Block 2 Final Exam

The nurse in a long-term care facility is caring for a client who has developed oropharyngeal candidiasis. What medication is the nurse most likely to administer? posaconazole clotrimazole itraconazole fluconazole

clotrimazole Explanation: Clotrimazole is an effective treatment for oropharyngeal candidiasis (in troche form) or to prevent oropharyngeal candidiasis in clients receiving radiation or chemotherapy. Itraconazole, amphotericin B, and posaconazole would not be appropriate for this client because they do not normally treat oropharyngeal candidiasis infections.

A nurse is caring for a client with fluid volume deficit. What provides most accurate data to evaluate the clients fluid status? Auscultating taking lung sounds every two hours. Proper measurement of daily weight. Accurate measurement of intake and output. Inspection of skin and mucous membranes.

Proper measurement of daily weight.

A client was brought to the hospital following a near drowning experience in the Atlantic Ocean. In providing care to this client, the nurse plans to carefully monitor for which of the following? Hyperkalemia Hypernatremia Hyponatremia Hypocalcemia

Hypernatremia

A client experiences orthostatic hypotension while receiving Captopril to treat hypertension. How should the nurse interventions? Administer intravenous fluids. Administer an adrenergic agonist. Hold the client's next dose. Instruct the client to sit for several minutes before standing.

Instruct the client to sit for several minutes before standing

A nurse is planning to delegate client care to a nursing assistant. Which is an appropriate activity for a nursing assistant? Select all that apply. Evaluating vital signs. Making occupied beds. Monitoring tube feedings. Helping clients to eat a meal. Providing client with physical hygiene. Assisting postoperative clients with their first ambulation.

Making occupied beds. Helping clients to eat a meal. Providing client with physical hygiene.

A client with SLE comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? Osteoporosis Hypertension Hyperglycemia Truncal obesity

Osteoporosis

The nurse administers a loop diuretic to the client. In addition to sodium and water, what other electrolyte would the nurse expect to be excreted in significant amounts? Potassium Calcium Magnesium Zinc

Potassium Explanation: Loop diuretics increase excretion of sodium, water, and potassium most significantly. Although other electrolytes may be excreted, loss of magnesium, calcium, and zinc are usually not significant.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. The clustering of the rooms on the unit The acuity level of the clients Client needs and workers' needs and abilities The number of anticipated client discharges

The acuity level of the clients Client needs and workers' needs and abilities

The nurse is providing client teaching about a prescribed opioid analgesic. When monitoring the client for potential adverse effects, what assessment should the nurse prioritize? heart rhythm coordination visual acuity blood pressure

blood pressure Explanation: Orthostatic hypotension is commonly seen in association with some narcotics. For most clients, changes in blood pressure are most likely than arrhythmias, ataxia and changes is vision.

Which of the following statements indicates that a client understands the measures used to treat systemic lupus erythematous (SLE)? "I should apply SPF 10 sunscreen when I go to the beach." "I will be able to continue with my tanning bed appointments." "I can go visit my grandmother this weekend who has been ill with a cold." "I can go for a walk on the beach after 4:00 pm."

"I can go for a walk on the beach after 4:00 pm."

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states what? "I read that a pancreas transplant will provide a cure for my diabetes." "I will make sure to follow the weight loss plan designed by the dietitian." "I will make sure I call the diabetes educator when I have questions about my insulin." "I will take my oral antidiabetic agents when my morning blood sugar is high."

"I will make sure to follow the weight loss plan designed by the dietitian." Explanation: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some clients may require insulin on an ongoing or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

A client is admitted with chronic renal failure. The nurse would use which of the following statements to explain the need to monitor for hypocalcemia? "Signs of hypocalcemia will appear before you experience pain from renal colic." "Your calcium level can decrease because it goes down when the creatinine in your bloodstream is high." "Your kidneys do not eliminate as much calcium, so we need to check for signs of hypocalcemia." "Your kidneys are unable to produce calcitriol comma which is needed to regulate calcium levels in the bloodstream."

"Your kidneys are unable to produce calcitriol comma which is needed to regulate calcium levels in the bloodstream."

The nurse in the clinic is caring for a client who has seasonal rhinitis and the client wants to know what causes this to occur. What is the nurse's best response? "Your sympathetic nervous system is responding to stress in your life causing you to have nasal congestion." "You are experiencing symptoms because bacteria have entered the nose and caused a local infection." "Your symptoms are happening because pathogens are invading the tissues in your nose and causing necrosis of the superficial cells." "Your upper airways are inflamed because you inhaled an antigen, causing sneezing and watery eyes."

"Your upper airways are inflamed because you inhaled an antigen, causing sneezing and watery eyes." Explanation: Seasonal rhinitis usually occurs when the upper airways become inflamed because of the body's response to an inhaled antigen. The sympathetic system's response to stress usually opens the airways and does not cause inflammation. Bacteria entering the nose do not cause inflammation of the rest of the upper airways or necrosis.

The nurse is caring for a client who has been prescribed nitroglycerin sublingually. When providing client education, the nurse should tell the client to expect relief of chest pain within what period of time? 15 to 20 minutes 30 to 60 minutes 5 to 10 minutes 1 to 3 minutes

1 to 3 minutes Explanation: Sublingual nitroglycerin acts within 1 to 3 minutes.

The nurse in the mental health unit is assigned to care for a female client with a diagnosis of acute depression. In communicating with the client, which statement would be appropriate for the nurse to make? 1. "You look lovely today." 2. "You're wearing a new blouse." 3. "Don't worry-everyone gets depressed once in a while." 4. "You will feel better when your medication starts to work."

2. "You're wearing a new blouse." Rationale: A client who is depressed sees the negative side of everything. Telling the client that she looks lovely today can be interpreted as "didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations. The client should not be told not to worry, that everyone gets depressed once in a while, or that he or she will feel better, because such statements are inappropriate.

The nurse is caring for a client with a diagnosis of agoraphobia. When communicating with the client about the disorder, the nurse should expect the client to describe which behavior? 1. A fear of dirt and germs 2. A fear of leaving the house 3. A fear of speaking in public 4. A fear of riding in elevators

2. A fear of leaving the house Rationale: Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. Option 1 describes an obsessive-compulsive behavior. Option 3 describes a social phobia. Option 4 describes claustrophobia.

The health care provider has prescribed medication therapy for a client with an alcohol abuse problem to assist in the maintenance of sobriety. The nurse reviews the client's record and expects to note that which medication has been prescribed? 1. Clonidine (Catapres) 2. Disulfiram (Antabuse) 3. Pyridoxine hydrochloride (vitamin B6) 4. Chlordiazepoxide hydrochloride (Librium)

2. Disulfiram (Antabuse) Rationale: Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge

2. Evidence of the client's disturbed body image Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? 1. Planning short-term goals 2. Making appointment referrals 3. Developing realistic solutions 4. Identifying expected outcomes

2. Making appointment referrals Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. The remaining options identify tasks appropriate for the working phase of the relationship.

A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis

2. Social phobia Rationale: Social phobia is a fear of situations in which one might be embarrassed or criticized, such as the fear of speaking, performing, or eating in public. The person fears making a fool of oneself. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.

Which describes the primary focus of milieu therapy? 1. A form of behavior modification therapy 2. A cognitive approach to changing behavior 3. A living, learning, or working environment 4. A behavioral approach to changing behavior

3. A living, learning, or working environment Rationale: Milieu therapy, or "therapeutic community," has as its focus a living, learning, or working environment. Such therapy may be based on numerous therapeutic modalities ranging from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu therapy may include behavioral approaches, the correct option describes its primary focus.

The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. What client is having this type of reaction? An older adult with rheumatoid arthritis A client with a diagnosis of myasthenia gravis A client with a skin reaction resulting from adhesive tape A child with an anaphylactic reaction after a bee sting

A child with an anaphylactic reaction after a bee sting Explanation: Anaphylactic (type I) hypersensitivity is an immediate reaction mediated by IgE antibodies and requires previous exposure to the specific antigen. Skin reactions are more commonly type IV and myasthenia gravis is thought to be a type II reaction. Rheumatoid arthritis is not a type I hypersensitivity reaction.

The nurse identifies which of the following clients admitted to the hospital as being at risk for developing hypokalemia? A client whose blood gases indicate metabolic acidosis A client with adult respiratory distress syndrome (ARDS) A client with acute renal failure A client with a nasogastric tube to low intermittent suction

A client with a nasogastric tube to low intermittent suction

A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? Utilize a peak flow monitoring device Administer corticosteroids by metered dose inhaler Administer inhaled anticholinergics Administer an inhaled beta-adrenergic agonist

Administer an inhaled beta-adrenergic agonist Explanation: Asthma exacerbations are best managed by early treatment and education of the client. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in clients who fail to respond to inhaled beta-adrenergic medication. A peak flow device will not resolve short-term shortness of breath.

A client is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which procedure will be involved? Myelography Angiography Paracentesis Arthrocentesis

Arthrocentesis Explanation: Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.

On the first day after surgery, a patient who is on a patient controlled analgesia pump reports that the pain control is inadequate. Which action should the nurse take first? Deliver the bolus dose per standing order. Contact your healthcare provider to increase the dose. Try nonpharmacologic comfort measures. Assess the pain for location, quality, and intensity.

Assess the pain for location, quality, and intensity.

The family nurse practitioner is caring for an adult client who has been noncompliant with the care regimen previously outlined for treatment of sinusitis. What should the nurse practitioner do to best promote compliance? Provide the instructions in large type. Assess the reasons why the client did not comply with treatment. Give the treatment instructions to the client's spouse. Give the treatment instructions to a member of the client's family.

Assess the reasons why the client did not comply with treatment. Explanation: Before performing any interventions, it is important that the nurse assess the reasons why the client did not comply. These findings would inform the nurse's choice of subsequent interventions.

The nurse is teaching a group of adults about health promotion. What should the nurse recommend in order to minimize participants' risk of COPD? Get the annual influenza vaccination. Avoid smoking Get screened for the genetic markers for COPD. Minimize exposure to dust and mold.

Avoid smoking Explanation: COPD is a permanent, chronic obstruction of airways, often related to cigarette smoking. Vaccines do not confer protection and dust and mold are not normally implicated. Genetic factors are minimal; smoking is the most salient risk factor.

The client receives a new diagnosis of peripheral artery disease and the nurse anticipates an order for what drug? Clopidogrel Persantine Warfarin Aspirin

Clopidogrel Explanation: Clopidogrel is indicated for the treatment of clients who are at risk for ischemic events; clients with a history of myocardial infarction, peripheral artery disease, or ischemic stroke; and clients with acute coronary syndrome. Persantine, aspirin, and warfarin would not be indicated for this client.

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache? Initiating a patient-controlled analgesia (PCA) of morphine sulfate Administering hydromorphone IV as needed Distracting the client with activity Dimming the lights and reducing stimulation

Dimming the lights and reducing stimulation Explanation: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patient's pain.

A client has been prescribed hydrochlorothiazide, and the nurse is preparing to give the client discharge instructions. Which adverse effects should the nurse caution the client about? Select all that apply. Constipation Nocturia Polyphagia Dizziness Muscle cramps

Dizziness Nocturia Muscle cramps Explanation: The adverse effects associated with hydrochlorothiazide are dizziness, vertigo, orthostatic hypotension, nausea, anorexia, vomiting, dry mouth, diarrhea, polyuria, nocturia, muscle cramps, and spasms. The client would not experience polyphagia and constipation.

The nurse is administering morphine to a trauma client for acute pain. What is a common side effect of morphine? Occipital headache Paresthesia in lower extremities Increased intracranial pressure Drowsiness

Drowsiness Explanation: Dizziness, drowsiness, and visual changes are common side effects. If any of these occur, avoid driving, operating complex machinery, or performing delicate tasks. If these effects occur in the hospital, the side rails on the bed may be raised for your own protection. Morphine does not generally cause paresthesia in the lower extremities, an occipital headache, or increased intracranial pressure.

Which of the following laboratory test results supports the diagnosis of systemic lupus erythematosus (SLE)? Increased platelet count Elevated blood urea nitrogen (BUN) Elevated antinuclear antibody (ANA) titer Elevated liver function levels

Elevated antinuclear antibody (ANA) titer

A client is admitted to the hospital with deep vein thrombosis. An infusion of heparin is established. What action best protects the client's safety? Ensure that the client's call light is easily accessible. Have two nurses independently monitor the client's heparin infusion. Ensure that protamine sulfate is readily available Keep a preloaded syringe of vitamin K in the room.

Ensure that protamine sulfate is readily available Explanation: The antidote for heparin is protamine sulfate, and it is prudent to have this on hand if a client is receiving an infusion of heparin. Vitamin K reverses the effect of warfarin. The administration of heparin must be established and monitored carefully, but it is not usual practice for two nurses to maintain the infusion independent of one another and could lead to errors and omissions. Clients' call lights should always be available, but this is less significant than ensuring the availability of the antidote.

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the client and family that what nonpharmacologic measures will decrease the body's need for insulin? Low stimulation Exercise Adequate sleep Low-fat diet

Exercise Explanation: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low-fat intake and low levels of stimulation do not reduce a client's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Facial paralysis Pain at the base of the tongue Diplopia

Facial paralysis Explanation: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus.

A client has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the client's condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply. Insect stings Autoimmunity Environmental pollutants Medications Foods

Foods Medications Insect stings Explanation: Substances that most commonly cause anaphylaxis include foods, medications, insect stings, and latex. Pollutants do not commonly cause anaphylaxis and autoimmune processes are more closely associated with types II and III hypersensitivities.

The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? Hyperkalemia Hyponatremia Hypocalcemia Hypermagnesemia

Hypocalcemia Explanation: You can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek sign.

A client has atrial fibrillation with a ventricular rate of 185 bpm. The nurse should assess the client for what clinical manifestations? Flat neck veins. Nausea and vomiting. Hypotension and dizziness. Hypertension and headache.

Hypotension and dizziness.

The nurse is providing education to a client with hypertension. Which statement indicates the client understands education? Because I have high blood pressure I will always require medications. I must achieve a normal weight to lower my blood pressure. If I am on a diuretic I do not have to watch my salt intake. I will try to modify my lifestyle to lower my blood pressure.

I will try to modify my lifestyle to lower my blood pressure.

The nurse is evaluating laboratory results for hypertensive client. What laboratory results would warrant notifying healthcare provider? ABG of pH 7.35, paCO2 34, and HCO3 18 Serum Potassium level of 3.5 mEq/L Serum Sodium level of 134 mEq/L INR of 4.2

INR of 4.2

The nurse's assessment of a client with thyroidectomy suggests tetany and a review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention? Oral calcium chloride and vitamin D Administration of parathyroid hormone (PTH) STAT levothyroxine IV calcium gluconate

IV calcium gluconate Explanation: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.

A client with coronary artery disease has been prescribed fluvastatin. When reviewing this client's more recent laboratory values, what finding should the nurse attribute to adverse effects of this medication? Decreased serum potassium levels Increased neutrophil levels Increased liver enzyme levels Decreased hemoglobin and hematocrit

Increased liver enzyme levels Explanation: Increased concentrations of liver enzymes commonly occur, and acute liver failure has been reported with the use of atorvastatin and fluvastatin. These medications are not normally associated with increased white cell levels, hypokalemia, or anemia.

A client is admitted to the hospital with a serum potassium level of 2 .8 mEq/L. The nurse anticipates assessment findings will include which of the following? Elastic skin turgor and vomiting a small amount of bile-stained emesis Respiratory rate 16 with equal bilateral breath sounds, and two loose stools this morning Pink nail beds, and ECG showing a normal sinus rhythm with a rate of 76 Irregular pulse rate and shallow respirations

Irregular pulse rate and shallow respirations

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? Observe the client swallowing a small mouthful of water Lightly touch the client's pharynx with a cotton swab Depress the client's tongue with a sterile tongue depressor Ask the client to swallow a small quantity of any soft food

Lightly touch the client's pharynx with a cotton swab Explanation: The gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. The gag reflex is not assessed by having the client swallow or by depressing the tongue.

A 10-year-old child with spina bifida is receiving bethanechol for treatment of neurogenic bladder. What assessment finding should suggest that the client is experiencing adverse effects? temperature of 100.6°F (38.1°C) diarrhea pruritus decreased level of consciousness

Loss of bowel and bladder control is an adverse effect of cholinergic agents that would cause stress in a child. Diarrhea and increased salivation are also potential adverse effects. Pruritus, fever, and decreased LOC are not among the more common adverse effects of bethanechol and would likely be attributable to other causes, possibly hypersensitivity or infection.

The nurse is caring for a client taking ezetimibe and monitors the client for what common adverse effects? Mild abdominal pain and diarrhea Bloating and flank pain Neuropathy and flatulence Constipation and flank pain

Mild abdominal pain and diarrhea Explanation: The most common adverse effects of ezetimibe are mild abdominal pain and diarrhea. Bloating and flatulence are associated with bile acid sequestrants and the fibrates. Constipation is usually associated with bile acid sequestrants. Neuropathy and flank pain are usually not associated with lipid-lowering agents.

A client with a feeding tube has been experiencing severe watery diarrhea. The client is lethargic with decreased skin turgor, pulse rate of 110, and hyperactive reflexes. The nurse would include which of the following interventions on the client's plan of care? Monitor and record intake, output, and daily weights Administer salt tablets and monitor hypertonic parenteral solutions Withhold tube feedings until diarrhea subsides Avoid adding additional water before and after tube feedings

Monitor and record intake, output, and daily weights

You place two containers next to one another, separated only by a semipermeable membrane. The solution in one container is hypotonic relative to the other. What would the fluid in the hypotonic container do? Move out of the hypotonic container and into the other container. Pull fluid from the other container into the hypotonic container. Stay unchanged within the hypotonic container. No fluid movement would occur.

Move out of the hypotonic container and into the other container.

A client is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the client's left eye. The nurse should associate this abnormal finding with trauma to what cerebral lobe? Temporal Parietal Occipital Frontal

Occipital Explanation: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy? Infection Phlebitis Sepsis Thrombus

Phlebitis Rationale:The most common complication related to IV therapy is phlebitis. Chemical irritation or mechanical trauma can cause injury to the vein and lead to phlebitis. Infection, thrombus, and sepsis manifest as redness, pus, warmth, induration, and pain similar to phlebitis and may be caused by poor aseptic technique.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? Pad the client's bed rails. Place the client in a side-lying position. Administer antianxiety medications as prescribed. Reassure the client and family members.

Place the client in a side-lying position. Explanation: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

The nurse is caring for a client hospitalized with a history of hypertension who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor? Sodium. Blood urea nitrogen. Potassium. Alkaline phosphatase.

Potassium.

A client with a recent diagnosis of hypothyroidism is being treated for an unrelated injury. When administering medications to the client, the nurse should know that the client's diminished thyroid function may have what effect? Increased risk of drug interactions Prolonged duration of effect Anaphylaxis Nausea and vomiting

Prolonged duration of effect Explanation: In all clients with hypothyroidism, the effects of analgesic agents, sedatives, and anesthetic agents are prolonged. There is no direct increase in the risk of anaphylaxis, nausea, or drug interactions, although these may potentially result from the prolonged half-life of drugs.

A client with a tricuspid valve disorder will have impaired blood flow between which areas of the heart? Vena cava and right atrium. Left atrium and left ventricle. Right atrium and right ventricle. Right ventricle and pulmonary artery.

Right atrium and right ventricle.

The nurse is teaching a client that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? Red meat Table salt Eggs Shellfish

Table salt Explanation: The major use of iodine in the body is by the thyroid. Iodized table salt is the best source of iodine.

The nurse in charge of a long-term care facility is planning the client assignments for the day. What client should be assigned to the UAP? The client on strict bedrest. The client with dyspnea who is receiving oxygen therapy. The client scheduled for transfer to the hospital for surgery. The client with a gastrostomy tube who requires tube feedings every 4 hours.

The client on strict bedrest.

The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? They are communicable. They have a genetic origin. They require IVIG as treatment. They are the result of intrauterine infection.

They have a genetic origin. Explanation: Primary immunodeficiency diseases are genetic in origin and result from intrinsic defects in the cells of the immune system. Primary immunodeficiency diseases do not always need IVIG as treatment, and they are not communicable. Primary immunodeficiencies do not result from intrauterine infection.

A nurse is caring for two clients who are status postoperative for abdominal surgery. What is the best way to evaluate pain response after administering analgesia? If a family member is present, ask him or her if the medication worked. Use a pain assessment tool before and 30 minutes after medication administration. Ask the non-licensed personnel (aide) to find out if the medication worked. The nurse should observe the client when the client is not aware the nurse is watching.

Use a pain assessment tool before and 30 minutes after medication administration. Explanation: A standard pain assessment tool should be used both pre- and post-analgesia. Observing when the client is not aware the nurse is watching, asking non-licensed personnel to find out if the medicine worked, or asking a family member if the medication worked are all inappropriate.

A client presents with a mildly elevated calcium level. After completing a nursing history, the nurse identifies which of the following is a contributing factor to the abnormal calcium level? Use of a thiazide diuretic Ingesting a biphosphonate weekly A high protein diet Recent reports of polyuria

Use of a thiazide diuretic

The nurse is caring for a 35-year-old client taking a beta-hydroxy-beta-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor to lower serum lipid levels. When teaching this client about the medication, what priority teaching point will the nurse include in the teaching plan? Information about a cholesterol-lowering diet Calling her doctor with any respiratory symptoms Use of barrier contraceptives Need for frequent ophthalmic examinations

Use of barrier contraceptives Explanation: It is important to teach a woman of childbearing age taking HMG-CoA reductase inhibitors to use barrier contraceptives because there is a risk of severe fetal abnormalities associated with these drugs if taken during pregnancy. Both men and women should have routine ophthalmic examinations, but taking this drug does not increase the frequency of examinations needed. A cholesterol-lowering diet should have been initiated before beginning medications to lower lipid levels. There are no associated respiratory risks with these medications, so the client would call the doctor with respiratory symptoms as one normally would.

The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. Performing hand hygiene Using safe injection practices Using appropriate personal protective equipment Placing clients in positive pressure isolation rooms Placing clients in negative pressure isolation rooms

Using appropriate personal protective equipment Using safe injection practices Performing hand hygiene Explanation: Some of the key elements of standard precautions include performing hand hygiene; using appropriate personal protective equipment, depending on the expected type of exposure; and using safe injection practices. Isolation is an infection control strategy but is not a component of standard precautions.

When is calcitonin released by the body? When serum calcium levels rise When PTH secretion mobilizes calcium When serum calcium levels fall When PTH secretion immobilizes calcium

When serum calcium levels rise Explanation: The release of calcitonin is not controlled by the hypothalamic-pituitary axis, but is regulated locally at the cellular level. Calcitonin is released when serum calcium levels rise.

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled? Within the next week Without delay because the bleed is emergent Within 24 hours As soon as all the day's elective surgeries have been completed

Without delay because the bleed is emergent Explanation: Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

The nurse is describing the function of the sodium-potassium pump when explaining the large difference in intracellular and extracellular serum levels of these electrolytes. What process is the nurse primarily referring to? passive transport neutral transport active transport cotransport

active transport Explanation: Active transport is what happens when cells use energy to move ions against an electrical or chemical gradient. Diffusion is a type of passive transport. There is no such thing as neutral transport. Cotransport is when the sodium ion and the solute are transported in the same direction.

When providing tracheostomy care to a client with a disposable inner cannula, at which point would the nurse put on sterile gloves? after removing the old inner cannula after opening the cotton-tipped applicators before opening the package containing the new cannula before filling the sterile cup with saline

after removing the old inner cannula Rationale:Sterile gloves are put on after the inner cannula is removed and discarded, just before the nurse picks up the new inner cannula whose package was opened previously. Gloves do not need to be worn when opening the package for the new cannula, opening the cotton-tipped applicators, or filling the sterile cup with saline.

The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? "A PFT measures how elastic your lungs are." "A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood." "A PFT measures how much air moves in and out of your lungs when you breathe." "A PFT measures how much energy you get from the oxygen you breathe."

"A PFT measures how much air moves in and out of your lungs when you breathe." Explanation: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.

The nurse provides which of the following instructions to a client going home with a prescription for spironolactone? "Cut back on your intake of foods on your list that are high in potassium." "Take this pill just before you go to bed." "You don't have to watch your intake of fluid while you're taking this medicine." "Be sure to take this medication on an empty stomach."

"Cut back on your intake of foods on your list that are high in potassium."

The nurse determines that a client with a serum calcium level of 12 mg/dL understands client teaching when the client states: "I'll need to be on strict bed rest to help with this problem." "I need to drink many more fluids than I have been, even up to 2 to 3 liters each day." "I will need to take my phosphorus supplements once a day." "If my stomach becomes upset, I can just take more Tums."

"I need to drink many more fluids than I have been, even up to 2 to 3 liters each day."

In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education? "I'll put on those compression stockings if I get pain in my calves." "I'll try to stay in bed for the first few days to allow myself to heal." "I'll keep pillows under my knees to help my blood circulate better." "I'll make sure that I don't cross my legs when I'm resting in bed."

"I'll make sure that I don't cross my legs when I'm resting in bed." Explanation: To prevent venous thromboembolism, clients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

A home care nurse making an initial home visit notes that a client is taking donepezil hydrochloride (Aricept). The nurse questions the client's spouse about a history of which disorder that is treated with this medication? 1. Dementia 2. Schizophrenia 3. Seizure disorder 4. Obsessive-compulsive disorder

1. Dementia Rationale: Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

A medical nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? 11:45 AM 11:15 AM 10:45 AM 11:50 AM

11:15 AM Explanation: Regular insulin is usually given 20 to 30 minutes before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

A nurse is working with a client who was diagnosed with HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? 75 cells/mm3 of blood 325 cells/mm3 of blood 450 cells/mm3 of blood 200 cells/mm3 of blood

200 cells/mm3 of blood Explanation: When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.

A 17-year-old client who sustained a head injury in a motorcycle collision two days ago is responsive only to pain. Which intravenous fluid order would the nurse question because it could increase the risk of complications? Lactated ringer's solution 5% dextrose in water 0.9% sodium chloride Ringer's solution

5% dextrose in water

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? A dysrhythmia in the peripheral nervous system A dysrhythmia in the nerve cells in one section of the brain Sudden disruptions in the blood flow throughout the brain Sudden electrolyte changes throughout the brain

A dysrhythmia in the nerve cells in one section of the brain Explanation: The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Supine positioning Early initiation of physical therapy Absolute bed rest in a quiet, nonstimulating environment Passive range-of-motion exercises to prevent contractures

Absolute bed rest in a quiet, nonstimulating environment Explanation: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.

An adolescent client's history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this client consequently faces an increased risk of what health problem? Systemic lupus erythematosus (SLE) Asthma Rheumatoid arthritis Bronchitis

Asthma Explanation: Nurses should be aware that atopic dermatitis is often the first step in a process that leads to asthma and allergic rhinitis. It is not linked as closely to bronchitis, SLE, and RA.

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? Pulmonary embolism Acute respiratory distress syndrome (ARDS) Aspiration Atelectasis

Atelectasis Explanation: A shallow, monotonous respiratory pattern coupled with immobility places the client at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

hich of the following findings would the nurse expect to assess in hypercalcemia? A. Prolonged QRS complex B. Tetany C. Petechiae D. Urinary calculi

D. Urinary calculi Urinary calculi may occur with hypercalcemia. Symptoms of hypercalcemia are usually seen when serum calcium levels are more than 12 mg/dl. Irrespective of the etiology, the broad signs and symptoms can be summarized as "groans, bones, stones, moans, thrones and psychic overtones". Tetany and petechiae are signs of hypocalcemia.

When the nurse administers warfarin, it is expected that the drug will have what effect on the body? Increase in vitamin K-dependent factors in the liver Increase in prothrombin Decrease in production of vitamin K-dependent clotting factors Increase in procoagulation factors

Decrease in production of vitamin K-dependent clotting factors Explanation: Warfarin, an oral anticoagulant drug, causes a decrease in the production of vitamin K-dependent clotting factors in the liver. The eventual effect is a depletion of these clotting factors and a prolongation of clotting times. It is used to maintain a state of anticoagulation in situations in which the client is susceptible to potentially dangerous clot formation. It does not increase prothrombin, vitamin K-dependent factors in the liver, or procoagulation factors.

The hypertensive client has an order for propranolol. What was the nurse and check the client to report immediately? Loss of energy. Decreased sexual function. Difficulty breathing. Increased sweating.

Difficulty breathing.

Which is the best indicator of overall diabetic control?

Glycosylated hemoglobin levels Explanation: The glycosylated hemoglobin indicates glucose bound to hemoglobin in red blood cells (RBCs) when RBCs are exposed to hyperglycemia. The binding is irreversible and lasts for the lifespan of RBCs (approximately 120 days). The test reflects the average blood sugar level during the previous 2 to 3 months. The goal is usually less than 7% (blood level 0.07). The range for people without diabetes is approximately 4% to 6% (blood level 0.04 to 0.06).

The anatomy and physiology instructor is discussing hormones with the pre-nursing class. Which gland would the instructor tell the students controls secretions of the pituitary gland? Pineal Thyroid Adrenal cortex Hypothalamus

Hypothalamus Explanation: The hypothalamus uses a number of hormones or factors to either stimulate or inhibit the release of hormones from the anterior pituitary. These factors are not secreted by the pineal, the thyroid, and the adrenal cortex.

A client with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the client for which of the following complications of therapy? Agranulocytosis Immunosuppression Anemia Thrombocytopenia

Immunosuppression Explanation: Corticosteroids such as prednisone can cause immunosuppression. Corticosteroids do not typically cause agranulocytosis, anemia, or low platelet counts.

A client is reporting an inability to breathe nasally because of severe rhinitis. The nurse should identify what important role in breathing that is disrupted when the nasal passages are blocked? Phagocytosis of pathogens. Respiratory regulation of acid-base balance Inspired air is warmed and humidified. Exhalation of carbon dioxide.

Inspired air is warmed and humidified. Explanation: Air usually moves into the body through the nose and into the nasal cavity. The nasal hairs catch and filter foreign substances that may be present in the inhaled air. The air is warmed and humidified as it passes by blood vessels close to the surface of the epithelial lining in the nasal cavity. Phagocytosis happens in goblet cells in the nose, but these are not wholly limited to that location. Carbon dioxide is exhaled through the mouth, not just the nose. Similarly, acid-base balance is not threatened by blocked nasal passages.

The nurse is caring for a client diagnosed with hypertension who is prescribed hydrochlorothiazide. Which intervention should the nurse implement when administering this medication? Check the clients apical pulse for one minute. Question administering if the clients potassium level is 4.2. Instruct the client to rise slowly from a lying to a sitting position. Tell the client to only drink 1000 mL of fluid daily.

Instruct the client to rise slowly from a lying to a sitting position.

A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe? It limits lung expansion within the thoracic cavity. It lubricates the movement of the thorax and lungs. It prevents the lungs from collapsing within the thoracic cavity. It allows for full expansion of the lungs within the thoracic cavity.

It lubricates the movement of the thorax and lungs. Explanation: The visceral pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleura do not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.

The nurse instructs a client receiving hydrochlorothiazide (HCTZ) to report which of the following symptoms to the healthcare provider? Fatigue and irritability Nausea and irritability Leg cramps and muscle weakness Muscle weakness and diarrhea

Leg cramps and muscle weakness

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the client's status? Sensory involvement Level of consciousness Cognitive ability Reflex activity

Level of consciousness Explanation: The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.

A client with a diagnosis of bipolar disorder has been drinking copious amounts of water and voiding frequently. The client is experiencing bounding pulse and confusion and is reporting headache. The nurse checks laboratory test results for which of the following? High urine specific gravity Low platelet count Low sodium level High serum osmolality

Low sodium level

The nurse is caring for a client with a feeding tube who has been experiencing loose watery stools. The client has poor skin turgor, tachycardia, lethargy, and hyperactive reflexes. Which intervention would the nurse include in the plan of care? Monitor intake, output, and daily weight Apply restraints to protect the feeding tube Monitor hypertonic intravenous therapy Assess electrocardiogram readings

Monitor intake, output, and daily weight Based on the current data, this client is exhibiting signs of hypernatremia (i.e., increased serum sodium levels) and dehydration (i.e., a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). This is likely the result of fluid losses caused by diarrhea. The most appropriate nursing intervention is to measure and record intake and output and daily weight.

The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in what? Formation of a pulmonary embolism Release of potassium ions from cardiac cells Myocardial ischemia Development of an atrial-septal defect

Myocardial ischemia Explanation: Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and can decrease myocardial perfusion. Clients, particularly those with CAD, can develop myocardial ischemia. An increase in heart rate will not usually result in a pulmonary embolism or create electrolyte imbalances. Atrial-septal defects are congenital.

The nurse caring for a client with a calcium imbalance places highest priority on nursing interventions that help to manage: Neuromuscular clinical manifestations Hematologic disorders Renal signs and symptoms Cardiac changes

Neuromuscular clinical manifestations

For a cognitively impaired patient who cannot accurately report pain, which action with the nurse take first? Closely assess for nonverbal signs such as grimacing or rocking. Obtain baseline behavioral indicators from family members. Note the time of and patient response to the last dose of analgesic. Give the maximum as needed those within the minimum timeframe for relief.

Obtain baseline behavioral indicators from family members.

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse's suspicions? Redness Pallor Heat Edema

Pallor Rationale:The nurse inspects the site for swelling, leakage, and coolness or pallor, which may indicate infiltration. When this happens, the catheter may become dislodged from the vein, and IV solution may flow into subcutaneous tissue. Heat, redness, and slight edema may indicate sepsis, phlebitis, or thrombus.

A client has been diagnosed with stenosis of the pulmonary artery that inhibits the flow of unoxygenated blood between the right ventricle and the alveoli. What function will be impaired in this client? Expiration Diffusion Ventilation Perfusion

Perfusion Explanation: The lung tissue receives its blood supply from the bronchial artery, which branches directly off the aorta. The alveoli receive unoxygenated blood from the right ventricle via the pulmonary artery. The delivery of this blood to the alveoli is referred to as pulmonary perfusion, not diffusion. Expiration is the act of exhaling to rid the body of excess carbon dioxide. Ventilation is the movement of air in and out of the lungs.

A patient spouse comes to the nurses station and says, "he needs more pain medicine. He is still having a lot of pain." Which response is best? The medication is prescribed to be given every four hours. If the medication is given too frequently, there are ill effects. Please tell him that I will be right there to check on him. Let's wait 40 minutes. If he still hurts, i'll call the healthcare provider.

Please tell him that I will be right there to check on him.

A client is scheduled for a bowel resection in the morning and the client's orders include a cleansing enema tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? Preventing potential contamination of the peritoneum Preventing aspiration of gastric contents Facilitating better absorption of medications Preventing the accumulation of abdominal gas postoperatively

Preventing potential contamination of the peritoneum Explanation: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The client should expect to develop gas in the postoperative period.

A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize? Stopping medication if dizziness persists Rising slowly from a lying or sitting position Taking medication first thing in the morning Increasing fluids to maintain BP

Rising slowly from a lying or sitting position Explanation: Clients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these clients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Clients should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice.

