1 Red tag 2 Black tag 3 Green tag 4 Yellow tag

1 According to the disaster triage tag system, a red colored tag is used for a client who has an immediate threat to life. A black colored tag is used for a client who is expected to die or is dead. Green colored tags are used for a client who has minor injuries. A yellow colored tag is used for a client who has major injuries and is requiring immediate treatment.

The registered nurse is teaching a student nurse about the disaster triage tag system. Which statement made by the student nurse indicates ineffective learning? 1 "I will use a yellow tag for clients with shock." 2 "I will use a green tag for clients with closed fractures." 3 "I will use a red tag for clients with airway obstruction." 4 "I will use a black tag for clients with massive head trauma."

1 According to the disaster triage tag system, a yellow tag is used for clients who require treatment within 30 minutes to 2 hours. Clients with shock require immediate attention and a red tag is appropriate. A green tag is used in clients with minor injuries, such as fractures and abrasions, who can be managed with delayed treatment. A red tag is used for the clients who have immediate threats to life, such as an airway obstruction. A black tag is used for clients who are expected to die or require mechanical ventilation in conditions such as massive head trauma and high cervical spinal cord injury.

What is an example of third spacing in a burn injury? 1 Blister formation 2 Edema formation 3 Fluid mobilization 4 Fluid accumulation

1 Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.

The nurse is assessing four clients who were injured in a mass casualty event. Which client does the nurse plan to treat first according to the disaster triage tag system? 1 Client belonging to class I 2 Client belonging to class II 3 Client belonging to class III 4 Client belonging to class IV

1 Class I clients are emergent clients who are marked with red tag. These clients have an immediate threat to life and need attention first. Class II clients have major injuries and need treatment within 30 minutes to 2 hours. Class III clients have minor injuries and can be treated in a delayed manner. Class IV clients are those who are expected to die or are dead.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis

1 Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

Which type of burn/injury may cause a client to have a cervical spine injury? 1 Electrical burns 2 Chemical burns 3 Inhalation injury 4 Cold thermal injury

1 Electrical burns may cause injuries to the cervical spine because intense electrical currents can fracture long bones and vertebrae. Chemical burns may cause eye and tissue damage. Inhalation injuries may damage the respiratory tract. Cold thermal injuries may cause tissue damage.

A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify? 1 Tachycardia 2 Hypoglycemia 3 Constricted pupils 4 Decreased blood pressure

1 Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will be dilated, not constricted. Epinephrine is more likely to cause hypertension than hypotension.

A 12-year-old child has just received a dose of epinephrine. What is the priority assessment after this medication is administered? 1 Tachycardia 2 Hypoglycemia 3 Constricted pupils 4 Decreased blood pressure

1 Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will dilate, not constrict. Epinephrine is more likely to cause hypertension than hypotension because of its effect of peripheral vasoconstriction.

Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7? 1 Preparing for intubation 2 Observing for chest wall trauma 3 Covering the client with a blanket 4 Applying direct pressure to the client's wound

1 If the Glasgow Coma Scale (GCS) score is 8 or less, the priority action by the nurse is to prepare for endotracheal intubation because the client is at risk for airway compromise. Observing for chest wall trauma, covering the client with a blanket, and applying direct pressure to a bleeding wound are all appropriate actions but not the priority.

The nurse is advising a client to carry a prescription of epinephrine autoinjector. Which insect bite or sting is responsible for the nurse providing this advice? 1 Wasp 2 Scorpions 3 Black widow spider 4 Brown recluse spider

1 If the client has allergic reaction to bee or wasp stings, the nurse should advise the client to carry an epinephrine autoinjector for emergencies. For scorpion stings, providing supplemental oxygen and IV fluid replacement immediately can act as emergency measures. The priority intervention for a black widow spider bite in a prehospital setting is to apply an ice pack because cold application decreases the action of the neurotoxin. In case of brown recluse spider bite, the application of an ice pack also decreases the action of the neurotoxin.

A client is admitted after incurring electrical burns to both hands while playing golf during a lightning storm. The nurse is assessing the entrance and exit wounds. Which information should the nurse consider about electrical burns? 1 Causes severe nervous tissue destruction along a path of least resistance 2 Results in severe tissue destruction when the burn is incurred by direct current 3 Causes a line of destruction beginning at the grounding point to the point of contact 4 Results in visible dermal wounds that denote the internal electrical current destruction

1 Nerves and blood vessels are the least resistant tissues. Electrical current flows from the point of contact to the point of grounding. It is difficult to track the path of electricity by external visualization; it often requires more extensive diagnostic exploration.

A nurse is planning care to prevent deformities and contractures in a client with burns. When will the nurse begin range-of-motion (ROM) exercises? 1 When pain has lessened 2 When vital signs are stable 3 When skin grafts are healed 4 When emotional status stabilizes

2 ROM exercises should be instituted as soon as it will not compromise the individual's cardiopulmonary status. Pain will continue for some time, and if ROM exercises are delayed until it subsides, contractures will develop. If ROM exercises are delayed until skin grafts heal, contractures will develop. Pain and inability to cope may be prolonged; if ROM exercises are delayed, contractures will develop.

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer? 1 Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution. 2 Add sodium chloride (NaCl) to the existing IV lactated Ringer solution. 3 Discontinue the IV NaCl with 20 mEq KCl solution and replace with IV 5% D5W solution. 4 Discontinue the IV 5% D5W with 40 mEq KCl solution and replace with IV 5% D5W solution.

1 Silver nitrate can precipitate electrolyte imbalances; the client's potassium is below the expected range of 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L) and should be supplemented by adding potassium chloride to the IV. The client's sodium level is within the expected range of 135 to 145 mEq/L (135 to 145 mmol/L); additional sodium chloride is not needed. Discontinuing the IV NaCl with 20 mEq KCl solution and replacing it with IV 5% D5W solution and discontinuing the IV 5% D5W with 40 mEq KCl solution and replacing it with IV 5% D5W solution will cause a further depletion of potassium.

A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? 1 Hypoxia 2 Hyperthermia 3 Emotional trauma 4 Aspiration pneumonia

1 The degree of hypoxia experienced by the child will determine the extent of neurological, liver, and renal damage. The child was hypothermic, not hyperthermic. Although emotional trauma can be overwhelming, it usually does not influence the ultimate physical prognosis as the extent of the hypoxia does. Although aspiration pneumonia may be severe initially, it does not result in long-term sequelae as hypoxia can.

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? 1. push-ups to strengthen arm muscles 2. leg lifts to prevent hip contractures 3. balancing exercises to promote equilibrium 4. quadriceps-setting exercises to maintain muscle tone

1 rationale: Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair. Equilibrium is not a problem. The client does not have neurologic control of the other activities.

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? 1. bladder control 2. nutritional intake 3. quadriceps setting 4. use of aids for ambulation

1 rationale: Because of the location of the micturition reflex center (in the sacral region of the spinal cord), bladder function may be impaired with lower spinal cord injuries. This client's ability to ingest, digest, or metabolize food is not affected; therefore nutrition is less of a problem than bladder control. Quadriceps settings require motor control, which the client does not have. Because there is no voluntary control over the lower extremities, mobility usually is accomplished through the use of a wheelchair rather than ambulation.

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? 1. hypertension and bradycardia 2. flaccid paralysis and numbness 3. absence of sweating and pyrexia 4. escalating tachycardia and shock

1 rationale: Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs.

A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client? 1. Consider that the client most likely will be able to have reflex penile erections. 2. Arrange for the client to see the healthcare provider because sexual performance is unlikely. 3. Discourage the client from forming sexual relationships because little pleasure will be possible. 4. Reassure the client that he will be able to have sexual relationships with the ability to reproduce.

1 rationale: The reflex arc for sexual activity is intact; control of ejaculation is not. The ability to perform sexually is determined on an individual basis. There are many ways to fulfill sexual needs. Reassuring the client that he will be able to have sexual relationships with the ability to reproduce may provide false reassurance. The ability to function is determined on an individual basis.

The healthcare team is caring for clients in an emergency department according to the five-level triage system. In what order should the clients receive care? 1. Client with cardiac arrest 2. Client with chest pain due to ischemia 3. Client with a hip fracture 4. Client with minor burns

1 2 3 4 Clients with life-threatening complications such as cardiac arrest are triaged as an emergency severity index one (ESI-1) which requires immediate care. Clients with chest pain due to ischemia are triaged as an ESI-2, which requires treatment within 10 minutes. Clients with hip fractures should be treated within an hour. Care for a client with minor burns can be delayed because this is not a life-threatening condition.

A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse immediately report to the primary healthcare provider? Select all that apply. 1 Weakness 2 Diaphoresis 3 Tachycardia 4 Cold extremities 5 Flushed skin tone

1 2 3 4 The stress ulcer can bleed, leading to shock. Weakness is related to the decrease in the oxygen-carrying capacity of the blood associated with shock. Diaphoresis and tachycardia are sympathetic nervous system responses associated with shock. Peripheral vasoconstriction is associated with the sympathetic nervous system response associated with shock and leads to cold extremities. The skin will be pale, rather than flushed, because of peripheral vasoconstriction.

What is a clinical manifestation of hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias

2 Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation? 1. Using a jaw-thrust maneuver to establish an airway 2. Providing bag-valve-mask (BVM) ventilation 3. Palpating for the presence of a radial pulse 4. Monitoring systolic blood pressure 5. Assessing the score of eye opening 6. Removing the clothing with scissors

1 2 3 4 5 6 A client with trauma should be assessed for airway, breathing, circulation, disability, and exposure. A jaw-thrust maneuver helps to establish an airway and breathing, and bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. Following respiratory assessment is the circulation assessment. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.

What actions should the nurse take when a client develops an anaphylactic reaction? Select all that apply. 1 Apply oxygen at 90 to 100% 2 Call the Rapid Response Team 3 Elevate the head of the bed to 45 degrees 4 Assign a nursing assistant to stay with the client 5 Ensure emergency airway equipment is at the bedside

1 2 3 5 Emergency care of the client with anaphylaxis includes applying oxygen at 90 to 100%, calling the Rapid Response Team, elevating the head of the bed to 45 degrees, and ensuring that emergency airway equipment is at the bedside. The nurse should stay with the client because the client is acutely ill and may need immediate emergency interventions that are beyond the scope of a nursing assistant's practice.

The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? Select all that apply. 1 Documenting vital signs 2 Documenting urine output 3 Assessing the laboratory findings 4 Administering diuretic intravenously 5 Repositioning the client every one or two hours

1 2 5 Patient care associates are unlicensed assistive personnel whose scope of practice includes documenting vital signs and urine output and repositioning the client every one or two hours. Assessing the laboratory findings should be carried out by the registered nurse only. Intravenous medications should be administered the registered nurse. Administration of oral and topical medications can be delegated to the licensed practical or vocational nurse.

The nurse is conducting a primary survey during the emergency assessment. Which nursing actions are appropriate during the airway assessment? Select all that apply. 1 Assessing for edema 2 Counting respiratory rate 3 Checking for foreign bodies 4 Noting use of accessory muscles 5 Monitoring for respiratory distress

1 3 5 Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress. Counting the respiratory rate and noting use of accessory muscles are nursing actions appropriate during the breathing assessment.

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound? Select all that apply. 1 Documenting the client's care 2 Formulating the client's plan of care 3 Reassessing the client's level of consciousness 4 Administering tetanus prophylaxis to the client 5 Transferring the client to the general medical unit

1 4 The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all client care and administering tetanus prophylaxis. Formulating the client's plan of care, reassessing level of consciousness, and transferring the client to the general medical unit are nursing actions implemented once the client is stable.

Which are the highest priorities when conducting a primary client survey during the emergency assessment? Select all that apply. 1 Airway 2 Disability 3 Breathing 4 Circulation 5 Cervical spine

1 5 Airway and stabilization of the cervical spine are the top priorities when conducting a primary client survey during the emergency assessment. The nurse will then focus on breathing, circulation, and disability.

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in order of priority?

1) Check for patent airway. 2) Maintaining effective circulation. 3) performing adequate fluid replacement. 4) Caring for the burn wound. Rationale: The priority nursing intervention for a client with severe burn wounds is checking for a patent airway. The next priority is to maintain effective circulation. Then, adequate fluid replacement is established. Once a patent airway, effective circulation, and adequate fluid replacement have been established, priority is given to care of the burn wound.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply.