A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this client's care, what nursing diagnosis is most appropriate? Risk for fluid volume excess Acute pain Risk for activity intolerance Risk for unilateral neglect

Risk for activity intolerance Explanation: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does not typically cause pain, fluid imbalances, or neglect of a unilateral nature.

When developing a plan of care for a client with hypocalcemia, the nurse chooses which of the following as a high priority nursing diagnosis? Risk for injury related to sensorium changes Potential complication: electrolyte excess Risk for injury related to tetany and seizures Deficient fluid volume

Risk for injury related to tetany and seizures

A client has presented to the emergency department with a new onset of unilateral weakness and visual disturbances. The care team suspects that the client has had a cerebrovascular accident and the administration of alteplase is being considered. What is the care priority prior to administering alteplase? Determining whether the client takes beta-adrenergic blockers or aminoglycoside antibiotics Ruling out a hemorrhagic stroke Determining the client's blood type Assessing the client's allergy status

Ruling out a hemorrhagic stroke Explanation: Administration of alteplase would exacerbate a hemorrhagic stroke by increase bleeding. For this reason, a hemorrhagic stroke must be ruled out. With regard to alteplase administration, this is a priority over the client's allergy status or blood type. Beta-blockers and aminoglycosides do not contraindicate the use of alteplase.

The critical care nurse is caring for a client who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located? AV node Bundle of His Purkinje cells SA node

SA node Explanation: The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal circumstances, the SA node has the highest inherent rate (60 to 100 impulses per minute).

After an extensive diagnostic workup, a client is diagnosed with systemic lupus erythematosus (SLE). Which statement about the incidence of SLE is true? SLE affects more Caucasians than African-Americans SLE is most common in women between ages 45 and 60 SLE tends to occur in families SLE is more common in underweight than overweight persons

SLE tends to occur in families

When a client's blood pressure drops, what do the kidneys do in response? Secrete renin. Produce aldosterone. Slow the release of ADH. Secrete ANP>

Secrete renin

The nurse should recognize a client's risk for impaired immune function if the client has undergone surgical removal of which of the following? Spleen Kidney Pancreas Thyroid gland

Spleen Explanation: A history of surgical removal of the spleen, lymph nodes, or thymus may place the client at risk for impaired immune function. Removal of the thyroid, kidney, or pancreas would not directly lead to impairment of the immune system.

The nurse is doing preoperative client education with a 61-year-old male client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? Stop smoking at least a month before the scheduled surgery to enhance pulmonary function and decrease infection. Reduce smoking by 50% to prevent the development of pneumonia. Stop smoking at least 4 months before the scheduled surgery to enhance pulmonary function and decrease infection. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications

Stop smoking at least a month before the scheduled surgery to enhance pulmonary function and decrease infection. Explanation: The reduction of smoking will enhance pulmonary function; in the preoperative period, clients who smoke should be urged to stop 30 days before surgery.

The nursing instructor is discussing the need for lubrication of the alveoli for effective gas exchange. The students know that what substance is produced by type II cells of the alveoli? Erythrocytes Pleural fluid Surfactant Lymphatic fluid

Surfactant Explanation: Type II cells produce surfactant. Erythrocytes are made in the bone marrow. Lymphatic fluid is produced by lymph glands. Pleural fluid is secreted by cells in the pleural cavity.

Why is it imperative for each nurse to become familiar with the nurse practice acts (NPA) of the state in which they practice? The NPA protects the nurse from malpractice suits. The NPA contains national standards and responsibilities. The NPA contains job descriptions for all nurses. The NPA defines nursing practice and standards of care for the nurse practicing in a specific state.

The NPA defines nursing practice and standards of care for the nurse practicing in a specific state.

The nurse is preparing to administer nifedipine. What data would cause the nurse to question administering this medication? The client's blood pressure is 110/70mmHg The client complains of being dizzy The client has a calcium level of 10.5 mg/dl The client reports having a dry mouth

The client complains of being dizzy

The operating room nurse is taking a male patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the operating room and nearly died 15 years ago. The nurse knows that the anesthetist is planning to use a volatile liquid as part of the anesthetic. What relevance is this information regarding the patient? The patient may be at risk for hypothermia. The patient may be nervous. The patient may be at risk for developing malignant hyperthermia. The grandmother's surgery has no relevance to the patient's surgery.

The patient may be at risk for developing malignant hyperthermia. Explanation: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. All of these drugs have the potential to trigger malignant hyperthermia and should be used with caution in any patient at high risk for developing it to avoid development of malignant hyperthermia. The patient's nervousness is not relevant, the grandmother's surgery is very relevant, and all patients are at risk for hypothermia.

Hydrostatic pressure, which pushed fluid out of the capillaries is opposed by oncotic pressure, which involves what? Reduced renin production. A decrease in aldosterone. The pulling power of albumin to reabsorb water. An increase in ADH secretion.

The pulling power of albumin to reabsorb water.

A client is prescribed salmeterol with dosage on a 4- to 6-hour schedule for the treatment of exercise-induced asthma. What is the recommended dosing schedule of asthma experts regarding this drug? Thirty minutes prior to exercise to prevent dyspnea during exercise Immediately before and after exercise to prevent dyspnea As needed to treat or prevent dyspnea during exercise Every 1-2 hours to treat or prevent dyspnea during exercise

Thirty minutes prior to exercise to prevent dyspnea during exercise Explanation: Salmeterol adult and pediatric (age 12 years and older): one puff every 12 hours or one puff 30 minutes before exercise.

When an analgesic is titrated to manage pain, what is the priority goal? Titrate to the smallest dose that provides relief with the fewest side effects. Titrate upwards until the patient is pain-free or an acceptable level is reached. Titrate downwards to prevent toxicity, overdose, and adverse effects. Titrate to a dosage that is adequate to meet the patient's subjective needs.

Titrate to the smallest dose that provides relief with the fewest side effects.

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To prevent aspiration of stomach contents To decrease cerebral arterial pressure To prevent flexion contractures To avoid impeding venous outflow

To avoid impeding venous outflow Explanation: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.

The nurse is providing discharge instructions to a 72-year-old client who has been discharged home on a diuretic. What should the nurse include when providing discharge instructions regarding the use of a diuretic at home? To weigh themselves on the same scale, at the same time of day, in the same clothing Decrease exercise to conserve energy Measuring intake and output of urine Restrict fluids to 500 mL/day to limit the need to urinate

To weigh themselves on the same scale, at the same time of day, in the same clothing Explanation: Clients taking a diuretic at home need to learn to weigh themselves every day, at the same time, and in the same clothes to monitor for loss or retention of fluid. They should not be asked to decrease activity. Restricting fluids can lead to a rebound fluid retention when compensatory mechanisms are activated. For most clients, it is unnecessary to monitor intake and output.

A client newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the client and advises that the client should avoid tobacco use. What is the primary rationale behind that advice to the client? Tobacco use is associated with a sedentary lifestyle. Tobacco use causes ventricular hypertrophy. Quitting smoking will cause the client's hypertension to resolve. Tobacco use increases the client's concurrent risk of heart disease. SUBMIT ANSWER

Tobacco use increases the client's concurrent risk of heart disease. Explanation: Smoking increases the risk for heart disease, for which a client with hypertension is already at an increased risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurse's advice; the association with heart disease is more salient.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next? Apply a cool cloth to the client's forehead. Turn the client completely to one side. Offer the client a small amount of ice chips. Administer a dose of IV analgesic.

Turn the client completely to one side. Explanation: Turning the client completely to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the child's pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? Non-insulin-dependent diabetes Type 2 diabetes Prediabetes Type 1 diabetes

Type 1 diabetes Explanation: Beta cell destruction is the hallmark of type 1 diabetes. Non-insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.

A 70-year-old client is being treated for chronic obstructive pulmonary disease (COPD) with theophylline. What will be a priority assessment by the nurse? Use of nicotine Activity level Intake of fatty foods Weight

Use of nicotine Explanation: Nutritional status, weight, and activity level would be important for a nurse to know about a COPD client. However, it would be most important for the nurse to know whether the client smokes or uses tobacco in other ways or smoking cessation methods that involve nicotine. Nicotine increases the metabolism of theophyllines; the dosage may need to be increased to produce a therapeutic effect.

An inhaled sympathomimetic drug has been ordered for a teenage athlete who has exercise-induced asthma. What should the client be instructed to do? Use the inhaler 30 to 60 minutes before exercising. Use the inhaler every day at the same time each day. Use the inhaler as soon as the symptoms start. Use the inhaler 2 to 3 hours before exercising to ensure peak effectiveness.

Use the inhaler 30 to 60 minutes before exercising. Explanation: Teaching a client about using an inhaled sympathomimetic for management of exercise-induced asthma should include instructions to use the inhaler 30 to 60 minutes before exercising to ensure therapeutic levels when needed. The inhaler would not be used daily and waiting until symptoms occur will be too late for prevention.

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen? Oxygen will increase the client's intracranial pressure and create confusion. Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. The client's calcium will rise dramatically due to pituitary stimulation. Oxygen may cause the client to hyperventilate and become acidotic.

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. Explanation: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. No information indicates the client's calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the client's intracranial pressure and create confusion. Increasing the oxygen would not stimulate the client to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? Face tent Venturi mask Non-rebreather air mask Tracheostomy collar

Venturi mask Explanation: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply. Calcium and vitamin D supplementation Regular exercise High-protein diet Smoking cessation Weight loss

Weight loss Regular exercise Smoking cessation Explanation: Clients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

The nurse is conducting an admission assessment on a client. When collecting data related to medications, the nurse asks, "What medications are you currently taking?" After collecting this information, what other questions should the nurse ask? Select all that apply. "Do you take any herbs, vitamins, or supplements?" "Do you take medications safely when you take them?" "What over-the-counter (OTC) medications do you take?" "Who prescribed these medications?" "Do you feel like you take enough medication, too much, or too little?"

What over-the-counter (OTC) medications do you take?" "Do you take any herbs, vitamins, or supplements?" Explanation: Clients often neglect to mention OTC drugs or alternative therapies (e.g., herbals) because they do not consider them to be actual drugs or they may be unwilling to admit their use to the healthcare provider. Ask clients specifically about OTC drug and alternative therapy use. The nurse must assess whether the client is taking medications safely, but this cannot be determined simply by asking the client if this is so. The name of the prescriber and the client's perception of doses/quantities are not priorities.

In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. When a neurogenic bladder develops When level of consciousness is decreased In the presence of peripheral nervous system disease With brain stem pathology When a spinal reflex is interrupted

When level of consciousness is decreased With brain stem pathology In the presence of peripheral nervous system disease Explanation: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement.

What client would be most likely to benefit from the administration of a beta2-specific adrenergic agonist? a client whose blood pressure is 86/41 mm Hg a client who is in atrial fibrillation a client who is having an exacerbation of chronic bronchitis a client whose eyes need to be dilated for an ophthalmic examination

a client who is having an exacerbation of chronic bronchitis Explanation: Most of the beta2-specific adrenergic agonists are used to manage and treat asthma, bronchospasm, and other obstructive pulmonary diseases. This is a more likely indication than hypotension, arrhythmias, or a need for pupil dilation.

What client is exhibiting an expected assessment finding after the administration of a sympathomimetic drug? a client whose respiratory rate has changed from 9 to 18 breaths/min a mechanically ventilated client who is no longer "fighting" the ventilator a client who had a bleeding duodenal ulcer which has stopped bleeding a client who has completed cardiac catheterization with no complications

a client whose respiratory rate has changed from 9 to 18 breaths/min Explanation: Sympathomimetic drugs increase respirations. These drugs do not have significant effects on coagulation. An agitated client who is "fighting" the ventilator may become worse, not better, with sympathomimetic medication. The drugs would not be administered for cardiac catheterization due to the accompanying stimulation of the adrenergic receptors.

The nurse is caring for a client with severe coronary artery disease (CAD) who is experiencing chest pain because the oxygen demand exceeds supply. What forces could potentially be lowered to reduce oxygen consumption? Select all that apply. pulse pressure heart rate stretch on the ventricles preload afterload

afterload stretch on the ventricles heart rate preload Explanation: The primary forces that determine the heart's use of oxygen or oxygen consumption include: heart rate (the more the heart has to pump, the more oxygen it requires), preload (the more blood that is returned to the heart, the harder it will have to work to pump the blood around), afterload (the higher the resistance in the system, the harder the heart will have to contract to force open the valves and pump the blood along), and stretch on the ventricles (if the ventricular muscle is stretched before it is stimulated to contract, more actomyosin bridges will be formed, which will take more energy). Pulse pressure does not impact oxygen consumption, though lowering blood pressure reduces afterload.

2. Which of the following electrolytes maintains cell electroneutrality? a. magnesium b. chloride c. potassium

c. Potassium maintains cell electroneutrality.

The nurse is collaborating with the healthcare provider of a client who presented with signs and symptoms of an infection. What information should the nurse prioritize so that the healthcare provider can prescribe the proper antibiotic? the client's intake and output for past 2 days results of complete blood count with differential first day of infection symptoms culture and sensitivity test results

culture and sensitivity test results Explanation: Antibiotics are best selected based on culture results that identify the type of organism causing the infection and sensitivity testing that shows what antibiotics are most effective in eliminating the bacteria. First day of symptoms of infection is likely already known if culture and sensitivity testing has been performed. Although measurement of intake and output is one indicator of renal function, a blood-urea-nitrogen test and assessment of creatinine levels would be better ways of assessing renal function, which will be used to determine dose of medication but not for selection of the correct antibiotic. The white blood cell count and differential would indicate the possibility of an infection but are not needed in choosing the proper antibiotic.

A young adult client who has no significant prior health history has been prescribed antibiotics for the first time. What nursing diagnosis would be most appropriate for this client? constipation related to increased fluid absorption imbalance nutrition: less than body requirements related to multiple GI effects of the drug deficient knowledge regarding drug therapy acute pain related to gastrointestinal (GI) effects of the drug

deficient knowledge regarding drug therapy Explanation: Because this is the first time the client has taken antibiotics, he or she is likely to have limited knowledge about the drug. The client may not understand the importance of taking the medication as ordered to increase effectiveness of the drug or to report adverse effects. Because the client has not started the drug yet, there is no way to know what adverse effects, if any, he or she will experience.

Information has been received by a client's neuron and transmitted into the cell body. What component of the neurologic system performed this function? dendrite nucleus axon soma

dendrite Explanation: Dendrites carry information to the nerve and axons; they also carry information from a nerve to be transmitted to effector cells, which are found in muscles, glands, or another nerve. Soma refers to the cell body. The nucleus is the central part of a cell, which is responsible for the cell's growth, reproduction, and metabolism.

The nurse is caring for a client who has been receiving a broad-spectrum anti-infective agent for several days. What signs and symptoms should the nurse monitor closely? destruction of normal flora increased inflammation tissue necrosis respiratory distress

destruction of normal flora Explanation: One common offshoot of the use of anti-infectives, especially broad-spectrum anti-infectives, is destruction of the normal flora resulting in superinfections. Tissue necrosis is a rare complication and inflammation would be unlikely to increase. Respiratory distress or other signs of anaphylaxis would be unlikely, since the client has been taking the drug for several days.

The nurse is caring for a client who received a new diagnosis of cancer. The client exhibits signs of a sympathetic stress reaction. What signs and symptoms will the nurse assess in this client consistent with an acute reaction to stress? Select all that apply. tachypnea confusion diaphoresis (profuse sweating) hypotension tachycardia

diaphoresis (profuse sweating) tachycardia tachypnea Explanation: Anxiety is often accompanied by signs and symptoms of the sympathetic stress reaction that may include sweating, fast heart rate, rapid breathing, and elevated blood pressure. Confusion is atypical.

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? electrocardiogram (ECG) results bowel sounds neuromuscular function respiratory rate

electrocardiogram (ECG) results Explanation: Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

A client newly diagnosed with HIV is receiving client teaching from the clinic nurse about antiretroviral medications. The nurse should teach the client to report what adverse effect to a healthcare provider most promptly? constipation full body rash nausea dizziness

full body rash Explanation: All options provided have the potential to be an adverse effect of antiviral medications prescribed to treat HIV. Most can be managed through diet or over-the-counter medications but a rash needs to be reported immediately because it could indicate a potentially serious reaction and requires immediate intervention.

A client with secondary hypertension has come into the clinic for a routine check-up. When comparing this client's diagnosis to primary hypertension, the nurse recognizes that secondary hypertension: does not normally respond to antihypertensive drug therapy. has a more gradual onset than primary hypertension. does not normally cause target organ damage. has a specific cause. SUBMIT ANSWER

has a specific cause. Explanation: Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.

The nurse anticipates what nonspecific response to a client's abrasion injury? inhibition of cell growth and conservation of energy heat and swelling increased protein catabolism decreased serum pH

heat and swelling Explanation: The inflammatory response is the local reaction of the body to invasion or injury. Any insult to the body that injures cells or tissues sets of a series of events and chemical reactions known as the inflammatory response, which includes heat and swelling. Protein catabolism is the breakdown of protein into particles small enough to be carried into the cell and is an incorrect choice. Cellular injury does not inhibit cell growth or lower pH.

A school-aged child has been diagnosed with a seizure disorder and phenytoin has been prescribed. What nursing diagnosis would be most appropriate if the child demonstrated adverse effects to the drug related to cellular toxicity? impaired skin integrity related to dermatological effects insomnia related to CNS stimulation noncompliance to drug therapy related to avoidance of adverse effects deficient fluid volume related to diuresis

impaired skin integrity related to dermatological effects Explanation: Impaired skin integrity related to dermatological effects would be appropriate because phenytoin can cause potentially serious dermatological effects. This is related to cellular toxicity Usually this drug will cause the client to be sleepy all day and should enhance sleep at night. Deficient fluid volume is not a concern with this drug. Noncompliance will probably not be an issue at this age because the parents and school nurse will administer the medication.

A nurse is writing a plan of care for a client who has been prescribed bethanechol. What outcome should the nurse include in the care plan? decreased secretions improved bladder function pupillary dilation increased blood pressure

improved bladder function Explanation: Bethanechol is prescribed for nonobstructive urinary retention and neurogenic bladder. The appropriate outcome for this client would be improved bladder function. This drug causes pupillary constriction and increased secretions. This drug would not increase blood pressure. However, it could cause hypotension in the older client.

The nurse administers a medication that stimulates the muscarinic receptors. What manifestations should the nurse expect to assess in this client? increased heart rate muscle contractions pupil dilation increased activity of bowel sounds

increased activity of bowel sounds Explanation: Stimulation of muscarinic receptors increases gastrointestinal (GI) motility which would cause increased activity of bowel sounds. Other effects include pupil constriction, increased urinary bladder contraction, and a slowing of the heart rate. Stimulation of nicotinic receptors causes muscle contractions.

A client sustained a closed-head injury 4 hours ago and now presents to the emergency department with difficulty breathing. The nurse should suspect damage to what part of the brain? medulla oblongata pituitary cerebrum thalamus

medulla oblongata Explanation: The hindbrain, which runs from the top of the spinal cord into the midbrain, is the most primitive area of the brain and contains the brainstem, where the pons and medulla oblongata are located. This area of the brain controls basic vital functions such as the respiratory centers, which control breathing; the cardiovascular centers, which regulate blood pressure; the chemoreceptor trigger zone and emetic zone, which control vomiting; the swallowing center, which coordinates the complex swallowing reflex; and the reticular activating system (RAS), which controls arousal and awareness of stimuli and contains the sleep center. The midbrain contains the thalamus and hypothalamus and the limbic system that transfer sensations into the cerebrum and control temperature. The pituitary gland is known as the master gland, controlling other glands with hormones secreted here.

What should the nursing instructor include when talking with students about anti-infective medication that are very selective in their actions? broad spectrum bactericidal narrow spectrum bacteriostatic

narrow spectrum Explanation: Some anti-infectives are so selective in their action that they are effective against only a few, or possibly only one, microorganism with a very specific metabolic pathway or enzyme. These drugs are said to have a narrow spectrum of activity. They are not called broad spectrum, which applies to a drug with little selectivity; bactericidal, which is a substance that causes death of bacteria; or bacteriostatic, which prevents replication of a bacterium.

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: extremities for signs of cyanosis. oxygen saturation level. level of consciousness (LOC). hemoglobin, hematocrit, and red blood cell levels.

oxygen saturation level. Explanation: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

A group of nurses is participating in orientation to a telemetry unit. The nurse who is providing the education should tell the class that ST segments: are the part of an ECG that reflects the time from ventricular depolarization through repolarization. represent early ventricular repolarization. are the part of an ECG used to calculate ventricular rate and rhythm. are the part of an ECG that reflects systole.

represent early ventricular repolarization. Explanation: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval.

A client has a neurologic disorder that affects the structure and function of the myelin sheath and Schwann cells. What effect will this client likely experience? personality changes chronic pain lack of coordination slower than normal nerve conduction

slower than normal nerve conduction Explanation: Myelinated nerves have Schwann cells, which speed up nerve conduction. Their absence does not cause personality changes, pain, or lack of coordination.

The nurse is working with a client who is newly diagnosed with hypothyroidism. Diagnostic testing has indicated that the client's health problem is caused by anterior pituitary dysfunction. This client's hypothyroidism is rooted in a deficiency of: tetraiodothyronine. triiodothyronine. thyroid-stimulating hormone (TSH). thyrotropin-releasing hormone (TRH).

thyroid-stimulating hormone (TSH). Explanation: Thyroid hormone production and release are regulated by the anterior pituitary hormone called thyroid-stimulating hormone (TSH). The secretion of TSH is regulated by thyrotropin-releasing hormone (TRH), a hypothalamic regulating factor. A client who has adequate levels of TRH will still have deficient TSH if the anterior pituitary is dysfunctioning. Tetraiodothyronine and triiodothyronine are thyroid hormones produced by the thyroid gland because of TSH stimulation.

The nurse has provided client teaching for a client who will be discharged to home on an anti-infective. What statement made by the client indicates the nurse needs to provide additional teaching concerning the use of anti-infectives? "Antibiotics will not help me when I have a viral infection." "It's not unusual to develop diarrhea as a result of taking an antibiotic." "I will stop taking the antibiotic once my symptoms have resolved." "A bacterial culture will be done before antibiotics are prescribed for me."

"I will stop taking the antibiotic once my symptoms have resolved." Explanation: Compliance with anti-infective therapy is a concern. Patients tend to stop taking the drugs when they begin to "feel better." A nurse should instruct the client to take the entire course of prescribed drug to ensure a sufficient period to rid the body of pathogens and to help prevent the development of resistance. Antibiotics are not prescribed for viral infections. It is important that cultures be performed before antibiotics are prescribed to determine what organism is causing the infection so that the correct drug is prescribed. Diarrhea is the most common adverse effect from anti-infectives.

What statement by the client indicates that the client understands the nurse's teaching about diuretics? "I will have to limit my high sugar foods." "I will weigh myself daily and report significant changes." "If my leg gets swollen again, I'll take an additional pill." "I will take my medication before bedtime on an empty stomach."

"I will weigh myself daily and report significant changes." Explanation: Daily weights and blood pressures should be monitored at home in a client taking diuretics. Additional doses cannot be safely taken, and there is no need to limit sugar. Bedtime administration causes nocturia.

A client does not want to take medication to treat existing hypertension if it can be avoided. The client asks the nurse whether any other options are available? What lifestyle changes should the nurse recommend? Select all that apply. "Reduce your overall intake of fluids." Try meditation, if it's something you're interested in." "Eliminate all salt from your diet." "Increase the amount of exercise that you do." "Lose some weight, if possible."

"Increase the amount of exercise that you do." "Lose some weight, if possible." Try meditation, if it's something you're interested in." Explanation: Exercising, losing weight, and meditation to reduce stress are all effective lifestyle changes the client can make. It is not necessary, or even possible, to eliminate all sodium from the diet, but cutting back will reduce water retention. Reducing intake of fluids is not a healthy option and would not be suggested unless comorbidities, such as the possibility of heart failure, were present.

A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a client with hypertension, the nurse learns that the client has a family history of hypertension and she herself has high cholesterol and lipid levels. The client says she smokes one pack of cigarettes daily and drinks "about a pack of beer" every day. The nurse notes what nonmodifiable risk factor for hypertension? Excessive alcohol intake A family history of hypertension Hyperlipidemia Closer adherence to medical regimen

A family history of hypertension Explanation: Unlike cholesterol levels, alcohol intake, and adherence to treatment, family history is not modifiable.

Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? Keep the head of the bed (HOB) flat at all times. Perform endotracheal suctioning every hour. Administer benzodiazepines on a PRN basis. Teach the client to perform the Valsalva maneuver.

Administer benzodiazepines on a PRN basis. Explanation: If the client with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done on a limited basis, due to increasing pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP.

An office worker takes a cookie that contains peanut butter. The worker begins wheezing, with an inspiratory stridor and air hunger and the occupational health nurse is called to the office. The nurse should recognize that the worker is likely suffering from which type of hypersensitivity? Anaphylactic (type 1) Immune complex (type III) Delayed-type (type IV) Cytotoxic (type II)

Anaphylactic (type 1) Explanation: The most severe form of a hypersensitivity reaction is anaphylaxis. An unanticipated severe allergic reaction that is often explosive in onset, anaphylaxis is characterized by edema in many tissues, including the larynx, and is often accompanied by hypotension, bronchospasm, and cardiovascular collapse in severe cases. Type II, or cytotoxic, hypersensitivity occurs when the system mistakenly identifies a normal constituent of the body as foreign. Immune complex (type III) hypersensitivity involves immune complexes formed when antigens bind to antibodies. Type III is associated with systemic lupus erythematosus, rheumatoid arthritis, certain types of nephritis, and bacterial endocarditis. Delayed-type (type IV), also known as cellular hypersensitivity, occurs 24 to 72 hours after exposure to an allergen.

A gardener sustained a deep laceration while working and requires sutures. The date of the client's last tetanus shot was over 10 years ago. Based on this information, the client will receive a tetanus immunization which will allow for the release of what? Phagocytes Antigens Cytokines Antibodies

Antibodies Explanation: Immunizations activate the humoral immune response, culminating in antibody production. Antigens are the substances that induce the production of antibodies. Immunizations do not prompt cytokine or phagocyte production.

A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response? Antibodies are made by B lymphocytes in response to a specific antigen. Specialized cells recognize and ingest cells that are recognized as foreign. T lymphocytes are assisted by cytokines to fight infection. Lymphocytes are stimulated to become cells that attack microbes directly.

Antibodies are made by B lymphocytes in response to a specific antigen. Explanation: The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response.

The nurse is assessing a client diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find? Fatigue Hair loss Moon face Bulging eyes

Bulging eyes Explanation: Clinical manifestations of the endocrine disorder Graves disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves disease is not associated with hair loss, a moon face, or fatigue.

A client with SLE has the classic rash of lesions on the cheeks and bridge of the nose. What term does the nurse use to describe this characteristic pattern? Papular rash Pustular rash Butterfly rash Bull's eye rash

Butterfly rash

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? Skin sloughing Butterfly rash Petechiae Jaundice

Butterfly rash Explanation: An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE. Clients with SLE do not typically experience jaundice or skin sloughing.

A student asks the pharmacology instructor to describe the function of a cholinergic agonist. What would the instructor reply?

Cholinergic agonists increase the activity of acetylcholine receptor sites throughout the body. Explanation: Cholinergic agonists are drugs that increase the activity of acetylcholine receptor sites throughout the body. Dopamine, GABA, and norepinephrine are not associated with cholinergic agonist function.

A client converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and diltiazem are given. The nurse caring for the client understands that the main goal of treatment is what? Decrease SA node conduction Improve oxygenation Maintain anticoagulation Control ventricular heart rate

Control ventricular heart rate Explanation: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.

An adult client experiences angina pectoris upon exertion. The nurse informs the client that the leading cause of angina is what? Smoking Infarction of the myocardium Inadequate cardiac output Coronary atherosclerosis

Coronary atherosclerosis Explanation: The person with atherosclerosis has a classic supply-and-demand problem. The heart may function without a problem until increases in activity or other stresses place a demand on it to beat faster or harder. Normally, the heart would stimulate the vessels to deliver more blood when this occurs, but the narrowed vessels are not able to respond and cannot supply the blood needed by the working heart. The heart muscle then becomes hypoxic. This imbalance between oxygen supply and demand is manifested as pain, or angina pectoris, which literally means "suffocation of the chest." Atherosclerosis of the coronary artery can block the coronary artery completely leading to infarction. Smoking causes further vasoconstriction, increasing risk of myocardial infarction or angina. Damage to the heart muscle causes a decrease in cardiac output.

A client's muscle weakness has been found to result from a lack of neurotransmitter communication between nerves and muscles. What neurotransmitter is most likely deficient? acetylcholine serotonin gamma-aminobutyric acid (GABA) dopamine

acetylcholine Explanation: Acetylcholine communicates between nerves and muscles. Dopamine is involved in the coordination of impulses and responses, both motor and intellectual. GABA inhibits nerve activity. Serotonin is important in arousal and sleep.

The nurse determines that which of the following nursing diagnoses has the highest priorityfor a client with rheumatoid arthritis? Fatigue Disturbed body image Ineffective role performance Pain

v

The perioperative nurse is planning the care of a client who will soon undergo surgery with general anesthetic. What nursing diagnoses should the nurse consider in this client's care plan? Select all that apply. Disturbed sensory perception related to anesthesia Chronic confusion related to central nervous system depression Imbalanced nutrition: Less than body requirements related to fasting for surgery Unilateral neglect related to temporary loss of neuromuscular function Anxiety related to risks of surgery

Disturbed sensory perception related to anesthesia Anxiety related to risks of surgery Explanation: Disturbed sensory perception can create a risk for injury, and anxiety is a common preoperative (and post-operative) phenomenon. General anesthetics affect cognition, but this does not lead to chronic confusion. Short-term fasting does not normally threaten a client's nutritional status. Loss of sensory and motor function does not create a risk of neglecting one side of the body exclusively.

The nurse administered Bethanechol to an elderly client. The nurse will be alert for what side effect of this medication? Tachycardia Hypertension Dizziness Urinary retention

Dizziness

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). Do not eliminate insulin when nauseated and vomiting. Eat three substantial meals a day, if possible. Reduce food intake and insulin doses in times of illness.

Do not eliminate insulin when nauseated and vomiting. Explanation: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

The nurse evaluates the client's latest serum phenytoin level which is revealed to be 16 mcg/mL. What is the nurse's best action? Contact the provider to discuss withholding the next scheduled dose. Document the fact that the client's phenytoin level is therapeutic. Contact the provider to discuss the need for a supplementary dose of phenytoin. Promptly establish seizure precautions.

Document the fact that the client's phenytoin level is therapeutic. Explanation: The therapeutic serum level range for phenytoin is between 10 and 20 mcg/mL. As such, there is no need to contact the provider. Seizure precautions are likely already in place, and if they are not, this laboratory result does not provide an indication for reinstituting them.

When the nurse cares for a client receiving an antibiotic, what instructions should the nurse provide no matter what medication is prescribed? Select all that apply. Take antibiotic with food to avoid gastrointestinal (GI) upset. Report difficulty breathing, severe headache, or changes in urine output. Drink plenty of fluids to avoid kidney damage. Take all medications as prescribed until all of the medication is gone. Take safety precautions such as changing position slowly

Drink plenty of fluids to avoid kidney damage. Take all medications as prescribed until all of the medication is gone. Report difficulty breathing, severe headache, or changes in urine output. Explanation: The client taking any antibiotic needs to drink plenty of fluids to avoid kidney damage and improve excretion of the metabolized drug; take all medications as prescribed until all of the medication is gone to avoid developing a resistant strain of bacteria; and report any difficulty breathing, severe headache, or changes in urine output because these are primary manifestations of serious adverse effects. Although some antibiotics need to be taken with food, others may be best taken on an empty stomach so this does not apply to all antibiotics. Not all antibiotics are associated with central nervous system (CNS) toxicity so taking safety precautions need only be included in client teaching if they are taking a drug associated with CNS adverse effects.

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? Early ambulation Increased dietary intake of protein Maintaining the client in a supine position Administering aspirin with warfarin

Early ambulation Explanation: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the client takes oral contraceptives. The nurse's postoperative plan of care should include what intervention? Doppler ultrasound of peripheral circulation twice daily Cessation of the oral contraceptives until 3 weeks postoperative Dependent positioning of the client's extremities when at rest Early ambulation and leg exercises

Early ambulation and leg exercises Explanation: Oral contraceptive use increases blood coagulability; with bed rest, the client may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

What type of diet should a patient taking diuretics have? Eat sodium-rich or low-sodium diet as appropriate Eat low-sodium, low-potassium diet No effect on diet Eat potassium-rich or low-potassium diet as appropriate

Eat potassium-rich or low-potassium diet as appropriate Explanation: Provide potassium-rich or low-potassium diet as appropriate to maintain electrolyte balance and replace lost potassium or prevent hyperkalemia.

A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of HIV infection. The nurse should prioritize what intervention? Screening programs for youth and young adults Appropriate use of standard precautions Lifestyle actions that improve immune function Educational programs that focus on control and prevention

Educational programs that focus on control and prevention Explanation: Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions applies to very few cases of HIV infection.

How should the nurse best position a client who has leg ulcers that are venous in origin? Elevate the client's lower extremities. Dangle the client's legs over the side of the bed. Keep the client's knees bent to 45-degree angle and supported with pillows. Keep the client's legs flat and straight.

Elevate the client's lower extremities. Explanation: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the client's legs and applying pillows may further compromise venous return.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? Position changes every 15 minutes while awake Elevation of the head of the bed Head turned slightly to the right side Extension of the neck

Elevation of the head of the bed Explanation: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

A nurse is preparing a client for allergy skin testing. What precautionary step is most important for the nurse to follow? The nurse should administer albuterol 30 to 45 minutes prior to the test. The client must not have received an immunization within 7 days. Prophylactic epinephrine should be given before the test. Emergency equipment should be readily available.

Emergency equipment should be readily available. Explanation: Emergency equipment must be readily available during testing to treat anaphylaxis. Immunizations do not contraindicate testing. Neither epinephrine nor albuterol is given prior to testing.

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? Encourage extended periods of sitting or standing. Encourage the client to engage in a moderate amount of exercise. Elevate his legs and arms above his heart when resting. Discourage walking in order to limit pain.

Encourage the client to engage in a moderate amount of exercise. Explanation: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the client to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A client is experiencing intense nausea while being treated with chemotherapeutics. What actions should the nurse perform? Select all that apply. Ensure that the client has had a dietician consult. Administer antacids as prescribed, 30 minutes before meals. Provide the client with a low-residue diet. Administer antiemetics as prescribed. Provide the client with small, frequent meals.

Ensure that the client has had a dietician consult. Administer antiemetics as prescribed. Provide the client with small, frequent meals. Explanation: A dietician should consult in the treatment of a client with nausea secondary to chemotherapy. Small, frequent meals and vigilant use of antiemetics are useful as well. There is no need for a low-residue diet and antacids do not normally prevent nausea.

A client is brought to the emergency department after losing consciousness at home. The client's low blood pressure and health history suggest a cholinergic reaction. What is the nurse's best action? Administer an intravenous bolus of 10% dextrose as prescribed. Ensure that there is ready access to atropine on the unit. Reposition the client in the Trendelenburg position. Anticipate the STAT administration of propranolol.

Ensure that there is ready access to atropine on the unit. Explanation: The antidote for a cholinergic reaction is atropine. This drug will block the cholinergic sites. Propranolol blocks beta-receptors in the sympathetic system and would exacerbate the client's hypotension. IV fluids would likely be prescribed, but a hypertonic solution would cause undesirable fluid shifts. Repositioning the client is a lower priority than administering atropine.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? Encourage fluid intake. Encourage the use of over-the-counter calcium supplements. Maintain a low sodium diet. Ensure the client has sufficient potassium intake.

Ensure the client has sufficient potassium intake. Explanation: Diuretics cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

The nurse is caring for a client experiencing acute bronchospasm. What drug is most likely to meet this client's needs? Cromolyn Ipratropium bromide Ephedrine Epinephrine

Epinephrine Explanation: Epinephrine may be injected subcutaneously in an acute attack of bronchoconstriction, with therapeutic effects in 5 minutes that last 4 hours. It is considered the drug of choice for the treatment of acute bronchospasm. Ipratropium bromide has an onset of action of 15 minutes when inhaled with a duration of 3 to 4 hours. Cromolyn is not for use during acute times of bronchospasm but is used to help prevent bronchospasm. Ephedrine can be used in acute bronchospasm, but epinephrine remains the drug of choice.

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? SELECT ALL THAT APPLY Erythrocyte sedimentation rate (ESR) is elevated and x-rays can show erosions and decalcification of involved joints The only treatment is high dose therapy with NSAIDs Inflamed synovial membranes and cartilage trigger complement activation which stimulates the release of additional inflammatory mediators Onset is acute and usually between ages 20-40 The patient experiences stiff, swollen joints bilaterallyThe patient may not exercise once the disease is diagnosed

Erythrocyte sedimentation rate (ESR) is elevated and x-rays can show erosions and decalcification of involved joints Inflamed synovial membranes and cartilage trigger complement activation which stimulates the release of additional inflammatory mediators The patient experiences stiff, swollen joints bilaterally

A registered nurse is a leader of a team consisting of two nursing assistants. Which assignment should the registered nurse keep rather than assigned to one of the nursing assistants? Select all that apply. Evaluating a clients response to the administration of an analgesic. Emptying the collection back of a urinary retention catheter. Obtaining a specimen of exudate from a draining wound. Taking vital signs of clients who are unstable. Teaching client range of motion exercises.

Evaluating a clients response to the administration of an analgesic. Obtaining a specimen of exudate from a draining wound. Taking vital signs of clients who are unstable. Teaching client range of motion exercises. Nursing assistants can perform basic skills such as emptying the collection bag of a urinary retention catheter.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of hemorrhagic stroke Previous thrombolytic therapy within the past 12 months Blood pressure of ≥ 180/110 mm Hg Evidence of stroke evolution

Evidence of hemorrhagic stroke Explanation: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

When discussing angina pectoris secondary to atherosclerotic disease with a client, the client asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena? Exercise increases the heart's oxygen demands. Exercise causes vasoconstriction of the coronary arteries. Exercise shunts blood flow from the heart to the mesenteric area. Exercise increases the metabolism of cardiac medications. SUBMIT ANSWER

Exercise increases the heart's oxygen demands. Explanation: Physical exertion increases the myocardial oxygen demand. If the client has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.

The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response? Obtain an order for a PRN benzodiazepine. Explore the factors underlying the client's anxiety. Describe the procedure in greater detail. Teach the client guided imagery techniques.

Explore the factors underlying the client's anxiety. Explanation: An assessment of anxiety levels is required in the client to assist the client in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the client's anxiety before providing interventions such as education or medications.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? Projectile vomiting Dysrhythmias Facial droop Periorbital edema

Facial droop Explanation: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and clients less commonly experience dysrhythmias or vomiting.

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? Labile BP Audio hallucinations Falls Respiratory depression

Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.

A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) Random plasma glucose greater than 126 mg/dL (7.0 mmol/L) Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions

Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) Explanation: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).

The nurse is caring for a client diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this client, what sign or symptom would the nurse expect? Flushed skin Palpitations Bulging eyes Fatigue

Fatigue Explanation: Symptoms of hypothyroidism include extreme fatigue, hair loss, brittle nails, dry skin, voice huskiness or hoarseness, menstrual disturbance, and numbness and tingling of the fingers. Bulging eyes, palpitations, and flushed skin would be signs and symptoms of hyperthyroidism.

An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? Administration of antihypertensive medications Fluid and electrolyte replacement Administering sodium bicarbonate intravenously Reversing acidosis by administering insulin

Fluid and electrolyte replacement Explanation: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

What would alert the nurse to suspect that a client is developing ketoacidosis? Fruity breath odor Fluid retention Hunger Blurred vision

Fruity breath odor Explanation: Fruity breath odor would be noted as ketones build up in the system and are excreted through the lungs. Dehydration would be noted as fluid and electrolytes are lost through the kidneys. Blurred vision and hunger would be associated with hypoglycemia.

A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? Deep tendon reflexes Abdominal girth Hearing acuity Gag reflex

Gag reflex Explanation: Preoperatively, the gag reflex and ability to swallow are evaluated. In clients with diminished gag response, care includes teaching the client to direct food and fluids toward the unaffected side, having the client sit upright to eat, offering a semisoft diet, and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing acuity are less commonly affected by brain tumors and do not affect the risk for aspiration.

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. At present, members of what group are most affected by new cases of HIV? Gay, bisexual, and other men who have sex with men Blood transfusion recipients Recreational drug users Health care providers

Gay, bisexual, and other men who have sex with men Explanation: Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 4% of the male population but 63% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients.

When assessing a client admitted with nausea and vomiting, which finding supports the nursing diagnosis of fluid volume deficit? Polyuria. Decreased pulse. Difficulty breathing. General restlessness.

General restlessness.

The client is at an increased risk for hearing loss if taking furosemide with what medication? Digoxin Gentamicin Codeine Ciprofloxacin

Gentamicin Explanation: The risk of ototoxicity increases if loop diuretics are combined with aminoglycoside antibiotics (gentamicin) or cisplatin. No known increased risk of ototoxicity exists when furosemide is taken with codeine, ciprofloxacin, or digoxin.

A 64-year-old client in hypertensive crisis is to receive furosemide 40 mg IV. Furosemide comes in 100 mg/10 mL containers. What is the correct action by the nurse when giving the prescribed medication? Fix 10 mL in an IV piggyback and deliver it over 30 minutes. Give 4 mL over 1 to 2 minutes. Flush the line with normal saline, give 4 mL at 1 mL/min, flush again when finished. Give 4 mL over 10 minutes.

Give 4 mL over 1 to 2 minutes. Explanation: Administer furosemide 40 mg over 1 to 2 minutes IV.

A client is administered a third-generation cephalosporin. The broad-spectrum agents like cephalosporins are most effective in treating which type of microorganism? Gram positive Gram negative Virus Fungi

Gram negative Explanation: Cephalosporins are broad-spectrum agents with activity against both gram-positive and gram-negative bacteria. But they are, in general, less active against gram-positive organisms and more active against gram-negative ones. Cephalosporins are not effective against fungi or viruses.

A client taking atorvastatin presents to the clinic reporting acute muscle pain not associated with exercise or injury. The nurse asks questions to determine if this client has been taking what contraindicated substance? Ginseng Saw palmetto Over-the-counter (OTC) medications Grapefruit juice

Grapefruit juice Explanation: Grapefruit juice can decrease the breakdown of atorvastatin, leading to increased serum levels and toxic adverse effects, including rhabdomyolysis. Clients on this drug should be cautioned to avoid drinking grapefruit juice. OTC drugs, ginseng, and saw palmetto are not associated with increased toxicity.

A client taking a calcium channel blocker is seen in the clinic and receives a diagnosis of drug toxicity. When collecting the nursing history, consumption of what product would indicate the likely cause of this drug toxicity? Dairy products in the morning Aged cheese One to two alcoholic drinks daily Grapefruit juice

Grapefruit juice Explanation: The calcium channel blockers are a class of drugs that interact with grapefruit juice. When grapefruit juice is present in the body, the concentrations of calcium channel blockers increase, sometimes to toxic levels. Advise clients to avoid drinking grapefruit juice taking a calcium channel blocker. If a client on a calcium channel blocker reports toxic effects, ask whether he or she is drinking grapefruit juice. Use of alcohol could be important if the client was ingesting large amounts but that would not be the most likely cause of drug toxicity. Dairy and cheese should not cause any food-drug interaction.

The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees? Apply the condom prior to erection. Grasp the condom by the cuff after withdrawal. A condom may be reused with the same partner if ejaculation has not occurred. Use skin lotion as a lubricant if alternatives are unavailable.

Grasp the condom by the cuff after withdrawal. Explanation: The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the penis. Condoms should never be reused.

The nurse is helping a client who was recently placed on a low-sodium diet to choose foods for lunch. The nurse recommends which of the following lunch menus would be best for this client? Bologna sandwich on wheat bread, canned fruit cocktail, salad, and a soda Ham and bean soup, fresh fruit salad, pickles, and a diet soda Cheeseburger, grapes, fresh pineapple, and tomato juice Grilled chicken sandwich on white bread, apple, salad, and iced tea

Grilled chicken sandwich on white bread, apple, salad, and iced tea

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication? Wasting syndrome HIV encephalopathy B-cell lymphoma Kaposi's sarcoma

HIV encephalopathy Explanation: HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor functions. The other listed complications do not normally have cognitive and behavioral manifestations.

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? Have a colleague follow the client closely with a wheelchair. Support the client's full body weight with a waist belt during ambulation. Avoid mobilizing the client in the early morning or late evening. Ensure that the client's family members do not participate in mobilization.

Have a colleague follow the client closely with a wheelchair. Explanation: During mobilization, a chair or wheelchair should be readily available in case the client suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the client's full body weight. Morning and evening activities are not necessarily problematic.

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? Have the client identify familiar odors with the eyes closed. Assess papillary reflex. Test for air and bone conduction (Rinne test). Utilize the Snellen chart.

Have the client identify familiar odors with the eyes closed. Explanation: Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic).

The nurse is providing care for a client with a new diagnosis of hypertension. How can the nurse best promote the client's adherence to the prescribed therapeutic regimen? Encourage the client to lose weight and exercise regularly. Screen the client for visual disturbances regularly. Have the client participate in monitoring his or her own BP. Emphasize the dire health outcomes associated with inadequate BP control.

Have the client participate in monitoring his or her own BP. Explanation: Adherence to the therapeutic regimen increases when clients actively participate in self-care, including self-monitoring of BP and diet. Dire warnings may motivate some clients, but for many clients this is not an appropriate or effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not necessarily promote adherence to a therapeutic regimen.

The nurse is caring for a client with angina who is taking a calcium-channel blocker. What adverse effects would the nurse caution this client about? Itching and rash Headache and dizziness Nausea and diarrhea Hypertension and tachycardia

Headache and dizziness Explanation: The adverse effects associated with these drugs are related to their effects on cardiac output and on smooth muscle. Central nervous system (CNS) effects include dizziness, light-headedness, headache, and fatigue. Gastrointestinal (GI) effects can include nausea and hepatic injury related to direct toxic effects on hepatic cells. Cardiovascular effects include hypotension, bradycardia, peripheral edema, and heart block. Skin effects include flushing and rash. The adverse effects do not, however, include diarrhea, hypertension, tachycardia, or itching.

A nurse is caring for a client who is diagnosed with an IV fluid overload and hyponatremia. For which clinical indicator of hyponatremia should the nurse assess the client? Select all that apply. Thirst. Headache. Muscle weakness. Increased temperature. Dry mucous membranes

Headache. Muscle weakness. Thirst, increased temperature, and dry mucous membranes are clinical indicators of hypernatremia.

A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? Sense of smell Visual acuity Hearing and equilibrium Movement of the tongue

Hearing and equilibrium Explanation: Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of smell.

A nurse is about to administer a parenteral benzodiazepine to a client in the hospital before the performance of an invasive diagnostic procedure. What action should the nurse prioritize before administration of the drug? Auscultate the client's lungs and set up pulse oximetry monitoring. Ask all visitors to leave the room and remain in the waiting area. Close the blinds and ensure appropriate room temperature for the client. Help the client out of bed to the bathroom and encourage the client to void.

Help the client out of bed to the bathroom and encourage the client to void. Explanation: The priority action would be to help the client up to void. After the medication is administered, the client should not get out of bed because of possible injury due to drowsiness. Safety should always be the priority concern. Respiratory assessment is not a priority, since respiratory depression does not normally occur. Creating a calm environment and asking visitors to leave may be necessary for the diagnostic procedure, but these actions do not have to precede benzodiazepine administration.

A nurse is about to administer a parenteral benzodiazepine to a client in the hospital before the performance of an invasive diagnostic procedure. What action should the nurse prioritize before administration of the drug? Auscultate the client's lungs and set up pulse oximetry monitoring. Help the client out of bed to the bathroom and encourage the client to void. Close the blinds and ensure appropriate room temperature for the client. Ask all visitors to leave the room and remain in the waiting area.

Help the client out of bed to the bathroom and encourage the client to void. Explanation: The priority action would be to help the client up to void. After the medication is administered, the client should not get out of bed because of possible injury due to drowsiness. Safety should always be the priority concern. Respiratory assessment is not a priority, since respiratory depression does not normally occur. Creating a calm environment and asking visitors to leave may be necessary for the diagnostic procedure, but these actions do not have to precede benzodiazepine administration.

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the client is at increased risk for what complication of his injury? Embolus Skull fracture Hematoma Stroke

Hematoma Explanation: Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the client's risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture. Strokes are more common among older adults, but not typically as a complication of falls.

The nurse is caring for a client who reports chest pain. The nurse is to administer 40 mg of isosorbide dinitrate to the client. What assessment finding would contraindicate the safe use of this drug? Platelets 202 ×109/L (202 ×103/μL) Hemoglobin 88 g/L (8.8 g/dL) Active sinusitis Orientation to person and place but not time

Hemoglobin 88 g/L (8.8 g/dL) Explanation: The nurse should assess for anemia because the decrease in cardiac output could be detrimental in a client who already has a decreased ability to deliver oxygen because of a low red blood cell count. Sinusitis would not be a contraindication to the drug. Decreased level of consciousness is not a contraindication. This client's platelet level is within reference ranges.

A client is admitted with an asthma attack caused by an allergic reaction to a medication. The immediate release of which substance is most likely causing this severe allergic response? Epinephrine Histamine Surfactant Antihistamine

Histamine Explanation: Asthma is characterized by reversible bronchospasm, inflammation, and hyperactive airways. The hyperactivity is triggered by allergens or nonallergic inhaled irritants or by factors such as exercise and emotions. The trigger causes an immediate release of histamine, which results in bronchospasm in about 10 minutes. An antihistamine is used to treat allergic responses because it counteracts the effects of histamine. Surfactant is a lubricating substance that is necessary to keep the alveoli open. Epinephrine is a medication used to treat acute allergic responses.

A client is receiving subcutaneous heparin 5,000 units every 8 hours. An activated thromboplastin time (aPTT) is drawn 1 hour before the 8:00 AM dose; the aPTT is at 3.5 times the control value. What is the nurse's priority action? Hold the dose and call the result to the prescriber. Check the client's vital signs prior to administering the dose. Give the dose as ordered and chart the results. Give a larger dose to increase the aPTT.

Hold the dose and call the result to the prescriber. Explanation: The therapeutic level of heparin is demonstrated by an activated partial thromboplastin time (aPTT) that is 1.5 to 3 times the control value. The client's value is 3.5 times control, which indicates clotting time is a bit too delayed and the dosage will likely either be reduced or a dosage may be held according to the order received from the physician. It would be inappropriate to give two doses at once, give the dose and chart the results, or simply check the vital signs without holding the dose and calling the physician.

The nurse is caring for a client who is receiving IV gentamicin and who reports difficulty hearing this morning. What should the nurse do? Administer the dose and report this information to the oncoming nurse. Hold the dose and notify the provider immediately. Administer the dose and document the finding in the client's health record. Make a referral for auditory testing.

Hold the dose and notify the provider immediately. Explanation: Aminoglycosides are contraindicated in the following conditions: known allergy to any of the aminoglycosides; renal or hepatic disease that could be exacerbated by toxic aminoglycoside effects and that could interfere with drug metabolism and excretion, leading to higher toxicity; preexisting hearing loss, which could be intensified by toxic drug-related adverse effects on the auditory nerve. Ototoxicity should be reported, and the drug should be stopped. Hearing assessment may be deemed necessary, but the priority is to hold the dose and contact the provider.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? How to differentiate between hemorrhagic and ischemic stroke How to correctly modify the home environment Risk factors for ischemic stroke Techniques for adjusting the client's medication dosages at home

How to correctly modify the home environment Explanation: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? Hydrostatic pressure resulting from the pumping action of the heart Action of the dissolved particles contained in a unit of blood Pressure of the blood in the renal capillaries Active transport of hydrogen ions across the capillary walls

Hydrostatic pressure resulting from the pumping action of the heart Explanation: An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing what electrolyte imbalance? Hypercalcemia Hypernatremia Hypophosphatemia Hypomagnesemia

Hypercalcemia Explanation: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The client's presentation is inconsistent with hypophosphatemia.

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing? Hypercalcemia Hyperkalemia Hyperglycemia Hypernatremia

Hyperkalemia Explanation: Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.

The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way? Hypertensive urgency is treated with rest and benzodiazepines to lower BP. Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. Hypertensive emergencies are associated with evidence of target organ damage. The BP is always higher in a hypertensive emergency.

Hypertensive emergencies are associated with evidence of target organ damage. Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the client's BP is required in both situations. The medications of choice in hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents, such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended for the treatment of hypertensive urgencies.

The nurse is caring for a client with hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH). Which intravenous solution will the nurse expect to be prescribed? Isotonic Hypotonic Hypertonic Lactated Ringers

Hypertonic This answer is correct because hypertonic solutions are administered for clients who are diagnosed with SIADH who are experiencing dilutional hyponatremia to restore homeostasis. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a condition in which the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water the body loses through the urine. Learning Outcomes ADH helps the kidneys control the amount of water the body loses through the urine. SIADH causes the body to retain too much water thereby causing dilutional hyponatremia. When hyponatremia is severe, hypertonic solutions may be used but should be infused with caution due to the potential for development of heart failure.

An elderly client is admitted with dehydration and a urinary tract infection. After IV infusion of 750 mL NS, the client begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. The nurse interprets that: Hypervolemia is developing Ascites is causing respiratory compromise The fluid volume deficit is worsening Hypotonic water intoxication is beginning

Hypervolemia is developing

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal? Hypophosphatemia Hypocalcemia Hypokalemia Hyponatremia

Hypocalcemia Explanation: Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the physician immediately, because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in her lips and fingers. She states that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should the nurse first suspect? Hyperkalemia Hypophosphatemia Hypocalcemia Hypermagnesemia

Hypocalcemia Explanation: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

A 49-year-old client is admitted with uncontrolled chest pain. The client is currently taking nitroglycerin. The health care provider adds nifedipine to the client's regimen. The nurse should observe the client for what adverse effects? Hypokalemia Hypoglycemia Hypotension Renal insufficiency

Hypotension Explanation: Both nitroglycerin and nifedipine have hypotension as a potential adverse effect, so frequent assessment of blood pressure is important. Other cardiovascular effects include bradycardia, peripheral edema, and heart block. Skin effects include flushing and rash. Adverse effects do not include renal insufficiency, hypokalemia, or hypoglycemia.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? Midbrain Cerebellum Thalamus Hypothalamus

Hypothalamus Explanation: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation.

The nurse is working on a burns unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of what imbalance? Metabolic alkalosis Hypercalcemia Hypovolemia Hypermagnesemia

Hypovolemia Explanation: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? The kidneys react rapidly to compensate for imbalances in the body. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The kidneys regulate the bicarbonate level in the intracellular fluid. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.

I The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. Explanation: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by kidney disease. Renal compensation for imbalances is relatively slow (a matter of hours or days).

The nurse is providing care for a client who has recently been diagnosed with COPD. When educating the client about exacerbations, the nurse should prioritize what topic? Prompt administration of corticosteroids during exacerbations The importance of prone positioning during exacerbations Identifying specific causes of exacerbations The relationship between activity level and exacerbations

Identifying specific causes of exacerbations Explanation: Prevention is key in the management of exacerbations, and it is important for the client to identify which factors cause exacerbations. Corticosteroids are not normally used as a "rescue" medication and prone positioning does not enhance oxygenation. Activity may or may not cause a client to have exacerbations; inactivity is not a risk factor.

A client is experiencing an allergy to a penicillin antibiotic. What immunoglobulin (Ig) will most directly relate to this immune response? IgM IgA IgE IgG

IgE Explanation: Five different types of immunoglobulins have been identified: IgE is present in small amounts and seems to be related to allergic responses and to the activation of mast cells. The first immunoglobulin released is M (IgM). It contains the antibodies produced at the first exposure to the antigen. IgG, another form of immunoglobulin, contains antibodies made by the memory cells that circulate and enter the tissue; most immunoglobulin found in the serum is IgG. IgA is found in tears, saliva, sweat, mucus, and bile. It is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells. These antibodies react with specific pathogens that are encountered in exposed areas of the body.

A client has come to the clinic for an allergy shot. The client asks the nurse what immunoglobulin (Ig) is located in the body's tissues and is thought to be responsible for allergic reactions. What is the nurse's appropriate response? IgG IgE IgA IgM

IgE Explanation: IgE is the immune globulin that is associated with allergic reactions. These antibodies react with mast cells, causing the release of histamine and other inflammatory chemicals when they have combined with the antigen. IgG, IgA, and IgM are not involved in allergic reactions.

A nurse received the seasonal influenza vaccine 10 weeks ago has now been exposed to that strain of the influenza virus. What immunoglobulin will hasten the nurse's immune response to this pathogen? IgA IgG IgE IgM

IgG Explanation: Five different types of immunoglobulins have been identified: IgA is found in tears, saliva, sweat, mucus, and bile. It is secreted by plasma cells in the GI and respiratory tracts and in epithelial cells. IgE is present in small amounts and seems to be related to allergic responses and to the activation of mast cells. The first immunoglobulin released is M (IgM); it contains the antibodies produced at the first exposure to the antigen. IgG, another form of immunoglobulin, contains antibodies made by the memory cells that circulate and enter the tissue; most of the immunoglobulin found in the serum is IgG and vaccinations make use of this immunoglobulin's characteristics. These antibodies react with specific pathogens that are encountered in exposed areas of the body.

The nurse is caring for a client with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine." What principle should guide the nurse's response to the colleague? Infections in immunodeficient clients have a slower onset but a more severe course. Laboratory blood work is often inaccurate in immunodeficient clients. Immunodeficient clients do not develop symptoms of infection. Immunodeficient clients will usually exhibit subtle and atypical signs of infection.

Immunodeficient clients will usually exhibit subtle and atypical signs of infection. Explanation: Immunodeficient clients often lack the typical objective and subjective signs and symptoms of infection. However, this does not mean that they wholly lack symptoms. Infections do not normally have a slower onset. Blood work may not be a reliable diagnostic tool, but that does not mean that the results are inaccurate.

A client with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin? Immunoglobulin A Immunoglobulin M Immunoglobulin E Immunoglobulin G

Immunoglobulin E Explanation: Atopy refers to allergic reactions characterized by the action of IgE antibodies and a genetic predisposition to allergic reactions.

A gerontologic nurse is caring for an older adult client who has a diagnosis of pneumonia. What age-related change increases older adults' susceptibility to respiratory infections? Decreased diaphragmatic muscle tone Atrophy of the thymus Bronchial stenosis Impaired ciliary action

Impaired ciliary action Explanation: As a consequence of impaired ciliary action due to exposure to smoke and environmental toxins, older adults are vulnerable to lung infections. This vulnerability is not the result of thymus atrophy, stenosis of the bronchi, or loss of diaphragmatic muscle tone.

A nurse is caring for an 80-year-old client with pneumonia. What would be the most appropriate nursing diagnosis for this client? Risk for aspiration Ineffective health maintenance Impaired gas exchange Decreased cardiac output

Impaired gas exchange Explanation: Pneumonia causes swelling, engorgement, and exudation of protective sera in the lower respiratory tract. The respiratory membrane is affected, resulting in decreased gas exchange. Pneumonia does not directly affect cardiac output. There is also no indication that this client has pneumonia because of ineffective health maintenance. Aspiration is a common cause of pneumonia but is not normally a consequence.

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? Teach the client's family about the relationship between brain tumors and seizure activity. Identify the triggers that precipitated the seizure. Ensure that the client is housed in a private room. Implement precautions to ensure the client's safety.

Implement precautions to ensure the client's safety. Explanation: Clients with seizures are carefully monitored and protected from injury. Client safety is a priority over health education, even though this is appropriate and necessary. Specific triggers may or may not be evident; identifying these are not the highest priority. A private room is preferable, but not absolutely necessary.

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Intermittent positive-pressure breathing (IPPB) Bronchoscopy Incentive spirometry Positive end-expiratory pressure (PEEP)

Incentive spirometry Explanation: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In clients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

A client has been prescribed an aminoglycoside. In order to prevent accumulation of the drug, what should the nurse encourage the client to do? Increase fluid intake. Take diuretics as prescribed. Perform moderate exercise daily, if possible. Take the drug on an empty stomach.

Increase fluid intake. Explanation: To prevent the accumulation of antiinfective drugs in the kidneys, which can damage the kidney, clients taking antiinfective drugs should be well hydrated. Diuretics do not have this effect. Exercising does not prevent accumulation and taking a drug on an empty stomach does not affect accumulation.

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? Increase activity. Lie in a low Fowler or supine position. Increase oral fluids unless contraindicated. Call the nurse for oral suctioning, as needed.

Increase oral fluids unless contraindicated. Explanation: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action? Smoking decreases the amount of mucus production. Smoke particles compete for binding sites on hemoglobin. Smoking causes atrophy of the alveoli. Smoking damages the ciliary cleansing mechanism.

Increase oral fluids unless contraindicated. Explanation: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The client should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.

A client's blood pressure is 161/106 mm Hg. How will this blood pressure affect the client's cardiac workload? Increased systolic pressure will increase the client's heart rate. The client's increased blood pressure causes an increase in preload and cardiac workload. Increased afterload creates increased oxygen consumption. The client's heart will have to pump harder to overcome the mitral and tricuspid valves.

Increased afterload creates increased oxygen consumption. Explanation: Increased blood pressure increases afterload and the overall workload of the heart. Hypertension does not increase preload, which is the volume of blood needing to be pumped. Similarly, hypertension does not make it more difficult to open the mitral and tricuspid valves between the atria and ventricles.

A client has just learned of a highly negative prognosis, which is entirely unexpected. What body responses should the nurse anticipate? Decreased sweating, decreased BP, and increased heart rate Increased sweating, decreased respiratory rate, and increased BP Increased blood pressure (BP), increased heart rate, and pupil dilation Pupil constriction, increased respiratory rate, and decreased heart rate

Increased blood pressure (BP), increased heart rate, and pupil dilation Explanation: When stimulated by a stressful or fearful situation, the sympathetic nervous system (SNS) prepares the body to flee or to turn and fight. Cardiovascular activity increases as do blood pressure, heart rate, and blood flow to skeletal muscles. Respiratory rate increases, pupils dilate, and sweating increases. Decrease in sweating, BP, heart rate, respiratory rate, and pupil constriction indicate stimulation of the parasympathetic nervous system, which would not be stimulated by fear.

A client has been admitted to the emergency department with signs of anaphylaxis following a bee sting. The nurse knows that if this is a true allergic reaction the client will present with what alteration in laboratory values? Decreased blood glucose Increased serum albumin Increased neutrophils Increased eosinophils

Increased eosinophils Explanation: Higher percentages of eosinophils are considered moderate to severe eosinophilia. Moderate eosinophilia is defined as 15% to 40% eosinophils and is found in clients with allergic disorders. Hypersensitivity does not result in hypoglycemia or increased albumin and neutrophil counts.

A nurse is caring for a client with COPD. The client's medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. Therapeutic effects of this medication would include which of the following? Select all that apply. Increased viscosity of lung secretions Increased expiratory flow rate Relief of dyspnea Increased respiratory rate Negative sputum culture

Increased expiratory flow rate Relief of dyspnea Explanation: The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process.

A cardiac care nurse is caring for a client who is experiencing positive chronotropy. What effect should the nurse prepare for? Increased heart rate Exacerbation of an existing dysrhythmia Resolution of ventricular tachycardia Initiation of a new dysrhythmia

Increased heart rate Explanation: Stimulation of the sympathetic system increases heart rate. This phenomenon is known as positive chronotropy. It does not influence dysrhythmias.

The nurse has admitted a new client to the unit. One of the client's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? Constricted bronchioles Decreased BP Increased heart rate Thin, watery saliva

Increased heart rate Explanation: The term "adrenergic" refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.

The nurse is performing a preoperative assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties should the nurse anticipate for this client? Increased risk for postoperative complications Nonadherence to prescribed treatment after surgery following surgery Alcohol withdrawal syndrome upon administration of general anesthesia Increased risk for allergic reactions

Increased risk for postoperative complications Explanation: Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence.

The nurse is teaching a 45-year-old client about ways to lower cholesterol level. What effects of exercise does the nurse describe? Increases LDL and decreases triglycerides Decreases both HDL and LDL Increases high-density lipoproteins (HDLs) and decreases low-density lipoproteins (LDL) Decreases HDL and increases LDL

Increases high-density lipoproteins (HDLs) and decreases low-density lipoproteins (LDL) Explanation: Moderate exercise increases HDL levels, which assist in lowering LDL levels. Exercise also decreases triglyceride levels.

A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? Increases the amount of mucus production Collapses the alveoli in the lungs Destabilizes hemoglobin Shrinks the alveoli in the lungs

Increases the amount of mucus production Explanation: Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung.

A nurse is planning the care of a client with AIDS who is admitted to the unit with Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client? Activity Intolerance Ineffective Airway Clearance Impaired Oral Mucous Membranes Imbalanced Nutrition: Less than Body Requirements

Ineffective Airway Clearance Explanation: Although all these nursing diagnoses are appropriate for a client with AIDS, Ineffective Airway Clearance is the priority nursing diagnosis for the client with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the other listed concerns because of the immediacy of the health consequences.

The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? Ineffective breathing pattern related to decreased cardiac output Impaired skin integrity related to CAD Anxiety related to fear of death Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) Explanation: Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

A client is admitted to the intensive care unit in shock with hypotension. What is an appropriate nursing diagnosis for this client? Risk for falls Ineffective peripheral tissue perfusion Impaired gas exchange Deficient fluid volume

Ineffective peripheral tissue perfusion Explanation: An appropriate nursing diagnosis would be ineffective peripheral tissue perfusion. If blood pressure becomes too low, the vital centers in the brain, as well as the rest of the tissues of the body, may not receive enough oxygenated blood to continue functioning. The client's risk for falls would be low because he or she is acutely ill and confined to bed. There is no direct indication of altered gas exchange or deficient fluid volume.

The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The nurse should plan interventions to address what nursing diagnosis? Risk for injury Chronic pain Ineffective tissue perfusion Impaired skin integrity

Ineffective tissue perfusion Explanation: Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.

An adult client has had symptoms of unstable angina during admission to the hospital. What is the most appropriate nursing diagnosis? Deficient knowledge about underlying disease and methods for avoiding complications Ineffective tissue perfusion related to reduced oxygen supply to the heart Anxiety related to fear of death Noncompliance related to failure to accept necessary lifestyle changes

Ineffective tissue perfusion related to reduced oxygen supply to the heart Explanation: The most appropriate nursing diagnosis is ineffective tissue perfusion related to reduced oxygen supply to the heart because this is the cause of the client's pain. Further assessment would be needed to determine whether the client lacks knowledge, fears death, or has made the necessary lifestyle changes.

The nurse is performing an admission assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor? Skin turgor cannot be assessed in clients over 70. Inelastic skin turgor is a normal part of aging. Dehydration causes the skin to appear spongy. Overhydration is common among healthy older adults.

Inelastic skin turgor is a normal part of aging. Explanation: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older clients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? Hyperglycemia Falls Infection Azotemia

Infection Explanation: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the client's physician because these symptoms are suggestive of what? Lung tumors Pneumothorax Infection Pulmonary edema

Infection Explanation: The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum (thick and yellow, green, or rust-colored) or a change in color of the sputum is a common sign of a bacterial infection. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema. A pneumothorax does not result in copious, green sputum.

The nurse has administered a client's prescribed dose of atropine that is intended to cause mydriasis and cycloplegia. Shortly after administration, the client's pupils are fully dilated and the client reports blurred vision. What is the nurse's best action? Perform an assessment of the client's visual acuity. Report this to the to the client's care provider promptly. Ensure the client keeps his or her eyes closed until further notice, if possible. Inform the client that this is expected and document the client's report.

Inform the client that this is expected and document the client's report. Explanation: Atropine can be used to cause dilated pupils, which is mydriasis resulting in cycloplegia, which is the inability of the lens of the eye to accommodate leading to blurred vision. This is expected, and there is no reason to contact the care provider.

The nurse is assessing a client who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurse's most recent assessment reveals that the client's left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurse's best action? Administer an ordered dose of subcutaneous heparin. Reposition the client with his left leg in a dependent position. Inform the client's health care provider of this assessment finding. Document this expected assessment finding during the initial postoperative period.

Inform the client's health care provider of this assessment finding. Explanation: If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.

An immunocompromised client is being treated in the hospital. The nurse's assessment reveals that the client's submandibular lymph nodes are swollen, a finding that represents a change from the previous day. What is the nurse's most appropriate action? Implement standard precautions in the client's care. Monitor the client's vital signs q2h for the next 24 hours. Inform the client's primary care provider of this finding. Administer a PRN dose of acetaminophen as ordered.

Inform the client's primary care provider of this finding. Explanation: Swollen lymph nodes are suggestive of infection and warrant prompt medical assessment and treatment. Acetaminophen is an ineffective response. The nurse should monitor the client's vital signs closely, but the physician should also be informed. Standard precautions should be in place regardless of the client's status.

A client with SLE has come to the clinic for a routine check-up. When auscultating the client's apical heart rate, the nurse notes the presence of a distinct "scratching" sound. What is the nurse's most appropriate action? Inform the primary provider that a friction rub may be present. Inform the primary provider that the client may have pneumonia. Reposition the client and auscultate posteriorly. Document the presence of S3 and monitor the client closely.

Inform the primary provider that a friction rub may be present. Explanation: Clients with SLE are susceptible to developing a pericardial friction rub, possibly associated with myocarditis and accompanying pleural effusions; this warrants prompt medical follow-up. This finding is not characteristic of pneumonia and does not constitute S3. Posterior auscultation is unlikely to yield additional meaningful data.