1) Providing oxygen immediately. 2) Notifying the rapid response team. Rationale: Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response? 1 "It helps debride necrotic tissue." 2 "It promotes rapid healing of the wound." 3 "When sutured in place, it provides better adherence." 4 "Topical lotions can be used concurrently with the graft."

2 The graft provides a framework for granulation and speeds healing. The graft promotes epithelialization; enzymatic preparations or surgery may be used to debride the burned tissue. Pigskin grafts are not sutured. Using topical lotions on burn wounds can increase the likelihood of infections.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. 1. Providing oxygen immediately 2. Notifying the rapid response team 3. Considering it a normal observation 4. Initiating an intravenous (IV) line and beginning fluid replacement 5. Obtaining an electrocardiogram (ECG) of the client

1. Providing oxygen immediately 2. Notifying the rapid response team Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

After a hurricane, the nurse is assessing the response of a client to stimuli on the Glasgow Coma Scale (GCS) as a part of the primary survey. The nurse observes that the client opens his eyes when his name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus. What is the Glasgow coma score for this client? Record your answer using a whole number.____________

11 Glasgow scale (GCS) is used by the nurse to conduct neurologic assessment as a part of primary survey. It is performed to determine the client's response to verbal and/or painful stimuli in order to assess the level of consciousness and degree of disability. A score of 3 is given when the client opens the eyes when the name is stated. If disorganized use of words is present, a score of 3 is given. A score of 5 is given when there is a lack of obedience but attempts to remove the offending stimulus. Therefore the client's GCS score would be 3+3+5= 11.

A 5-year-old child is admitted with burns covering the face and anterior arms and hands. Using the total body surface area (TBSA) percentages shown in the diagram, determine what percentage of the child's body has been burned. Record your answer using a whole number. ____%

15% Rationale: The front of a 5-year-old's head accounts for 6.5% of the TBSA. The anterior portion of each arm and hand accounts for 4.25% of the TBSA. Adding 6.5 + 4.25 + 4.25 = 15.

The registered nurse is teaching a student nurse about the ongoing monitoring of a client with electrical burns. Which statement made by the student nurse indicates the need for further teaching? 1 "I should monitor the airway." 2 "I should monitor the eye pH." 3 "I should monitor vital signs." 4 "I should monitor urine output."

2 The pH of the eye is monitored when chemical burns occur to the eye. The nurse should monitor the airway for breathing, vital signs, heart rhythm, neurovascular status of injured limbs, level of consciousness, and urine output.

According to the disaster triage tag system, which color tag would the nurse feel is most suitable for a client who died in an earthquake? 1 Red 2 Black 3 Green 4 Yellow

2 Clients who are dead or are expected to die are issued a black tag according to the disaster triage tag system. A red tag is issued to the clients who have an immediate threat to life. A green tag is issued to the nonurgent or "walking wounded" clients. A yellow tag is issued to clients who can wait a short time to receive care.

When changing the dressings on deep partial-thickness burns on a client's hand, the nurse should use which type of gauze and which technique? 1 Cotton-backed; fully extending the fingers with thumb in opposition 2 Non-cotton-backed; placing a hand roll with fingers slightly flexed 3 Non-cotton-backed; extending fingers fully with gauze between each finger 4 Cotton-backed; a hand roll, with fingers completely flexed and thumb in opposition

2 Non-cotton-backed gauze is less apt to adhere to the wound than cotton-backed gauze; the hands should be maintained in an anatomic position of slight flexion with each finger separated. Cotton-filled or cotton-backed gauze should not be used because it may adhere to the wound; the hands should be in anatomic position with fingers slightly flexed. The hands should not be positioned anatomically in full extension or full flexion; the hands should be slightly flexed in functional alignment.

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? 1 Partial-thickness burns require grafting before they can heal. 2 Partial-thickness burns are often painful, reddened, and have blisters. 3 Partial-thickness burns cause destruction of both the epidermis and dermis. 4 Partial-thickness burns often take months of extensive treatment before healing.

2 Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.

Four near-drowning victims are admitted to the emergency department. Which victim does the nurse determine to be at greatest risk for hypovolemia? 1 72-year-old rescued from a lake 2 50-year-old rescued from the ocean 3 17-year-old rescued from a backyard pool 4 2-year-old rescued from a bathtub

2 The high osmotic pressure of the saltwater from the ocean draws fluid from the vascular space into the alveoli, causing hypovolemia. The others involve aspiration of freshwater, which causes fluid to move rapidly into the capillary bed and circulation, leading to fluid overload. A lake, backyard pool, and bathtub don't use saltwater, so there is less risk.

A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first? 1. assess for the cause 2. place the client in sitting position 3. check the client for fecal impaction 4. give an alpha blocker prophylactically

2 rationale: Clients experiencing autonomic dysreflexia should immediately be placed in a sitting position because the condition may cause involuntary nervous system reaction and dangerous spikes in blood pressure. The next step is to assess for the cause for autonomic dysreflexia. Fecal impaction and other colorectal complications are routinely assessed in the client. Alpha blockers can be given to treat recurrent autonomic dysreflexia.

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action? 1. Placing the child's head on a pillow for support 2. Immobilizing the child's spine to limit additional injury 3. Log-rolling the child to check for lacerations on the back 4. Moving the child onto a firm stretcher for transport to the radiography department

2 rationale: Immobilization of the spine is most important to minimize additional injury while the child is being assessed. Placing a pillow under the head is contraindicated because the vertebral column and spinal cord might move, resulting in additional damage to the spinal cord. Log-rolling is unsafe without prior immobilization of the spine, as is moving the child.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? 1. The injury results in loss of the reflex arc. 2. The injury is above the sixth thoracic vertebra. 3. There has been a partial transection of the cord. 4. There is a flaccid paralysis of the lower extremities.

2 rationale: The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? 1. you shouldnt give up hope 2. being incapacitated is difficult for you 3. would you like to speak to a religious advisor 4. have you talked to your family about your feelings

2 rationale: The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings. The response "You shouldn't give up hope" rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to someone else. The response "Have you talked to your family about your feelings?" changes the focus from the client's feelings to the family's role.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? 1. "Wear sterile gloves when doing the procedure." 2. "Wash your hands before performing the procedure." 3. "Perform the self-catheterization every 12 hours." 4. "Dispose of the catheter after you have catheterized yourself."

2 rationale: To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1 Blood glucose is 70-100 mg/dL 2 An increased serum lactate level 3 An increased neutrophil level 4 A white blood count of 5000 cells/µL

2 The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count > 12,000 cells/µL or < 4,000 cells/µL and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL. Blood glucose levels of 70-100 mg/dL are considered normal.

A nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction? Select all that apply. 1 Soot on legs 2 Brassy cough 3 Deep breathing 4 Singed nasal hair 5 Dark mucous membranes

2 4 5 A brassy cough is indicative of possible pulmonary damage caused by an inhalation burn. Singed nasal hair indicates possible pulmonary damage. Dark mucous membranes are a sign of potential respiratory insufficiency that results from inhalation burns. Sputum will be sooty; sooty legs is not an indication. Deep breathing indicates metabolic acidosis, not respiratory insufficiency.

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours? 1. Wound sepsis 2. Pulmonary distress 3. Fear and separation anxiety 4. Fluid and electrolyte imbalance

2. Pulmonary distress Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia resulting from irritation and edema of the respiratory passages and lungs. Although wound sepsis is a possible complication, it will not be evident until the third to fifth day. Although the child is probably fearful, maintaining a patent airway is the priority. This child is too old for separation anxiety; however, complications related to stress may occur later. Fluid losses may be extremely high but reach their maximum about the fourth day; the initial priority is maintaining a patent airway.

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1 Inserting a nasogastric tube 2 Immobilizing the cervical spine 3 Arranging for diagnostic studies 4 Preparing for chest tube insertion 5 Applying direct pressure to a wound

2 4 5 The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound. The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries. Nursing actions appropriate during the secondary, not primary, survey include inserting a nasogastric tube and arranging for diagnostic studies.

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?

2) 60 minutes before the dressing change. Rationale: Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change. Although pain medications can cause constipation, the nurse would not administer a stool softener each time the morphine is administered. If the client is experiencing pain and rates it anywhere on the pain scale, the client can receive pain medication if it is within the timeframe. It is important to premedicate a client before a painful procedure.

A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate for pain. What route of administration should the nurse expect to administer this medication?

2) Intravenously. Rationale: The intravenous route is the preferred route for medication for a client with impaired peripheral circulation. Oral medications usually are not given to burn clients because of the frequent occurrence of paralytic ileus; oral analgesics take too long to provide immediate relief from pain. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered subcutaneously. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered intramuscularly.

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics?

2) Topical Rationale: Topical antibiotics are applied directly to the wound and are effective against many gram-positive and gram-negative organisms found on the skin. Although oral, intravenous, and intramuscular antibiotics may be administered, they are most effective for systemic rather than local infections; the vasculature in and around a burn is impaired, and the medication may not reach the organisms in the wound.

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?

2) Urinary output every hour. Rationale: A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what?

2) Urinary output. Rationale: As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

The registered nurse has instructed the client about effective ways of reducing burn injury. Which statement made by the client shows ineffective learning? 1. "I will refrain from smoking when lying in bed." 2. "I will set the bathing water temperature below 160° F." 3. "I will use a potholder when taking the food from an oven." 4. "I will keep the screens and doors closed on the front of any fireplace."

2. "I will set the bathing water temperature below 160° F." The water tank should be set below 140° F; higher temperatures may result in scald burns. Smoking in bed should be avoided to prevent injury due to fire. Potholders should be used while taking food from the oven to prevent thermal burn injuries. For preventing flame burn injuries, the screens and the doors should be kept closed on the front of fireplaces.

A client is admitted to the emergency department with burns to the anterior trunk, entire right arm, and anterior right leg. The practitioner prescribes morphine sulfate for pain. What route of administration should the nurse expect to administer this medication? 1. Orally 2. Intravenously 3. Subcutaneously 4. Intramuscularly

2. Intravenously The intravenous route is the preferred route for medication for a client with impaired peripheral circulation. Oral medications usually are not given to burn clients because of the frequent occurrence of paralytic ileus; oral analgesics take too long to provide immediate relief from pain. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered subcutaneously. Impaired peripheral circulation does not permit accurate prediction of the dose absorbed when it is administered intramuscularly.

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1. Oral 2. Topical 3. Intravenous 4. Intramuscular

2. Topical Topical antibiotics are applied directly to the wound and are effective against many gram-positive and gram-negative organisms found on the skin. Although oral, intravenous, and intramuscular antibiotics may be administered, they are most effective for systemic rather than local infections; the vasculature in and around a burn is impaired, and the medication may not reach the organisms in the wound.

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data? 1. Weights every day 2. Urinary output every hour 3. Blood pressure every 15 minutes 4. Extent of peripheral edema every 4 hours

2. Urinary output every hour A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned?

22.5%

A health care provider prescribes 2 L of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record the answer using a whole number. ___ gtts/min

28

A nurse needs to administer fluid in a severely burned child of 2 years, but the peripheral vein is obscured. Which other route should the nurse use? 1 Intrathecal 2 Intraarterial 3 Intraosseous 4 Intraperitoneal

3 A nurse should use the intraosseous route for administering fluid if the peripheral vein is not accessible. Intrathecal administration is often associated with long-term medication administration through surgically implanted catheters. Intraarterial infusions are common in clients who have arterial clots. Chemotherapeutic agents, insulin, and antibiotics are administered by the intraperitoneal route. Hence, the nurse should not use these routes.

A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. What should the nurse assess for in this client? 1 Dehydration 2 Dry brittle hair 3 Prolonged wound healing 4 Clubbing of the fingertips

3 Adequate intake of protein, carbohydrates, vitamin C, and minerals is necessary for tissue building and wound healing. There are no data to indicate dehydration; although the client is not eating, the client may be drinking fluids. Dry brittle hair will take a prolonged period of time; it will not occur during a short period. Clubbing of the fingertips is associated with prolonged hypoxia.

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching? 1 "Type I immune response to latex has an immediate onset." 2 "Type I immune reaction to latex leads to release of IgE antibodies." 3 "The client's first exposure to latex will cause a type IV allergic reaction." 4 "Type IV immune response to latex occurs after 12 to 48 hours after exposure."