A client has been diagnosed with asthma and prescribed inhaled steroids. What should the nurse teach the client about this treatment? Systemic adverse effects should be expected and can be serious. Inhaled corticosteroids should not be used on an emergency basis. Effective levels are usually reached within 72 hours of starting treatment. The drug will stimulate the sympathetic nervous system.

Inhaled corticosteroids should not be used on an emergency basis. Explanation: Inhaled steroids are not for emergency use and not for use during an acute asthma attack or status asthmaticus. They do not stimulate the sympathetic nervous system. Because of the route of administration, systemic side effects are uncommon. Effective levels may take 2 to 3 weeks to be reached.

A postsurgical client is being sent home on enoxaparin. The nurse should describe what benefit of this medication? Dissolving any clots that form Enhancing the flow of blood in peripheral vessels Stimulating production of certain clotting factors Inhibiting the formation of clots

Inhibiting the formation of clots Explanation: Low molecular weight heparins inhibit thrombus and clot formation by blocking factors Xa and IIa. Because of the size and nature of the molecules, these drugs do not greatly affect thrombin, clotting, or the PT; therefore, they cause fewer systemic adverse effects. Enoxaparin does not dissolve existing clots or directly enhance blood flow. It does not stimulate the production of clotting factors.

Following the administration of a selective alpha adrenergic agonist nasal spray, the nurse would assess for what adverse drug effects? Insomnia, nervousness, and hypertension. Nausea, vomiting, and hypotension. Dry mouth, drowsiness, and dyspnea. Increased bronchial secretions, hypotension, and bradycardia.

Insomnia, nervousness, and hypertension.

The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications she takes, the dosage, and frequency. What intervention provides the client with the most accurate information? Instruct the client to continue any herbal supplements unless otherwise instructed, and inform the client that these supplements have minimal effect on the surgical procedure. Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. Instruct the client to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. Instruct the client to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias.

Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. Explanation: Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical clients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Clients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided.

The nurse caring for a client with a leg ulcer has finished assessing the client and is developing a problem list prior to writing a plan of care. What priority risk would the care plan address? Ineffective health maintenance Disuse syndrome Sedentary lifestyle Insufficient nutrition

Insufficient nutrition Explanation: The client with leg ulcers is at risk for insufficient nutrition related to the increased need for nutrients that promote wound healing. The risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or a sedentary lifestyle.

A 68-year-old client with type 1 diabetes is to receive hydrochlorothiazide. Before administration of this medication, what information is most important for the nurse to communicate to the client? Insulin doses may need to be increased. The client's urine will need to be checked for ketones four times a day. Insulin doses may need to be decreased. The client will need to have a creatinine clearance measured monthly.

Insulin doses may need to be increased. Explanation: This medication has the potential to increase glucose levels, requiring an increase in insulin. There would be no reason to check ketones four times daily or to have a creatinine clearance once a month.

A client has an order for acetaminophen every six hours as needed for temperature over 100F. Which parameter in addition to temperature, will the nurse monitor if the client requires this medication? Pain level. Platelet level. Intake and output. Oxygen saturation.

Intake and Output

The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. This pain is relieved with rest and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address what health problem? Arterial embolus Intermittent claudication Raynaud disease Coronary artery disease (CAD)

Intermittent claudication Explanation: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by clients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the client has CAD, arterial embolus, or Raynaud disease; none of these health problems produce this cluster of signs and symptoms.

The nurse is preparing to administer warfarin to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the client's warfarin is at therapeutic levels? Partial thromboplastin time (PTT) within normal reference range Prothrombin time (PT) 8 to 10 times the control International normalized ratio (INR) between 2 and 3 Hematocrit of 32%

International normalized ratio (INR) between 2 and 3 Explanation: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately? Intravenous phenobarbital Oral phenytoin Oral lorazepam Intravenous diazepam

Intravenous diazepam Explanation: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

A nurse practitioner is teaching a group of nurses about actions that have the potential to prevent antibiotic resistance. What teaching point should the nurse practitioner include? It is very important to take the full course of an antibiotic as prescribed and not save remaining drugs for future infections. Antibiotic dosage should be reduced and used for shorter periods of time to reduce unnecessary exposure to the drug. Standing prescriptions for antibiotics should be available to clients so they can be filled as soon as clients suspect they have an infection. Antibiotics should be taken promptly to treat colds and other viral infections before the invading organism has a chance to multiply.

It is very important to take the full course of an antibiotic as prescribed and not save remaining drugs for future infections. Explanation: Teaching clients to take the full course of their antibiotic as prescribed can help to decrease the number of drug-resistant strains. Antibiotics should only be used to treat bacterial infections that have been cultured to identify the antibiotic sensitivity and then clients should be instructed to use the antibiotic for the prescribed course, which will help to eliminate drug-resistant strains. Reducing dosage and time intervals increases the chance for drug resistance because antiinfectives are most effective when taken exactly as indicated.

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? Joint stiffness, especially in the morning Signs of systemic infection Cool joints with decreased range of motion Visible atrophy of the knee and shoulder joints

Joint stiffness, especially in the morning Explanation: In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the disease. Joints are often warm rather than cool.

A client has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the client to do? Wear powdered latex gloves when in public. Wash her hands with antibacterial soap every few hours. Maintain room temperature at 75 to 80°F (24° to 27°C) whenever possible. Keep her hands well moisturized at all times.

Keep her hands well moisturized at all times. Explanation: Powdered latex gloves can cause contact dermatitis. Skin should be kept well hydrated and should be washed with mild soap. Maintaining room temperature at 75 to 80°F (24° to 27°C) is excessively warm.

When discussing cephalosporins with the nursing class, the pharmacology instructor explains that this classification of drug is primarily excreted through which organ? Kidney Skin Liver Lung

Kidney Explanation: The cephalosporins are primarily metabolized in the liver and excreted in the urine. These drugs cross the placenta and enter breast milk. They are not excreted through the lungs, the liver, or the skin.

The case manager for a group of clients with COPD is providing health education. What is most important for the nurse to assess when providing instructions on self-management to these clients? Knowledge of the pathophysiology of the disease process Knowledge about self-care and their therapeutic regimen Knowledge of alternative treatment modalities Family awareness of functional ability and activities of daily living (ADLs)

Knowledge about self-care and their therapeutic regimen Explanation: When providing instructions about self-management, it is important for the nurse to assess the knowledge of clients and family members about self-care and the therapeutic regimen. This supersedes knowledge of alternative treatments or the pathophysiology of the disease, neither of which is absolutely necessary for clients to know. The client's own knowledge is more important than that of the family.

The nurse is assessing a client new to the clinic. Records brought to the clinic show that the client's hypertension has not improved. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? Possibility of medication interactions Possible heavy alcohol use or use of recreational drugs Lack of adherence to prescribed drug therapy Progressive target organ damage

Lack of adherence to prescribed drug therapy Explanation: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. An estimated 50% of clients discontinue their medications within 1 year of beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug interactions.

The nurse is caring for a client with chronic obstructive pulmonary disease. The plan of care will focus on what client problem? Adverse effects of medication therapy Risk for aspiration Lack of patent airway Activity intolerance

Lack of patent airway Explanation: Asthma, emphysema, chronic obstructive pulmonary disease (COPD), and respiratory distress syndrome (RDS) are pulmonary obstructive diseases. All but RDS involve obstruction of the major airways. RDS obstructs the alveoli. Pain, activity intolerance, and adverse effects of medication therapy are conditions identified to detect, manage, and minimize the unexpected outcomes the nurse should be especially aware of the potential for an obstructed airway in these clients.

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit? Last bowel movement Latex allergy Number of pregnancies Difficulty falling asleep

Latex allergy Explanation: Due to the increased number of clients with latex allergies, it is essential to identify this allergy early on so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a priority over pregnancy history, insomnia, or recent bowel function, though some of these may be relevant.

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI? Midline between the xiphoid process and the left nipple Left midclavicular line of the chest at the fifth intercostal space Left midclavicular line of the chest at the level of the nipple Two to three centimeters to the left of the sternum

Left midclavicular line of the chest at the fifth intercostal space Explanation: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? Leg exercise help increase the client's level of consciousness after surgery. Leg exercises improve circulation and prevent venous thrombosis. Leg exercises increase the client's muscle mass postoperatively. Leg exercises help to prevent pressure sores to the sacrum and heels.

Leg exercises improve circulation and prevent venous thrombosis. Explanation: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

The nurse is caring for a patient who is receiving an opioid analgesic. What would be a priority assessment by the nurse? Pain intensity and blood glucose level Respiratory rate and electrolytes Level of consciousness and respiratory rate Urine output and pain intensity

Level of consciousness and respiratory rate Explanation: The nurse should assess respiratory rate and level of consciousness because respiratory depression and sedation are adverse effects of opioid analgesics. Blood glucose levels, electrolytes, and urine output are not priority assessments with opioid ingestion.

The nurse is caring for an elderly client who is receiving IV fluids postoperatively. During the 0800 assessment of this client, the nurse notes that the IV solution, which was ordered to infuse at 125 mL per hour has infused 950 mL since it was hung at 0400. Which nursing intervention would be the priority action at this time? Notify the physician and complete an incident report. Listen to the clients lung sounds and assess respiratory status. Slow the right to keep vein open until next bag is due at noon. Obtain a new bag of IV solution to maintain patency of the site.

Listen to the clients lung sounds and assess respiratory status.

The nurse provides care for numerous children with asthma. The nurse should expect to administer what drugs? Select all that apply. Topical steroid nasal decongestants Long-acting inhaled steroids Xanthines Leukotriene-receptor antagonists Beta-agonists

Long-acting inhaled steroids Leukotriene-receptor antagonists Beta-agonists Explanation: Antiasthmatics are frequently used in children. The leukotriene-receptor antagonists have been found to be especially effective for long-term prophylaxis in children. Acute episodes are best treated with a beta-agonist and then a long-acting inhaled steroid or a mast cell stabilizer. Xanthines (e.g., theophylline) have been used in children, but because of their many adverse effects and the better control afforded by newer agents, their use is reserved for clients who do not respond to other therapies. Topical steroid nasal decongestants may be used for symptom relief for nasal congestion but are not a regular part of asthma therapy in children.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Restrain the client to prevent injury. Open the client's jaws to insert an oral airway. Loosen the client's restrictive clothing. Place client in high Fowler position.

Loosen the client's restrictive clothing. Explanation: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes? Lose weight, if obese Undergo eye examinations regularly Have blood glucose levels checked annually Stop using tobacco in any form

Lose weight, if obese Explanation: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent diabetes.

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? Loss of hearing, tinnitus, and vertigo Loss of vision, change in mental status, and hyperthermia Loss of vision, headache, and tachycardia Loss of hearing, increased sodium retention, and hypertension

Loss of hearing, tinnitus, and vertigo Explanation: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The client with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.

The nurse is providing care for a client with high cholesterol and triglyceride values. In teaching the client about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? Absence of detectable total cholesterol levels Elevated blood lipids, fasting glucose less than 100 High HDL values and high triglyceride values Low LDL values and high HDL values

Low LDL values and high HDL values Explanation: The desired goal for cholesterol readings is for a client to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.

The nurse is caring for an acutely ill client who is on anticoagulant therapy. The client has a comorbidity of renal insufficiency. How will this client's renal status affect heparin therapy? Warfarin will be substituted for heparin. Heparin may be given subcutaneously, but not IV. Lower doses of heparin are required for this client. Heparin is contraindicated in the treatment of this client.

Lower doses of heparin are required for this client. Explanation: If renal insufficiency exists, lower doses of heparin are required. Warfarin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Computed tomography (CT) scan Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies

Lumbar puncture Explanation: A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client? Maintain normal cardiac structure. Maintain a resting heart rate below 70 bpm. Maintain adequate control of chest pain. Maintain adequate cardiac output.

Maintain adequate cardiac output. Explanation: For client safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications as a result of decreased cardiac output. A resting rate of less than 70 bpm is not appropriate for every client. Chest pain is more closely associated with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally influence the physical structure of the heart.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? Relieve anxiety and pain. Relieve sensory deprivation. Prevent complications of immobility. Maintain and improve cerebral tissue perfusion.

Maintain and improve cerebral tissue perfusion. Explanation: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

A nurse is caring for a client with an arrhythmia. What is the priority goal for this client? Maintain fluid intake Maintain cardiac output Maintain nutritional intake Maintain urine output

Maintain cardiac output Explanation: Disruptions in the normal rhythm of the heart can interfere with myocardial contractions and affect the cardiac output, the amount of blood pumped with each beat. Arrhythmias that seriously disrupt cardiac output can be fatal. Therefore, the primary goal of treating a cardiac arrhythmia is to maintain adequate cardiac output to support life. The other goals may be important to individual client care, but sustaining life takes priority.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Position client in prone position. Maintain bed in Trendelenburg position. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position the client supine.

Maintain head of bed (HOB) elevated at 30 to 45 degrees. Explanation: The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

The assistive personnel (AP) notifies the nurse that after a routine bed bath their patient is requesting trachea suctioning. The nurse verifies the trachea suction order is active on the chart. What is most appropriate action when performing this intervention? Notify the physician Maintain sterile technique Ensure the patient is wearing O2 via nasal canula prior to trachea suctioning Request the AP present to assist with trachea suctioning

Maintain sterile technique

The patient has severe pain and bladder distention related to urinary retention and possible obstruction. Insertion of an indwelling catheter is prescribed. An experienced unlicensed assistive personnel states that they are trained to do this procedure. Which task can be delegated to this UAP? Assessing the bladder distention and the pain associated with urinary retention. Inserting the indwelling catheter after verifying their knowledge of sterile technique. Evaluating the relief of pain and bladder distention after the catheter is inserted. Measuring the urine output after the catheter is inserted and obtaining a specimen.

Measuring the urine output after the catheter is inserted and obtaining a specimen.

The nurse is caring for a client who suffered a head injury and is now having difficulty breathing. The client should be assessed for damage to what part of the central nervous system? Medulla oblongata Cerebral cortex Hypothalamus Cerebellum

Medulla oblongata Explanation: The act of breathing is controlled by the medulla, which depends on a functioning muscular system and a balance between the sympathetic and parasympathetic systems. The cerebral cortex, cerebellum, and hypothalamus are not directly involved with this process.

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Catheter occlusion CSF leak Meningitis Encephalitis

Meningitis Explanation: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter.

A client with diabetic ketoacidosis (DKA) is admitted to the medical floor for observation. The nurse knows that a client with DKA is likely to have an acid base imbalance. Which acid base imbalance is this client most likely to have? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Metabolic acidosis This answer is correct because the client admitted with DKA is most likely to have the acid base imbalance of metabolic acidosis (Hint: note the word "acid" in the name of DKA!) Clients with DKA may have Kussmaul respirations, which are basically a very deep, gasping type of respiration. This type of breathing pattern leads to a buildup of acid in the body, which leads to metabolic acidosis.

The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? Metabolic acidosis with a compensatory respiratory alkalosis Metabolic acidosis with no compensation Respiratory acidosis with no compensation Metabolic alkalosis with a compensatory alkalosis

Metabolic acidosis with a compensatory respiratory alkalosis Explanation: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below reference range. The nurse should assess for signs and symptoms of what imbalance? Hypercalcemia Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Metabolic alkalosis Explanation: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

The home care nurse is taking care of a client on IV vancomycin for cellulitis of the left calf. The client's lack of response to treatment suggests possible resistance. What process may have caused this phenomenon? Microorganisms may have stopped healthy somatic cells from reproducing. Microorganisms may have produced a chemical that is an antagonist to the drug. Microorganisms may have changed their cell membrane to mimic that of the drug. Microorganisms may have altered the blood supply to the infected region.

Microorganisms may have produced a chemical that is an antagonist to the drug. Explanation: Microorganisms develop resistance in a number of ways, including the following: changing cellular permeability to prevent the drug from entering the cell or altering transport systems to exclude the drug from active transport into the cell; altering binding sites on the membranes or ribosomes, which then no longer accept the drug; and producing a chemical that acts as an antagonist to the drug. Microorganisms do not alter the blood supply to the infection or stop a cell from reproducing. Anti-infectives are chemicals; they do not have cell membranes.

The nurse is writing a plan of care for a client receiving an alpha-specific adrenergic agonist. What is the priority component of the client's plan of care? Monitor blood pressure and heart rate frequently. Assess the client's muscle strength bilaterally. Review the client's complete blood count and electrolytes whenever available. Assess skin turgor for fluid deficit twice per shift.

Monitor blood pressure and heart rate frequently. Explanation: Sympathetic stimulation will cause hypertension and increased heart rate so it is important these be monitored. These assessments address a greater safety risk to the client than abnormal laboratory results, fluid imbalance or musculoskeletal dysfunction.

The nurse administers a medication to the wrong client. What are the appropriate nursing action required? Select all that apply Monitor the client for adverse reactions. Document the error if the client has an adverse reaction. Report the error to the healthcare provider. Notify the hospital legal department of that error. Document the error in a critical incident/occurrence report.

Monitor the client for adverse reactions. Report the error to the healthcare provider. Document the error in a critical incident/occurrence report.

The nurse is caring for a client who has a history of atrial fibrillation (AF) and whose condition has recently worsened. The client is awaiting cardioversion. In addition to cardiac monitoring, what assessment should the nurse prioritize? Monitor the client for signs of pulmonary embolism. Review the client's electrolyte levels when available. Carefully monitor the client's fluid balance. Monitor the client for signs of myocardial infarction.

Monitor the client for signs of pulmonary embolism. Explanation: In clients with AF, there is a substantial risk that clots or emboli will be pumped into the ventricles and then into the lungs (from the right auricle), which could lead to pulmonary emboli, or to the brain or periphery (from the left auricle), which could cause a stroke or occlusion of peripheral vessels. Fluid balance and electrolytes are relevant, but secondary, concerns. AF does not directly affect coronary circulation.

The nurse caring for a client with dystocia (difficult labor) determines that the priority is which action? Position changes and providing comfort measures. Explanations to the family members about what is happening to the client. Monitoring for change in the physical condition of the mother and fetus. Reinforcement of breathing techniques learned in childbirth classes.

Monitoring for change in the physical condition of the mother and fetus.

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? Promoting mobility Monitoring neurologic status closely Providing health education Maintaining the client's functional independence

Monitoring neurologic status closely Explanation: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? Providing emotional support to family Maintaining a clean environment Maintaining the client's cognitive status Monitoring the client's physiologic status

Monitoring the client's physiologic status Explanation: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A client has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. This client experienced damage to what area of the heart? Visceral pericardium Pericardium Endocardium Myocardium

Myocardium Explanation: The myocardium is the layer of the heart responsible for the pumping action.

The client returns to the unit following surgery. The client reports being in pain. After checking the medication administration record in the client's chart, the nurse sees that the client has not received the morphine the health care provider has ordered for over an hour. As the order reads q 1-2 hours, the nurse administers the low dose of the morphine. The PACU nurse calls to tell the floor nurse that the nurse forgot to chart the last dose of morphine the client had received just before the client was transferred to the floor. What drug would the floor nurse be sure to have on the unit that is used to reverse the effects of opioids? Butorphanol Naloxone hydrochloride (Narcan) tartrate Nalbuphine hydrochloride (Nubain) Buprenorphine (Buprenex)

Naloxone hydrochloride (Narcan) tartrate Explanation: Naloxone is the drug of choice for treatment of opioid overdose. Butorphanol is a morphinan-type synthetic opioid analgesic. Brand name Stadol was recently discontinued by the manufacturer. It is now only available in its generic formulations. Buprenex (buprenorphine hydrochloride) is a narcotic under the Controlled Substances Act due to its chemical derivation from thebaine. Nalbuphine is a synthetic opioid used commercially as an analgesic under a variety of trade names, including Nubain.

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Neck flexion produces flexion of knees and hips Inability to stand with eyes closed and arms extended without swaying Numbness and tingling in the lower extremities Pain upon ankle dorsiflexion of the foot

Neck flexion produces flexion of knees and hips Explanation: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

A client's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at this client's site of inflammation? Neutrophils Red blood cells Lymphocytes Eosinophils

Neutrophils Explanation: Neutrophils are the first cells to arrive at the site where inflammation occurs. Eosinophils increase in number during allergic reactions and stress responses, but are not always present during inflammation. RBCs do not migrate during an immune response. Lymphocytes become active but do not migrate to the site of inflammation.

A client has questioned the nurse's administration of IV normal saline, asking, "Wouldn't sterile water would be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously? Never, because it rapidly enters red blood cells, causing them to rupture. When a client's fluid volume deficit is due to acute or chronic kidney disease When the client is in excess of calcium and/or magnesium ions When the client is severely dehydrated resulting in neurologic signs and symptoms

Never, because it rapidly enters red blood cells, causing them to rupture. Explanation: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.

The nurse is collecting a nursing history from a preoperative client who is to receive local anesthesia. While taking the admission history, the client reports an allergy to lidocaine. What is the nurse's priority action? Notify the surgeon. Notify the anesthesiologist. Cancel the surgery. Tell the perioperative nurse.

Notify the anesthesiologist. Explanation: The priority action is to inform the anesthesiologist who will administer the anesthetic because local anesthesia often involves use of lidocaine. It is not within the nurse's scope of practice to cancel surgery. Notifying the surgeon and the perioperative nurse is appropriate but is not the priority of care.

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate? Keep the IV in place, notify the health care provider, and start treatment for phlebitis. Notify the health care provider, discontinue the IV, and start it at another site. Discontinue the IV and start it at another site. If phlebitis worsens, notify the health care provider. Keep the IV in place until the solution has been infused, and then discontinue it and notify the health care provider.

Notify the health care provider, discontinue the IV, and start it at another site. Rationale:When the nurse suspects phlebitis due to the findings of redness, swelling, and heat, the health care provider should be notified. The IV will need to be discontinued and restarted at another site. The health care provider should be notified immediately, not just if the phlebitis worsens.

The nurse teaches the client at risk for coronary artery disease (CAD) that some risk factors can be controlled or modified. What modifiable factors would the nurse include? Gender, obesity, family history, and smoking Inactivity, stress, gender, and smoking Stress, family history, and obesity. Obesity, inactivity, diet, and smoking

Obesity, inactivity, diet, and smoking Explanation: The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? Administer the whisper or watch-tick test. Note any hoarseness in the client's voice. Palpate trapezius muscle while client shrugs shoulders against resistance. Observe for facial movement symmetry, such as a smile.

Observe for facial movement symmetry, such as a smile. Explanation: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the client performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Cranial nerve XI (spinal accessory) does not affect the muscles of the face. Assessing cranial nerve VIII (acoustic) would involve evaluating hearing. Cranial nerve X (vagus) does not affect the face.

A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin? Review the client's first hemoglobin A1C result after discharge. Observe the client drawing up and administering the insulin. Provide a health education session reviewing the main points of insulin delivery. Ask the client to describe the process in detail.

Observe the client drawing up and administering the insulin. Explanation: Nurses should assess the client's ability to perform diabetes-related self-care as soon as possible during the hospitalization or office visit to determine whether the client requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the client performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the client about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? Have the client go to the bathroom. Wait until the client gets to the operating room and is catheterized. Offer the client a bedpan or urinal. Assist the client to the bathroom.

Offer the client a bedpan or urinal. Explanation: If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal. The client should not get out of bed because of the potential for lightheadedness.

When providing client education about nitroglycerin to the client, what should the nurse include in the teaching plan about a nitroglycerin patch? It only has to be changed every 3 days. One patch lasts an entire day. It is faster-acting than tablets. It is more effective than tablets in treating angina.

One patch lasts an entire day. Explanation: Transdermal nitroglycerin has a long 24-hour duration of action compared with the sublingual form that lasts 30 to 60 minutes or oral tablets that last 8 to 12 hours. Transdermal patches are neither more nor less effective, but rather it is the speed of onset and duration of action that differ.

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? Hydrostatic pressure Osmosis and osmolality Diffusion Active transport

Osmosis and osmolality Explanation: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

A nurse is caring for a neonate born with a congenital heart anomaly. To better help the parents understand the impact of this disorder, the nurse begins by describing the usual flow of blood through the heart. What course should the nurse describe? Oxygenated blood from the lungs enters the left atrium through the pulmonary veins. Deoxygenated blood from the lungs enters the right atrium through pulmonary veins. Deoxygenated blood from the lungs enters the left atrium through the pulmonary artery. Oxygenated blood from the lungs enters the right atrium through the pulmonary veins.

Oxygenated blood from the lungs enters the left atrium through the pulmonary veins. Explanation: Oxygenated blood from the lungs enters the left atrium through the pulmonary veins and passes through the mitral valve into the left ventricle, which contracts and ejects blood through the aortic valve into the aorta and out to the systemic circulation.

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? Parietal—occipital area Temporal lobe Inferior-posterior frontal areas Posterior frontal area

Parietal—occipital area Explanation: Difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal—occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? Administer osmotic diuretics as prescribed. Prepare the client for craniotomy. Position the client the high Fowler position as tolerated. Participate in interventions to increase cerebral perfusion pressure (CPP).

Participate in interventions to increase cerebral perfusion pressure (CPP). Explanation: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition.

Which patients must be assigned to an experienced RN? Select all that apply. Patient who is in an automobile crash and sustained multiple injuries. Patient with chronic back pain related to a workplace injury. Patient who has returned from surgery and has a chest tube in place. Patient with abdominal cramps related to food poisoning. Patient with a severe headache of unknown origin. Patient with chest pain who has a history of arteriosclerosis.

Patient who is in an automobile crash and sustained multiple injuries. Patient who has returned from surgery and has a chest tube in place. Patient with a severe headache of unknown origin. Patient with chest pain who has a history of arteriosclerosis.

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. What should the nurse integrate into the management of this client's hypertension? Carefully assess for weight loss because of impaired kidney function resulting from normal aging. Ensure that the client receives a larger initial dose of antihypertensive medication due to impaired absorption. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. Recognize that an older adult is less likely to adhere to the medication regimen than a younger client.

Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. Explanation: Older adults have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible? Performing documentation Estimating the client's blood loss Setting up the sterile tables Keeping track of drains and sponges

Performing documentation Explanation: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes early evidence of gangrene on one of the resident's great toes. The nurse should assess for further evidence of what health problem? Chronic venous insufficiency Venous thromboembolism Peripheral artery disease (PAD) Raynaud phenomenon

Peripheral artery disease (PAD) Explanation: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly clients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud phenomenon do not cause the ischemia that underlies gangrene.

A client taking diltiazem for hypertension has come to the clinic for a follow-up appointment. What adverse effects should the nurse assess the client for? Shortness of breath and wheezing Chest pain and pale skin Tachycardia and anxiety Peripheral edema and bradycardia

Peripheral edema and bradycardia Explanation: Cardiovascular adverse effects of diltiazem include bradycardia, peripheral edema, and hypotension. Skin flushing and rash may occur. There should be no effect on the lungs, and anxiety is not expected.

The nurse is providing drug teaching for a client who is prescribed captopril. What drug-specific adverse effect will the nurse include in the drug teaching? Hypersensitivity reaction Persistent cough Hepatic dysfunction Sedation

Persistent cough Explanation: Captopril is generally well tolerated but may cause an unrelenting cough, possibly related to adverse effects in the lungs, where the angiotensin-converting enzyme is inhibited. This can lead clients to discontinue the drug. Sedation, hypersensitivity reaction, and hepatic dysfunction are not among the known adverse effects.

A 16-year-old has been brought to the emergency department by his parents after falling through the glass of a patio door, suffering a laceration. The nurse caring for this client knows that the site of the injury will have an invasion of what? Apoptosis Phagocytic cells Interferons Cytokines

Phagocytic cells Explanation: Monocytes migrate to injury sites and function as phagocytic cells, engulfing, ingesting, and destroying greater numbers and quantities of foreign bodies or toxins than granulocytes. This occurs in response to the foreign bodies that have invaded the laceration from the dirt on the broken glass. Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body and is capable of activating other components of the immune system. Apoptosis, or programmed cell death, is the body's way of destroying worn out cells such as blood or skin cells or cells that need to be renewed. Cytokines are the various proteins that mediate the immune response. These do not migrate to injury sites.

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Prednisone Phenytoin Cafergot Dexamethasone

Phenytoin Explanation: Anticonvulsant medication (phenytoin, diazepam) is often prescribed prophylactically for clients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Sepsis Infiltration Air embolism Phlebitis

Phlebitis Rationale:Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? Pia mater Arachnoid Dura mater Fascia

Pia mater Explanation: The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid. This is not known as "fascia."

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? Place the bed in a low position with the side rails up. Encourage light ambulation. Take the client's vital signs every 15 minutes. Tell the client that he will be asleep before he leaves for surgery.

Place the bed in a low position with the side rails up. Explanation: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The client should not get up without assistance. The client may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

The hospital nurse is caring for a client who tells the nurse that he has an angina attack beginning. What is the nurse's most appropriate initial action? Place the client on bed rest in a semi-Fowler position. Have the client perform pursed-lip breathing. Have the client sit down and put his head between his knees. Have the client stand still and bend over at the waist.

Place the client on bed rest in a semi-Fowler position. Explanation: When a client experiences angina, the client is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. There is no need to have the client put his head between his legs because cerebral perfusion is not lacking

A client who is receiving an immune suppressant has been admitted to the hospital unit. What action should the nurse prioritize? Monitor the client's nutritional status. Place the client on protective isolation. Provide client teaching regarding pharmacokinetics. Provide support and comfort measures related to adverse effects.

Place the client on protective isolation. Explanation: Clients taking immune suppressant drugs are more susceptible to infection because the client's normal body defenses will be diminished. As a result, the priority action by the nurse would to protect the client from exposure to infection through room selection, good hand hygiene, and taking care to avoid exposure to sick staff members. Nutritional status is important, as are comfort and support measures and other instructions concerning the drug. However, protecting the client from infection should be the priority action because this involves client safety.

Which statement describes the purpose of the American Nurses Association (ANA) Standards of Nursing Practice? Legal statutes that guide nursing actions Progressive actions for a nursing procedure Requirements for a registered nurse licensure Policy statements defining the obligations of nurses

Policy statements defining the obligations of nurses; The ANA has general resolutions that recommend the responsibilities and obligations of nurses; these standards help determine whether a nurse has acted as any prudent reasonable nurse would given a similar education, experiential background, and environment

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Sluggish pupil reaction Negative Brudzinski sign Positive Kernig sign Hyperpatellar reflex

Positive Kernig sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis.

The emergency department (ED) nurse is caring for a client who is experiencing pulmonary edema. The client is treated with furosemide. What will the nurse monitor most closely? Bone narrow function Potassium levels Calcium levels Sodium levels

Potassium levels Explanation: Furosemide is associated with loss of potassium, so that the client will need to be monitored carefully for low potassium levels, which could cause cardiac arrhythmias and further aggravate pulmonary edema. The nurse would not monitor sodium or calcium levels or bone marrow function because of the effects of the drug during the acute treatment of pulmonary edema.

The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? Ability to demonstrate deep inspiration Absence of nausea Presence of a cough and gag reflex Oxygen saturation of ≥92%

Presence of a cough and gag reflex Explanation: After the procedure, it is important that the client takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of aspiration.

The circulating nurse will be participating in a 78-year-old client's total hip replacement. What consideration should the nurse prioritize during the preparation of the client in the OR? Pressure points should be assessed and well padded. The client should be placed in Trendelenburg position. The preoperative shave should be done by the circulating nurse. The client must be firmly restrained at all times.

Pressure points should be assessed and well padded. Explanation: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the client is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly client is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this client. Once anesthetized for a total hip replacement, the client cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

Indications for the nurse to administer heparin include what? Select all that apply. Treatment of hemophilia Diagnosis and treatment of disseminated intravascular coagulation (DIC) Prevention and treatment of venous thrombosis Treatment of atrial fibrillation with embolization Prevention and treatment of pulmonary emboli

Prevention and treatment of pulmonary emboli Treatment of atrial fibrillation with embolization Prevention and treatment of venous thrombosis Diagnosis and treatment of disseminated intravascular coagulation (DIC) Explanation: Indications include prevention and treatment of venous thrombosis and pulmonary emboli, treatment of atrial fibrillation with embolization, and diagnosis and treatment of DIC. Heparin is not given to clients with hemophilia because the drug would worsen bleeding.

The nurse is caring for a client who is going home on warfarin. What lab test(s) will the client require to evaluate therapeutic effects of the drug? Prothrombin time (PT) and international normalized ratio (INR) Activated partial thromboplastin time (APTT) Platelet levels Prothrombin time (PT) and activated partial thromboplastin time (APTT)

Prothrombin time (PT) and international normalized ratio (INR) Explanation: PT and INR are ordered to evaluate for therapeutic effects of warfarin. Normal values of PT is 1.3 to 1.5 times the control value, and the ratio of PT to INR is 2 to 3.5.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? Help the client complete his or her sentences as needed. Have the client speak to loved ones on the phone daily. Provide a board of commonly used needs and phrases. Speak in a loud and deliberate voice to the client.

Provide a board of commonly used needs and phrases. Explanation: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

The nurse is caring for a client with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? Apply an antibiotic ointment on the surrounding skin with each dressing change. Provide a high-calorie, high-protein diet. Apply a clean occlusive dressing once daily and whenever soiled. Irrigate the wound with hydrogen peroxide once daily.

Provide a high-calorie, high-protein diet. Explanation: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? Infection Sepsis Hematoma Pulmonary embolism

Pulmonary embolism Explanation: Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client's arterial oxygen saturation (SaO2). What procedure will best accomplish this? Arterial blood gas (ABG) measurement Peak flow measurement Pulse oximetry Incentive spirometry

Pulse oximetry Explanation: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed. It can be used during transport and causes the client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to measure levels of expired air.

A geriatric client received a narcotic analgesic before leaving the postanesthesia care unit to return to the regular unit. What is the priority nursing intervention for the nurse receiving the client on the regular unit? Create a restful, dark, quiet environment. Maintain the head of the client's bed at ≥ 45°. Put side rails up and place bed in low position. Encourage fluid intake.

Put side rails up and place bed in low position. Explanation: Older clients are more susceptible to the central nervous system effects of narcotics; it is important to ensure their safety by using side rails and placing the bed in the low position in case the client tries to get up unaided. Postoperative clients are allowed nothing by mouth until bowel function returns so an oral medication or encouraging fluids would not be appropriate. This client will require careful observation for respiratory depression, so a dark room would be unsafe. There is no need to keep the head of the client's bed raised.

The nursing educator is presenting a case study of an adult client who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? QRS complex T wave P wave U wave

QRS complex Explanation: The QRS complex represents the depolarization of the ventricles and, as such, the electrical activity of that ventricle.

The nurse is collaborating with the dietitian and a client with hypertension to plan dietary modifications. What modifications should be made? Increased intake of potassium, vitamin B12 and vitamin D Reduced intake of protein and carbohydrates Reduced intake of fat and sodium Increased intake of calcium and vitamin D

Reduced intake of fat and sodium Explanation: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some clients, but a specific reduction in protein and carbohydrates is not normally indicated.

The nurse is caring for a client with high serum cholesterol and triglyceride levels. In teaching the client about therapeutic lifestyle changes and the use of medications, the nurse explains that the desired goal for cholesterol levels is what? Reduced low-density lipoprotein (LDL) values and increased HDL values 1:1:1 ratio of LDL, HDL, and total cholesterol Increased high-density lipoprotein (HDL) values and increased triglyceride values Elevated blood lipids and fasting glucose less than 5.6 mmol/L (100 mg/dL)

Reduced low-density lipoprotein (LDL) values and increased HDL values Explanation: The desired goal for cholesterol readings is for a client to have low LDL and high HDL values. Consequently, a 1:1:1 ratio of LDL, HDL, and total cholesterol would not be desirable. HDL serves as a protective mechanism to reduce cholesterol, so higher levels are desirable. Elevated blood lipids are never desirable, but control of blood sugar levels reduces CAD risk.

A client with cardiovascular disease is being treated with amlodipine, which is intended to cause what therapeutic effect? Preventing platelet aggregation and subsequent thrombosis Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart Reducing the heart's workload by decreasing heart rate and myocardial contraction

Reducing the heart's workload by decreasing heart rate and myocardial contraction Explanation: Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are given to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.

During a client's care conference, the team is discussing whether the client is a candidate for surgery maze procedure. What would be the most important criterion for a client to have this surgery? Refractory atrial fibrillation Angina pectoris not responsive to other treatments Decreased activity tolerance related to decreased cardiac output Ventricular fibrillation not responsive to other treatments

Refractory atrial fibrillation Explanation: The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Angina, reduced activity tolerance, and ventricular fibrillation are not criteria.

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate? Make sure the flow clamp is open and that the drip chamber is approximately half full. Disconnect the tubing from the client to purge the air from the tubing. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. Change the IV solution administration set immediately.

Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. Rationale:If the bubbles are above the roller clamp, the nurse can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with a finger so the bubbles rise to the drip chamber. Ensuring that the flow clamp is open and that the drip chamber is half full helps to promote fluid flow. It would not be necessary to change the administration set to troubleshoot this problem. Disconnecting the tubing from the client would be inappropriate and disrupt the integrity of the sterile IV administration system.

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? Removing all metal-containing objects Withholding stimulants 24 to 48 hours prior to exam Initiating an IV line for administration of contrast Instructing the patient to void prior to the MRI

Removing all metal-containing objects Explanation: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.

The nurse is caring for a client whose potassium level is 5.9 mmol/L (5.9 mg/dL). How will the client's kidneys respond to this potassium level? Removing more potassium in the distal convoluted tubule Inactivating aldosterone Increasing the excretion of hydrogen ions, causing increased potassium excretion Blocking the reabsorption of potassium in Bowman capsules

Removing more potassium in the distal convoluted tubule Explanation: The fine-tuning of potassium levels occurs in the distal convoluted tubule, where aldosterone activates the sodium-potassium exchange, leading to a loss of potassium. Inactivating aldosterone would further increase the client's potassium level. About 65% of the potassium that is filtered at the glomerulus is reabsorbed at Bowman capsule and the proximal convoluted tubule, but this is not the site where potassium levels are adjusted. Hydrogen ions do not directly affect potassium levels.

After the completion of testing, a child's allergies have been attributed to her family's cat. When introducing the family to the principles of avoidance therapy, the nurse should promote what action? Keeping the cat restricted from the child's bedroom Removing the cat from the family's home Administering over-the-counter (OTC) antihistamines to the child regularly Maximizing airflow in the house

Removing the cat from the family's home Explanation: In avoidance therapy, every attempt is made to remove the allergens that act as precipitating factors. Fully removing the cat from the environment is preferable to just keeping the cat out of the child's bedroom. Avoidance therapy does not involve improving airflow or using antihistamines.

The nurse is caring for a client who has been nonadherent with treatment for hypertension. The nurse explains that untreated hypertension increases the risk of what? Select all that apply. Heart failure Migraine headache Cerebral infarction Cholecystitis Renal disease

Renal disease Cerebral infarction Heart failure Explanation: Hypertension is a common chronic disorder. It is estimated that at least 20% of the people in the United States have hypertension. Hypertension increases risks of myocardial infarction, heart failure, cerebral infarction and hemorrhage, and renal disease. It does not increase the risk of cholecystitis or migraine headache.

When providing client teaching to a client beginning therapy with a hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor, the nurse will explain the need for regular monitoring of what laboratory studies? Select all that apply Liver function tests Hemoccult of stool Renal function tests Lipid panel Albumin level

Renal function tests Liver function tests Lipid panel Explanation: It is important to monitor renal and liver function to identify early signs of toxicity or rhabdomyolysis. Monitoring lipid levels contributes to evaluation of the effectiveness of drug therapy. Hemoccult of stool would be more important with bile acid sequestrants that are associated with GI irritation. Altered albumin levels are not associated with HMG-CoA reductase inhibitors.

The nurse is caring for a client whose blood pressure is 90/49 mm Hg. This client's kidneys will compensate by secreting: Aldosterone Renin Angiotensin Antidiuretic hormone

Renin Explanation: Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II. The vasoconstriction causes the blood pressure to increase. ADH is secreted by the pituitary gland, not the kidneys.

A nurse is formulating a nursing assistant assignment. Which activity should the nurse delegate to the nursing assistant? Select all that apply. Reporting unusual clinical manifestations to the nurse. Ensuring that clients swallow their medication. Orienting a new employee to the unit. Teaching clients personal hygiene. Distributing meal trays to clients. Obtaining routine vital signs.

Reporting unusual clinical manifestations to the nurse. Distributing meal trays to clients. Obtaining routine vital signs. It is illegal for the nursing assistant to administer drugs even if done under the supervision of the nurse. A nursing assistant should not be responsible for the supervision or orientation of other employees. The nursing assistant cannot teach.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

Respiratory acidosis Explanation: The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis

Respiratory alkalosis Explanation: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? CNS disturbances Increased PaCO2 Respiratory alkalosis Respiratory acidosis

Respiratory alkalosis Explanation: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.

What function does the kidney perform to assist in maintaining acid-base balance within the necessary normal range? Return bicarbonate to the body's circulation Excrete bicarbonate in the urine Return acid to the body's circulation Excrete acid in the lungs

Return bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in this balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine.

A client has been prescribed phenytoin for the treatment of seizures. How should the nurse most accurately determine whether the client has therapeutic levels of the medication? Assess the client's cognitive status. Review the client's laboratory blood work. Assess the client carefully for adverse effects. Monitor the client for seizure activity.

Review the client's laboratory blood work. Explanation: Measuring serum drug levels evaluates whether the therapeutic range of circulating drug can be found in the serum. It does not directly evaluate effectiveness of therapy, however, which can only be evaluated by determining whether the drug is having the desired effect of reducing number of seizures. Short-term absence of seizures does not necessarily indicate that drug is within therapeutic range.

A client with hyperlipidemia has been taking atorvastatin for several months. How can the therapeutic effect of the medication be best determined? Assessing the client's exercise tolerance and activities of daily living Performing a focused cardiac assessment Reviewing the client's laboratory blood work results Assessing the client's resting heart rate and postural blood pressures

Reviewing the client's laboratory blood work results Explanation: The benefits of lipid-lowering agents are frequently not perceived by the client and do not often change the client's day-to-day cardiac function or activity level. They are most often assessed by reviewing the client's cholesterol levels.

The nurse is planning the care of a client who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the client's care plan? Risk for Ineffective Role Performance Related to Dermatitis Risk for Self-Care Deficit Related to Skin Lesions Risk for Disuse Syndrome Related to Dermatitis Risk for Disturbed Body Image Related to Skin Lesions

Risk for Disturbed Body Image Related to Skin Lesions Explanation: The highly visible skin lesions associated with atopic dermatitis constitute a risk for disturbed body image. This may culminate in ineffective role performance, but this is not likely the case for the majority of clients. Dermatitis is unlikely to cause a disuse syndrome or self-care deficit.

The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the client's plan of care? Risk for falls related to orthostatic hypotension Risk for ineffective breathing pattern related to hypotension Risk for ineffective role performance related to hypotension Risk for imbalanced fluid balance related to hemodynamic variability

Risk for falls related to orthostatic hypotension Explanation: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompanies it. It does not normally affect breathing or fluid balance. The client's ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.

The nurse is developing a plan of care for a client whose scheduled surgery will last approximately 3 hours. What intraoperative nursing diagnosis should the nurse prioritize? Risk for impaired skin integrity related to immobility Risk for deficient fluid volume related to absence of oral intake Acute pain related to disruption of tissue during surgery Impaired swallowing related to intubation and mechanical ventilation

Risk for impaired skin integrity related to immobility Explanation: The client would need to be moved or turned periodically to prevent skin breakdown and the formation of decubitus ulcers. The client's risk for pain is addressed by the anesthesiologist through the administration of general anesthesia. The client's absence of swallowing is expected during general anesthesia. The nurse is not primarily responsible for monitoring the client's fluid balance during surgery.

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? SA node to AV node to Purkinje fibers to bundle of His SA node to AV node to bundle of His to Purkinje fibers SA node to bundle of His to Purkinje fibers to AV node SA node to bundle of His to AV node to Purkinje fibers

SA node to AV node to bundle of His to Purkinje fibers Explanation: The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinje fibers.

A client who will be traveling on a ferry has been prescribed a scopolamine transdermal patch. What health education should the nurse provide to the client? "You might find that your heart beats more quickly than usual, even when you're at rest." "You might find yourself having to pass urine more often than you usually do." "It's normal for your pupils to get smaller with this drug, so don't be surprised if someone points that out." "Some people have diarrhea when they first start taking this, but it will usually resolve on its own."

Scopolamine blocks the parasympathetic nervous system, which may result in dilated pupils and increased heart rate (i.e., tachycardia). Blocking the parasympathetic system also results in decreased GI activity and urinary bladder tone causing constipation and urinary retention.

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding? Shortness of breath. Deceased blood pressure. Change in the level of consciousness. Pounding headache.

Shortness of breath. Rationale:Fluid overload is caused when too large a volume of fluid infuses into the circulatory system. This complication manifests as engorged neck veins, shortness of breath and abnormal breath sounds (suggesting respiratory failure), increased blood pressure, and difficulty breathing. A pounding headache is a sign of speed shock and the change in level of consciousness is related to the existence of an air embolus.

A client returns to the unit following a thyroidectomy. The nurse plans to frequently assess for which of the following? Hypoactive deep tendon reflexes Signs of laryngospasm Polyuria Hypertension

Signs of laryngospasm

The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? Three large, bland meals a day Small, frequent meals, high in protein and calories A reduced calorie diet, high in nutrients A diet high in fiber and plant-sourced fat

Small, frequent meals, high in protein and calories Explanation: A client with hyperthyroidism has an increased appetite. The client should be counseled to consume several small, well-balanced meals. High-calorie, high-protein foods are encouraged. A clear liquid diet would not satisfy the client's caloric or hunger needs. A diet rich in fiber and fat should be avoided because these foods may lead to GI upset or increase peristalsis.

A nurse caring for a client who has an immunosuppressive disorder knows that continual monitoring of the client is critical. What is the primary rationale behind the need for continual monitoring? So that the client's functional needs can be met immediately So that medications can be given as prescribed and signs of adverse reactions noted So that the nurse's documentation can be thorough and accurate So that early signs of impending infection can be detected and treated

So that early signs of impending infection can be detected and treated Explanation: Continual monitoring of the client's condition is critical, so that early signs of impending infection may be detected and treated before they seriously compromise the client's status. Continual monitoring is not primarily motivated by the client's functional needs or medication schedule. The nurse's documentation is important, but less than infection control.

The nurse plans to administer which of the following intravenous (IV) treatments to a client for treatment of hyperkalemia associated with severe acidosis? Insulin and dextrose to make the client hypoglycemic Normal Saline (NS) to provide extra sodium so the potassium will move out of the ICF and into the ECF Sodium bicarbonate to make the client alkalotic so the potassium will shift into the ICF Calcium gluconate to make the potassium shift from the intracellular fluid (ICF) to the extracellular fluid (ECF)

Sodium bicarbonate to make the client alkalotic so the potassium will shift into the ICF

The nurse is describing some of the key characteristics of cardiac cells to a client. What action does the nurse explain cardiac cells perform? Survive in an ischemic state for four to six times longer than skeletal muscle cells. Synthesize a small amount of glucose in order to prolong their survival. Produce neurotransmitters that stimulate electrical impulses independent of external stimulation. Spontaneously generate an action potential.

Spontaneously generate an action potential. Explanation: All cardiac cells possess some degree of automaticity, in which they can generate action potentials or electrical impulses without being excited to do so by external stimuli. This does not involve neurotransmitters. Cardiac cells cannot survive far longer than skeletal muscle without oxygen. Cardiac cells do not independently synthesize glucose.

The nurse is working with a client who is taking nadolol for angina. What nursing action should the nurse perform to best address the likely adverse effects? Cue the client to void on a scheduled basis at the beginning of therapy. Spread out the client's activities to prevent fatigue or overexertion. Administer stool softeners as prescribed. Ensure the client sips water throughout the day to relieve dry mouth.

Spread out the client's activities to prevent fatigue or overexertion. Explanation: Nadolol is a beta-blocker that can cause a decreased tolerance to exercise because of the inability to experience the effects of the stress reaction. Dry mouth and constipation are often seen with anticholinergic drugs but not with beta-blockers. There is no need to cue the client to void, because urinary function is rarely affected.

A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment? Alterations in bile metabolism and release have likely caused hyperglycemia. The client's volatile fluid balance surrounding surgery has likely caused unstable blood sugars. Stress has likely caused an increase in the client's blood sugar levels. The client has likely overestimated her ability to control her diabetes using nonpharmacologic measures.

Stress has likely caused an increase in the client's blood sugar levels. Explanation: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The client's need for insulin is unrelated to the action of bile, the client's overestimation of previous blood sugar control, or fluid imbalance.

A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? Ejection fraction Repolarization Diastole Systole

Systole Explanation: Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxation), ejection fraction (the amount of blood expelled), or repolarization (electrical charging).

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart? QRS complex T wave P wave U wave

T wave Explanation: The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex.

The nurse is caring for a client who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? P wave inversion Q wave changes with no change in ST or T wave T wave inversion P wave enlargement

T wave inversion Explanation: T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? Oral temperature of 37.2°C (99°F) Weight loss of 0.45 kg (1 lb) since yesterday Tachypnea and restlessness Frequent loose stools

Tachypnea and restlessness Explanation: In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue addressed.

The nurse is reviewing the discharge instructions with the client going home on an opioid analgesic for pain management. What would the nurse include in the instructions? Select all that apply. Keep a record of bowel movements. Keep the room well lit during the day. Limit fluid intake. Take a laxative/stool softener. Rise slowly from a sitting or lying position.

Take a laxative/stool softener. Keep the room well lit during the day. Rise slowly from a sitting or lying position. Keep a record of bowel movements. Explanation: Constipation is an issue in clients receiving opioid analgesics, therefore taking a laxative/stool softener may be necessary, as well as increasing fluid intake and keeping a record of bowel movements. A drop in blood pressure (orthostatic hypotension) would require care in rising from a sitting or lying position. Miosis (pinpoint pupils) decreases the ability to see in dim light.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? Take ibuprofen for complaints of a serious headache. Mild, intermittent seizures can be expected. Take antihypertensive medication as prescribed. Drowsiness is normal for the first week after discharge.

Take antihypertensive medication as prescribed. Explanation: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; complaints of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing? Gradually increase levels of physical exertion. Change filters on heaters and air conditioners frequently. Take prescribed medications as scheduled. Avoid goose-down pillows.

Take prescribed medications as scheduled. Explanation: Although all of the measures are appropriate for a client with asthma, taking prescribed medications on time is the most important measure in preventing asthma attacks.

The nurse is providing client education regarding the administration of levothyroxine (Synthroid). Which information should the nurse include? Take the medication before going to bed at night. Take the medication on an empty stomach. Take with a full glass of water. Remain in the upright position for 30 minutes after taking the medication.

Take with a full glass of water. Explanation: The client should be instructed to take the medication with a full glass of water to help prevent difficulty swallowing. The medication should not be taken on an empty stomach and the client does not have to remain in the upright position after taking the medication. The medication should be taken as a single daily dose before breakfast each day to ensure consistent therapeutic levels.

The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which action? Taking the BP 10 minutes after nicotine or coffee ingestion Using a bare forearm supported at heart level on a firm surface Measuring the BP after the client has been seated quietly for more than 5 minutes Using a cuff with a bladder that encircles at least 80% of the limb

Taking the BP 10 minutes after nicotine or coffee ingestion Explanation: Blood pressures should be taken with the client seated with arm bare, supported, and at heart level. The client should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.

What is an example of an independent registered nursing intervention? Administering blood. Starting an intravenous fluid. Teaching a client about the effects of prescribed drugs. Administering emergency drugs during a code situation.

Teaching a client about the effects of prescribed drugs.

A client with a history of partial seizures has been taking lamotrigine for the past several days. The client calls the clinic and reports the development of a facial and torso rash to the nurse. What is the nurse's best action? Recommend that the client take 50 mg diphenhydramine PO and check back tomorrow. Rule out any shortness of breath and inform the client that this adverse effect will resolve with time. Tell the client to take no further doses and come be assessed at the clinic immediately. Tell the client to take the medication with a high-fat food to minimize adverse effects.

Tell the client to take no further doses and come be assessed at the clinic immediately. Explanation: The nurse should inform the client to discontinue the drug and return to the clinic. Rashes associated with the use of lamotrigine can be life-threatening. The client needs to return to the clinic to be evaluated and will need a change of medication. Recommending another medication is insufficient, and is also beyond the nurse's scope. High-fat foods are of no benefit.

Diuretics can either block the reabsorption of components of the urine or block the reabsorption of water back into the body. What does the increase in urine flow from the body depend on with a patient on loop diuretics? The amount of sodium and chloride reabsorption that it blocks The amount of water reabsorption back into the body The amount of water excreted by the body The amount of sodium and chloride that it excretes through the kidney

The amount of sodium and chloride reabsorption that it blocks Explanation: The increase in urine flow that a diuretic produces is related to the amount of sodium and chloride reabsorption that it blocks. The other answers are not correct.

The nurse is working with a client who had an MI and is now active in rehabilitation. The nurse should teach this client to cease activity if which of the following occurs? The client experiences a noticeable increase in heart rate during activity. The client's respiratory rate exceeds 30 breaths/min. The client's oxygen saturation level drops below 96%. The client experiences chest pain, palpitations, or dyspnea.

The client experiences chest pain, palpitations, or dyspnea. Explanation: Any activity or exercise that causes dyspnea and chest pain should be stopped in the client with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most clients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

The nurse is assessing a client who is being considered for anticoagulant therapy. What aspect of the client's health history should the nurse follow up most closely? The client has a history of GI ulcers. The client has a history of recurrent urinary tract infections. The client's last menstrual period was 10 days ago. The client's body mass index is 32 (obese).

The client has a history of GI ulcers. Explanation: Beginning anticoagulant therapy with active GI ulcers could result in severe bleeding. The date of this client's last menstrual period presents no obvious safety risk. Recurrent urinary tract infections and obesity should not impact anticoagulant therapy.

A client has come into the free clinic asking to be tested for HIV infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in the blood, this indicates what? The client has been infected with HIV. The client's immune system is intact. The client is immune to HIV. The client has AIDS-related complications.

The client has been infected with HIV. Explanation: Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDS-related complications.

An older adult client has been diagnosed with COPD. What characteristic of the client's current health status would rule out the safe and effective use of a metered-dose inhaler (MDI)? The client has not yet quit smoking. The client has cataracts. The client requires both corticosteroids and beta2-agonists. The client has severe arthritis in her hands.

The client has severe arthritis in her hands. Explanation: Safe and effective MDI use requires the client to be able to manipulate the device independently, which may be difficult if the client has arthritis. Smoking does not preclude MDI use. A modest loss of vision does not preclude the use of an MDI and a client can safely use more than one MDI.

What action by the client would indicate that the client understands how to use an inhaler? The client holds his or her breath for several seconds after compressing the canister. The client uses a spacer to administer a powdered medication. The client inhales as soon as the inhaler enters his or her mouth. The client exhales as soon as he or she compresses the inhaler.

The client holds his or her breath for several seconds after compressing the canister. Explanation: Holding the breath prevents exhalation of medication still remaining in the mouth. The client should inhale when the canister is compressed, not as soon as the inhaler enters his or her mouth. The client should only administer one dose of medication at a time, and the client should wait to exhale until after the breath has been held as long as possible. Spacers are not used with powdered medications.

What assessment finding of a client should the nurse attribute to the stimulation of muscarinic receptors? The client reports pruritis (itching). The client appears agitated. The client is drooling. The client's respiratory rate is 20 breaths/min.

The client is drooling. Explanation: Stimulation of muscarinic receptors causes increased saliva production. It is not associated with agitation or pruritis. A respiratory rate of 20 breaths/min is expected and is not suggestive of increased stimulation of any particular cholinergic receptor.

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? The grandmother's surgery has minimal relevance to the client's surgery. The client may be experiencing presurgical anxiety. The client may be at risk for malignant hyperthermia. The client may be at risk for a sudden onset of postsurgical infection.

The client may be at risk for malignant hyperthermia. Explanation: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandmother's surgery is very relevant, and all clients are at risk for hypothermia.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? The client should be approached on the opposite side of where the visual perception is intact to promote recovery. The client should be approached on the side where visual perception is intact. Attention to the affected side should be minimized in order to decrease anxiety. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation.

The client should be approached on the side where visual perception is intact. Explanation: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? The client should mobilize as soon as she is physically able. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. The client should remain on bed rest until she expresses a desire to mobilize. Lack of mobility will greatly increase the client's risk of stroke recurrence.

The client should mobilize as soon as she is physically able. Explanation: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. Explanation: The client assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the client is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

A client with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the client about this treatment? The client will remain in the clinic to be monitored for 30 minutes following the injection. The client will be given a low dose of epinephrine before the treatment. The allergen will be given by the peripheral intravenous route. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months.

The client will remain in the clinic to be monitored for 30 minutes following the injection. Explanation: Although severe systemic reactions are rare, the risk of systemic and potentially fatal anaphylaxis exists. Because of this risk, the client must remain in the office or clinic for at least 30 minutes after the injection and is observed for possible systemic symptoms. Therapeutic failure is evident when a client does not experience a decrease in symptoms within 12 to 24 months. Epinephrine is not given prior to treatment and the IV route is not used.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? The client's activities immediately prior to the seizure. The ability of the client to follow instructions during the seizure. The success or failure of the care team to physically restrain the client. The client's ability to explain his seizure during the postictal period.

The client's activities immediately prior to the seizure. Explanation: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure is not clinically relevant.

A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? The client should withhold his next scheduled dose of insulin. The client would benefit from a dose of metformin. The client should promptly eat some protein and carbohydrates. The client's insulin levels are inadequate.

The client's insulin levels are inadequate. Explanation: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

The nurse is caring for a client who is experiencing a backflow of blood from the left ventricle to the left atrium. How should the nurse best interpret this finding? The client has increased preload. The client is likely having premature ventricular contractions (PVCs). There is a deficit involving the tricuspid valve. The client's mitral valve is incompetent.

The client's mitral valve is incompetent. Explanation: The valve between the atrium and ventricle on the left side of the heart, called the mitral or bicuspid valve, is composed of two leaflets or cusps that allow the left ventricle to fill with blood and then close to prevent backflow of blood into the left atrium. If this valve is damaged, contraction of the ventricle will push blood back into the left atrium and result in inadequate cardiac output. The tricuspid valve is the valve between the right atria and ventricle. PVCs are a conduction problem that would not cause backflow of blood. Increased preload means the heart must work harder to move a larger volume of blood, but this would not cause regurgitation in the absence of a valve defect.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information? The client's coping strategies surrounding the attacks The client's understanding of the pathology of angina The client's symptoms and the activities that precipitate attacks The client's activities limitations and level of consciousness after the attacks

The client's symptoms and the activities that precipitate attacks Explanation: The nurse must gather information about the client's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

A client who is scheduled for a skin test informs the nurse that he has been taking corticosteroids to help control his allergy symptoms. What nursing intervention should the nurse implement? The client should take his corticosteroids regularly prior to testing. The client's test should be cancelled until he is off his corticosteroids. The nurse should have an emergency cart available in case of anaphylaxis during the test. The client should only be tested for grass, mold, and dust initially.

The client's test should be cancelled until he is off his corticosteroids. Explanation: Corticosteroids and antihistamines, including over-the-counter (OTC) allergy medications, suppress skin test reactivity and should be stopped 48 to 96 hours before testing, depending on the duration of their activity. Emergency equipment must be at hand during allergy testing, but the test would be postponed.

A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's treatment? The drug should be used for as short a time as possible. The drug should be used at the highest dose the client can tolerate. The client must stop all other drugs 72 hours before starting prednisone. The client will need daily blood testing for the duration of treatment.

The drug should be used for as short a time as possible. Explanation: Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects. Daily blood work is not necessary and the client does not need to stop other drugs prior to using corticosteroids.

A client with a urinary tract infection has been prescribed Bactrim, a medication that is a combination of sulfamethoxazole and trimethoprim. What is the most likely rationale for the use of a combination antibiotic? The drugs' combined effect exceeds the sum of their individual effects. One antibiotic is narrow-spectrum and one is broad-spectrum. One of the antibiotics exists solely to facilitate absorption of the other. It is not possible to culture the microorganisms most likely responsible for the infection.

The drugs' combined effect exceeds the sum of their individual effects. Explanation: Some drugs are synergistic, which means that they are more powerful when given in combination. Combination drugs do not normally exist to promote absorption and they are not always a combination of narrow- and broad-spectrum. An inability to perform culture and sensitivity testing would not directly require combination therapy.

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue? The need to monitor urine for the presence of albumin The need for frequent eye examinations for clients with diabetes The relationship between kidney function and blood glucose levels The fact that clients with diabetes have an elevated risk of myocardial infarction

The fact that clients with diabetes have an elevated risk of myocardial infarction Explanation: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and kidney function are considered to be microvascular.

A nurse is discussing hypertension with a group of clients. What topic should be included in the discussion? Select all that apply. The importance of a low cholesterol, low-fat, low salt diet. Encouragement of 30 minutes of physical activity most days of the week. Explanation that uncontrolled diabetes increases blood pressure. Recommendation of relaxation classes to help decrease stress. Instruction to elevate the head of the bed to sleep.

The importance of a low cholesterol, low-fat, low salt diet. Encouragement of 30 minutes of physical activity most days of the week. Explanation that uncontrolled diabetes increases blood pressure. Recommendation of relaxation classes to help decrease stress.

Graduated compression stockings have been prescribed to treat a client's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the client? The need to wear the stockings on a "one day on, one day off" schedule The need to take anticoagulants concurrent with using compression stockings The importance of wearing the stockings around the clock to ensure maximum benefit The importance of ensuring the stockings are applied evenly with no pressure points

The importance of ensuring the stockings are applied evenly with no pressure points Explanation: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory clients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in clients who are using compression stockings.

A nurse is planning care for a nephrology client with a new nursing graduate. The nurse states, "A client with kidney disease partially loses the ability to regulate changes in pH." What is the cause of this partial inability? The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH. The kidneys regulate and reabsorb carbonic acid to change and maintain pH. The kidneys buffer acids through electrolyte changes.

The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. Explanation: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.

The nurse explains that the reason the left ventricle is so much larger than the right ventricle is what? The left ventricle needs to pump blood through the entire body. The left ventricle needs to pump blood through both lungs. The right ventricle pumps blood through the entire body. The right ventricle pulls blood back into the heart from the lungs.

The left ventricle needs to pump blood through the entire body. Explanation: The left ventricle is much larger because it has to pump strongly enough to circulate blood through the entire body. The right ventricle pumps blood only to the lungs, which are nearby.

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is the nurse's priority for health education? The need for the child to avoid all foods that have a high potential for allergies The need to vigilantly maintain the child's immunization status The need for the parents to carry an epinephrine pen The need to begin immunotherapy as soon as possible

The need for the parents to carry an epinephrine pen Explanation: All clients with food allergies, especially seafood and nuts, should have an EpiPen device prescribed. The child does not necessarily need to avoid all common food allergens. Immunotherapy is not indicated in the treatment of childhood food allergies. Immunizations are important, but do not address food allergies.

What is the best rationale for intubation during a surgical procedure? The tube provides an airway for ventilation. The patient may receive an anti-emetic through the tube. The tube protects the esophagus. The patient's heart rate can be monitored with the tube.

The tube provides an airway for ventilation. Explanation: Intubation and mechanical ventilation must be used in most cases of general anesthesia. The anesthetic is administered, and the patient's airway is maintained through either an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus, because the tube goes into the lungs no medications are given through the tube. The patient's heart rate is not monitored through the tube.

The nurse is performing a respiratory assessment of an adult client and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? Whether they are heard on inspiration or expiration The volume of the sounds Whether or not they are continuous breath sounds Their location over a specific area of the lung

Their location over a specific area of the lung Explanation: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous. They are not distinguished solely on the basis of volume.

The perioperative nurse is caring for a surgical client whose anesthesiologist has just administered atropine. When assessing the client, what finding should the nurse interpret as achieving the desired effect? The client's pupils are dilated and minimally responsive to light. There is no evidence of excessive oral or bronchial secretions. The client expresses no anxiety about the administration of anesthesia. There is less than 50 mL of urine in the client's urinary catheter collection bag.

There is no evidence of excessive oral or bronchial secretions. Explanation: Atropine is administered preoperatively to reduce secretions, but added indications include gastrointestinal (GI) effects that reduce GI activity. Atropine has no sedating or relaxing effects and is not given preoperatively for its pupil dilation effects. It is not given to reduce urine output.

A combination of drugs needs to be incorporated into the drug regimen for a hypertensive client. What type of diuretic would the nurse expect to administer? Thiazide Osmotic Loop Potassium-sparing

Thiazide Explanation: A somewhat controversial study, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), reported in 2002 that clients taking the less expensive, less toxic diuretics did better and had better blood pressure control than clients using other antihypertensive agents. Replications of this study have supported its findings, and the use of a thiazide diuretic is currently considered the first drug used in the stepped-care management of hypertension.

The nurse has administered a diuretic that acts to block the chloride pump in the distal convoluted tubules and leads to a loss of sodium and potassium and a minor loss of water. What type of diuretic did the nurse administer? Potassium-sparing diuretic Osmotic diuretic Thiazide diuretic Carbonic anhydrase inhibitor

Thiazide diuretic Explanation: Thiazide diuretics work to block the chloride pump, which leads to a loss of sodium, potassium, and some water. They are considered mild diuretics. Carbonic anhydrase inhibitors work to block the formation of carbonic acid and bicarbonate in the renal tubules. Osmotic diuretics use hypertonic pull to remove fluid from the intravascular spaces and to deliver large amounts of water into the renal tubules. Potassium-sparing diuretics are mild and act to spare potassium in exchange for the loss of sodium and water.

A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to the client's discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine in what site? Forearm Thigh Abdomen Deltoid muscle

Thigh Explanation: The client is taught to position the device at the middle portion of the thigh and push the device into the thigh as far as possible. The device will automatically inject a premeasured dose of epinephrine into the subcutaneous tissue.

The nurse is preparing to administer sublingual nitroglycerin to a client for the first time. What effect might the client experience right after administration? Throbbing headache or dizziness Drowsiness or blurred vision Tinnitus or diplopia. Nervousness or paresthesia

Throbbing headache or dizziness Explanation: Headache and dizziness commonly occur at the start of nitroglycerin therapy. When administering nitroglycerin, the nurse must use caution to avoid self-contamination, especially with the topical paste formulation because the nurse can experience the same symptoms. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not occur as a result of nitroglycerin therapy.

A client with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the client about what potential adverse effects? Drowsiness or blurred vision Nervousness or paresthesia Tinnitus or diplopia Throbbing headache or dizziness

Throbbing headache or dizziness Explanation: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

Which of the following goals for medication prescribed to treat rheumatoid arthritis is correct? To prevent osteoporosis To encourage bone regeneration To cure the disease To control inflammation

To control inflammation

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? To prevent chronic obstructive pulmonary disease (COPD) To prevent pneumothorax To promote optimal lung expansion To enhance peripheral circulation

To promote optimal lung expansion Explanation: One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. Cerebrovascular disease Retinal hemorrhage Transient ischemic attacks (TIAs) Right ventricular hypertrophy Venous insufficiency

Transient ischemic attacks (TIAs) Cerebrovascular disease Retinal hemorrhage Explanation: Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks; cerebrovascular disease; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.

The nurse administers clopidogrel appropriately to the client for what purpose? Preventing emboli from valve replacements Maintaining the patency of grafts Treating peripheral artery disease Dissolving a pulmonary embolus and improving oxygenation

Treating peripheral artery disease Explanation: Clopidogrel is used to inhibit platelet aggregation, decreasing the formation of clots in narrowed or injured blood vessels like those found in peripheral artery disease. Maintaining the patency of grafts or preventing emboli from valve replacements would be accomplished using an anticoagulant. Dissolving emboli would be accomplished using streptokinase or a similar enzyme to stimulate the conversion of plasminogen to plasmin.

A client has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse should confirm that the client has done which of the following? Refrained from smoking for at least 8 hours Tried to rest quietly for 5 minutes before the reading is taken Drank adequate fluids during the day prior Avoided drinking coffee for 12 hours before the visit

Tried to rest quietly for 5 minutes before the reading is taken Explanation: Prior to the nurse assessing the client's BP, the client should try to rest quietly for 5 minutes. The forearm should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes prior to the visit. Recent fluid intake is not normally relevant.

A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position? Inform that physician that the client is in a recumbent position and anticipate an order for a portable chest x-ray. Avoid turning the client, and assess the accessible breath sounds from the anterior chest wall. Turn the client to enable assessment of all the patient's lung fields. Obtain a pulse oximetry reading, and, if the reading is low, reposition the client and auscultate breath sounds.

Turn the client to enable assessment of all the patient's lung fields. Explanation: Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the client is recumbent, it is essential to turn the client to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. The ability to interpret the results of diagnostic tests Knowledge of nursing interventions related to assessment and diagnostic testing Understanding of the tests used to diagnose neurologic disorders Knowledge of the anatomy of the nervous system The ability to select basic medications for the neurologic dysfunction

Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system Explanation: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

A client's drug regimen includes diphenhydramine. What potential indications may this drug be used for? Select all that apply. Productive cough Motion sickness Angioedema Urticaria Vasomotor rhinitis

Urticaria Vasomotor rhinitis Motion sickness Angioedema Explanation: Diphenhydramine is used for the symptomatic relief of perennial and seasonal rhinitis, vasomotor rhinitis, allergic conjunctivitis, urticaria, and angioedema; it is also used for treating motion sickness and parkinsonism, as a nighttime sleep aid, and to suppress cough. It would not be used to treat a productive cough, because it is not an expectorant.

A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises? Use diaphragmatic breathing Avoid pursed-lip breathing unless absolutely necessary. Lie supine to facilitate air entry Use chest breathing

Use diaphragmatic breathing Explanation: Inspiratory muscle training and breathing retraining may help improve breathing patterns in clients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration. Diaphragmatic breathing, not chest breathing, increases lung expansion. Supine positioning does not aid breathing.