3 Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.

A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 75 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. Which intervention should the nurse anticipate will be prescribed by the healthcare provider? 1 Deep suctioning 2 Bronchodilators 3 Breathing exercises 4 Mechanical ventilation

3 Breathing exercises are needed. The client has hypoxemia; the expected range for PaO2 is 80 to 100 mm Hg. This intervention expands the alveoli, moves secretions toward the mouth to be expectorated, and increases the amount of oxygen that is delivered to alveolar capillary beds. Routine suctioning may injure already traumatized tissues and is contraindicated. Bronchodilators and mechanical ventilation are not indicated at this time based upon the x-ray results and PaCO2 and pH results.

A 10-year-old child who was rescued from a house fire is brought to the emergency department with burns of the extremities. During assessment of the child, what finding is of most concern to the nurse? 1 Increased temperature 2 Increasing activity level 3 Burns around the mouth 4 Edema distal to the burns

3 Burns around the mouth indicate that the child may have inhalation burns; respiratory tract injury may result in edema, causing an airway obstruction. An increase in temperature indicates the presence of an infection; it is too early for an infection to occur. Increased activity is promising because it indicates that the burns were not severe. Edema distal to burns of the extremities is an expected finding.

A- waxy, white, darkbrown appearance B- redness, pain, minimal edema C-mostly blebs, blisters, severe pain D- dry, leathery eschar, no pain The nurse is examining four different clients who present with thermal burns. Which client does the nurse diagnose as having second-degree burns? 1 Client A 2 Client B 3 Client C 4 Client D

3 Client C has second-degree burns. The client is experiencing severe pain and the skin shows moist blebs and blisters. Client A may have third- and fourth-degree burns, in which the skin is waxy white, dark brown in appearance. Client B may have first-degree burns, in which the skin is red in color with minimal edema and pain. Client D may have third- and fourth-degree burns as the skin is dry, leathery eschar and there is absence of pain.

During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old? 1 Cow's milk 2 Soy products 3 Peanut butter 4 Chocolate candy

3 Peanut allergies tend to be very severe. To reduce the risk of peanut allergies, parents should delay their introduction into the diet until the gastrointestinal tract has matured. Cow's milk is introduced after 1 year. Although often considered hypoallergenic, soy products can cause food allergies. However, because of the infrequency of soy in the American diet, its entry is not delayed after the first year. Chocolate may be introduced after the first year of life.

A- Open Fractures B- Airway obstruction C- Sprain D- Shock The registered nurse is teaching a student nurse about the disaster triage tag system. The nurse provides details of our clients along with their conditions for identification. Which statement made by the student nurse indicates effective learning? 1 "I would issue a red tag to client A." 2 "I would issue a black tag to client B." 3 "I would issue a green tag to client C." 4 "I would issue a yellow tag to client D."

3 Client C with a sprain, which is a minor injury that does not require immediate treatment, should be given a green tag according to the triage tag system. Client A with open fractures that are due to a major injury should be given a yellow tag according to the triage tag system. Client B with airway obstruction has an immediate threat to life and should be given a red tag according to the triage tag system. Client D with shock has an immediate threat to life and should be given a red tag according to the triage tag system.

A- Massive Head Injury- Red B- Compound fracture- Green C- 90% full thickness burns- Black D- Skin lacerations- Yellow The nurse is triaging clients who have arrived at the hospital after a large-scale disaster. Based on the data in the table, which client is appropriately tagged according to the disaster triage tag system? 1 Client A 2 Client B 3 Client C 4 Client D

3 Clients who are expected to die are issued black tags. Client C with full-thickness burns is triaged into the expectant category and would be given a black tag. Clients who require immediate treatment are issued red tags. Client A with a massive head injury would likely be triaged into the expectant category and would be given a black tag, not a red tag. A yellow tag is issued to clients with major injuries such as compound fractures. So, client B with a compound fracture should be given a yellow tag. Green tags are issued to clients with minor injuries. So, client D with skin lacerations should be issued a green tag.

Which color tagged clients usually make up the greatest number in most large-scale multi-casualty situations, based on the disaster triage tag system? 1 Red 2 Black 3 Green 4 Yellow

3 Green-tags clients usually make up the greatest number in most large-scale multi-casualty situations. These clients have minor injuries and they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries. Clients belonging to these three categories usually do not make up the greatest number in most large-scale multi-casualty situations.

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? 1 Flame burn 2 Chemical burn 3 Electrical burn 4 Radiation burn

3 In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? 1 Dyspnea 2 Hyperpnea 3 Kussmaul breathing 4 Cheyne-Stokes breathing

3 Kussmaul breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that is usually associated with pathology of the respiratory center in the brain.

Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do? 1 Give the client orange juice by mouth. 2 Increase the client's intravenous (IV) flow rate. 3 Moisten the client's lips with a wet 4 × 4 gauze. 4 Offer the client 4 oz (120 mL) of water by mouth.

3 No bowel sounds are present; therefore, the client must remain NPO. Comfort measures may be helpful until bowel sounds return and the primary healthcare provider changes the dietary prescription. Giving the client orange juice or offering 4 oz (120 mL) of water by mouth is unsafe; the client must be kept NPO until bowel sounds are present. The urinary output is adequate; there is no need to increase IV fluids. Also, the nurse cannot increase the IV flow rate without a primary healthcare provider's prescription.

What is the mechanism of action of norepinephrine in managing anaphylaxis? 1 Norepinephrine blocks the effects of histamine 2 Norepinephrine inhibits the degranulation of mast cells 3 Norepinephrine increases blood pressure and cardiac output 4 Norepinephrine rapidly stimulates alpha- and beta-adrenergic receptors

3 Norepinephrine is a vasopressor that elevates the blood pressure and cardiac output in clients suffering from anaphylactic reactions. Diphenhydramine HCL blocks the effects of histamine on various organs. Corticosteroids such as dexamethasone prevent the degranulation of mast cells. Epinephrine works by rapidly stimulating alpha- and beta-adrenergic receptors.

n the immediate period after admission to the burn unit with severe burns, a 5-year-old child requests a drink of milk. What is the most appropriate nursing intervention? 1 Giving ice chips as desired 2 Permitting milk if it has been iced 3 Maintaining NPO status for 24 to 48 hours 4 Limiting oral fluid to 15 mL every 4 hours

3 Nothing-by-mouth (NPO) status is maintained during the early emergency/resuscitative phase because of the probability of paralytic ileus. It is unsafe to offer ice chips because the fluid that is ingested interferes with monitoring and control of the child's fluid and electrolyte status. It is unsafe to offer oral fluids, not only because of the danger of paralytic ileus but also because they interfere with monitoring and control of the child's fluid and electrolyte status.

Which complication may be caused by sepsis in burns? 1 Diarrhea 2 Constipation 3 Paralytic ileus 4 Curling's ulcer

3 Paralytic ileus, or hypoactive bowel, is a complication caused by sepsis in clients with burns. Diarrhea can be caused by the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions. It is caused by a generalized stress response to decreased blood flow to the gastrointentinal tract in clients with burns.

To prevent septic shock in the hospitalized client, what should the nurse do? 1 Maintain the client in a normothermic state. 2 Administer blood products to replace fluid losses. 3 Use aseptic technique during all invasive procedures. 4 Keep the critically ill client immobilized to reduce metabolic demands.

3 Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary healthcare provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the primary healthcare provider to prescribe to confirm this diagnosis? 1 Cystoscopy and bilirubin level 2 Specific gravity and pH of the urine 3 Urinalysis and urine culture and sensitivity 4 Creatinine clearance and albumin/globulin (A/G) ratio

3 The client's manifestations may indicate a urinary tract infection; a culture of the urine will identify the microorganism, and sensitivity will identify the most appropriate antibiotic. A cystoscopy is too invasive as a screening procedure; altered bilirubin results indicate liver or biliary problems, not urinary signs and symptoms. Creatinine clearance reflects renal function; A/G ratio reflects liver function. Although an increased urine specific gravity may indicate red blood cells (RBCs), white blood cells (WBCs), or casts in the urine, which are associated with urinary tract infection, it will not identify the causative organism.

A 4-year-old child who barely survived a near-drowning episode is in critical condition in the pediatric intensive care unit. Suddenly the child opens her eyes and smiles, prompting a parent to say to the nurse, "Look! I think she'll get better now." What is the best response by the nurse? 1 "You're right; that's a very good sign." 2 "Try to have your child hold your hand." 3 "We're doing everything we can to promote recovery." 4 "God certainly must be watching over your child today."

3 The nurse must emphasize that everything possible is being done because the outcome cannot be predicted at this time. Encouraging the parent's positive interpretation of the child's reflexive behavior raises false hope. Telling the parent that God is watching over the child constitutes false hope. The parent's statement did not ask for the nurse's religious viewpoint; if the child does not improve, the parent may then perceive that God is not watching over the child.

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed? 1 Assessing for crepitus 2 Assessing for bleeding 3 Maintaining a patent airway 4 Performing neurologic assessment

3 The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurologic assessment for mental status, sensory level, and motor function, which holds a medium priority.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? 1 Decreased rate of glomerular filtration 2 Excessive blood loss through the burned tissues 3 Plasma proteins moving out of the intravascular compartment 4 Sodium retention occurring as a result of the aldosterone mechanism

3 The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

The nurse is caring for a client in active labor with a history of T5 spinal cord injury. Which of the following findings indicates to the nurse that the client is experiencing a complication of the labor process? 1. increased pulse rate 2. increased urine output 3. increased blood pressure 4. flaccidity in the lower extremities

3 rationale: A client with a spinal cord injury at T6 or higher is at risk for autonomic dysreflexia, marked by increased blood pressure and bradycardia. The nurse will need to carefully monitor this client throughout the labor process. An increased pulse rate may be a result of the adaptation of the labor process. Increased urine output would be expected, because clients are well hydrated in labor; this does not indicate a complication. Flaccidity is an expected assessment finding for a client with this history.

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? 1. hemodynamic changes related to tilt table positioning 2. deteriorating myelin sheath 3. distended large intestine 4. crushed spinal cord

3 rationale: Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. The client being upright on a tilt table is not involved in the autonomic hyperreflexia phenomenon. The myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the autonomic hyperreflexia phenomenon.

A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client? 1. Performing vagal maneuver 2. Performing Valsalva maneuver 3. Performing jaw-thrust maneuver 4. Performing oculocephalic maneuver

3 rationale: Road traffic accidents and other traumas can cause an airway occlusion. Therefore it may be necessary to ensure a patent airway by opening the jaw with a jaw-thrust maneuver. This helps to clear the airway. The nurse should also protect the cervical spine by manually aligning the neck in a neutral, in-line position. The vagal maneuver induces vagal nerve stimulation to slow cardiac conduction. The Valsalva maneuver involves breath holding, bearing down for bowel movements, and coughing to prevent cardiac problems. Oculocephalic maneuvers are performed to assess whether brainstem eye movement pathways are intact.

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary? 1. reflexes have been lost 2. there is partial transection of the cord 3. there is damage above the sixth thoracic vertebra 4. flaccid paralysis of the lower extremities has occurred

3 rationale: The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? 1. Change the client's diet to bland. 2. Obtain a stool specimen for occult blood. 3. Prepare for insertion of a nasogastric tube. 4. Monitor recent laboratory reports for hemoglobin levels.

3 rationale: The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should monitor the amount and characteristics of the drainage. Coffee-ground gastric fluid indicates blood that has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory reports for hemoglobin levels is unsafe; the client needs immediate medical attention.

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? 1. Inhibiting urinary tract infections 2. Preventing contractures and atrophy 3. Avoiding flexion or hyperextension of the spine 4. Preparing the client for vocational rehabilitation

3 rationale: The priority of care at this time is to protect the spine from additional damage to the traumatized area while it heals. Infection can result from prolonged immobility; although important, it is not the immediate priority. Although important, preventing contractures and atrophy is not the priority in the immediate postinjury period. Vocational rehabilitation will assume greater importance after the client's condition stabilizes.