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. What should the nurse include in health education? Maintaining a diet high in dairy to increase protein necessary to prevent organ damage Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker Use of strategies to prevent falls stemming from postural hypotension Limiting exercise to avoid injury that can be caused by increased intracranial pressure

Use of strategies to prevent falls stemming from postural hypotension Explanation: Older adults have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches clients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly clients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, are strongly recommended. Increasing fluids in elderly clients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.

The nurse is caring for a client with influenza and is explaining why viruses are more difficult to treat than many bacteria. What should the nurse teach the client? Drugs exist to treat all viral infections but they carry serious adverse effects and the benefit often does not outweigh the risk. Individual antiviral drugs are often effective in treating many different viruses because one virus in a category behaves like others in the same category. Release of interferons by the host cell makes the virus replicate more quickly allowing the virus to spread. Viruses are contained inside the human cell and cannot be destroyed without destroying that cell.

Viruses are contained inside the human cell and cannot be destroyed without destroying that cell. Explanation: Because viruses are contained inside human cells while they are in the body, researchers have difficulty developing effective drugs that destroy a virus without harming the human host. Interferons are released by the host in response to viral invasion of a cell and act to prevent the replication of that particular virus. Some interferons that affect particular viruses can now be genetically engineered to treat particular viral infections. Other drugs that are used in treating viral infections are not natural substances and have been effective against only a limited number of viruses. Very few viruses are treatable with medications; a few more can be prevented through immunization but most have no known treatment. Each antiviral is generally only suited to treat the single virus it was developed for and will not be effective against other viruses.

A nurse is planning patient education for a client being discharged home with a diagnosis of rheumatoid arthritis. The client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect? Hirsutism Stomatitis Visual changes Tinnitus

Visual changes Explanation: Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary. Tinnitus is associated with salicylate therapy and hirsutism is associated with corticosteroid therapy. Antimalarials do not normally cause stomatitis.

A client is being admitted to the medical surgical floor with a diagnosis of metabolic alkalosis. The nurse knows that this acid base in balance is commonly caused by which of the following problems? Anxiety or panic attacks COPD or sleep apnea Vomiting or diuretic use Diarrhea or renal failure

Vomiting or diuretic use This answer is correct because vomiting & diuretic use are common causes of metabolic alkalosis. The body is losing excess acid in both of these cases. The result is a build up of bicarbonate (base)in the body.

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? Drinking large amounts of fluids Exposing his skin to sunlight Using artificial tears Washing his face

Washing his face Explanation: Washing the face should be avoided if possible because this activity can trigger an attack of pain in a client with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this client. Temperature extremes in beverages should be avoided.

When caring for an adult client diagnosed with hyponatremia, the nurse plans to restrict which of the following? Chloride Water Sodium Potassium

Water

A nurse's assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the client is experiencing bronchospasm? Reduced respiratory rate or lethargy Wheezes or diminished breath sounds on auscultation Slow, deliberate respirations and diaphoresis Fine or coarse crackles on auscultation

Wheezes or diminished breath sounds on auscultation Explanation: Wheezing and diminished breath sounds are consistent with bronchospasm. Crackles are usually attributable to other respiratory or cardiac pathologies. Bronchospasm usually results in rapid, inefficient breathing and agitation.

The nurse is caring for a client who is scheduled for cardiac surgery. What should the nurse include in preoperative care? With the client, clarify the surgical procedure that will be performed. Withhold the client's scheduled medications for at least 12 hours preoperatively. Inform the client that health teaching will begin as soon as possible after surgery. Avoid discussing the client's fears as not to exacerbate them.

With the client, clarify the surgical procedure that will be performed. Explanation: Preoperatively, it is necessary to evaluate the client's understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the client's medication regimen, if necessary; this will vary from client to client. Fears should be addressed directly and empathically.

During a mumps outbreak at a local school, a teacher has been exposed. The client has previously been immunized for mumps, and consequently possesses: acquired immunity. phagocytic immunity. humoral immunity. natural immunity.

acquired immunity. Explanation: Acquired immunity usually develops as a result of prior exposure to an antigen, often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has three means of defense. The first line of defense, the phagocytic immune response, involves the WBCs that have the ability to ingest foreign particles. A second protective response is the humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present at birth.

While providing client teaching relative to inflammatory disorders, the nurse would explain the presence of inflammation as: a normal response to infection or trauma, which results in necrotic tissue formation. a typical response to bacterial infection. an attempt by the body to remove the damaging agent and repair the damaged tissue. the initial stage of infection, requiring antibiotic medication for resolution.

an attempt by the body to remove the damaging agent and repair the damaged tissue. Explanation: Inflammation is the normal body response to tissue damage from any source, and it may occur in any tissue or organ. Local manifestations are redness, heat, edema, and pain. Inflammation may be a component of virtually any illness. Inflammation can be a result of an infection, which may require antibiotic therapy.

A client has been administered a scheduled dose of atropine to treat bradycardia. The nurse understands that the therapeutic effects of the drug are due to: increased reuptake of ACh in the synaptic clefts of the parasympathetic nervous system. antagonism of the muscarinic effectors in the parasympathetic nervous system. agonism of the alpha- and beta-adrenergic receptors in the sympathetic nervous system. blocking of the muscarinic and nicotinic receptors in the peripheral nervous system.

antagonism of the muscarinic effectors in the parasympathetic nervous system. Explanation: Both atropine and scopolamine work by blocking only the muscarinic effectors in the parasympathetic nervous system and the few cholinergic receptors in the sympathetic nervous system (SNS), such as those that control sweating. They act by competing with acetylcholine for the muscarinic acetylcholine receptor sites. They do not block the nicotinic receptors and therefore have little or no effect at the neuromuscular junction. Muscarinic and nicotinic receptors are in the parasympathetic NS, not the peripheral NS. Anticholinergics do not work by increasing reuptake of ACh.

A surgical client develops nonobstructive postoperative urinary retention. What drug would the nurse expect to be ordered for this client? ambenonium neostigmine pyridostigmine bethanechol

bethanechol Explanation: The agent bethanechol, which has an affinity for the cholinergic receptors in the urinary bladder, is available for use orally and subcutaneously to treat nonobstructive postoperative and postpartum urinary retention and to treat neurogenic bladder atony. The other options are not indicated for this purpose.

A client is being treated for a herpes outbreak, and the healthcare provider has prescribed acyclovir. In order to screen for potential problems with the client's excretion of the drug, which assessment data should the nurse review? blood urea nitrogen and creatinine levels GGT, AST, ALT and bilirubin levels nutritional status complete blood count and WBC differential

blood urea nitrogen and creatinine levels Explanation: The nurse should evaluate the client's renal function tests to determine baseline function of the kidneys and to assess adverse effects on the kidney and need to adjust the dose of the drug. The client's white cell count, liver function, and nutritional status have comparatively minor effects on excretion.

The nurse is caring for an older adult client who is displaying alterations in the conduction of impulses in the SA node. What assessment finding is most likely? cardiac arrhythmias cardiac gallop heart murmurs tachycardia

cardiac arrhythmias Explanation: Alterations in the generation of conduction of impulses in the heart cause arrhythmias (arrhythmias), which can upset the normal balance in the cardiovascular system and lead to a decrease in cardiac output, affecting all of the cells of the body. Tachycardia is only one of the possible arrhythmias that may result. Cardiac gallop and murmurs in the older adult with no history of congenital anomalies is usually caused by a poorly functioning heart valve and not by an alteration in conduction.

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be: drug therapy and smoking cessation. diet and drug therapy. diet therapy only. diet therapy and smoking cessation.

diet therapy and smoking cessation. Explanation: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

The nurse is providing health education to a client with an infection who lives in the community. What characteristic of the client's anti-infective regimen will best prevent the development of resistant strains of microbes? maximizing the frequency of drug ingestion ensuring that the duration of drug use is appropriate proactively addressing the possibility of adverse effects performing culture and sensitivity testing after the completion of treatment

ensuring that the duration of drug use is appropriate Explanation: Exposure of pathogens to an antimicrobial agent without cellular death leads to the development of resistance so it is important to limit the use of these agents to treat pathogens with a known sensitivity to the drug being used. The duration of drug use is critical to ensure that microbes are completely eliminated and not given the chance to grow and develop resistant strains. Adverse effects must be addressed, but this is not directly related to the development of resistance. Dosing frequency must be determined with the goal of enhancing the therapeutic action, but excessive frequency can cause problems with the client's adherence. Follow-up testing is not a major component of preventing resistance.

What is the major inhibitory neurotransmitter in the CNS? gamma-aminobutyric acid (GABA) dopamine acetylcholine serotonin

gamma-aminobutyric acid (GABA) Explanation: GABA, which is found in the brain, inhibits nerve activity and is important in preventing overexcitability or stimulation such as seizure activity. Acetylcholine, which communicates between nerves and muscles, is also important as the preganglionic neurotransmitter throughout the autonomic nervous system and as the postganglionic neurotransmitter in the parasympathetic nervous system and in several pathways in the brain. Dopamine is involved in the coordination of impulses and responses, both motor and intellectual. Acetylcholine, dopamine, and serotonin are not the major inhibitory neurotransmitter in the CNS. Serotonin is important in arousal and sleep.

The nurse admitted a client diagnosed with a systemic fungal infection. Before administering ketoconazole as prescribed, what should the nurse confirm? complete blood count (CBC) and white cell differential blood type hepatic function height and weight

hepatic function Explanation: It would be important for the nurse to know the client's CBC, height, and weight. All of these factors could help determine a specific dosage. However, the most important factor would be the client's hepatic function because hepatotoxicity could occur quickly if the liver is not functioning properly. There is no obvious need to know the client's blood type.

A client has developed urosepsis following a urinary tract infection. The nurse is explaining how B cells are programmed to identify specific proteins or antigens in the fight against the client's infection. What process is the nurse describing? humoral immunity T-cell immunity passive immunity autoimmunity

humoral immunity Explanation: B cells are programmed to identify specific proteins, or antigens. They provide what is called "humoral immunity." Autoimmunity occurs when the body attacks its own self-cells. Passive immunity is the transfer of antibodies from one person to another. Active immunity is immunity produced by the body in response to an organism.

The nurse administers a medication that stimulates the parasympathetic nervous system (PNS). What manifestations would indicate the medication is having the desired effect? Select all that apply. hyperactive bowel sounds urinary incontinence constricted pupils increased saliva production elevated heart rate

hyperactive bowel sounds increased saliva production constricted pupils Explanation: PNS stimulation results in increased motility and secretions in the gastrointestinal (GI) tract to promote digestion and absorption of nutrients: decreased heart rate and contractility to conserve energy and provide rest for the heart; constriction of the bronchi, with increased secretions; relaxation of the GI and urinary bladder sphincters, allowing evacuation of waste products; pupillary constriction, which decreases the light entering the eye and decreases stimulation of the retina. While urinary sphincters relax, they do not lose control so incontinence would not be an expected manifestation.

The nurse is assessing a client admitted with AIDS whose current antiretroviral regimen includes a nonnucleoside reverse transcriptase inhibitor. What nursing diagnosis related to drug therapy is most likely to be appropriate for this client? imbalanced nutrition: less than body requirements, related to gastrointestinal (GI) effects of the drugs deficient fluid volume related to diuretic effects risk for injury related to central nervous system (CNS) effects of the drug excess fluid volume related to renal failure

imbalanced nutrition: less than body requirements, related to gastrointestinal (GI) effects of the drugs Explanation: The adverse effects most commonly experienced with these drugs are GI related—dry mouth, constipation or diarrhea, nausea, abdominal pain, and dyspepsia. As a result, this client is most at risk for imbalanced nutrition; less than body requirements. CNS effects are not common with this classification of drug. Renal failure is not a common adverse effect. Diuresis is not expected.

A client states that he or she was exposed to chicken pox as a child, but he or she does not understand why that now makes him or her immune to subsequent infections with the same virus. During client teaching, the nurse should describe the actions of what immunoglobulin? immunoglobulin E immunoglobulin G immunoglobulin M immunoglobulin A

immunoglobulin G Explanation: After an active infection, the B memory cells will continue to make a supply of immunoglobulin, IgG, for use on future exposure to the chicken pox virus. The presence of this IgG confers immunity on the client. This is not a direct result of the actions of other immunoglobulins.

A nurse has administered a prescribed dose of an anticholinergic agent to a client. What assessment finding most clearly indicates a therapeutic response? increased salivation resolution of anxiety reduction in respiratory rate from 29 to 20 breaths/min increased heart rate

increased heart rate Explanation: Drugs that are used to block the effects of acetylcholine are called anticholinergic drugs. They cause a reduction in parasympathetic activity, resulting in increased sympathetic activity, such as increased heart rate. A reduction in parasympathetic activity would exacerbate, not resolve, anxiety. Anticholinergics reduce, not increase, secretions such as saliva. Respiratory rate would increase, not decrease.

An older adult client is brought to the emergency department by family members. The family states the client has been uncharacteristically confused and appears to have abnormal perception of movement. The nurse reviews the client's current medication regimen and suspects the client overdosed on what medication? metoprolol lorazepam cephalexin acetaminophen

lorazepam Explanation: Common manifestations of benzodiazepine toxicity include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Less common but more serious manifestations include confusion, abnormal perception of movement, depersonalization, psychosis, and seizures. These symptoms are not found in association with antibiotics, beta-blockers, or acetaminophen.

A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of: antibodies. capillaries. lymphocytes. cytoblasts.

lymphocytes. Explanation: The white blood cells involved in immunity (including lymphocytes) are produced in the bone marrow. Cytoblasts are the protoplasm of the cell outside the nucleus. Antibodies are produced by lymphocytes, but not in the bone marrow. Capillaries are small blood vessels

The client has a diagnosis of atherosclerosis. When a branch of the coronary artery becomes completely blocked, what event will the nurse expect to occur? arrhythmia heart failure hypertension myocardial infarction

myocardial infarction Explanation: The blood supply is most frequently altered, however, when the coronary vessels narrow and do not respond to stimuli to dilate and deliver more blood. This happens in atherosclerosis or coronary artery disease. The end result of this narrowing can be total blockage of a coronary artery, leading to hypoxia and eventual death of the cells that depend on that vessel for oxygen. This is called myocardial infarction (MI); as of 2010, it is the leading cause of death in the United States. An arrhythmia is an alteration in the conduction system. Heart failure is caused by ineffective pumping action of the heart muscle. Hypertension is an increase in blood pressure.

The nurse is reviewing the results of the complete blood count of a client who is diagnosed with bacterial meningitis. What value should the nurse expect to see elevated? eosinophil count neutrophil count hematocrit basophil count

neutrophil count Explanation: During an acute infection, the neutrophils are rapidly produced in response to the interleukins released by active white blood cells. They move to the site of insult to attack the foreign substance. Eosinophils are often increased in an allergic response. Basophils would only increase with generalized bone marrow stimulation. The hematocrit level is increased in polycythemia.

Before administering a client's prescribed nonselective adrenergic blocker, what should the nurse assess? bowel sounds and appetite pulse and blood pressure serum albumin level serum sodium and potassium levels

pulse and blood pressure Explanation: The nurse should monitor vital signs and assess cardiovascular status including pulse, blood pressure, and cardiac output to evaluate for possible cardiac effects. Although assessment of bowel sounds, appetite, serum albumin level, or serum sodium and potassium levels may be important to client care, they are not related to administration of a nonselective adrenergic blocking agent.

A client with a history of glaucoma is prescribed pilocarpine, a muscarinic receptor agonist. For what potential local and systemic effects should the nurse assess? Select all that apply. pupil dilation increased secretions increased bladder contraction increased heart rate pupil constriction

pupil constriction increased secretions increased bladder contraction Explanation: Stimulation of muscarinic receptors causes pupil constriction, increased gastrointestinal (GI) motility and secretions (including saliva), increased urinary bladder contraction, and a slowing of the heart rate. Pupils are constricted, not dilated and heart rate slows, it does not increase.

The nurse has administered the first dose of a client's newly-prescribed antibiotic. What assessment finding should the nurse interpret as adverse effect that suggests a more serious concern? decrease in blood pressure from 128/77 mm HG preadministration to 119/70 postadministration drowsiness new onset of pain rash to the face and trunk

rash to the face and trunk Explanation: A rash poses no threat in and of itself but suggests the possibility of drug intolerance or hypersensitivity. A modest decrease in blood pressure or level of consciousness would be less clinically significant. The nurse must address the client's pain, but this is unlikely to be a consequence of antibiotic use.

The nurse is providing client education for a client newly prescribed a hydantoin antiseizure medication. The nurse has taught the client about the need to taper down the dose of the drug slowly when the provider decides it should be discontinued. What benefit of tapering should the nurse describe? shorter duration of absence seizures reduced risk of cardiac arrhythmias reduced risk of status epilepticus improved blood pressure stability

reduced risk of status epilepticus Explanation: Discontinuing hydantoins could result in status epilepticus so that drugs should be withdrawn, or added to the medication regimen, carefully to avoid danger. An abrupt withdrawal of antiseizure medications would not precipitate hypertensive crisis, arrhythmias. The actual duration of absence seizures would not be affected.

The nurse is describing the structure and function of the two hemispheres of the brain to a recent graduate. What regulatory function should the nurse describe? regulation of the efferent conduction system regulation of communication between sensory and motor neurons regulation of the afferent conduction system regulation of the electrical conduction system of the brain

regulation of communication between sensory and motor neurons Explanation: The cerebral cortex consists of two hemispheres, which regulate the communication between sensory and motor neurons and are the sites of thinking and learning. The regulatory functions of the hemispheres do not focus electrical, afferent, or efferent conduction.

The nurse is admitting a client to the postanesthesia care unit (PACU) who received general anesthesia for the removal of a bunion. The nurse should prioritize what assessments? respirations and airway lung auscultation and apical heart rate pain and temperature skin integrity and peripheral perfusion

respirations and airway Explanation: Postanesthetic recovery requires frequent, comprehensive assessments including all of the listed parameters. Among the priority assessments, however, are the client's airway patency and respiratory status. This is because both are heavily influenced by anesthesia and have rapid, serious consequences if disrupted.

The nurse administers a drug that stimulates beta2 receptors. What type of health condition would this drug treat? heart disease respiratory disease diabetes high lipid levels

respiratory disease Explanation: Beta2-receptors are found in the smooth muscle in blood vessels, in the bronchi, in the periphery, and in uterine muscle. Beta2-receptors also cause dilation in the bronchi. Beta1-receptor stimulation would improve some heart disease and are responsible for increased lipolysis. Because beta2-receptors increase release of glucagon and the breakdown of glycogen, increasing serum glucose levels, stimulation of these receptors would exacerbate diabetes.

A client is preoperative and there is a need to decrease the client's sympathetic stimulation to ensure the client does not remember the procedure. The nurse should anticipate the use of what type of agent? antihistamine antiemetic sedative-hypnotic opioid agonist

sedative-hypnotic Explanation: Sedative-hypnotics relax the client, facilitate amnesia, and decrease sympathetic stimulation. Antihistamines decrease the chance of allergic reaction and help dry secretions. Antiemetics decrease the nausea and vomiting associated with gastrointestinal (GI) depression. Narcotics (opioid agonists) aid in the analgesic and sedative effects.

Which structure should the nurse identify as separating the right half of the heart from the left? syncytia septum auricle bundle of his

septum Explanation: The septum is a partition that separates the right and left halves of the heart. The right half receives deoxygenated blood from everywhere in the body and the left half receives oxygenated blood from the lungs. The auricle is an appendage attached to each atrium, which collects blood that is pumped into the ventricles by atrial contractions. Impulses are sent from the atria into the ventricles by way of the bundle of His, which then enters the septum and subdivides into three bundle branches that become a network of fibers that delivers the electrical impulse to the ventricular cells. The myocardium forms two intertwining networks, atrial and ventricular syncytia, which enable first the atria and then the ventricles to contract synchronously when excited by the same stimulus.

A client has developed left-sided heart failure. What assessment finding should the nurse attribute to this health problem? shortness of breath increased abdominal girth irregular heart rhythm pitting edema to the ankles and feet

shortness of breath Explanation: Pulmonary edema can occur when the heart is damaged and the left side of the heart is unable to effectively pump blood returning from the right side of the heart into systemic circulation. Accumulation of fluid in the lungs can cause shortness of breath. Right-sided failure is more closely associated with peripheral edema. Heart failure does not directly cause arrhythmias. Increased abdominal girth is more closely associated with fluid imbalances.

A client has been diagnosed with chronic obstructive pulmonary disease. The client has been prescribed bronchodilators by nebulizer for home use. The nurse should teach the client to: keep an extra oxygen tank on hand for propelling the medication. gargle with an alcohol-based mouthwash after each dose. sit in a fully upright position when administering the medication. take the exact number of puffs that have been prescribed.

sit in a fully upright position when administering the medication. Explanation: Clients should sit in the Fowler position when inhaling nebulized medications. Compressed air (not oxygen) is used. Inhalers require a prescribed number of "puffs," not nebulizers. The client should rinse his or her mouth after administration, but an alcohol-based solution is not necessary.

What is the purpose of the myelin sheath? speeds electrical conduction produces Schwann cells secretes neurotransmitters protects the nerve from damage

speeds electrical conduction Explanation: Long nerves are myelinated: they have a myelin sheath that speeds electrical conduction and protects the nerves from the fatigue that results from frequent formation of action potentials, not from damage. Although myelin sheaths have Schwann cells, they do not produce these cells and the myelin sheath does not secrete neurotransmitters.

The nurse is preparing to administer a sympathomimetic drug to a client. How does this drug achieve a therapeutic effect?

stimulating alpha- and beta-receptors Explanation: Drugs that are generally sympathomimetic are called alpha-agonists (stimulate alpha-receptors) and beta-agonists (stimulate beta-receptors). These agonists stimulate all of the adrenergic receptors; that is, they affect both alpha- and beta-receptors.

The nurse accompanies the healthcare provider into the client's room and remains after the client is told that they have cancer and a poor prognosis. The client's respirations become rapid and deep, their pupils dilate, and they appear diaphoretic. What type of response is the nurse witnessing? nicotinic receptor stimulation response muscarinic receptor stimulation response sympathetic nervous system (SNS) response parasympathetic nervous system (PNS) response

sympathetic nervous system (SNS) response Explanation: When stimulated, the SNS prepares the body to flee or to turn and fight. Cardiovascular activity increases, as do blood pressure, heart rate, and blood flow to the skeletal muscles. Respiratory efficiency also increases; bronchi dilate to allow more air to enter with each breath, and the respiratory rate increases. Pupils dilate to permit more light to enter the eye to improve vision in darkened areas. PNS would lower heart rate and blood pressure and would constrict pupils. The client's response could not be wholly isolated to a muscarinic or nicotinic response.

The nurse is preparing to administer scheduled medications to a client in the community. What are responsibilities of the nurse related to the client's drug therapy? Select all that apply. altering the drug regimen to optimize the client's outcomes evaluating the effectiveness of the client's drug therapy teaching the client how to participate in therapy to ensure best outcomes recommending appropriate over-the-counter medications as alternatives to prescription drug therapy providing therapeutic interventions that complement the medications

teaching the client how to participate in therapy to ensure best outcomes providing therapeutic interventions that complement the medications evaluating the effectiveness of the client's drug therapy Explanation: A nurse is, therefore, a key healthcare provider who is in a position to assess the whole client, to administer therapy as well as medications, to teach the client how best to cope with the therapy to ensure the most favorable outcome, and to evaluate the effectiveness of the therapy. Nurses do not alter drug therapy or recommend over-the-counter medications as direct alternatives to prescribed medications.

The nurse is preparing to provide health education to a client. The client's learning will take place in what brain region? the areas that coordinate speech and communication the area that coordinates sensation the area that coordinates movement the areas that communicate between motor and sensory neurons

the areas that coordinate speech and communication Explanation: The forebrain is made up of two cerebral hemispheres that contain areas that coordinate speech and communication and are thought to be the area where learning takes place. The forebrain does not coordinate sensation or movement or communicate between the sensory and motor systems.

A client with a gram-negative infection is being treated with an aminoglycoside. What assessment should the nurse prioritize during treatment? breath sounds and oxygen saturation visual acuity muscle strength and coordination urine output and BUN and creatinine levels

urine output and BUN and creatinine levels Explanation: Renal function should be tested daily because aminoglycosides depend on the kidney for excretion and if the glomerular filtration rate (GFR) is abnormal, it may be toxic to the kidney. The results of the renal function testing could change the daily dosage. Aminoglycosides do not usually adversely affect respiratory or musculoskeletal function, although baseline data concerning these systems is always needed. Auditory effects are more likely than visual effects.

A parent calls the clinic and tells the nurse that the parent's toddler has a temperature of 102°F (38.9°C). What should the nurse teach the parent about the child's fever? "Neutrophils release pyrogen, a fever-causing substance, which helps act as a catalyst for the body's inflammatory and immune responses." "Inflammation causes the activation of a chemical called Hageman factor that initiates a process to bring more blood to the injured area and allows white blood cells to escape into the tissues." "A fever is the body's way of fighting an infection and supporting the body's immune system." "Leukotrienes activated by arachidonic acid attract neutrophils to start the process of fighting inflammation."

"A fever is the body's way of fighting an infection and supporting the body's immune system." Explanation: The best response by the nurse would be that a fever actually increases the efficiency of the immune and inflammatory responses, helping the body to fight the infection. While the other three statements are correct, they are more technical and include terminology that a new mother may not understand or even care about. If the appropriate response does not suffice and the mother still has questions, the nurse would then go into more detail and use the rationale from the other options to explain in greater detail.

A client has just been diagnosed with HIV. When developing the teaching plan, what information would the nurse share with this client related to use of alternative or complementary therapies? "Researchers have not looked at the benefits of alternative therapy for clients with HIV, so it is suggested you avoid these therapies until research data are available." "Alternative therapies have benefits and risks. Are there any types of alternative or complementary therapies that you follow or are there any herbs or supplements that you take?" "You do not take herbs or practice some type of alternative medicine such as acupuncture, massage therapy, hypnosis or diet therapy, do you?" "Complementary therapies such as acupuncture or herbal therapy are generally considered to be dangerous to clients with HIV, so we discourage them."

"Alternative therapies have benefits and risks. Are there any types of alternative or complementary therapies that you follow or are there any herbs or supplements that you take?" Explanation: With a new diagnosis of HIV, it is important for the nurse to assess the client for use of alternative therapies because some alternative therapies are contraindicated while on antiviral medication. The nurse should avoid negative statements that discourage the client from sharing information with the nurse. The statement about lack of research gives the client information but does not elicit information in return and is therefore inappropriate for the nurse to use.

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the client? "Can you tell me what concerns you most about dying?" "Would you like me to have the chaplain come speak with you?" "You need to maintain hope because you may live for several years." "You'll learn much about the promise of a cure for HIV."

"Can you tell me what concerns you most about dying?" Explanation: The nurse can help the client verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the client to identify fears about being diagnosed with a life-threatening chronic illness. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the client's expressed fears.

A newly admitted client with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the client the etiology of type 1 diabetes, what process should the nurse describe? "The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin." "The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase" "Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it." "Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."

"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down." Explanation: Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not "make" glucose.

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? "Do you feel flushed or sweaty?" "Are you experiencing any dizziness or lightheadedness?" "Do you feel any muscle twitches or spasms?" "Are you having any pain that seems to be radiating from your bones?"

"Do you feel any muscle twitches or spasms?" Explanation: As the blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This is characteristic of hypoparathyroidism. Flushing, diaphoresis, dizziness, and pain are atypical signs of the resulting hypocalcemia.

A nurse is providing health education to a client in the community in an effort to prevent administration errors or adverse effects. What teaching points should the nurse provide? Select all that apply. "Keep any adjustments to your medication doses to a minimum, even if you're not feeling well." "Take all of your medications within 5 minutes of the time you're instructed." "Feel free to ask questions if there's anything that's not clear to you." "Unless you're told otherwise, store your medications in a warm humid place." "Keep an updated list of your prescribed medications with you."

"Feel free to ask questions if there's anything that's not clear to you." "Keep an updated list of your prescribed medications with you." Explanation: Appropriate client teaching will reduce the risk of medication errors and complications. Nurses teach clients to speak up, ask questions, and act as his or her own advocate when medications are being prescribed. He or she should keep a complete list of medications and have a copy available at all times in case of accident. Store drugs in a dry, cool place away from children and pets that could be harmed. Take medications as they have been prescribed and do not adjust dosage without authorization from the prescriber. Take medications at the time they are prescribed to be taken; however, there is nearly always more than 5 minutes' flexibility, especially in a community-dwelling client.

The nurse is admitting a 12-year-old child to the acute care facility and notices discolored secondary teeth. The parent doesn't know why the teeth are discolored and reports that the child is very good about brushing and flossing and sees the dentist regularly. What question should the nurse ask? "Have they ever received gentamicin?" "Have they ever received cephalexin?" "Have they ever received tetracycline?" "Have they ever received ampicillin?"

"Have they ever received tetracycline?" Explanation: The nurse would question whether the child was ever given tetracycline because this drug is commonly associated with discoloration of secondary teeth when it is administered to children who still have their primary teeth. Gentamicin, ampicillin, and cephalexin are not associated with discoloration of the teeth.

The nurse is taking a health history on a 58-year-old client who is taking atorvastatin for high cholesterol. What assessment question should the nurse prioritize related to the safe use of this drug? "How many alcoholic drinks do you have in a typical day or week?" "Do you use any over-the-counter medications for headaches or colds?" "Do you do any physical exercise on a regular basis?" "How would you describe your caffeine intake?"

"How many alcoholic drinks do you have in a typical day or week?" Explanation: Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors are contraindicated with active liver disease or a history of alcohol-related liver disease, so it is important for the nurse to ask about the client's use of alcohol. For most clients, heavy alcohol use would be more dangerous than high caffeine intake or the use of OTC medications. Exercise has multiple benefits and should be addressed by the nurse, but it is unrelated to safe medication use.

A nurse is teaching a 54-year-old client how to take sublingual nitroglycerin. What statement by the client indicates an understanding of the nurse's instructions? "A headache means a toxic level has been reached." "I can take up to three tablets at 5-minute intervals." "If I become dizzy after taking the medication, I should stop taking it." "I can the drug as I require it because it is not habit-forming."

"I can take up to three tablets at 5-minute intervals." Explanation: Sublingual nitroglycerin may be taken at 5-minute intervals up to a maximum of three doses to relieve anginal chest pain. Headaches are very common due to vasodilation and do not indicate a toxic level. Nitroglycerin causes significant peripheral vasodilation in addition to its therapeutic effects of coronary artery dilation so no more than three tablets should be taken, even though it is not habit-forming. Dizziness could be an adverse effect of the drug or a manifestation of inadequate cardiac output, but it would not indicate the client should stop taking it.

A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? "I seem to have lost my appetite, which is unusual for me." "When I eat a meal that's high in fat, I get really nauseous." "I feel so foggy in the mornings and it takes me so long to wake up." "I have this ringing in my ears that just won't go away."

"I have this ringing in my ears that just won't go away." Explanation: Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance of high-fat meals, or anorexia.

The nurse concludes that a client has an understanding of the side effects of furosemide and its relationship to potassium levels when the client states: "I should call the doctor if I develop diarrhea." "I should call my doctor if I feel myself becoming dizzy when I stand up." "I don't need to take my pulse anymore when I take my digoxin." "I don't need to eat bananas for breakfast anymore since I am taking this medication."

"I should call my doctor if I feel myself becoming dizzy when I stand up."

The nurse is preparing a client for discharge who will receive a prescription for a hydroxymethylglutaryl-coenzyme A (HMG-CoA) inhibitor. What statement by the client demonstrates a clear understanding of the teaching provided by the nurse? "After I start taking this drug, I can scale back the exercise routine the doctor prescribed." "I will not need to follow that low-fat diet anymore because this drug will take care of my lipids." "I should take this drug first thing in the morning and make sure I drink a full glass of water." "I should plan to take this drug before bedtime, because my body makes lipids mostly at night."

"I should plan to take this drug before bedtime, because my body makes lipids mostly at night." Explanation: HMG-CoA inhibitors should be taken at bedtime because the body produces lipids mostly at night. Diet and exercise are still important when taking these drugs because the drug is most effective in combination with other lipid-lowering actions.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the patient about methods to manage fatigue. Which statement by the client indicates a need for further instructions? "I should do some exercises, such as walking, when I am not fatigued." "I should sit whenever possible to conserve my energy." "I should avoid long periods of immobility because it causes joint stiffness." "I should take hot baths because they are very relaxing."

"I should take hot baths because they are very relaxing."

A nurse is preparing to discharge a client who has been prescribed warfarin. While assessing the client's knowledge of the drug, what statement should the nurse address? "I aim to walk 2 miles a day." "I take aspirin to help with the pain of my arthritis." "I drink a glass of wine with dinner some evenings." "I take vitamin C when I feel like I'm getting a cold."

"I take aspirin to help with the pain of my arthritis." Explanation: Increased bleeding can occur if a salicylate is taken in combination with warfarin. The nurse will instruct the client to stop taking aspirin. Walking, taking vitamin C, and drinking an occasional glass of wine should not interfere with the therapeutic effects of warfarin.

The nurse determines that teaching about warfarin is successful when the client makes what statement? "If I miss a dose, I will take 2 pills the next day." "I will check with my health care provider before taking any herbal supplements." "I will make sure to get my annual flu vaccine this fall." "I will minimize my physical activity so I don't start bleeding."

"I will check with my health care provider before taking any herbal supplements." Explanation: Warfarin is involved in many drug-drug and drug-herb interactions, so the client's statement about checking with the doctor before starting any new drugs or supplements would be correct. The other statements made by the client indicate the need for further teaching because he or she should not take two pills after missing a dose. The client should make an effort to avoid preventable injuries, but minimizing physical activity in general would not be necessary or beneficial. Vaccinations are beneficial but not to any greater extent than with a client who is not taking warfarin.

An 11 year-old client has been diagnosed with epilepsy and prescribed phenytoin 100 mg PO b.i.d. What statement by the client's parent suggests an accurate understanding of the client's medication regimen? "I will make sure my child has routine visits to the dentist." "I will stop the drug immediately if any side effects occur." "I will make sure my child takes the medication on an empty stomach." "I will weigh my child daily and feed them a high-calorie diet."

"I will make sure my child has routine visits to the dentist." Explanation: Gingival hyperplasia is common in clients, especially children, who take phenytoin, which makes regular dentist visits important to oral health. Taking the medication on a full stomach or with meals reduces gastrointestinal (GI) adverse effects. The mother should call the healthcare provider if adverse effects are noted and needs to understand the risks associated with abrupt withdrawal of the medication. Daily weight taking and high-calorie diets are not necessary during phenytoin administration.

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what? "I will call the doctor if my blood sugar is over 300 mg/dL (16.6 mmol/L) or if I have ketones in my urine." "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea."