Which client conditions require the nurse to tag with red according to the disaster triage tag system? Select all that apply. 1 Sprains 2 Abrasions 3 Hemorrhage 4 Airway obstruction 5 Compound fracture

3 4 The clients with conditions such as airway obstruction need immediate emergency care. According to the disaster triage tag system, these clients are issued a red tag. A hemorrhage needs immediate care as this is potentially life-threatening and these clients are also issued a red tag. Sprains and abrasions are minor injuries and do not require immediate care. Clients with such conditions are issued a green tag. Compound fractures are major injuries that require treatment and these clients will be issued a yellow tag.

A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent?

3) Stress ulcer. Rationale: An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H2 antagonists.

A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? 1. Flame burn 2. Chemical burn 3. Electrical burn 4. Radiation burn

3. Electrical burn In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves.

A client is admitted with traumatic injuries after a tornado. While performing resuscitation during the primary survey, the nurse notices a compromised airway. Which nursing intervention would be of most benefit to the client? 1 Preparing for chest decompression if needed 2 Monitoring vital signs, especially blood pressure and pulse 3 Preventing hypothermia using blankets and heating devices 4 Preparing for endotracheal intubation and mechanical ventilation

4 Preparing for endotracheal intubation and mechanical ventilation ensures airway patency during the primary survey in order to reduce the severity of airway compromise. Preparing for chest decompression is done during the primary survey when there are no breath sounds. Monitoring vital signs, especially blood pressure and pulse, is performed to assess circulatory disorders. Preventing hypothermia using blankets and heating devices is done during the exposure assessment.

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? 1. "Do you want me to get someone else to change you?" 2. "You shouldn't be embarrassed; this is part of my job." 3. "I'll be back in a little while; why don't you rest until then?" 4. "While I'm bathing you I'll start teaching you about bowel training."

4 rationale: A matter-of-fact approach eases embarrassment and then focuses on a method of helping the client regain control. The response "Do you want me to get someone else to change you?" ignores the issue, and with it the nurse is abandoning responsibility. The response "You shouldn't be embarrassed; this is part of my job" lacks empathy and does not offer hope for improvement. The response "I'll be back in a little while; why don't you rest until then?" cuts off communication and ignores the client's need to be changed.

The nurse is caring for a client one week after the client experienced a spinal cord injury at the T3 level. What is an appropriate short-term goal for this client? 1. the client will understand limitations 2. the client will consider lifestyle changes 3. the client will perform independent ambulation 4. the client will carry out personal hygiene activities

4 rationale: If the client has the capability to perform personal hygiene activities, it will help maintain a positive identity. Understanding limitations, considering lifestyle changes, and performing independent ambulation are necessary for progression to long-term goals.

A client was admitted to the hospital with a direct injury to the vertebral column from a gunshot after a mass shooting. The nurse suspects a spinal cord injury. Which mechanism of injury might be the reason for the injury? 1. hyperflexion 2. hyperextension 3. excessive rotation 4. penetrating trauma

4 rationale: The mechanism of penetrating trauma is involved when an injury occurs due to piercing, which is classified by the velocity of the piercing vehicle such as a bullet. A hyperflexion injury happens when extreme flexion of the neck occurs due to a sudden and forceful forward acceleration of the head. Hyperextension occurs when the head is suddenly accelerated and then decelerated or during a fall if the client's chin is struck. When the head is rotated or turned beyond the normal range, excessive rotation injury occurs.

The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client?

4) Gentamicin sulfate. Ratioanale: Gentamicin sulfate may cause nephrotoxicity in the client; therefore the client who is prescribed this drug should be carefully monitored for serum creatinine and blood urea nitrogen. The client on nitrofurantoin should be closely observed for signs of allergic reactions. Blood gas and serum electrolyte levels should be monitored in clients on mafenide acetate. In clients who are on silver sulfadiazine, wounds should be monitored for infections.

A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client?

4) Slight breathlessness. Rationale: Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur.

The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client? 1. Nitrofurantoin 2. Mafenide acetate 3. Silver sulfadiazine 4. Gentamicin sulfate

4. Gentamicin sulfate Gentamicin sulfate may cause nephrotoxicity in the client; therefore the client who is prescribed this drug should be carefully monitored for serum creatinine and blood urea nitrogen. The client on nitrofurantoin should be closely observed for signs of allergic reactions. Blood gas and serum electrolyte levels should be monitored in clients on mafenide acetate. In clients who are on silver sulfadiazine, wounds should be monitored for infections.

Compartment syndrome assessment- cap refill

6 P's Paresthesia pain distal to injury which is unrelieved pressure increases in compartment pallor, coolness, loss of color paralysis pulselessness

Elevated WBC

=to keep up with the demand of neutrophils, the bone marrow releases more neutrophils into circulation causing elevated WBC.. and especially neutrophils

After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide? a. Lower extremities are paralyzed. b. Upper extremities are paralyzed. c. One side of the body is paralyzed. d. Both lower and upper extremities are paralyzed.

A

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? Select all that apply. A. Using Credé maneuver B. Using an indwelling catheter C. Using anticholinergic medications D. Monitoring and restricting fluid intake to 800 mL daily E. Monitoring for and reporting signs of urinary tract infection

A & E Rationale: Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with multiple sclerosis. Early recognition and treatment of infection is important to decrease the risk of exacerbation in the client with multiple sclerosis. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties as concentrated urine increases the risk of urinary tract infection.

A client with myasthenia gravis asks the nurse why the disease has occurred. What pathology underlies the nurse's reply?

A decreased number of functioning acetylcholine receptor (AChR) sites. (One of the pathologic changes is electron microscopic evidence of fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites).

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Select all that apply.

A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside.

A nurse is assessing a 38-year-old female client who has been admitted for a biopsy of a lump in her right breast. Which finding may indicate a malignancy?

A lesion in the upper outer quadrant that is poorly delineated and immobile

An ambulatory client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a. What adverse effects does the nurse explain may occur when taking this medication? Select all that apply. A. Depression B. Constipation C. Flulike symptoms D. Increased heart rate E. Decreased perspiration

A, B, C, D Rationale: Central nervous system effects include depression that may lead to suicide attempts. Gastrointestinal side effects include constipation, diarrhea, vomiting, and abdominal pain. Interferon immune modifier causes flulike symptoms, such as fever, muscle aches, and lethargy. Drugs for increased heart rate include side effects such as tachycardia, palpitations, and hypertension. An integumentary response to this drug is sweating, not lack of perspiration (anhidrosis).

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. A. Double vision B. Problems with cognition C. Difficulty swallowing saliva D. Intention tremors of the hands E. Drooping of the upper eyelids F. Nonintention tremors of the extremities

A, C, E Rationale: Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? A. Nonintention tremors B. Frequent bouts of diarrhea C. Masklike facial expression D. Hyperextension of the neck E. Rigidity to passive movement

A, C, E- Nonintentional tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? A. Bladder control B. Nutritional intake C. Quadriceps setting D. Use of aids for ambulation

A- Because of the location of the micturition reflex center (in the sacral region of the spinal cord), bladder function may be impaired with lower spinal cord injuries. This client's ability to ingest, digest, or metabolize food is not affected; therefore nutrition is less of a problem than bladder control. Quadriceps settings require motor control, which the client does not have. Because there is no voluntary control over the lower extremities, mobility usually is accomplished through the use of a wheelchair rather than ambulation.

One week after being hospitalized for an acute myocardial infarction, a client reports loss of appetite and feeling nauseated. Which of the client's prescribed medications should be withheld and the healthcare provider notified? A. Digoxin B. Propranolol C. Furosemide D. Spironolactone

A. Digoxin

A client with left ventricular heart failure is taking digoxin 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply. A. Diuresis B. Tachycardia C. Decreased edema D. Decreased pulse rate E. Reduced heart murmur F. Jugular vein distention

A. Diuresis C. Decreased edema D. Decreased pulse rate

The primary healthcare provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question is priority that the nurse should ask the client? A. "Do you take antidepressants?" B. "Do you have any respiratory disorders?" C. "Do you wear contact lens?" D. "Do you have allergies to sulfonamides?"

A- Clients prescribed adrenergic agonists should be asked whether they are taking any antidepressants, such as phenezeline, because these medications increase blood pressure as do the adrenergic agonists; hence, this may lead to a hypertensive crisis. Clients prescribed beta-adrenergic blockers should be asked about any respiratory disorders, such as asthma, because the drug causes constriction of pulmonary smooth muscle which may lead to narrowing of the airway. Carbonic anhydrase inhibitors are similar to sulfonamides. Therefore, they should not be prescribed to clients who are allergic to sulfonamides. While asking about contact lensesis appropriate, this is not the priority for adrenergic agonist; discoloration of lens is not a critical as hypertensive crisis.

The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response? A. Emotional lability is associated with brain trauma. B. Their presence allows the client to express feelings. C. The client is depressed about the loss of functional abilities. D. Nonverbal expressions of feelings are more accurate than verbal ones.

A- Emotional lability is associated with brain trauma from ischemia or injury. The frontal lobe, hypothalamus, thalamus, and cortical limbic system are involved in expression of emotions. Emotional lability is not limited to interactions with family. Although the client may be depressed, the uncontrollable tearfulness is because of the disease process. Although nonverbal messages are often helpful in determining emotional response, these emotional outbursts may be unrelated to feelings.

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A. Monitor the client for signs of brain injury. B. Check for hemorrhaging from the oral and nasal cavities. C. Elevate the foot of the bed if the client develops symptoms of shock. D. Observe for clinical indicators of decreased intracranial pressure and temperature.

A- Head injuries can cause trauma to the brain, and the client should be monitored for symptoms of increased intracranial pressure (e.g., headache, dizziness, and visual disturbances). Checking for hemorrhaging from the oral and nasal cavities is not indicated in this situation. Elevating the lower extremities should be avoided because it will increase intracranial pressure. The intracranial pressure may increase after trauma because of bleeding and edema. The temperature may increase because of injury to or pressure on the hypothalamus.

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities? A. Shortening and eventual atrophy of the muscles will occur. B. Hypertrophy of the muscles eventually will result from disuse. C. Rigid extension can occur, making therapy painful and difficult. D. Decreased movement on the affected side predisposes the client to infection.

A- Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose to infection but to atrophy and contractures.

A client is diagnosed with the genetic disorder osteogenesis imperfecta. Which condition can be anticipated in the client at an age of 30? A. Loss of auditory acuity B. Loss of visual acuity C. Loss of smell perception D. Loss of touch perception

A- Some genetic disorders, such as osteogenesis imperfecta and Down syndrome, lead to progressive hearing loss in adults. Familial tendency and some genetic conditions may cause visual impairment. Osteogenesis imperfecta typically does not cause loss of smell or touch perception.

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? A. Avoid leaning forward. B. Hesitate between steps. C. Rest when tremors are experienced. D. Keep arms close to the center of gravity.

A- The client with Parkinson disease often has a stooped posture [1] [1] [2] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.

Which structure is a component of the auditory ossicles? A. Malleus B. Vestibule C. Tympanic membrane D. External acoustic meatus

A- The malleus along with the incus and stapes constitutes the auditory ossicles. The vestibule is present in the inner ear and is an organ of balance. The tympanic membrane (eardrum) is a part of the middle ear. The external acoustic meatus is a component of the external ear.

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position? A. 1 to 2 hours B. 3 to 4 hours C. 15 to 20 minutes D. 30 to 40 minutes

A-Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility [1] [2]. Too protracted a period of time in one position, such as every 3 to 4 hours, increases the potential for respiratory, urinary, and neuromuscular impairment. Prolonged physical pressure increases the possibility of skin breakdown. Fifteen to 20 minutes and 30 to 40 minutes are unnecessarily short time intervals- too frequent repositioning may interfere with the client's rest.

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. What will the nurse instruct the client to do regarding nutrition? Select all that apply. A. Eat more dark green leafy vegetables such as spinach. B. Eat more vitamin-enriched products. C. Return to previous eating habits. D. Increase intake of dairy products. E. Increase intake of beans.

A. Eat more dark green leafy vegetables such as spinach. E. Increase intake of beans.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? A. "That must have really shocked you. Tell me what the healthcare provider told you about it." B. "You should see a psychiatrist who will help you cope with this overwhelming news." C. "Don't worry; early treatment often alleviates symptoms of the disease." D. "You should be glad that we caught it early so it can be cured."