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." Explanation: The nurse must explain the "sick day rules" again to the client who plans to stop taking insulin when sick. The nurse should emphasize that the client should take insulin agents as usual and test one's blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring clients may need supplemental doses of regular insulin every 3 to 4 hours. The client should report elevated glucose levels (greater than 300 mg/dL or 16.6 mmol/L, or as otherwise instructed) or urine ketones to the physician. If the client is not able to eat normally, the client should be instructed to substitute with soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the client should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

A client presents at the clinic with signs and symptoms of seasonal allergic rhinitis. The client is prescribed a nasal steroid to relieve symptoms. Two days later, the client calls the clinic stating that he is not experiencing any relief. What is the most appropriate response by the nurse? "You probably need to try a different nasal steroid. This one should be effective by now." "It could be that you are administering the drug incorrectly. Come in and we can review the process." "The drug must not work for you. I'll contact your provider to see if you can change to an oral steroid." "It may take up to 2 weeks to get the full clinical effect. Try to keep using the drug as prescribed."

"It may take up to 2 weeks to get the full clinical effect. Try to keep using the drug as prescribed." Explanation: Nasal steroids require about 2 weeks to reach their full clinical effect so the client should be encouraged to use the drug for that length of time before changing drugs or giving up. The other responses could be appropriate if after 2 weeks the client is still not getting relief.

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being suggestive of diabetes? "I've always been a fan of sweet foods, but lately I'm turned off by them." "No matter how much sleep I get, it seems to take me hours to wake up." "Lately, I drink and drink and can't seem to quench my thirst." "When I went to the washroom the last few days, my urine smelled odd."

"Lately, I drink and drink and can't seem to quench my thirst." Explanation: Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? "It is normal to be a little confused following surgery, and it is safe not to urinate at night." "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. " "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup."

"Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." Explanation: In elderly clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.

An older adult client taking high-dose corticosteroids to treat arthritis requests a measles vaccine. What is the nurse's best response? "Live virus vaccines cannot be given to people whose immune systems are suppressed." "Clients taking corticosteroids are well protected from viruses and do not need vaccines." "Corticosteroids interact with the measles vaccine to create serious adverse effects." "Measles vaccines are only given if you are at risk for serious complications of the disease."

"Live virus vaccines cannot be given to people whose immune systems are suppressed." Explanation: Corticosteroids block the inflammatory response and are very helpful in conditions such as arthritis. However, they also block the immune response, making a person immunosuppressed. The vaccine would not be given to this client because of the increased risk for infection. Vaccination against measles is universally recommended. Corticosteroids do not protect against viruses. The vaccine is contraindicated because of risk for infection and not because of a potential drug-drug interaction.

The nurse is discharging a 35-year-old client with diabetes who has been prescribed an adrenergic blocking agent. What is the priority teaching point for the nurse to discuss with this client? "Increase insulin dosage to compensate for the drug's effect in increasing blood sugar" "Reduce carbohydrate intake more than usual while taking the new drug" "Document signs and symptoms of hyperglycemia and hypoglycemia" "Monitor blood glucose levels closely and report any instability"

"Monitor blood glucose levels closely and report any instability" Explanation: It is important for the client to be instructed to monitor blood sugar levels more frequently because adrenergic blocking agents mask the normal hypo- and hyperglycemic manifestations that normally alert clients such as sweating, feeling tense, increased heart rate, and rapid breathing. There is no need to change the diet or the diabetic medications. There may be no signs and symptoms to record because they are blocked by the adrenergic blocker.

A client is undergoing diagnostic testing to determine the etiology of recent joint pain. The client asks the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees." "OA originates with an infection. RA is a result of your body's cells attacking one another." "OA is associated with impaired immune function; RA is a consequence of physical damage." "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

"OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Explanation: OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on the articular surfaces of weight-bearing joints, with spur development. RA is characterized by inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by the joints affected and neither has an infectious etiology.

The nurse is teaching a client with orthostatic hypotension about the role of renin in maintaining blood pressure. What process should the nurse describe? "Renin is involved in venous blood pressure and controls the flow of blood through the tubules." "Renin is directly involved in the control of arterial blood pressure and it is essential for proper functioning of the glomerulus." "Renin is involved in venous blood pressure and it is essential for proper functioning of the glomerulus." "Renin is directly involved in the control of arterial blood pressure and the flow of blood through the pyramids of the kidney."

"Renin is directly involved in the control of arterial blood pressure and it is essential for proper functioning of the glomerulus." Explanation: Renin is a hormone directly involved in the control of arterial (not venous) blood pressure. It is essential for proper functioning of the glomerulus, not the "pyramids of the kidney."

The nurse is describing the differing functions of the sympathetic nervous system (SNS) and parasympathetic nervous system to a client. The nurse has explained how the SNS is associated with a "fight-or-flight" reaction. How should the nurse describe the characteristics of the parasympathetic nervous system? "Rest and digest" "Respond and return" "Recover and repair" "Reflect and recharge"

"Rest and digest" Explanation: Although the SNS is associated with the stress reaction and expenditure of energy, the parasympathetic nervous system is associated with activities that help the body to store or conserve energy, a "rest-and-digest" response.

The client in the clinic receives a prescription for an anti-infective to treat a urinary tract infection. The client asks the nurse, "Would you ask the doctor to give me refills on this prescription? I get a urinary tract infection every few months, it seems, and I'd like to have a refill on hand for next time." What is the nurse's best response? "Most medications, if not used, should be discarded after a year so it is better to get a new prescription next year when you need it." "Sure, I'd be glad to ask. How many refills do you think you would need?" "Saving antibiotics for another time and trying to diagnose your own health problems can lead to resistant organisms that no longer respond to drugs." "This antibiotic doesn't destroy every virus that could cause a urinary tract infection so it is better to get a different antibiotic next time."

"Saving antibiotics for another time and trying to diagnose your own health problems can lead to resistant organisms that no longer respond to drugs." Explanation: Clients should not be given refills to use indiscriminately. The priority is teaching this client about drug-resistant organisms and how they can be prevented, as well as what happens if an infection results from a resistant organism. The expiration date of medications is not relevant to the discussion. Antibiotics are not used to treat viruses.

The client receives a prescription for niacin, and the nurse is providing education about the medication. What should the nurse teach the client about possible adverse effects of the medication? "Sometimes this causes a full body rash when you first take it, but that doesn't necessarily mean you're allergic to it." "Some people get very flushed skin when they take this medication." It's important to avoid eating shellfish and to tell your care provider before having any diagnostic imaging tests." "You're likely to have some nausea when you begin taking the drug, but this will dissipate with time."

"Some people get very flushed skin when they take this medication." Explanation: Niacin is associated with intense cutaneous flushing, nausea, and abdominal pain, making its use somewhat limited. A full body rash should always be reported and self-limiting nausea is not expected. There is no need to avoid shellfish or contrast solution when taking niacin.

A client presents to the clinic and is diagnosed with a vaginal fungal infection. What should the nurse teach the client about self-administration of the prescribed vaginal antifungal medication? "Stay lying down for at least 15 minutes after insertion." "Gently rub the cream into your vaginal wall after insertion." "Insert low into the opening of the vagina." "Temporarily discontinue the medication when you're menstruating."

"Stay lying down for at least 15 minutes after insertion." Explanation: The client should remain recumbent at least 10 to 15 minutes after the medication is deposited high in the vagina so that leakage will not occur and absorption will take place. The effectiveness of the medication is determined by the consistent application for each specified dose for maximal results. The nurse would instruct the client to continue the medication during menstruation. Stopping the drug and restarting it later can lead to the development of resistant strains of the drug. The cream need not be rubbed into the vaginal wall as it will coat the wall naturally after insertion.

A client who is using a topical antifungal agent to treat mycosis calls the clinic to report a severe rash that is accompanied by blisters. What should the nurse instruct the client to do? "Scrub the rash gently with soap and water." "Stop using the drug immediately." "Decrease the amount of the medication used." "Make an appointment so you can be tested for allergies."

"Stop using the drug immediately." Explanation: The client should stop using the drug. The rash could indicate sensitivity to the drug or worsening of the condition being treated. Scrubbing the rash could cause further irritation and increase the risk for other infections. Continuing the drug could cause further complications. Decreasing the medication would be ineffective in treating the infection while continuing to risk further complications. It would be unnecessary to have clinical allergy testing prior to discontinuing the medication.

An older adult client is taking a sustained-release antihypertensive drug. What is the nurse's priority teaching point about this medication? "Swallow the drug whole and do not to cut, crush, or chew it." "Take your blood pressure only at night so that it's most accurate." "Take the drug before bedtime to reduce your risk of falling." "Use over-the-counter (OTC) cold medications cautiously."

"Swallow the drug whole and do not to cut, crush, or chew it." Explanation: Sustained-release drugs cannot be cut, crushed, or chewed; it destroys the matrix system and allows absorption of the complete dose all at once. Older clients should be especially cautioned about sustained-release antihypertensives that cannot be cut, crushed, or chewed to avoid the potential for excessive dosing if these drugs are inappropriately cut. Many OTC drugs contain ingredients that increase blood pressure and so are not recommended for clients with hypertension. The client can take his or her blood pressure any time in the day, but it is usually recommended for the morning.

The nurse has provided health teaching for a 15-year-old client newly diagnosed with asthma. What statement made by the client indicates a good understanding of the teaching the nurse has done regarding inhalers? "I need to take 3 short, quick breaths when I administer the inhaler." "I should hold my breath when administering a puff." "I should insert the inhaler about 1 inch into my mouth." "The aerosol canister should be shaken well before using."

"The aerosol canister should be shaken well before using." Explanation: Inhalers should be shaken well, immediately before each use. It would not be appropriate to teach the client to hold his breath when administering a puff because this would inhibit inhalation. The client should hold the device around one inch from the open mouth, not inside it. There is no need to take three quick breaths.

The nurse is caring for a patient newly diagnosed with multiple sclerosis. The patient asks why MS is called an autoimmune disease. What would be the nurse's best response? "The body attacks its own cells because it responds to specific self-antigens to produce antibodies." "The body responds to a cell invaded by bacteria with antibody production against similar cells." "Production of autoantibodies is a normal process that goes on all the time, but immunosuppression limits B-cell response." "People with multiple sclerosis have a genetic predisposition to destroy autoantibodies."

"The body attacks its own cells because it responds to specific self-antigens to produce antibodies." Explanation: Autoimmune disease occurs when the body responds to specific self-antigens to produce antibodies or cell-mediated immune responses against its own cells. The actual cause of autoimmune disease is not known, but theories speculate that (1) it could be a result of response to a cell that was invaded by a virus, leading to antibody production to similar cells; (2) production of autoantibodies is a normal process that goes continuously, but in a state of immunosuppression, the suppressor T cells do not suppress autoantibody production; or (3) a genetic predisposition to develop autoantibodies is present.

An adolescent presents to the free clinic with reports of allergic rhinitis. The adolescent asks the nurse what makes the nose get so stuffy. What is the nurse's best response? "The inside of the nose swells because the blood vessels expand." "Cells called leukotrienes are attacking the mucous membranes of your nose and causing irritation." "Allergies make the sinuses drain into the nasal passages and it stuffs them up." "The inside of the nose swells closed because of drainage from the sinuses."

"The inside of the nose swells because the blood vessels expand." Explanation: Histamine is the major mediator of allergic reactions in the nasal mucosa. Tissue edema results from vasodilation and increased capillary permeability. Tissue edema is not caused by drainage from the sinuses or from leukotrienes.

A nurse is teaching a client who has just been prescribed lansoprazole . What statement would indicate that the client correctly understands the action of this medication? "The medication will repair my ulcer." "The medication is an analgesic." "The medication inhibits acid secretions." "The medication is an antibiotic."

"The medication inhibits acid secretions." Explanation: The gastric acid pump or proton pump inhibitors suppress gastric acid secretion by specifically inhibiting the hydrogen-potassium adenosine triphosphatase (H+,K+-ATPase) enzyme system on the secretory surface of the gastric parietal cells. The statement, "The medication inhibits acid secretions," indicates that the client understands that the medication inhibits acid secretion. This medication does not act as an antibiotic or analgesic, nor will it repair the ulcer.

A client who has been newly diagnosed with chronic obstructive pulmonary disease (COPD) calls the clinic and asks the nurse to explain what the newly prescribed medications are for. What would be the most appropriate response by the nurse? "The medications that have been ordered for you are what the physician thinks will help your breathing the most." "The medications that have been ordered for you are to help relieve the inflammation and to open your airways." "The medications that have been ordered for you are to help you breathe with less resistance from your diaphragm." "The medications that have been ordered for you are designed to work together to reduce your oxygen requirements."

"The medications that have been ordered for you are to help relieve the inflammation and to open your airways." Explanation: Drug treatment of asthma and COPD aims to relieve inflammation and promote bronchial dilation. Drugs affecting the lower airway do not normally affect the diaphragm. They do not reduce the body's oxygen demand. Stating that the physician thinks they are best is not a sufficient or helpful response.

A client has been living with seasonal allergies for many years, but does not take antihistamines, stating, "When I was young I used to take antihistamines, but they always put me to sleep." How should the nurse best respond? "The newer antihistamines are different than in years past, and cause less sedation." "Most people find that they develop a tolerance to sedation after a few months." "Newer antihistamines are combined with a stimulant that offsets drowsiness." "Have you considered taking them at bedtime instead of in the morning?"

"The newer antihistamines are different than in years past, and cause less sedation." Explanation: Unlike first-generation H1 receptor antagonists, newer antihistamines bind to peripheral rather than central nervous system H1 receptors, causing less sedation, if at all. Tolerance to sedation did not usually occur with first-generation drugs and newer antihistamines are not combined with a stimulant.

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? "Because the physician isn't taking my ovaries, I'll still be able to have children." "The physician is going to remove my uterus and told me about the risk of bleeding." "I know I'll be fine because the physician said he has done this procedure hundreds of times." "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum."

"The physician is going to remove my uterus and told me about the risk of bleeding." Explanation: The surgeon must inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the physician. In the correct response, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed.

A nurse is providing education to a client who has been experiencing unstable angina. What is the nurse's best explanation of this condition? The pain is caused by a spasm of a blood vessel, not just from the vessel narrowing." A coronary vessel has become completely plugged and is unable to deliver blood to your heart." "Your body's response to a lack of oxygen in the heart muscle is pain." "There is serious narrowing of a coronary artery that is causing a reduction in oxygen to the heart."

"There is serious narrowing of a coronary artery that is causing a reduction in oxygen to the heart." Explanation: Unstable angina is described as increased narrowing of coronary arteries with the heart experiencing episodes of ischemia even at rest. If a coronary vessel is completely occluded and unable to deliver blood to the cardiac muscle, a myocardial infarction has occurred. Prinzmetal angina is an unusual form of angina caused by spasm of the blood vessel and not just by vessel narrowing. Although pain is the body's response to ischemia in the heart muscle, this description could encompass angina or a myocardial infarction and is not specific enough to explain the condition.

The nurse is caring for a client who is immunocompromised and is explaining the function of cytotoxic T cells. What should the nurse explain to this client? "Cytotoxic T cells are programmed to identify specific proteins or antigens that are foreign to your body." "These are cells that respond to rising levels of chemicals associated with an immune response in order to suppress or slow the reaction." "These T cells can either destroy a foreign cell or mark it for aggressive destruction by another cell." "These cells respond to chemical indicators of immune activity and stimulate other lymphocytes to be more aggressive and responsive."

"These T cells can either destroy a foreign cell or mark it for aggressive destruction by another cell." Explanation: Effector or cytotoxic T cells either destroy a foreign cell or make it available for aggressive destruction. Cells that identify specific proteins or antigens are B cells. Cells that respond to chemical indicators to stimulate other cells are helper T cells. Cells that suppress or slow the reaction are suppressor T cells.

The nurse admits a client with septicemia (infection in the bloodstream). The client denies any allergies, and the doctor has ordered cefuroxime based on blood culture and sensitivity testing. The client states, "I'd prefer vancomycin because I've been reading about drug-resistant bacteria and I don't want to take any chances." What is the nurse's best response? "You can't believe anything you read on the internet because most of it is just someone's opinion and not fact." "I appreciate your concern but you can certainly rest assured that the health care provider ordered the right medication for your needs." "Vancomycin is a powerful drug with many adverse effects and it is generally reserved for when no other drug will work." "There are some resistant infections that require vancomycin so you are right to prefer a stronger antibiotic."

"Vancomycin is a powerful drug with many adverse effects and it is generally reserved for when no other drug will work." Explanation: The client is right in saying that vancomycin is effective against drug-resistant bacteria but needs help to understand that he or she does not have a resistant infection as indicated by the culture and sensitivity and that use of such a powerful drug when it is not needed increases risk of developing a vancomycin-resistant infection. It is never right to tell a client "not to worry" because they have every right to participate in his or her own care and should not be patronized. Although some information on the internet may not be accurate, it would be incorrect to say it is all just someone's opinion and not fact, especially given that the client's information is accurate.

A nurse in the rehabilitation unit is caring for an older adult client who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the client to walk for 10 minutes 3 times a day. The client questions the relationship between walking and heart function. How should the nurse best reply? "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart." "Walking helps your heart adjust to your new arteries and helps build your self-esteem." "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." "Walking increases your heart rate and blood pressure. Therefore, your heart is under less stress."

"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart." Explanation: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart's pumping ability, which increases heart rate and blood pressure and the heart's ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the client had an MI—there are no "new arteries."

A client with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the client expresses anger and irritation when her call bell isn't answered immediately. What would be the most appropriate response? "You seem like you're feeling angry. Is that something that we could talk about?" "Would you like to talk about the problem with the nursing supervisor?" "I can see you're angry. I'll come back when you've calmed down." "Try to remember that stress can make your symptoms worse."

"You seem like you're feeling angry. Is that something that we could talk about?" Explanation: The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care, as well as sensitivity to the psychological reactions of the client. Offering to listen to the client express anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said. Offering to get the nursing supervisor also does not acknowledge the client's feelings.

The nurse is caring for a client in the postoperative period following an abdominal hysterectomy. The client states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time."

"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time." Explanation: Postoperatively, medications are given to relieve pain and maintain comfort without increasing the risk of inadequate air exchange. The nurse should address the client's concerns about drug dependency and the nurse's need to increase the client's ability to move and recover from surgery. The other responses offer incorrect information, such as increasing the client's ability to breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression.

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for the specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? "The presence of food in the stomach interferes with the absorption of anesthetic agents." "You will need to have food and fluid restricted before surgery so you are not at risk for choking." "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

"You will need to have food and fluid restricted before surgery so you are not at risk for choking." Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in clients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

A 29-year-old client is admitted with severe bleeding from a fractured femur. Which intravenous (IV) fluid does the nurse anticipate as the most appropriate for use to replace potential fluid loss? 3% sodium chloride (3% NaCl) 5% dextrose in water (D5W) 0.9% sodium chloride (0.9% NaCl) 5% dextrose in 0.45% sodium chloride (D5½NS)

0.9% sodium chloride (0.9% NaCl)

Which are characteristics of the termination stage of group development? Select all that apply. 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with each other. 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation.

1 and 6 Rationale: The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with each other, and some structuring of group norms, roles, and responsibilities takes place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage, the group evaluates the experience and explores members' feelings about the group and the impending separation.

The nurse is preparing a client for electroconvulsive therapy (ECT). The family of the client asks the nurse about this treatment. The nurse responds, knowing that which statements are accurate regarding this treatment? Select all that apply. 1. The average series involves 6 to 12 treatments. 2. Some confusion may be noted after the procedure. 3. Memory loss will occur but will resolve with time. 4. This treatment is a permanent cure to the condition. 5. This treatment is tried before the use of medications.

1, 2, 3 Rationale: ECT as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition.

The nurse is preparing a client for electroconvulsive therapy (ECT), which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1. Obtain an informed consent. 2. Have the client void before the procedure. 3. Remove dentures and contact lenses before the procedure. 4. Withhold food and fluids for 6 hours before the treatment. 5. Administer tap water enemas on the evening before the procedure.

1, 2, 3, 4 Rationale: Enemas are not a component of the pretreatment care for a client scheduled for ECT. Options 1, 2, 3, and 4 are a part of the pretreatment plan. Additionally, the nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure.

The nurse is developing a plan of care for a client with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. 1. Assist the client in selecting foods from the food menu. 2. Offer high-calorie fluids throughout the day and evening. 3. Allow the client to eat alone in the room if the client requests to do so. 4. Offer small high-calorie, high-protein snacks during the day and evening. 5. Select the foods for the client to be sure that the client eats a balanced diet.

1, 2, 4 Rationale: In caring for a client with depression whose nutritional intake is poor, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.

The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

1, 2, 4, 5 Rationale: Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

1, 3, 4 Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1, 3, 4, 6 Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate.

1, 3, 4, 6 Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide? 1. "Discussing suicide with a client is not harmful." 2. "Those clients who talk about suicide never do it." 3. "Depressed clients are the only persons who commit suicide." 4. "When a person talks about making suicide threats, the only thing the person wants is attention from family and friends."

1. "Discussing suicide with a client is not harmful." Rationale: An open discussion of suicide will not encourage a client to make a decision to commit suicide and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. Options 2, 3, and 4 are inaccurate statements regarding suicide.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."

1. "I no longer feel that I deserve the beatings my husband inflicts on me." Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.

A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group? 1. "The leader is a nurse or psychiatrist." 2. "The members provide support to each other." 3. "People who have a similar problem are able to help others." 4. "It is designed to serve people who have a common problem."

1. "The leader is a nurse or psychiatrist." Rationale: The sponsor of a self-help group is an experienced member of the group. The nurse or psychiatrist may be asked by the group to serve as a resource, but would not be the leader of the group. The remaining options are characteristics of a self-help group.

A client with depression is scheduled to receive three sessions of electroconvulsive therapy (ECT). The client asks the nurse about the length of time it will take for improvement in the condition. The nurse should tell the client he or she will see improvement approximately how long after the three treatments? 1. 1 week 2. 3 weeks 3. 4 weeks 4. 8 weeks

1. 1 week Rationale: Health care providers generally administer ECT treatments three times a week, with an average series including 8 to 12 treatments. After three sessions of ECT, the client should start to demonstrate improvement in 1 week. Options 2, 3, and 4 are incorrect.

Which client is most at risk for committing suicide? 1. A 75-year-old client with metastatic cancer 2. A 71-year-old client with a cardiac disorder 3. A 24-year-old client who just had an argument with her roommate 4. A 30-year-old newly divorced client who states she has custody of the children

1. A 75-year-old client with metastatic cancer Rationale: The person most at risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble

1. Admitting to having a problem Rationale: The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective coping mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

1. An expected coping mechanism Rationale: The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

1. Ask the client why he started taking illegal drugs. Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.

1. Call the nursing supervisor. Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization

1. Denial Rational: Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. In this case the client is not acknowledging the trauma of the assault either verbally or nonverbally. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.

A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing? 1. Denial 2. Projection 3. Regression 4. Rationalization

1. Denial Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. Regression allows the client to return to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation

1. Information regarding shelters Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.

The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client.

1. Initiate confinement measures. Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.

The nurse understands that which best describes Gestalt therapy? 1. It emphasizes self-expression, self-exploration, and self-awareness in the present. 2. It promotes the individual's comfort in the group, which then transfers to other relationships. 3. The therapist focuses on how irrational beliefs and thoughts contribute to psychological distress. 4. The therapist's goal is to help others express their feelings toward one another during group sessions.

1. It emphasizes self-expression, self-exploration, and self-awareness in the present. Rationale: Gestalt therapy emphasizes self-expression, self-exploration, and self-awareness in the present. The client and therapist focus on everyday problems and try to solve them. Interpersonal group therapy promotes the individual's comfort in the group, which then transfers to other relationships. In rational emotive therapy, the therapist focuses on how irrational beliefs and thoughts contribute to psychological distress. In Rogerian therapy, the therapist's goal is to help others express their feelings toward one another during group sessions.

Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals? 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Rational emotive therapy

1. Milieu therapy Rationale: All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted thinking.

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self or others. 2. Assist in completing an application for admission. 3. Supply the client with written information about their mental illness. 4. Provide an opportunity for the family to discuss why they felt the admission was needed.

1. Monitor closely for harm to self or others. Rationale: Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the illness is likely premature initially. The family may have had no role to play in the client's admission.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by the client indicates ineffective coping? 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens' program 4. Visiting their spouse's grave once a month

1. Neglecting personal grooming Rational: Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. The correct option is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately

1. One-to-one suicide precautions Rationale: One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Provide hope and reassurance that the problems will resolve themselves.

1. Provide authority, action, and participation. Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies.

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment. 4. Offer the client a less stimulating area to calm down in and gain control.

1. Provide safety for the client and other clients on the unit. Rationale: Safety of the client and other clients is the priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions

1. Setting limits on the client's behavior Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer. Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent.

A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which should the nurse document in the client's record? 1. The client has a flat affect. 2. The client has an inappropriate affect. 3. The client is exhibiting bizarre behavior. 4. The client's emotional responses exhibit a blunted affect.

1. The client has a flat affect. Rationale: A flat affect is manifested as an immobile facial expression or blank look. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicates a manifestation associated with dementia? 1. Uses confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care

1. Uses confabulation Rationale: The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Using open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes? 23% 33% 43% 13%

13% Explanation: Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into the brain or subarachnoid space.

A client is semi-conscious, restless, and exhibits tremors and muscle weakness. Physical exam reveals a dry swollen tongue and body temperature of 99.8 F. The nurse anticipates that the serum sodium level for this patient is most likely to be which of the following? 155 mEq/L 142 mEq/L 132 mEq/L 120 mEq/L

155 mEq/L

The nurse is developing a plan of care for the client with a diagnosis of paranoia and should include which interventions in the plan of care? Select all that apply. 1. Provide a warm approach to the client. 2. Ask permission before touching the client. 3. Eliminate physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client.

2, 3, 4, 5 Rationale: When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."

2, 3, 5 Rationale: Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement. "I'm afraid of spiders," is more relative to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.

The nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk? 1. "What are you feeling right now?" 2. "Do you have a plan to commit suicide?" 3. "How many times have you attempted suicide in the past?" 4. "Why were your attempts at suicide unsuccessful in the past?"

2. "Do you have a plan to commit suicide?" Rationale: When assessing for suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although options 1, 3, and 4 are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

The nurse in the mental health unit is having a conversation with a client diagnosed with posttraumatic stress disorder. The client seems upset and looks anxious. What is the appropriate nursing statement the nurse should make to the client? 1. "Don't worry so much." 2. "I can see that you are upset." 3. "Everything is going to be all right." 4. "Why are you having so much trouble controlling your anxiety?"

2. "I can see that you are upset." Rationale: The correct option is the only one that addresses the client's feelings and concerns. Options 1 and 3 provide false reassurance and place the client's feelings on hold. Option 4 is a nontherapeutic communication technique and will increase the client's anxiety.

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? 1. "It uses positive reinforcement." 2. "It uses negative reinforcement." 3. "It increases social behaviors in the client." 4. "It increases the level of self-care in the client."

2. "It uses negative reinforcement." Rationale: Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. Options 1, 3, and 4 are accurate characteristics of this form of therapy.

A mental health nurse in a psychiatric unit is meeting with a client who has a long history of acting out and violent behavior. The client also is known to have abused drugs on numerous occasions. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic? 1. "You have said this many times before!" 2. "Tell me what makes you feel that you are ready." 3. "I have not seen any changes in you to believe that you are ready to go straight." 4. "I'm so glad to hear you talking this way. I will let your health care provider know."

2. "Tell me what makes you feel that you are ready." Rationale: Clients with a long history of acting out and violent behavior and those who have used drugs need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? 1. "Why don't you tell your wife about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation."

2. "What do you find difficult about this situation?" Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime

2. A client undergoing diagnostic tests Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger.

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2. Avoid laughing or whispering in front of the client. Rationale: Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

2. Examine and treat the wound sites. Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically.

The mental health nurse is conducting a group therapy session and is monitoring a client with a diagnosis of agoraphobia who has been attending the sessions for several months. The nurse notes that the client is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior? 1. Manipulation 2. Improvement 3. Attention seeking 4. Desire to be accepted

2. Improvement Rationale: The behaviors identified in the question indicate improvement in the client's condition. The question presents no information indicating that the client is being manipulative. Acting out is attention-seeking behavior. All clients have a desire to be accepted.

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise rigorously.

2. Interrupt the client and offer to take her for a walk. Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client's preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that she is not allowed to complete the exercise program will increase the client's anxiety.

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Signs of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

2. Normal reactions to a devastating event Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction. Options 1, 3, and 4 are incorrect interpretations.

A client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. What should the nurse plan to do to meet the client's nutritional needs? 1. Force foods and fluids. 2. Provide small, frequent meals. 3. Provide snacks and meals as requested. 4. Tell the client that social activities will be restricted unless food intake is increased.

2. Provide small, frequent meals. Rationale: A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing further. Providing snacks and meals when the client requests them will not ensure adequate nutritional intake. Forcing foods and fluids and telling the client that social activities will be restricted will cause further withdrawal by the client. Telling the client that social activities will be restricted also is a demeaning action.

The mental health nurse is reviewing the discharge plan for a hospitalized client. In reviewing the plan, the nurse recognizes that which is the most prominent problem in the management of a client with a mental health problem in the community? 1. The community's opposition 2. The client's noncompliance with medication therapy 3. The associated increased incidence of social problems 4. The family's reaction to keeping the client in the community

2. The client's noncompliance with medication therapy Rationale: Clients often forget to take their medications as scheduled, and this is the most prominent problem. Options 1, 3, and 4 may occur, but the problems described are not the most prominent and can be addressed and often controlled.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. The death of a loved one Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster; it is unplanned or accidental.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurse's station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2. Use an indirect light source and turn off the television. Rationale: Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping Pong 4. Basketball

2. Writing Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

The nurse is caring for a number of clients. Which client has lost a barrier defense, increasing the client's risk for infection? 68-year-old client diagnosed with prostate cancer 24-year-old client diagnosed with partial-thickness burns 72-year-old client diagnosed with bacterial pneumonia 13-year-old client diagnosed with chickenpox

24-year-old client diagnosed with partial-thickness burns Explanation: A burn client loses the protective barrier of the skin and is at risk for infection. In a partial-thickness burn, the glands of the skin secrete chemicals that destroy many pathogens and also the normal flora that live on the skin. A cancer client has decreased cellular defenses. The client with chickenpox and the client with pneumonia both have a diminished immune defense along with the prostate cancer client but still are at less risk for infection than the burn client.

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?" Rationale: It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

3. "Tell me more about the incident that causes you to feel like the rape just occurred." Rationale: The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem-solving totally on the client.

The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?" Rationale: The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

3. "You seem restless; tell me what is happening." Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis."

3. "You're feeling angry that your family continues to hope for you to be cured?" Rationale: Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. While it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse's attempt to focus on the central issue of anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.

When the mental health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes, I have trouble sleeping too."

3. "You're having difficulty sleeping?" Rationale: The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourage the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

The nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development? 1. Acknowledging that the group has identified goals 2. Encouraging the accomplishment of the group's work 3. Acknowledging the contributions of each group member 4. Encouraging members to become acquainted with one another

3. Acknowledging the contributions of each group member Rationale: In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and assist each other to prepare for the future. Acknowledging that the group has identified goals and encouraging group bonding both occur during the initial stage. Encouraging accomplishment of the group's work is appropriate during the working stage.

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a staff member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3. Assigning a staff member to the client who will remain with the client at all times Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder

3. Conversion disorder Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.

A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

3. Escort the client to their room, with the assistance of other staff. Rationale: The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan on responding to the client's statement? 1. Reassure the client that things will get better. 2. Tell the client that this is not true and that we all have a purpose in life. 3. Identify recent behaviors or accomplishments that demonstrate the client's skills. 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3. Identify recent behaviors or accomplishments that demonstrate the client's skills. Rationale: Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

3. Increasing the level of suicide precautions Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers and although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

3. Observing rigid rules and regulations Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3. Remain with the client until the anxiety decreases. Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the case worker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member

3. Removing the client from any immediate danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the day before ECT includes ensuring that the client follows which guideline? 1. Does not smoke at all 2. Receives no visitors and participates in limited unit activities 3. Reports to the clinic for blood draws and an electrocardiogram (ECG) 4. Is placed on nothing by mouth (NPO) status for 16 to 24 hours before the ECT

3. Reports to the clinic for blood draws and an electrocardiogram (ECG) Rationale: Before ECT, blood tests are performed and an ECG is done to determine a baseline status of the client. The nurse needs to explain the need for these preprocedures to the client. Maintaining *NPO status for 6 to 8 hours before treatment* is adequate; NPO status for 16 to 24 hours is not necessary. Some hospitals place clients on NPO status at midnight before ECT in the morning. Some clients who are on cardiovascular medication may be instructed to take their medicine with sips of water several hours before ECT. Options 1 and 2 are incorrect.

The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch him.

3. Sit beside the client in silence with occasional open-ended questions. Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

The nurse in the mental health unit is performing an assessment in a client who has a history of multiple somatic complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1. Depression 2. Schizophrenia 3. Somatization disorder 4. Obsessive-compulsive disorder

3. Somatization disorder Rationale: Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

A nursing instructor teaches a group of nursing students about violence in the family. Which statement by a student indicates a need for further teaching? 1. "Abusers use fear and intimidation." 2. "Abusers usually have poor self-esteem." 3. "Abusers often are jealous or self-centered." 4. "Abuse occurs more often in low-income families."

4. "Abuse occurs more often in low-income families." Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect.

A client with a diagnosis of depression has been meeting with the mental health nurse for therapy sessions for the past 6 weeks. During the session the client says to the nurse, "I lost my job this week, and I'm going to be evicted from my apartment if I can't pay my bill. The only person that I have is my daughter, but I don't want to burden her with my problems." Which response by the nurse would be therapeutic? 1. "Why did you lose your job?" 2. "There are homeless shelters available, and we will get you into one if you are evicted from your apartment." 3. "If you get evicted from your apartment, we will commit you to the hospital, so you will have a place to eat and sleep." 4. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?"

4. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?" Rationale: The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced." Rationale: Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

During a therapy session with a client with paranoid disorder, the client says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would be therapeutic? 1. "Your comment is inappropriate." 2. "Thank you for noticing. I just bought this new perfume." 3. "My hair has been a mess. I really needed to have it done." 4. "We are not here to discuss how I look or smell. We are here to talk about you."

4. "We are not here to discuss how I look or smell. We are here to talk about you." Rationale: The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Option 1 may be judgmental and may provide an opening for a verbal struggle. Options 2 and 3 are social responses and could be misinterpreted by the client.

The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do." Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.

The mental health nurse is caring for a client with a social phobia. The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse that she cannot sing and refuses to attend. What is the appropriate nursing response? 1. "You must go. You have no choice." 2. "Why don't you want to attend? What is the real reason?" 3. "The health care provider has prescribed this therapy for you." 4. "You don't have to sing at the session. You can listen and enjoy the music."

4. "You don't have to sing at the session. You can listen and enjoy the music." Rationale: The correct option encourages the client to socialize and indicates that it is not necessary to sing. Option 2 asks why, and use of this word should be avoided. Options 1 and 3 imply a demand and do not address the client's concern. The correct option is the only one that addresses the client's concern.