A. "That must have really shocked you. Tell me what the healthcare provider told you about it." Rationale: The response "That must have really shocked you. Tell me what the healthcare provider told you about it" acknowledges the effect of the diagnosis on the client and explores what is known. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary. The statement "Don't worry; early treatment often alleviates symptoms of the disease" provides false reassurance. The statement "You should be glad we caught it early so it can be cured" does not address the client's current emotional state, and it is inaccurate; MS is a chronic autoimmune disease.

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse? A. "You don't feel able to make a decision at this time?" B. "Have you spoken to your fiancé about your feelings?" C. "Your fiancé loves you and I'm sure still wants to marry you." D. "These are your feelings now, but don't decide until you feel better and can cope."

A. "You don't feel able to make a decision at this time?" Rationale: The response "You don't feel able to make a decision at this time?" reflects the client's concern and provides an opportunity for further verbalization while indicating the nurse's understanding. The response "Have you spoken to your fiancé about your feelings?" changes the emphasis to the fiancé's opinion and asks a direct question, which closes off communication. The response "Your fiancé loves you and I'm sure still wants to marry you" is false reassurance that belittles the client's concerns. The response "These are your feelings now, but don't decide until you feel better and can cope" gives advice and cuts off further exploration of the client's feelings.

A client who has just started on a regimen of haloperidol is observed pacing and shifting weight from one foot to the other. What side effect does the nurse document in the client's chart? A. Akathisia B. Parkinsonism C. Tardive dyskinesia D. Acute dystonic reaction

A. Akathisia

The nurse is preparing to administer ear drops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. A. Allergy to the medication B. Itching in the ear canal C. Drainage from the ear canal D. Tympanic membrane rupture E. Partial hearing loss in the affected ear

A. Allergy to the medication C. Drainage from the ear canal D. Tympanic membrane rupture

A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats per minute. What is an appropriate treatment plan? A. Amiodarone bolus B. Intracardiac epinephrine C. Insertion of a pacemaker D. Cardiopulmonary resuscitation (CPR)

A. Amiodarone bolus

A client suspected of having myasthenia gravis is scheduled for an edrophonium chloride test. To treat a common complication associated with the test, the nurse will have what drug available? A. Atropine B. Phenytoin C. Neostigmine D. Diphenhydramine

A. Atropine Rationale: Atropine, an anticholinergic, always should be available to treat a cholinergic crisis (sudden, severe episode of muscle weakness that affects breathing and swallowing) should the edrophonium chloride test trigger this response. Phenytoin is an anticonvulsant that will not avert or treat complications resulting from a Tensilon test. Neostigmine is a cholinergic that has the same action as edrophonium chloride; it is contraindicated if a cholinergic crisis occurs. Diphenhydramine is an antihistamine that will not avert complications or effectively treat a cholinergic crisis.

A nurse is teaching a client who is taking a loop diuretic about foods that are high in potassium. Which foods should the nurse emphasize? Select all that apply. A. Bananas B. Apricots C. Roasted chicken D. Macaroni and cheese E. Baked potatoes with skins

A. Bananas B. Apricots E. Baked potatoes with skins

For which side effects should a nurse assess a client with cancer who is being treated with chemotherapeutic agents? Select all that apply. A. Diarrhea B. Leukocytosis C. Bleeding tendencies D. Lowered sedimentation rate E. Increased hemoglobin levels

A. Diarrhea C. Bleeding tendencies

A client is prescribed epoetin injections. To ensure the client's safety, which lab value should the nurse assess before administration? A. Hemoglobin B. Platelet count C. Prothrombin time D. Partial thromboplastin time

A. Hemoglobin

A client who is receiving hydrochlorothiazide asks what this drug actually does. What information about the drug's therapeutic action will the nurse consider when formulating a response? A. Increases the excretion of sodium B. Increases the glomerular filtration rate C. Decreases the reabsorption of potassium D. Decreases the amount of fluid reabsorption in the loop of Henle

A. Increases the excretion of sodium

A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What findings does the nurse expect to identify when performing an admission assessment? Select all that apply. A. Melena B. Tachycardia C. Constipation D. Clay-colored stools E. Painful bowel movements

A. Melena (blood in the stool) B. Tachycardia

The client with amyotrophic lateral sclerosis (ALS) is degenerating rapidly and will soon need respiratory support. What will the nurse plan to review with this client?

Advance Directives (Mechanical ventilation enables the client to breathe and prolongs survival, but it will not alter progression of the disease. For this reason, many clients elect not to be placed on a mechanical ventilator, according to their wishes or advance directives).

A nurse is assessing a 3-year-old child with a tentative diagnosis of lead poisoning. What clinical finding supports this diagnosis?

Clumsiness

What clinical finding does the nurse expect when assessing a client with myasthenia gravis? A. Partial improvement of muscle strength with mild exercise B. Fluctuating weakness of muscles innervated by the cranial nerves C. Dramatic worsening in muscle strength with anticholinesterase drugs D. Minimal changes in muscle strength regardless of the therapy initiated

B. Fluctuating weakness of muscles innervated by the cranial nerves Rationale: Myasthenia gravis is a chronic disorder of muscles enervated by weakened cranial nerves; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs increase, not decrease, muscle strength. Anticholinesterase drugs improve muscle strength.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress?

Answer:A bland, nonirritating diet is recommended during the acute symptomatic phase. -During the acute phase, a regular diet can cause discomfort. -Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. - Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. -Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

A visitor comes to the nursing station and tells the nurse that a client and a relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take?

Ask security to make sure the room is safe Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and ensured that any other people in the room are safe.

A depressed client is admitted to the hospital after being found bleeding from a superficial self-inflicted gunshot wound. The client does not respond to any of the nurse's questions. What should the nurse do to assess the client's current potential for suicide?

Ask the family about any recent suicide attempts or threats by the client

A client in the ICU after sustaining a T2 spinal cord injury, which priority intervention should the nurse include in the clients plan of care

Assess for respiratory complications, monitoring and maintaining blood pressure

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?

Assessing maternal vital signs

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

Assessment of skin turgor Administration of antiemetic drugs Correct 5 Replacement of fluid and electrolytes When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

A client calls out to all nursing staff members who pass by the door and asks them to do or get something. How can the nurse best manage this problem while meeting this client's needs? 1 Assign one staff member to approach the client regularly and interact with the client. 2 Close the door to the room so that the client cannot see the staff members as they pass by. 3 Inform the client that one staff member will come in frequently and check whether the client has any requests. 4 Arrange for a variety of staff members to take turns going into the room to see whether the client has any requests.

Assign one staff member to approach the client regularly and interact with the client. Assigning one staff member to approach the client regularly and interact with the client provides continuity and demonstrates to the client that the nursing staff is concerned; frequent contact should reduce the client's need to call the staff for reassurance. Closing the door to the room so that the client cannot see the staff members as they pass by may increase the client's anxiety and the need for contact with staff. Telling the client is not the same as doing it; the client may not believe that staff will come in frequently. Arranging for a variety of staff members to take turns going into the room to see whether the client has any requests will not facilitate the development of a therapeutic relationship with a staff member.

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency? Hemorrhage Hypovolemic shock Gastrointestinal atony Autonomic hyperreflexia

Autonomic hyperreflexia. Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency.

A client is being evaluated based on client reports of an impairment of a portion of the peripheral vision. After testing is completed, a diagnosis of retinal detachment is made, and a cryosurgical procedure is scheduled. As part of the preoperative teaching, the nurse provides information about what the client can expect and includes which information? A. An explanation that the surgery will be brief B. A description of the surgical suite environment C. The procedure and risks of the repair of the retina D. The importance of postoperative coughing and deep-breathing exercises

B- Because vision will be limited somewhat after surgery, it is important to familiarize the client with vital aspects of the environment, which provides for physical and emotional safety. Surgery usually takes approximately two hours, followed by a stay in the postanesthesia care unit. The healthcare provider should discuss the procedure and risks; informed consent is the primary healthcare provider's responsibility not the nurse's. Coughing or other activity that increases intraocular pressure should be avoided.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? A. The injury results in loss of the reflex arc. B. The injury is above the sixth thoracic vertebra. C. There has been a partial transection of the cord. D. There is a flaccid paralysis of the lower extremities.

B- The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock. As the inflammation subsides, spasticity gradually increases.

Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to which structure? A. Thalamus B. Hypothalamus C. Temporal lobe D. Globus pallidus

B- The hypothalamus connects with the autonomic area for vasoconstriction, vasodilation, and perspiration and with the somatic centers for shivering. Therefore, it is an important area for regulating body temperature. The thalamus receives all sensory stimuli, except taste, for transmission to the cerebral cortex. It is also involved with emotions and instinctive activities. The temporal lobe is concerned with auditory stimuli. It also may be involved with the sense of smell. The globus pallidus is part of the basal ganglia, required for specific body movements.

A client with myasthenia gravis improves and is discharged from the hospital. The discharge medications include pyridostigmine bromide 10 mg every 6 hours. The nurse evaluates that the drug regimen is understood when the client makes which statement? A. "I will take the medication on an empty stomach." B. "I need to set an alarm so I take the medication on time." C. "It will be important to check my heart rate before taking the medication." D. "I should monitor for an increase in blood pressure after taking the medication."

B. "I need to set an alarm so I take the medication on time." Rationale: Pyridostigmine is a vital drug that must be taken on time; a missed or late dose can result in severe respiratory and neuromuscular consequences or even death. Pyridostigmine should be taken with a small amount of food to prevent gastric irritation. It is unnecessary to take the pulse rate before taking pyridostigmine. Pyridostigmine may cause hypotension, not hypertension, which is a sign of cholinergic crisis.

A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed? A. "I avoid use of a straw to drink liquids." B. "I will take a hot bath to help relax my muscles." C. "I plan to use an incontinence pad when I go out." D. "I may be having a rough time now, but I hope tomorrow will be better."

B. "I will take a hot bath to help relax my muscles." Rationale: The nurse needs to address the hot baths to correct this misconception. Hot baths tend to increase symptoms and may result in burns because of decreased sensation. All the rest are correct and do not require teaching. Using a straw gives the client less control of liquid intake, which may lead to aspiration. Although a bladder regimen to maintain control is preferable, the use of pads can avoid embarrassment. The disease does have periods of remission and exacerbation.

The healthcare provider prescribes neostigmine for a client with myasthenia gravis. The nurse evaluates that the client understands the teaching about this drug when the client makes what statement regarding drug management plans? A. "Keep the drug in a container in the refrigerator." B. "Take the drug at the exact time that is listed on the prescription." C. "Plan to take the drug between meals to promote absorption." D. "Expect that the onset of the action of the drug will occur several hours after I take it."

B. "Take the drug at the exact time that is listed on the prescription." Rationale: Neostigmine should be taken as prescribed, usually before meals, to limit dysphagia and possible aspiration. Keeping neostigmine refrigerated is not necessary; it may be kept at room temperature. Neostigmine should be taken with milk to prevent gastrointestinal irritation; usually it is taken about 30 minutes before meals. The onset of the action of neostigmine occurs 45 to 75 minutes after administration; the duration of its action is 2.5 to 4 hours.

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication? A. 15 minutes before the dressing change B. 60 minutes before the dressing change C. Along with a stool softener each time it is administered D. Only if the client rates pain between 8 and 10 on the pain scale

B. 60 minutes before the dressing change

A client is considered to be in septic shock when what changes are assessed in the client's labwork? A. Blood glucose is 70-100 mg/dL B. An increased serum lactate level C. An increased neutrophil level D. A white blood count of 5000 cells/µL

B. An increased serum lactate level

A client with myasthenia gravis has been receiving neostigmine and asks about its action. What information about its action should the nurse consider when formulating a response? A. Stimulates the cerebral cortex B. Blocks the action of cholinesterase C. Replaces deficient neurotransmitters D. Accelerates transmission along neural sheaths

B. Blocks the action of cholinesterase Rationale: Neostigmine, an anticholinesterase, inhibits the breakdown of acetylcholine, thus prolonging neurotransmission. Neostigmine's action is at the myoneural junction, not the cerebral cortex. Neostigmine prevents neurotransmitter breakdown, but it is not a neurotransmitter. Neostigmine's action is at the myoneural junction, not the sheath.

When a client has gluteal edema, why should the nurse avoid using the gluteus maximus muscle for administration of intramuscular medications? A. Deposition of an injected drug causes pain. B. Blood supply is likely insufficient for adequate absorption. C. Fluid leaks from the site for a long time after the injection. D. Tissue fluid dilutes the drug before it enters the circulation.

B. Blood supply is likely insufficient for adequate absorption.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? A. Encourage bed rest. B. Space activities throughout the day. C. Teach the limitations imposed by the disease. D. Have one of the client's relatives stay at the bedside.

B. Space activities throughout the day. Rationale: Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? A. Hiking B. Swimming C. Sewing Classes D. Watching television

B. Swimming Rationale: Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

A client is to receive total parenteral nutrition (TPN) via a central venous access device/catheter. What information about this treatment would the nurse recognize as accurate? A. The jugular vein is the most commonly used catheter insertion site. B. The TPN may be administered intermittently rather than continuously. C. The client will experience a moderate amount of pain during the procedure. D. Catheter placement must be confirmed by fluoroscopy before the TPN is initiated.

B. The TPN may be administered intermittently rather than continuously.

Which nursing action is specific to the plan of care for a client with trigeminal neuralgia?

Be alert to prevent dehydration or starvation (Pain may prevent the client from ingesting anything by mouth. Facial exercises may precipitate an attack. Hot or cold foods or compresses should be avoided because they may trigger a painful attack. Brushing the teeth may initiate an acute attack of trigeminal neuralgia; often clients must limit oral hygiene to rinsing the mouth.).

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?

Behavioral Changes

The nurse encourages the ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique?

Blinking for yes or no.

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

C

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response? a. "Tell me about your fears regarding pain." b. "Analgesics will be prescribed to control the pain." c. "Pain is not a characteristic symptom of this condition." d. "Let's make a list of the things you need to ask your primary healthcare provider."

C

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. 1 . Headaches 2. Nystagmus 3. Skin infections 4. Scanning speech 5. Intention tremors a. 1, 3, 5 b. 2, 4 c. 2, 4, 5 d. 3, 5

C

A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? a. Progressive deterioration until death b. Deficiencies of essential neurotransmitters c. Increased risk for respiratory complications d. Involuntary twitching of small muscle groups

C

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? a. Hemodynamic changes related to tilt table positioning b. Deteriorating myelin sheath c. Distended large intestine d. Crushed spinal cord

C

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. What information should the nurse include in the response? A. Clients with this disease have an excellent prognosis. B. The disorder affects males and females in equal numbers. C. The disorder is considered one of hypersensitivity, and the exact cause is unknown. D. Clients with this disease have problems with only the kidneys and the retina of the eyes.

C- An autoimmune response plays a role in the development of polyarteritis, although drugs and infections may precipitate it. The disorder often is fatal, usually as a result of heart or renal failure. Men are affected three times more often than women. Arteriolar pathology can affect any organ or system.

A client with a cerebrovascular accident ("brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? A. Routine hygiene B. Liquid formula diet C. Prevention of aspiration D. Effective communication

C- Clients with dysarthria have difficulty communicating verbally, and an alternate means of communication may be indicated. Routine hygiene, liquid formula diet, and prevention of aspiration are important aspects of care, but they are not related to dysarthria. Dysphagia can lead to aspiration

A client who sustains a stroke has a loss of proprioception and fine touch. Which artery does the nurse suspect is damaged? A. Lateral cerebral B. Middle cerebral C. Anterior cerebral D. Posterior cerebral

C- Damage to the anterior cerebral artery can lead to a loss of proprioception and fine touch. Damage to the vertebral artery can cause dysphagia and dysarthria. Injury to the middle cerebral artery can cause motor and sensory deficits. Posterior cerebral artery damage can cause visual hallucinations and hemianopsia. There is no artery called lateral cerebral.

A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response? A. Blood loss B. Tissue death C. Vascular spasms D. Electrolyte imbalance

C- In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm). This in turn contributes to the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause generalized weakness. However, hemiparesis and aphasia are not the result of electrolyte loss.

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response? A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of only the ptosis

C- Tensilon acts systemically to increase muscle strength; it lasts several minutes. Tensilon produces a brief increase in muscle strength; with a negative response the client will demonstrate no change in symptoms. Tensilon may intensify muscle weakness in a cholinergic crisis. Tensilon does not cause lasting effects. Tensilon acts systemically on all muscles, rather than selectively on the eyelids.

A client with multiple sclerosis is informed that this is a chronic, progressive neurologic condition. The client asks the nurse, "Will I experience unbearable pain?" What is the nurse's best response? A. "Tell me about your fears regarding pain." B. "Analgesics will be prescribed to control the pain." C. "Some clients report feeling a tingling or burning sensation but not unbearable pain." D. "Let's make a list of the things you need to ask your healthcare provider."

C. "Some clients report feeling a tingling or burning sensation but not unbearable pain." Rationale: The response, "Some clients report feeling a tingling or burning sensation [1] [2], but not unbearable pain," is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it does not occur in all clients. These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations). The response, "Tell me about your fears regarding pain," avoids the client's question and may increase anxiety. Analgesics are not commonly prescribed unless pain results from some other condition. The response, "Let's make a list of the things you need to ask your healthcare provider," avoids the client's question and abdicates the nurse's responsibility.

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

C. "The prognosis is variable; most individuals experience remissions and exacerbations." Rationale: "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 question. The response "Why don't you speak with your healthcare provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? A. A genetic defect in the production of acetylcholine (ACh) B. An inefficient use of the neurotransmitter acetylcholine C. A decreased number of functioning acetylcholine receptor (AChR) sites D. An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C. A decreased number of functioning acetylcholine receptor (AChR) sites Rationale: One of the pathologic changes is fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites. There is no genetic defect in the production of ACh; rather than a genetic cause, it is thought that myasthenia gravis has an autoimmune etiology. Although the defect is at the neuromuscular junction, it is not an inefficiency in the use of ACh but a decrease in the number of receptor sites for ACh. AChE is inhibited by anticholinesterase drugs used to treat myasthenia gravis, leaving more ACh available to the damaged or decreased ACh receptors.

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 which information? A. Plan activities for later in the day. B. Eat meals in a semirecumbent position. C. Avoid people with respiratory infections. D. Take muscle relaxants when under stress.

C. Avoid people with respiratory infections. Rationale: 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.

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about what the client can anticipate should be incorporated into the nurse's response? A. High cure rate with proper treatment B. Slowly progressive course without remissions C. Chronic illness with exacerbations and remissions D. Poor prognosis, with death occurring in a few months

C. Chronic illness with exacerbations and remissions Rationale: Myasthenia gravis is a chronic disorder with remissions and exacerbations that are precipitated by emotional stress, ingestion of alcohol, and physiologic stress such as infection. There is no cure for myasthenia gravis, but it can be managed. The disease is characterized by exacerbations and remissions. The disease is chronic. Death does not occur within a short period.

Twenty minutes after the start of an intravenous (IV) vancomycin infusion, the client appears flushed and complains of palpitations. What action should the nurse take? A. Stop the infusion; the client is having an allergic reaction. B. Continue to monitor the client; this is an expected reaction. C. Contact the primary healthcare provider to obtain a prescription to decrease the infusion rate. D. Contact the primary healthcare provider to obtain a prescription for an antianxiety medication.

C. Contact the primary healthcare provider to obtain a prescription to decrease the infusion rate.

A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine is prescribed. When teaching the client about this medication, the nurse explains to expect an increase in what function? A. Intestinal peristalsis B. Salivary and gastric secretions C. Contraction of skeletal muscles D. Secretion and discharge of tears

C. Contraction of skeletal muscles Rationale: 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 client with myasthenia gravis is to receive immunosuppressive therapy. What assures the nurse that this therapy will be effective? A. Inhibits the breakdown of acetylcholine at the neuromuscular junction B. timulates the production of acetylcholine at the neuromuscular junction C. Decreases the production of autoantibodies that attack acetylcholine receptors D. Promotes the removal of autoantibodies that impair the transmission of impulses

C. Decreases the production of autoantibodies that attack acetylcholine receptors Rationale: Steroids decrease the body's immune response, limiting the production of antibodies that attack acetylcholine receptors at the neuromuscular junction. Inhibiting the breakdown of acetylcholine at the neuromuscular junction is the action of anticholinergic medications. Stimulating the production of acetylcholine at the neuromuscular junction is not the action of immunosuppressives. Promoting the removal of autoantibodies that impair the transmission of impulses is the rationale for plasmapheresis.

A client has a diagnosis of multiple sclerosis and is currently in remission. The client is a parent of two active preschoolers. What should the nurse encourage the client to do? A. Plan a schedule of specific times each day that will be set aside for playtime with the children. B. While in remission, provide support to other people with multiple sclerosis who also have young children. C. Develop a flexible schedule for completion of routine daily activities. D. Meet with a self-help group for people with the diagnosis of multiple sclerosis.

C. Develop a flexible schedule for completion of routine daily activities. Rationale: The client must be flexible and adjust activities to provide for rest when necessary; activity should cease before the point of fatigue. Although quality time with children is important, it must be done on a flexible schedule to prevent fatigue. Although laudable, providing support to other people with multiple sclerosis who also have young children cannot be done if the client is in need of support or if it overtaxes physical resources. Meeting with a self-help group for people with the diagnosis of multiple sclerosis may not be a need at this time; prevention of fatigue always is important.

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? A. Cogwheel gait B. Impaired cognition C. Difficulty swallowing D. Nonintention tremors

C. Difficulty swallowing Rationale: Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. What clinical finding does the nurse anticipate if the client develops water intoxication? A. Sooty-colored sputum B. Frothy, pink-tinged sputum C. Disorientation with twitching D. Urine output of 25 mL/hr

C. Disorientation with twitching

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? A. Ability to chew and speak distinctly B. Capacity to smile and close the eyelids C. Effectiveness of respiratory exchange and ability to swallow D. Degree of anxiety and concern about the suspected diagnosis

C. Effectiveness of respiratory exchange and ability to swallow Rationale: Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? A. Narrowed airways B. Impaired immunity C. Ineffective coughing D. Viscosity of secretions

C. Ineffective coughing Rationale: Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, what teaching does the nurse provide? A. Weekly Z-track injections provide needed control. B. Daily intramuscular injections are required for control. C. Intramuscular injections once a month will maintain control. D. Oral vitamin B12 tablets taken daily will provide symptom control.

C. Intramuscular injections once a month will maintain control.

The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicates to the nurse that the client's fluid replacement is adequate? A. Increasing hematocrit level B. Urinary output of 15 to 20 mL/hr C. Slowing of a previously rapid pulse rate D. Central venous pressure progressing from 5 to 1 mm Hg

C. Slowing of a previously rapid pulse rate

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip is prescribed. Several hours later, vancomycin intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? A. Stop the heparin, flush the line, and administer the vancomycin. B. Use a piggyback setup to administer the vancomycin into the heparin. C. Start another IV line for the vancomycin and continue the heparin as prescribed. D. Hold the vancomycin and tell the healthcare provider that the drug is incompatible with heparin.

C. Start another IV line for the vancomycin and continue the heparin as prescribed.

The healthcare provider prescribes an intravenous medication for a client who has been admitted for a chronic obstructive pulmonary disease exacerbation. When preparing to initiate an intravenous line, the nurse applies the tourniquet to select the site. When should the nurse release the tourniquet? A. After cleaning the insertion site B. As soon as the needle pierces the skin C. When the needle enters the vein D. After the device is secured with tape

C. When the needle enters the vein

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply. 1 Carrots 2 Oranges 3 Tomatoes 4 Skim milk 5 Leafy greens

Carrots Leafy greens Yellow/orange vegetables contain large quantities of the pigments alpha-, beta-, and gamma-carotene; beta-carotene is the major chemical precursor of vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots also are high in vitamin A. Dark green leafy vegetables contain large quantities of the pigments alpha-, beta-, and gamma-carotene; beta-carotene is the major chemical precursor of vitamin A in human nutrition. Broccoli, cabbage, spinach, and collards also are high in vitamin A. Oranges are considered a good source of both vitamin C and potassium. Tomatoes are a good source of vitamin C. Levels of vitamin A are higher in whole milk than in skim milk. Study Tip: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

The nurse is providing care for a client diagnosed with invasive cancer of the head of the pancreas that has had a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Postoperatively, the nurse should care for the T-tube by:

Cleansing the area around the insertion site to prevent skin breakdown

Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. 1 Client with corneal arcus 2 Client with periorbital edema 3 Client with decreased skin turgor 4 Client with paleness of conjunctivae 5 Client with yellow lipid lesions on eyelids

Client with corneal arcus Client with yellow lipid lesions on eyelids The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.

A nurse is working as a triage nurse in the emergency department. Place the following clients in the order in which they should receive care. 1. Man with acute pancreatitis 2. Infant having a seizure 3. Woman with acute chest pain 4. Adolescent with a blood glucose level of 190 5. Child with a non-life threatening cut that needs stitches

Correct 1. Infant having a seizure Correct 2. Woman with acute chest pain Correct 3. Man with acute pancreatitis Incorrect 5. Child with a non-life threatening cut that needs stitches 4. Adolescent with a blood glucose level of 190 Incorrect An infant having a seizure should receive care first because the infant is in acute distress. A person having a seizure should never be left alone. The primary responsibilities include maintaining client safety and observing the characteristics of the seizure. A woman having acute chest pain should receive care second because chest pain can indicate a myocardial infarction or other potential fatal cardiac event. Acute pancreatitis is extremely painful and therefore this client should be medicated as soon as possible after clients with life-threatening problems are stabilized. A child with a non-life-threatening cut and needing stitches can wait until the more acute clients are attended to and stabilized. Although a blood glucose level of 190 is elevated it is not life threatening; therefore, meeting the needs of clients with more acute problems first is appropriate.

A client is receiving therapy that includes a radioactive sealed implant. What nursing intervention should be implemented to protect against exposure to radiation? 1 Wearing a dosimeter film badge at all times 2 Limiting exposure to the client to one hour daily 3 Using long-handled forceps to retrieve a dislodged implant 4 Ensuring that visitors maintain a minimum distance of 3 feet from the client

Correct3 Using long-handled forceps to retrieve a dislodged implant sing long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily.

A client is awaiting surgery for a ruptured lumbar nucleus pulposus. Which activities should the nurse inform the client will most likely increase pain? Select all that apply. 1 Lying on the side 2 Flexing the knees Correct 3 Coughing excessively 4 Sitting for long periods of time Correct 5 Bearing down when having a bowel movement

Coughing excessively Bearing down when having a bowel movement Coughing places strain on the lumbar area, increasing herniation of the disc. The Valsalva maneuver increases intervertebral pressure and may cause pain. Lying on the side does not increase intervertebral pressure that can result in pain. Flexing the knees will not increase pressure or cause pain; flexing the knees usually promotes comfort. Sitting for long periods of time will not increase intervertebral pressure causing pain.

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities

Coughing/sneezing, straining when having a BM

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person who suffers extensive burns. An appropriate response by the nurse is to call 911 and:

Cover the burned areas with a bed sheet

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink:

Cranberry Juice

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity? Cranial nerve I Cranial nerve X Cranial nerve V Cranial nerve VIII

Cranial nerve I

Cardiac interventions

Crystalloid solutions- warmed LR (because worried about hypothermia) through two large bore catheters Hourly urine output- 30-50 ml/hr or 0.5-1 ml/kg/hr HR- should be less than 110 Assess for narrowed pulse pressure- significant hypotension occurs when volume decreases by 30%

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? a. "You may be able to lessen your feelings of guilt by seeking counseling." b. "It would be helpful if you become involved in volunteer work at this time." c. "I recognize it's hard to deal with this, but try to remember that this too shall pass." d. "Joining a support group of people who are coping with this problem may be helpful."

D

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? a. Virus-induced iritis b. Intracranial pressure c. Closed-angle glaucoma d. Optic nerve inflammation

D

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? a. Recognize that depression often occurs after surgery b. Ask the primary healthcare provider to arrange for a psychologic consultation c. Reassure the client that things will feel better after the discharge date has been set d. Talk with the client about the prognosis and emphasize activities the client is still able to perform

D

An 80-year-old client with dementia of the Alzheimer type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand the aging process? a. "Most people at that age should be careful about weight gain." b. "This is typical of older adults; they really don't eat well." c. "It looks as though the frequent tanning has taken its toll." d. "As we age, we lose the tissue that helps puff out the skin."

D

The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? A. Asking the family member to step out of the room so the client can rest B. Placing a vest restraint on the client to prevent the client from falling out of bed C. Explaining to the family that it is common for older clients to get confused while in the hospital D. Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider

D- Because this is new for the client, the nurse should notify the primary healthcare provider. The client should be monitored continually for a while to prevent falling or injuring himself. This is an appropriate task to delegate to a nursing assistant. Since this is new for the client, reassuring the family that older adult clients often get confused in the hospital is not helpful. Evidence-based practice has shown that having a family member with the client is helpful. Therefore, the family member should be encouraged to stay with the client. Placing a restraint on the client should be done as a last resort and not instituted without a primary healthcare provider's prescription

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow, which action should the nurse take? A. Clear the ear of draining fluid. B. Discontinue anticonvulsant therapy. C. Elevate the head of the bed 30 degrees. D. Monitor serum carbon dioxide levels routinely.

D- Carbon dioxide levels must be maintained since carbon dioxide can cause vasodilation, increasing intracranial pressure, and decreasing blood flow. The fluid may be cerebrospinal fluid; clearing the ear may cause further damage. Because of manipulation during a craniotomy, anticonvulsants are given prophylactically to prevent seizures. Elevating the head of the bed 30 degrees will not increase cerebral blood flow.

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis? A. Myelography B. Lumbar puncture C. Electromyography D. Computed tomography

D- Computed tomography is the most definitive test for identifying unexpected structures in the brain. It provides a three-dimensional view of cranial contents and defines outlines of masses and other abnormalities. Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans are also beneficial and in some cases are better. Myelography is an x-ray examination of the spinal cord and vertebral canal, not the cranium. A lumbar puncture is contraindicated- removal of cerebrospinal fluid in the presence of an increase in intracranial pressure, which usually accompanies a brain tumor, may cause compression of the brainstem. Electromyography measures electrical currents produced by skeletal muscles, not the cranium

The nursing is caring for four different clients with eye disorders. Which client should be assessed for asthma before prescribing beta-adrenergic blockers? A: Increased lens density, reduced visual sensory perception B: Increased tear secretion, blood shot eye appearance C: Degeneration of corneal tissue, severe visual impairment D: Reduced outflow of aqueous humor, increased intraocular pressure

D- Reduced outflow of aqueous humor and increased intraocular pressure causes glaucoma, which can be treated with different types of drugs. Before prescribing beta-adrenergic blockers, the client should be assessed for moderate to severe asthma because if these drugs are absorbed systematically, they constrict pulmonary smooth muscle and narrow airways. Increased lens density and reduced visual sensory perception indicates cataracts that can be treated only with cataract surgery. Increased tear secretion and blood shot eye appearance is observed in a client with conjuctivitis. This can be treated with ophthalmic antibiotics. Degeneration of corneal tissue indicates keratoconus, which can be cured by performing a surgery called keratoplasty (corneal transplant).

A client is admitted with paresis of the ciliary muscles of the left eye. What function should the nurse expect to be affected? A. Closing the eyelids B. Convergence of both eyes C. Ability to discriminate colors D. Focusing the lens on near objects

D- The contraction of the ciliary muscles permits the lens to return to its normal bulge and decreases focal length, promoting the ability to focus on near objects. The ciliary muscles are intrinsic (within the eyeball); the third cranial nerve (oculomotor), an extrinsic nerve, controls some movements of the eyelid. The rectus and oblique muscles of the eye are involved in convergence. Color blindness is an inherited trait.

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? A. "You may be able to lessen your feelings of guilt by seeking counseling." B. "It would be helpful if you become involved in volunteer work at this time." C. "I recognize it's hard to deal with this, but try to remember that this too shall pass." D. "Joining a support group of people who are coping with this problem may be helpful."

D. "Joining a support group of people who are coping with this problem may be helpful." Rationale: Talking with others in similar circumstances provides support and allows for sharing of experiences. The response "You may be able to lessen your feelings of guilt by seeking counseling" is inappropriate because the feeling of guilt was not expressed directly and is too early for this intervention. The response "It would be helpful if you become involved in volunteer work at this time" avoids the partner's concerns and makes a recommendation for which the partner may not have the energy. Also, it cuts off communication. Although the response "I recognize it's hard to deal with this, but try to remember that this too shall pass" identifies feelings, it offers false reassurance.

Ampicillin 250 mg by mouth every 6 hours is prescribed for a client who is to be discharged. Which statement indicates to the nurse that the client understands the teaching about ampicillin? A. "I should drink a glass of milk with each pill." B. "I should drink at least six glasses of water every day." C. "The medicine should be taken with meals and at bedtime." D. "The medicine should be taken one hour before or two hours after meals."

D. "The medicine should be taken one hour before or two hours after meals."

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? A. A reduction of confusion B. An absence of ecchymotic areas C. A decreased viscosity of the blood D. An activated partial thromboplastin twice the usual value

D. An activated partial thromboplastin twice the usual value

A healthcare provider prescribes tolterodine for a client with an overactive bladder. What is most important for the nurse to teach the client to do? A. Maintain a strict record of fluid intake and urinary output. B. Chew the extended-release capsule thoroughly before swallowing. C. Report episodes of diarrhea or any increase in respiratory secretions. D. Avoid activities requiring alertness until the response to medication is known.

D. Avoid activities requiring alertness until the response to medication is known.

A client with myasthenia gravis is receiving pyridostigmine bromide to control symptoms. Recently, the client has begun experiencing increased difficulty in swallowing. What nursing action is most effective in preventing aspiration of food? A. Place a tracheostomy set in the client's room. B. Assess respiratory status after meals. C. Request for the diet to be changed from soft to clear liquids. D. Coordinate mealtimes with the peak effect of the medication.

D. Coordinate mealtimes with the peak effect of the medication. Rationale: Dysphagia should be minimized during peak effect of pyridostigmine bromide, thereby decreasing the probability of aspiration. A tracheostomy set is a treatment for, rather than equipment to prevent, aspiration. Although it is vital that the client's respiratory function be monitored, assessing the client's respiratory status will not prevent aspiration. There are insufficient data to determine whether changing the diet from soft foods to clear liquids is appropriate; also, liquids are aspirated more easily than semisolids.

A client with hyperthyroidism is to receive potassium iodide solution before a subtotal thyroidectomy is performed. What action does the nurse include when providing teaching about this drug? A. Decreases the total basal metabolic rate B. Maintains the function of the parathyroids C. Blocks the formation of thyroxine by the thyroid gland D. Decreases the size and vascularity of the thyroid gland

D. Decreases the size and vascularity of the thyroid gland

A healthcare provider has prescribed isoniazid for a client. Which instruction should be a priority for the nurse to give the client about this medication? A. Prolonged use can cause dark, concentrated urine. Incorrect B. The medication is best absorbed when taken on an empty stomach. C. Take the medication with aluminum hydroxide to minimize gastrointestinal (GI) upset. D. Drinking alcohol daily can cause drug-induced hepatitis.

D. Drinking alcohol daily can cause drug-induced hepatitis.

Steroid therapy is prescribed for a client with common signs and symptoms of multiple sclerosis. In response to the steroid therapy, what symptom does the nurse expect to decrease? A. Emotional lability B. Muscular contractions C. Pain in the extremities D. Episodes of vision loss

D. Episodes of vision loss Rationale: Steroids decrease the inflammatory process around the optic nerve, thus improving vision; visual impairment is the most common physiological manifestation of multiple sclerosis. Steroids are associated with increased emotional lability. Steroids are not effective in easing muscle contractions. Pain in the extremities is not common unless spasms are present; steroids do not relieve spasms.

A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach? A. Z-track B. Intravenous C. Subcutaneous D. Intradermal scratch

D. Intradermal scratch

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? A. Virus-induced iritis B. Intracranial pressure C. Closed-angle glaucoma D. Optic nerve inflammation

D. Optic nerve inflammation Rationale: Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication? A. Prevents an infection B. Limits abdominal distention C. Minimizes intestinal edema D. Reduces the blood ammonia level

D. Reduces the blood ammonia level

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. Which assessment finding should the nurse expect the client to report? A. Weakness decreases after hot baths B. Weakness improves with muscle use C. Strength improves immediately after meals D. Strength decreases with repeated muscle use

D. Strength decreases with repeated muscle use Rationale: Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength as the day progresses. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement

Pyridostigmine is prescribed for a client with myasthenia gravis. Why does the nurse instruct the client to take pyridostigmine about one hour before meals? A. This timing limits the appetite. B. It promotes absorption. C. Taking it before meals prevents gastric irritation. D. Taking it before meals increases ability to chew.

D. Taking it before meals increases ability to chew. Rationale: Peak action of the medication will occur during meals to promote chewing and swallowing and prevent aspiration. It should be given with a small amount of food to prevent gastric irritation. Pyridostigmine improves muscle strength; it does not affect appetite. Absorption is not affected significantly by the presence of food in the stomach. Gastric irritation is reduced best by the administration of drugs with food, not on an empty stomach.

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report? A. The tremors increase when I fall asleep. B. The tremors increase when I feel fatigued. C. The tremors increase when I become nervous. D. The tremors increase when I perform an activity.

D. The tremors increase when I perform an activity. Rationale: Multiple foci of demyelination cause interruption or distortion of the impulse, resulting in intention tremors (tremor when performing an activity). There are no tremors when the client is asleep. Fatigue will exacerbate the signs and symptoms of multiple sclerosis, but it will not precipitate intention tremors. Intention tremors are associated with muscle contraction, not feelings; however, stress can exacerbate the signs and symptoms of multiple sclerosis.

The nurse is caring for a patient who has been in a long term care facility for several months following a SCI. The patient has had issues with urinalysis retention and subsequent overflow incontinence and a bladder training program was recently initiated. Which are expected outcomes of the training program

Demonstrates a predictable pattern of voiding, is able to empty the bladder completely, does not experience a UTI

The nurse frequently provides care for clients with hearing aids. The nurse recalls that the condition that best responds to hearing aids is: 1 Destruction of the auditory nerve Correct2 Diminished sensitivity of the cochlea 3 Perforation of the tympanic membrane Incorrect4 Immobilization of the auditory ossicles

Diminished sensitivity of the cochlea Because hearing aids use the person's own middle ear, they increase hearing acuity in cases of diminished sensitivity of the cochlea; the amplified signal from the hearing aid gives the cochlea greater stimulation and promotes hearing. Destruction of the auditory nerve results in deafness because impulses cannot be transmitted to the brain's auditory center. Perforation of the tympanic membrane prevents ossicular conduction, which involves transmission of resonant vibrations from the tympanic membrane to the ossicles to the cochlea. Hearing aids will not correct this type of hearing loss; surgery is preferred. Immobilization of the ossicles prevents conduction of resonant vibrations from the tympanic membrane to the cochlea. Hearing aids may help but will not correct this problem; surgery is preferred.

Arrange the steps taken by a nurse while assessing the visual level of a client in sequential order. Direct the client to stand or sit 60 cm away from eye level Close the opposite eye to superimpose the field of vision Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye Ask the client to report when he or she is able to see the finger Move a finger equidistant between the nurse and the client outside the field of vision

Direct the client to stand or sit 60 cm away from eye level Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye Close the opposite eye to superimpose the field of vision Move a finger equidistant between the nurse and the client outside the field of vision Ask the client to report when he or she is able to see the finger The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level. Next, the nurse should ask the client to gently close or cover one eye and look at the nurse's eye directly opposite. Then, the nurse should also close his or her right eye to superimpose the field of vision. After this, the nurse should move a finger equidistant between the nurse and the client outside the field of vision. Finally, the nurse should ask the client to report when he or she is able to see the finger.

The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressure. What is the most important nursing intervention for this client? 1 Educate the client on managing stress. 2 Teach the client to maintain a balanced diet. 3 Instruct the client to have regular health checkups. 4 Ask the client to use sunscreen when working outdoors.

Educate the client on managing stress. The client is experiencing job-related pressure, so the nurse should educate the client about managing stress as it is a lifestyle risk factor. Stress threatens both mental health and physical well-being. Stress is associated with illnesses such as heart disease, cancer, and gastrointestinal disorders. The nurse teaches the client to maintain a balanced diet as a primary preventive care to promote health. The nurse should instruct the client to have regular health checkups as a primary preventive measure. The nurse should ask the client to use sunscreen when working outdoors to avoid excess sun exposure and prevent skin cancer.

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury

Hypertensive Crisis

The client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates correct understanding of the nurse's instruction?

I should call 911 if a sudden increase in weakness occurs (A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. The family member should call 911 for emergency assistance).

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. 2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. 3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.

Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. The nurse concludes that these signs are suggestive of: 1 Spinal shock 2 Hypovolemic shock 3 Brain herniation 4 Increased intracranial pressure

Increased intracranial pressure Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.

A spouse of a client, while visiting at the hospital, slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take? 1 Initiate an agency incident report. 2 Report the fall to the state health department. 3 Write a brief description of the incident to be kept by the nurse manager. 4 Determine that no documentation is needed because the visitor is not a client in the hospital.

Initiate an agency incident report. Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.

A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition? 1 Sims position 2 Supine position 3 Lithotomy position 4 Dorsal recumbent position

Lithotomy position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinations. Supine position is recommended for examining anterior thorax, lungs, breasts, axilla, heart abdomen, extremities, and pulse. Dorsal recumbent position is mainly indicated to examine the abdomen because it promotes abdominal relaxation.

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease?

Mineralocorticoids

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.)

Pain Releif, Antipyresis, Reduced Inflammation

what is pharyngitis?

Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis.

A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. To safely position this client the nurse takes into consideration that the feet and legs should be: Correct1 Placed dependent to the torso 2 Dependent by using a fully extended knee gatch Incorrect3 Raised to a two pillow height above the buttocks 4 Elevated by raising the foot of the bed on blocks

Placed dependent to the torso Gravity will assist the flow of blood to the dependent legs and feet. An extended knee gatch keeps extremities horizontal, not dependent, and does not facilitate blood flow to the feet. Elevation impedes flow of arterial blood to the extremities; it facilitates venous return.

A nurse is providing education to a community group about hospice. The nurse clarifies that the primary goal of hospice is help clients do what? 1 Have the option of assisted suicide 2 Remain comfortable until the end of life 3 Explore the newest treatments for their form of cancer 4 Release family members from participating in care

Remain comfortable until the end of life Hospice care attempts to break the cycle of fear and pain; care focuses on keeping the client as comfortable and high functioning as possible. Hospice care does not provide assisted suicide. Hospice care is provided after all treatments have failed; this care is provided during terminal stages of illness. Family members can be involved in the client's care; hospice services provide a supportive environment for both client and family.

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. Correct3 Start another IV line for the vancomycin and continue the heparin as prescribed. Incorrect4 Hold the vancomycin and tell the health care provider that the drug is incompatible with heparin.

Start another IV line for the vancomycin and continue the heparin as prescribed. The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the health care provider's, to administer them safely.

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer?

Sudden massive hemorrhage

The nurse is caring for a hospitalized immunosuppressed client. Which interventions will be beneficial for safe and effective care of this client? Select all that apply.

Supplies from common areas should not be used for neutropenic clients to prevent contracting infection. Physical activity at a level appropriate for client's condition should be encouraged to promote health. Alcohol-based hand rubs should be used before touching the client to decrease the risk of infection. Immunosuppressed clients should avoid eating raw fruits and vegetables; they should eat low-bacteria diet. Gauge-containing wound dressings should be changed on a daily basis, not on alternative days, to prevent infection.

The nurse is giving homecare instructions to the patient that will be discharged home with a halo device, what does the nurse instruct the patient to avoid

Swimming or contact sports, driving

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next? 1 Turn the client to the unaffected side 2 Cleanse the client's ear with sterile gauze 3 Place sterile cotton loosely in the external canal of the left ear 4 Test the drainage from the client's ear with a glucose reagent strip

Test the drainage from the client's ear with a glucose reagent strip If a basilar skull fracture has occurred, the cerebrospinal fluid (CSF) may drain through the client's ears or nose. This clear fluid may be tested with a glucose reagent strip; if the result is positive for glucose, then the fluid might be CSF. However, this test is not always reliable. Turning the client to the unaffected side will allow fluid to collect in the ear, and more importantly, manipulation of the neck while turning the client may cause further injury. Placing sterile cotton loosely in the external ear will absorb the drainage without causing further trauma, but does not help in determining the source of the fluid.

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary?

There is damage above the sixth thoracic vertebra

A client newly diagnosed with type 1 diabetes is taught to exercise on a regular basis. What is the primary reason for instruction on exercise? To decrease insulin sensitivity To stimulate glucagon production To improve the cellular uptake of glucose To reduce metabolic requirements for glucose

To 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 nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? A. Take the antibiotic until the wound feels better. B. Take the analgesic every day to promote adequate rest for healing. C.Be sure to wash hands after changing the dressing to avoid infection. Correct D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Correct E. Notify the health care provider of redness, swelling, and increased drainage.

answer: C and D rationale=Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?

answer: Nevi Rationale=Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells

what are steroids used for?

answer: are used for their antiinflammatory, vasoconstrictive, and antipruritic effects. -Steroids increase the incidence of infections because they are antiinflammatory agents and mask symptoms of infection. -Steroids increase fluid retention because they promote the reabsorption of sodium from the tubular fluid into the plasma. Although steroid ointments have an antipruritic effect, their major purpose after surgery is their systemic antiinflammatory effect.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client?

answer: nutritional needs rationale=To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished The consumption of a high-calorie, high-protein diet is advised.

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? A. Administer aspirin on a scheduled basis around the clock. B. Provide acetaminophen every 4 hours to maintain consistent blood levels. C. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F D. Provide drug interventions if complementary and alternative therapies have failed.

answer:B rationale= Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?

answer= Involvement starting distally with rectal bleeding that spreads continuously up the colon rationale=Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine.

Which laboratory test will be elevated in a client with inflammatory arthritis?

answer=Erythrocyte sedimentation rate (ESR) rationale=The erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. The ESR is chronically elevated with inflammatory arthritis

A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client?

answer=hypovolemia rationale=Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

assess the client's airway

A client is scheduled for surgery to repair an irreducible (incarcerated) hernia. What nursing intervention is of primary importance?

assessing the client's bowel movement

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates?

discontinue the infusion

A lactating woman with hypertension was diagnosed with a migraine. What would be the drug combination of choice if she wishes to continue breast-feeding?

labetalol, sumatriptan

chronic inflammation

lasts for weeks, months or even years. the injurious agent persists or repeatedly injures tissue. -predominant cell types are macrophages or lymphocytes. ex; rheumatoid arthritis and osteomyelitis. - the prolongation of inflammation may be the result of an autoimmune response and can lead to physical deterioration.

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

lethargy

What is a nursing priority to prevent complications in clients with respiratory acidosis?

monitoring breathing status

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client?

mucosal edema

A nursing student is learning about Erikson's theory of psychosocial development. Which statement made by the client indicates 'Initiative versus Guilt' stage?

my child like to fantasize and tries out new charactes every day

A client develops acute glomerulonephritis after a recent streptococcal infection. The nurse should expect to find which clinical manifestation during the health history and physical examination?

periorbital edema

Which behavior does the delegator adopt when communicating with the delegatee if the relationship between them is new, the delegatee has limited knowledge, and the delegator does not expect the relationship to be ongoing?

telling

During the assessment, the nurse discovers the client takes megadoses of vitamin A. How should the nurse interpret this finding?

the body stores excess vitamin A, even to toxic amounts

The parents inform the nurse that their preschooler's teachers often complain about the child's bullying behavior in school. The parents are surprised, because they say the child is well behaved at home. What could be the reason for this inconsistency in the child's behavior?

the child is scared of he parents and displaces anger on others.

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report?

the tremors increase when I perform an activity

The primary healthcare provider prescribed zoledronic acid to a client with osteoporosis. Before administration, the nurse instructs the client to have a dental examination. What is the rationale for this nursing intervention?

to prevent maxillaty osteonecrosis

The nurse in the birthing unit is caring for several postpartum clients. Which factor will increase the risk for hypotonic uterine dystocia?

twin gestation