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4. "You sound very upset. Are you thinking of hurting yourself?" Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings.

A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?"

4. "You've been feeling like a failure for a while?" Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word "why" is nontherapeutic.

The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client. Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of physical activities that will provide exercise 3. No socializing activities, until the client asks to participate in milieu 4. A structured program of activities in which the client can participate

4. A structured program of activities in which the client can participate Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.

On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger and aggressiveness directed toward others. 3. An understanding of the pathology and symptoms of the diagnosis. 4. A willingness to participate in the planning of the care and treatment plan.

4. A willingness to participate in the planning of the care and treatment plan. Rationale: In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee a client's understanding of their illness, only of their desire for help.

The nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental health unit. The client is confused and disoriented. During the assessment, what is the nurse's primary goal for this client? 1. Explain the unit rules. 2. Orient the client to the unit. 3. Stabilize the client's psychiatric needs. 4. Accept the client and make the client feel safe.

4. Accept the client and make the client feel safe. Rationale: It is important to make a confused client feel safe. Explaining the unit rules and orientation to the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.

During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristic of bulimia? 1. Refusing to eat and excessive exercising 2. Eating only vegetables and fruits and fasting 3. Hoarding of food and difficulty controlling food intake 4. Eating a lot of food in a short period of time and misuse of laxatives

4. Eating a lot of food in a short period of time and misuse of laxatives Rationale: Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.

A client recently admitted to the hospital in the manic phase of bipolar disorder is dehydrated, unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. The nurse determines that which intervention is most appropriate for these complaints? 1. Teach self-grooming skills. 2. Reward cleanliness with unit privileges. 3. Monitor the adequacy of the antipsychotic dosage. 4. Encourage frequent fluid intake and a high-fiber diet.

4. Encourage frequent fluid intake and a high-fiber diet. Rationale: Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question, dehydrated, unkempt, and abdominal fullness and discomfort, in combination with antipsychotic medications, are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.

When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse understands that which is the purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs

4. Helping the client to examine dysfunctional thoughts and beliefs Rationale: Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations

4. Hypertension, changes in level of consciousness, hallucinations Rationale: Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse should document the findings using which description of the client's behavioral response? 1. Flat affect 2. Bizarre affect 3. Blunted affect 4. Inappropriate affect

4. Inappropriate affect Rationale: An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

The nurse is planning care for a client with bipolar disorder who is experiencing psychomotor agitation. Which activity should the nurse plan for this client? 1. Reading letters and books in a quiet environment 2. Providing an activity such as checkers for the client 3. Involving the client in a card game with other clients on the unit 4. Including the client in a clay-molding class that is scheduled for today

4. Including the client in a clay-molding class that is scheduled for today Rationale: When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger-painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

4. Inquiring about and examining the client's feelings for any that may block adaptive coping Rational: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.

The nurse is monitoring a client who has been placed in restraints because of violent behavior. When should the nurse determine that it will be safe to remove the restraints? 1. Administered medication has taken effect. 2. The client verbalizes the reasons for the violent behavior. 3. The client apologizes and tells the nurse that it will never happen again. 4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.

4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. Rationale: The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. Options 1, 2, and 3 do not ensure that the client has controlled the behavior.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake

4. Nonstop physical activity and poor nutritional intake Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. The correct option clearly presents a problem, however, that compromises physiological integrity and needs to be addressed immediately.

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care? 1. Disrupted appearance because of weight 2. Inability to feed self because of weakness 3. Pain because of an inflamed gastric mucosa 4. Nutritional imbalance because of lack of intake

4. Nutritional imbalance because of lack of intake Rationale: The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance. Although the problems identified in options 1, 2, and 3 may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.

The nurse is reviewing the record of a client admitted to the mental health unit. The nurse notes documentation that the client experiences flashbacks. What diagnosis should the nurse expect to be documented for this client? 1. Anxiety 2. Agoraphobia 3. Schizophrenia 4. Posttraumatic stress disorder (PTSD)

4. Posttraumatic stress disorder (PTSD) Rationale: The major clinical manifestation associated with PTSD is client experience of flashbacks. Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.

The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar? 1. Biofeedback has the advantage of using no equipment at all. 2. Guided imagery is a helpful technique but requires video equipment for its use. 3. Confrontation is a useful method for solving potentially stressful conflicts with others. 4. Progressive muscle relaxation techniques are useful for easing tension from many causes.

4. Progressive muscle relaxation techniques are useful for easing tension from many causes. Rationale: Biofeedback, guided imagery, progressive muscle relaxation, and meditation are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling of self-control. Biofeedback uses electronic equipment, whereas each of the other techniques requires no equipment after it is learned. Confrontation is not a stress management technique; it is a communication technique.

The mental health nurse is talking to a client who has been diagnosed with posttraumatic stress disorder. During the conversation, the nurse notes that the client is exhibiting a paranoid stare and that he begins to pace and fidget. What is the appropriate nursing intervention? 1. Allow the client to pace. 2. Escort the client to a quiet room. 3. Change the conversation to a less threatening subject. 4. Share the observation with the client and help the client to recognize his feelings.

4. Share the observation with the client and help the client to recognize his feelings. Rationale: Sharing observations with the client may help him recognize and acknowledge feelings. Allowing the client to pace may also allow him to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize his behaviors and feelings.

While being treated, a client is introduced to short periods of exposure to the phobic object while in a relaxed state. What term is used to describe this form of behavior modification? 1. Milieu therapy 2. Aversion therapy 3. Self-control therapy 4. Systematic desensitization

4. Systematic desensitization Rationale: Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Exposure is gradually increased until the anxiety about or fear of the object or situation has ceased. Milieu management refers to providing a safe, therapeutic environment and is applicable to not just this scenario. The remaining options are incorrect since they do not involve the intervention described.

A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 1. Trusting 2. Working 3. Orientation 4. Termination

4. Termination In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. The remaining options are not specifically associated with this issue of unresolved feelings.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that now others need a chance to contribute.

4. Thank the client for the input, but inform the client that now others need a chance to contribute. Rationale: If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed towards helping the client in a therapeutic manner.

A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement best describes the nurse's obligation to the client? 1. The nurse must have the client go to the local mental health center daily for counseling. 2. The nurse must ask the client not to reveal suicidal plans if the information needs to be kept confidential. 3. The nurse cannot tell anyone what the client said and must strictly adhere to the professional duty for confidentiality. 4. The nurse must override the duty to observe confidentiality and notify the client's health care provider (HCP) about the suicidal ideation.

4. The nurse must override the duty to observe confidentiality and notify the client's health care provider (HCP) about the suicidal ideation. Rationale: In this situation, the nurse must override the duty to observe confidentiality and notify the client's HCP about the client's suicidal ideation. Option 1 is incorrect because the client is homebound. Option 2 is incorrect because the nurse has a professional obligation to intervene when a client tells the nurse about ideas or plans to harm himself or herself or others. Option 3 is incorrect because the nurse has a moral obligation to protect the client.

A client has been prescribed disulfiram (Antabuse). Before giving the client the first dose of this medication, what should the psychiatric home health nurse determine? 1. If there is a history of hyperthyroidism 2. When the last full meal was consumed 3. If there is a history of diabetes insipidus 4. When the last alcoholic drink was consumed

4. When the last alcoholic drink was consumed Rationale: Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed. The medication should be used cautiously in clients with hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication.

A hospitalized client is receiving clozapine (Clozaril) for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell (WBC) count

4. White blood cell (WBC) count Rationale: Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The WBC count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 3 are incorrect and unrelated to this medication.

The nurse is caring for a client whose blood pressure is 120/78 mm Hg. What is the client's pulse pressure? 99 mm Hg 120 mm Hg 198 mm Hg 42 mm Hg

42 mm Hg Explanation: The pulse pressure is the difference between systolic and diastolic pressure. The systolic pressure is usually 40 points greater than the diastolic pressure. A pulse pressure of over 50 points or less than 30 points is considered abnormal. This client's pulse pressure is 42 mm Hg (120 minus 78).

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What should the nurse describe? 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein

50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein Explanation: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

The nurse caring for the following group of clients considers which client to be at highest risk for developing deficient fluid volume? A 60-year-old male who had a left inguinal hernia repair 12 hours ago A 76-year-old male who has a nasogastric (NG) tube two intermittent suction following a colon resection A thin, 52-year-old female receiving steroid therapy for bronchitis A 68-year-old female who is NPO for a flexible sigmoidoscopy procedure

A 76-year-old male who has a nasogastric (NG) tube two intermittent suction following a colon resection

The nurse is assessing a client whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this client? Long, thin fingers A barrel chest Signs of oxygen toxicity Chronic chest pain

A barrel chest Explanation: In COPD clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The nurse most likely would not assess chest pain or long, thin fingers; these are not characteristic of emphysema. The client would not show signs of oxygen toxicity unless they received excess supplementary oxygen.

A client has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the health care provider prescribe for this client? A thiazolidinedione An alpha-glucosidase inhibitor A sulfonylurea A biguanide

A biguanide Explanation: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha-glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

Which of the following clients with type 1 diabetes is most likely to experience adequate glucose control? A client who eliminates carbohydrates from his daily intake A client who adheres closely to a meal plan and meal schedule A client who never deviates from her prescribed dose of insulin A client who skips breakfast when his glucose reading is greater than 220 mg/dL (12.3 mmol/L)

A client who adheres closely to a meal plan and meal schedule Explanation: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

A nurse has four clients to assess. Which client should the nurse assess first? A client who has just received intravenous morphine. A client with a diagnosis of lung cancer who is experiencing thrombocytopenia A client who has an inflamed IV site while receiving packed red blood cells A client who experiences relief of dyspnea after receiving a small volume nebulizer (SVN)

A client who has just received intravenous morphine

The charge nurse is making assignments for the next shift. Which client should be assigned to the new nurse who has been working for two months and has been pulled from their surgical unit to the medical unit? A client on airborne precautions for bacterial meningitis. A client who just returned from a bronchoscopy and biopsy. A client who needs teaching about the use of incentive spirometry. A client with COPD who is ventilator dependent.

A client who needs teaching about the use of incentive spirometry.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? A client who requires urine specimen collections A client with difficulty swallowing food and fluids A client requiring a colostomy irrigation A client receiving continuous tube feedings

A client who requires urine specimen collections

The client is experiencing an unexpected assessment finding after the administration of a sympathomimetic drug? A client whose respiratory rate has changed from 18 to 8 breaths per minute. A client whose blood pressure has changed from 118/60 to 82/37 mmHg. A client whose heart rate has changed from 47 to 82 bpm. A client who is lung sounds have changed from clear to wheezes throughout the lung fields.

A client whose heart rate has changed from 47 to 82 bpm.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? A client who is ambulatory demonstrating steady gait A client scheduled for physical therapy for the first crutch-walking session A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C A postoperative client who is asking for an opioid pain medication

A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

The nurse is assigned to care for four clients. In planning client rounds, which clients are the nurse assess first? A postoperative client preparing for discharge with a new medication. Client requiring daily dressing changes of a recent surgical incision. A client scheduled for a chest x-ray after insertion of a nasogastric tube. A client with asthma who requested a breathing treatment during the previous shift.

A client with asthma who requested a breathing treatment during the previous shift.

The nurse employed in an emergency department (ED) is assigned to triage clients coming to the ED for treatment. The nurse should assign priority to which client? A client complaining of muscle aches, a headache, and history of seizures. A client who twisted their ankle when rollerblading and is requesting medication for pain. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce. A client with a minor laceration on the index finger sustained while cutting an eggplant.

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce.

The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? A change in position from standing to sitting A heart rate of 54 bpm A pulse oximetry reading of 94% An increase in preload related to ambulation

A heart rate of 54 bpm Explanation: Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more likely increase rather than decrease cardiac output.

The ED nurse is assessing a client complaining of dyspnea. The nurse auscultates the client's chest and hears wheezing throughout the lung fields. What might this indicate about the client? A narrowed airway. Hemothorax. The need for physiotherapy. Pneumonia.

A narrowed airway. Explanation: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

A 56-year-old male client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response? "Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination." "We will need to reevaluate your blood pressure because your age places you at high risk for hypertension." "You have no need to worry. Your pressure is probably elevated because you are being tested." "A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." SUBMIT ANSWER

A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made." Explanation: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the student that there is no need to worry.

Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate? A. Instituting seizure precaution to prevent injury. B. Instructing the client on the importance of preventing infection. C. Avoiding the use of tight tourniquet when drawing blood. D. Teaching the client the importance of early ambulation.

A. Instituting seizure precaution to prevent injury. Instituting seizure precaution is an appropriate intervention because the client with hypomagnesemia is at risk for seizures. Changes in mentation or the development of seizure activity in severe low magnesium increase the risk of client injury. Provide a quiet environment and subdued lighting. Reduces extraneous stimuli; promotes rest.

Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A. Positive Trousseau's sign B. Positive Chvostek's sign C. Tetany D. Paresthesia

A. Positive Trousseau's sign In a client with hypocalcemia, a positive Trousseau's sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed.

Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess? A. Tented skin turgor and thirst B. Muscle twitching and tetany C. Fruity breath and Kussmaul's respirations D. Muscle weakness and paresthesia

A. Tented skin turgor and thirst Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Most patients present with symptoms suggestive of fluid loss and clinical signs of dehydration. Symptoms and signs of hypernatremia are secondary to central nervous system dysfunction and are seen when serum sodium rises rapidly or is greater than 160 meq/L.

A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing what health problem? Acute kidney injury Right ventricular hypertrophy Anemia Glaucoma

Acute kidney injury Explanation: When uncontrolled hypertension is prolonged, it can result in acute kidney injury, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.

The nurse is caring for an older adult client who is in cardiac rehabilitation following heart surgery. The client has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The client states that he has cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The client's care plan should address what problem? Acute pain related to intermittent claudication Decreased mobility related to VTE Acute pain related to vasculitis Decreased mobility related to venous insufficiency

Acute pain related to intermittent claudication Explanation: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Clients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? Acute respiratory failure Pneumoconiosis Pleural effusion Pneumonia

Acute respiratory failure Explanation: Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A client is being treated for a pulmonary embolism and the medical nurse is aware that the client suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? pH balance in the pulmonary veins and arteries Maintenance of constant osmotic pressure in the alveoli Maintenance of muscle tone in the diaphragm Adequate flow of blood through the pulmonary circulation.

Adequate flow of blood through the pulmonary circulation. Explanation: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.

The clients morning assessment includes bounding peripheral pulses, weight gain of 1 kg, pitting ankle edema, and moist crackles bilaterally with dyspnea. Which order from the healthcare provider takes priority? Weigh client every morning. Strict intake and output. Fluid restriction of 1500 mL per day. Administer Furosemide 40 mg IV push.

Administer Furosemide 40 mg IV push.

A registered nurse is the leader of a team consisting of one licensed practical nurse and two nursing assistants. Which assignment should the registered nurse delegate to the licensed practical nurse? Select all that apply Administer an enema to a client who is having surgery in the morning. Give a medication via the direct IV push technique. Perform a venipuncture to obtain a blood specimen. Change the dressing on a pressure ulcer. Collect clinical data about clients.

Administer an enema to a client who is having surgery in the morning. Give a medication via the direct IV push technique. Perform a venipuncture to obtain a blood specimen. Change the dressing on a pressure ulcer. Collect clinical data about clients. Licensed practical nurses cannot administer medication via the direct IV push technique. Also, they cannot administer IV anti-neoplastic medication's or the initial bag of an IV solution.

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. Monitor pain levels and administer analgesics Administer antipyretics as prescribed Obtain a blood type and cross-match Perform frequent neurologic assessments Place the client in positive pressure isolation

Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics Explanation: Clients with meningitis require antipyretics and analgesia to treat fever and pain. As well, their neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised.

The nurse is caring for a client with a nursing diagnosis of ineffective breathing pattern. What action is most appropriate to delegate to the experienced LPN? Assist the client with basic activities of daily living. Client about the use of home oxygen therapy. Instruct client regarding the importance of increasing activity. Administer the third dose of Epogen subcutaneously.

Administer the third dose of Epogen subcutaneously.

The nurse checks on a client who was admitted to the hospital with pneumonia. The client has been coughing profusely and has required nasotracheal suctioning. The client has an IV infusion of antibiotics and is febrile. The client asks the nurse if they can have a bath because they have been perspiring profusely. Which of the following is the most appropriate to delegate to the UAP? Assessing vital signs. Changing IV dressing. Nasotracheal suctioning. Administering a bed bath.

Administering a bed bath.

A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action? A STAT MRI STAT computed tomography (CT) health care provider Administration of anticonvulsants Intubation

Administration of anticonvulsants Explanation: Seizure activity necessitates anticonvulsants. In most cases, the development of seizure activity does not require immediate diagnostic imaging. Intubation is unnecessary except in cases of respiratory failure.

A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results? After a meal high in fat As close to the end of the day as possible After a 12-hour fast Thirty minutes after a normal meal

After a 12-hour fast Explanation: Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid profile should be obtained after a 12-hour fast.

The nurse is caring for a 41-year-old male client with rheumatoid arthritis. Which of the following would be the best time to plan ambulation? Just before the patient's noontime meal After the patient returns from physical therapy After the patient has a bath When the patient first awakens in the morning

After the patient has a bath

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? Heart rate and rhythm Skin integrity Airway patency Core body temperature

Airway patency Explanation: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nurse is assessing a client who takes a loop diuretic. For what adverse effect should the nurse assess? Hypercalcemia Hyperkalemia Alkalosis Hypertension

Alkalosis Explanation: Alkalosis is a rise in serum pH to an alkaline state and can be caused by loop diuretics. Hypokalemia, hypocalcemia, and hypotension are also adverse effect of these drugs.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? Tonic-clonic seizures Shortness of breath Generalized pain Alteration in level of consciousness (LOC)

Alteration in level of consciousness (LOC) Explanation: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

When describing the location where gas exchange takes place, what part of the anatomy should the nurse explain the function of? Alveoli Bronchi Trachea Bronchioles

Alveoli Explanation: Gas exchange occurs across the respiratory membrane in the alveolar sac. It does not occur in the bronchioles, the trachea, or the bronchi.

The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? Bed rest with bathroom privileges Ambulation and activity as tolerated Complete bed rest Out of bed (OOB) to the chair twice a day

Ambulation and activity as tolerated Explanation: Mobility, with walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium. Bed rest should be discouraged because it increases calcium excretion and the risk of renal calculi. Limiting the client to getting out of bed only a few times a day also increases calcium excretion and the associated risks.

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client's blood? A complete blood count (CBC) A capillary blood sample Pulse oximetry An arterial blood gas (ABG) study

An arterial blood gas (ABG) study Explanation: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.

The nurse explains to a client the action of a hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor. What enzyme does the nurse state this drug inhibits? An enzyme that controls the production of cellular cholesterol An enzyme that combines with proteins to become chylomicrons An enzyme used to make bile acids An enzyme used immediately for energy

An enzyme that controls the production of cellular cholesterol Explanation: HMG-CoA reductase is an enzyme that controls the final step in production of cellular cholesterol. Some fats are used immediately for energy. Bile acids act like detergents to break down or metabolize fats into small molecules called micelles, which are absorbed into the intestinal wall and combined with proteins to become chylomicrons, to allow transport throughout the circulatory system. Cholesterol is a fat that is used make bile acids.

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy? An older adult client receiving an IV infusion for pneumonia. An infant receiving an IV infusion for bronchitis. An adult injured in a car accident receiving medication via an IV infusion. A teenager receiving an IV infusion for dehydration.

An older adult client receiving an IV infusion for pneumonia. Rationale:Although any client receiving IV therapy could develop fluid overload, older adult clients are more at risk for fluid overload due to the possible decrease in cardiac and/or renal functions.

The nurse is caring for a diverse group of clients on a hospital medical unit. What client is most likely to experiencing a superinfection? a client who has acute kidney injury following Escherichia coli infection a client who is recovering from viral meningitis an older adult client with Clostridium difficile-associated diarrhea a client who has been admitted for the treatment of a dehisced and infected surgical incision

An older adult client with Clostridium difficile-associated diarrhea Explanation: In recent years the emergence of Clostridium difficile infections has been associated with the use of specific antibiotics. An E. coli infection, meningitis and an infected abdominal incision are not as likely to be the consequence of a superinfection.

The nurse performs an electrocardiogram and finds the older adult client is in atrial fibrillation (AF). The date of onset is unknown but could be as long as 3 months earlier when the client was last assessed. What drug will the nurse expect to be ordered? Quinidine Angiotensin-converting enzyme (ACE) inhibitor Digoxin Anticoagulant

Anticoagulant Explanation: If the onset of AF is not known and it is suspected that the atria may have been fibrillating for longer than 1 week, the client is better off staying in AF without drug therapy or electrocardioversion. Prophylactic oral anticoagulants are given to decrease the risk of clot formation and emboli being pumped into the system. In 2011, the American Heart Association and American College of Cardiology endorsed dabigatran as the anticoagulant of choice for prophylaxis in AF. Conversion, in this case, could result in potentially life-threatening embolization of the lungs, brain, or other tissues. Administration of other antiarrhythmics or ACE inhibitors would not be indicated.

The nurse is providing discharge teaching for a client who developed a pulmonary embolism after total knee surgery. The client has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? Anticoagulant therapy usually lasts between 3 and 6 months. Warfarin must be taken concurrent with ASA to achieve anticoagulation. Warfarin will continue to break up the clot over a period of weeks He should take a vitamin supplement containing vitamin K

Anticoagulant therapy usually lasts between 3 and 6 months. Explanation: Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

The nurse is writing a care plan for a client who has been diagnosed with angina pectoris. The client describes herself as being "distressed" and "shocked" by her new diagnosis. What nursing diagnosis is most clearly suggested by the woman's statement? Spiritual distress related to change in health status Anxiety related to cardiac symptoms Acute confusion related to prognosis for recovery Deficient knowledge related to treatment of angina pectoris

Anxiety related to cardiac symptoms Explanation: Although further assessment is warranted, it is not unlikely that the client is experiencing anxiety. In clients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it is not clear that a lack of knowledge or information is the root of her anxiety.

A resident of an extended-care facility has athlete's foot. After applying the prescribed antifungal cream, what should the nurse do next? Apply clean, dry socks. Wrap a sterile rolled gauze dressing around both feet. Elevate the client's feet for 30 minutes. Wipe away excess medication from the affected area.

Apply clean, dry socks. Explanation: Clean dry socks should be applied when treating athlete's foot to help eradicate the infection because they will keep the feet dry as well as prevent the cream from being wiped away. A rolled gauze dressing is not necessary as it would bind the feet and interfere with mobility and increase the risk of systemic absorption. Medication should not be removed once applied, and there is no need to elevate the feet unless another medical condition warrants this action.

The team is providing emergency care to a patient who received an excessive dose of opiate pain medication. Which task is best to assign to the LPN? Calling the healthcare provider to report SBAR. Giving naloxone and evaluating response to therapy. Monitoring the respiratory status for the first 30 minutes. Applying oxygen per nasal cannula per orders.

Applying oxygen per nasal cannula per orders.

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? Administering an antifibrinolytic agent Applying thigh-high elastic stockings Placing the client on a fluid restriction as ordered Assisting the client with passive range-of-motion (PROM) exercises

Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a client with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The client should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

A hospital client is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? Send the client to the x-ray department, and have the staff in the department wear masks. Ensure that the radiology department has been disinfected prior to the test. Have the client wear a mask to the x-ray department. Arrange for a portable x-ray machine to be used.

Arrange for a portable x-ray machine to be used. Explanation: A client who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the client's room. This confers more protection than disinfecting the radiology department or using masks.

The nurse working on a cardiac care unit is caring for a client whose stroke volume has increased. The nurse is aware that afterload influences a client's stroke volume. The nurse recognizes that afterload is increased when there is what? Arterial vasoconstriction Arterial vasodilation Venous vasodilation Venous vasoconstriction

Arterial vasoconstriction Explanation: Arterial vasoconstriction increases the systemic vascular resistance, which increases the afterload. Venous vasoconstriction decreases preload thereby decreasing stroke volume. Venous vasodilation increases preload.

The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? During the intraoperative period When the client returns from the PACU As soon as possible before the surgical procedure Upon the client's admission to the postanesthesia care unit (PACU)

As soon as possible before the surgical procedure Explanation: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physician's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective.

A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status? Select all that apply. Measure the child's oxygen saturation by oximeter. Facilitate lung function testing. Assess the child's respiratory rate. Assess breath sounds. Monitor the child's respiratory pattern.

Assess breath sounds. Measure the child's oxygen saturation by oximeter. Monitor the child's respiratory pattern. Assess the child's respiratory rate. Explanation: The respiratory status is evaluated by monitoring the respiratory rate and pattern and by assessing for breathing difficulties, low oxygen saturation, or abnormal lung sounds such as wheezing. Lung function testing is a lengthy procedure that is not appropriate in an emergency context.

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse? Assess for signs and symptoms of anaphylaxis. Assess for erythema and urticaria. Administer epinephrine. Administer an over-the-counter (OTC) antihistamine.

Assess for signs and symptoms of anaphylaxis. Explanation: If a client is experiencing an allergic response, the nurse's initial action is to assess the client for signs and symptoms of anaphylaxis. Erythema and urticaria may be present, but these are not the most significant or most common signs of anaphylaxis. Assessment must precede interventions, such as administering an antihistamine. Epinephrine is indicated in the treatment of anaphylaxis, not for every allergic reaction.

A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? Perform Doppler evaluation once daily. Assess the client for signs and symptoms of compartment syndrome every 2 hours. Palpate the affected leg for pain during every assessment. Assess pulse of affected extremity every 15 minutes at first.

Assess pulse of affected extremity every 15 minutes at first. Explanation: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the client's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.

The nurse is caring for an older adult in the long-term care facility who has begun to display signs of anxiety and insomnia. What is the priority nursing action? Suggest the family visit more often to reduce the resident's stress level. Increase the client's social time, encouraging interaction with others. Call the provider and request an antianxiety drug order. Assess the client for physical problems.

Assess the client for physical problems. Explanation: The client should be screened for physical problems, neurological deterioration, or depression, which could contribute to the insomnia or anxiety. Only after physical problems are ruled out would the nurse consider nondrug measures such as increased socialization with other residents or family members. If nothing else is effective, pharmacological intervention may be necessary.

A client with angina has been prescribed nifedipine 15 mg PO t.i.d. The client has received the first two doses of the medication and reports dizziness. What is the nurse's best action? Assess the client's blood pressure. Withhold the next scheduled dose and implement falls precautions. Report this finding to the client's care provider. Reassure the client that this is an expected adverse effect.

Assess the client's blood pressure. Explanation: If a client reports dizziness after beginning treatment with a calcium channel blocker, hypotension is a likely cause. The nurse should obtain objective data by assessing the client's blood pressure before taking further action. The nurse should not independently withhold the drug. The nurse should assess the client before providing reassurance. There may be no need to report this to the provider if it is transient.

The nurse is admitting an adult client to the preoperative unit in preparation for an elective inguinal hernia repair procedure to be performed under general anesthesia. What is the nurse's initial priority nursing assessment related to the anesthesia? Assess the client's veins for ideal intravenous access sites. Assess the client's expectations for recovery. Assess the client's apical heart rate and rhythm. Assess the client's weight.

Assess the client's weight. Explanation: Weighing the client is an initial priority because his or her weight will be used to determine appropriate dosing of all medications and will establish a baseline used for evaluation of any potential adverse effects. The other options are all actions the nurse will need to perform, but none are of higher priority than weighing the client with regard to anesthesia.

A patient received as needed morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel reports that the patient has a respiratory rate of 10 breaths per minute. Which action is the priority? Call the healthcare provider to obtain a prescription for naloxone. Assess the patient responsiveness and respiratory status. Obtain a bag valve mask and deliver breaths at 20 breaths per minute. Double check the prescription to see which drugs were prescribed.

Assess the patient responsiveness and respiratory status.

A client's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? Administer the treatment with the client in a high Fowler's or semi-Fowler's position. Apply percussion firmly to bare skin to facilitate drainage. Assist the client into a position that will allow gravity to move secretions. Perform the procedure immediately following the client's meals.

Assist the client into a position that will allow gravity to move secretions. Explanation: Postural drainage is usually performed two to four times per day. The client uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not given in an upright position or directly following a meal.

In the care of patients with pain and discomfort, which task is most important to delegate to UAP? Assisting the patient with preparation of the sitz bath. Monitoring the patient for signs of discomfort while ambulating. Coaching a patient to deep breathe during painful procedures. Evaluating relief after applying a cold compress.

Assisting the patient with preparation of the sitz bath.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? Atelectasis Peripheral edema Dehydration Anemia

Atelectasis Explanation: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

The nurse is providing care for a client with a diagnosis of hypertension. The nurse should consequently assess the client for signs and symptoms of which other health problem? Migraines Thrombocytopenia Atrial-septal defect Atherosclerosis

Atherosclerosis Explanation: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.

A 71-year-old client with a history of atrial fibrillation, chronic obstructive pulmonary disease, and type 2 diabetes has had an antihistamine prescribed. What assessment should the nurse prioritize? Chest auscultation and assessment of respiratory rate Assessment of orientation and level of consciousness Auscultation of apical heart rate and rhythm Q4h blood glucose checks

Auscultation of apical heart rate and rhythm Explanation: Antihistamines have been associated with prolongation of the QT interval, which can lead to potentially fatal cardiac arrhythmias. The client's history of an arrhythmia heightens the importance of assessing cardiac function. Assessing the client's blood glucose every four hours is likely beyond what is necessary. Respiratory assessment is necessary because of the client's history of COPD, but antihistamines do not exacerbate this condition. Cognitive changes are not expected.

What intervention does the nurse include in the plan of care for a client receiving a continuous intravenous infusion of heparin? Measuring hourly urinary outputs Avoid IM injections Assessing for symptoms of respiratory depression Monitoring BP hourly

Avoid IM injections Explanation: The most commonly encountered adverse effect of the anticoagulants is bleeding, ranging from bleeding gums during toothbrushing to severe internal hemorrhage. Avoid all invasive procedures, including giving IM injections, while the client is on heparin therapy. It would not be necessary to assess for respiratory depression, measure hourly output, or monitor the BP hourly as related because of heparin administration.

A nurse practitioner provides primary care in a rural setting. The nurse should perform what actions in order to minimize the emergence of drug-resistant microbials? Select all that apply. Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Use narrow-spectrum agents if they are thought to be effective. Do not use vancomycin. Give antibiotics every time the patient wants them. Start antibiotics promptly before the culture and sensitivity report returns. Administer the highest tolerated dosage.

Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Use narrow-spectrum agents if they are thought to be effective. Do not use vancomycin. Explanation: Exposure to an antimicrobial agent leads to the development of resistance, so it is important to limit the use of antimicrobial agents to the treatment of specific pathogens known to be sensitive to the drug being used. Drug dosage is important in preventing the development of resistance. Doses should be high enough and the duration of drug therapy should be long enough to eradicate even slightly resistant microorganisms, but the prescriber does not aim for the highest possible tolerated dose. It is best to wait until cultures return before initiating antibiotics when possible, but clients with severe infections may be started on broad-spectrum antibiotics while waiting for culture results.

The nurse has cared for an increasing number of clients who have antibiotic resistance. What principles should the nurse and the other members of the care team follow in order to prevent antibiotic resistance? Select all that apply. Teach clients not to save antibiotics for self-medication in the future. Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Perform culture and sensitivity testing immediately after starting a course of antibiotics. Treat infections with tetracyclines or penicillins whenever possible. Use narrow-spectrum agents if they are thought to be effective.

Avoid the use of broad-spectrum antibacterial drugs when treating trivial or viral infections. Use narrow-spectrum agents if they are thought to be effective. Teach clients not to save antibiotics for self-medication in the future. Explanation: To prevent or contain the growing threat of drug-resistant strains of bacteria, it is very important to use antibiotics cautiously, to complete the full course of an antibiotic prescription, and to avoid saving antibiotics for self-medication in the future. Antibiotic treatment of minor or viral infections is linked to antibiotic resistance. Narrow-spectrum antibiotics are less likely, overall, to lead to resistance. The use of tetracyclines or penicillins does not necessarily reduce antibiotic resistance. Culture and sensitivity testing should take place before beginning therapy, whenever possible.

An elderly client with diabetes comes to the clinic with her daughter. The nurse reviews foot care with the client and her daughter. Why would the nurse feel that foot care is so important to this client? Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities. Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. An elderly client with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy.

Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. Explanation: The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs given for diabetes.

The body's compensation of metabolic alkalosis involves: A. Increasing the respiratory rate B. Decreasing the respiratory rate C. Increasing urine output D. Decreasing urine output

B. Decreasing the respiratory rate The body attempts to compensate for metabolic alkalosis by decreasing the respiratory rate and conserving carbon dioxide (an acid). The body compensates for both alkalosis and acidosis mainly through the lungs. The lungs change the alkalinity of the blood by allowing more or less carbon dioxide to escape as the client breathes. The kidneys also play a role by controlling the elimination of bicarbonate ions.

Osmotic pressure is created through the process of: A. Osmosis B. Diffusion C. Filtration D. Capillary dynamics

B. Diffusion In diffusion, the solute moves from an area of higher concentration to one of lower concentration, creating osmotic pressure. There is a form of passive transport called facilitated diffusion. It occurs when molecules such as glucose or amino acids move from high concentration to low concentration facilitated by carrier proteins or pores in the membrane.

Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia? A. Muscle pain and acute rhabdomyolysis B. Hot flushed skin and diaphoresis C. Soft-tissue calcification and hyperreflexia D. Increased respiratory rate and depth

B. Hot, flushed skin and diaphoresis Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. The most frequent symptoms and signs may include weakness, nausea, dizziness, and confusion (less than 7.0 mg/dL). Increasing values (7 to 12 mg/dL) induce decreased reflexes, worsening confusional state, drowsiness, bladder paralysis, flushing, headache, and constipation.

Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume? A. Hypotonic FVD B. Isotonic FVD C. Hypertonic FVD D. Isotonic FVE

B. Isotonic FVD Isotonic FVD involves an equal decrease in solute concentration and water volume. ISOTONIC FLUID VOLUME deficit is a proportionate loss of sodium and water. Characterized by decreased extracellular fluid, including decreased circulating blood volume, isotonic fluid volume deficit results in signs and symptoms of dehydration. Common causes include vomiting, diarrhea, and polyuria.

Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client's blood gas values through improved ventilation and oxygen therapy, which is the client's primary stimulus for breathing? A. High PCO2 B. Low PO2 C. Normal pH D. Normal bicarbonate (HCO3)

B. Low PO2 A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimulus for breathing in this client.

A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order? A. Potassium B. Sodium bicarbonate C. Serum sodium level D. Bronchodilator

B. Sodium bicarbonate Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic acidosis. The management of metabolic acidosis should address the cause of the underlying acid-base derangement. For example, adequate fluid resuscitation and correction of electrolyte abnormalities are necessary for sepsis and diabetic ketoacidosis. Potassium, serum sodium determinations, and a bronchodilator would be inappropriate orders for this client.

A client's most recent laboratory results show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend? Fish Bananas Rice Apples

Bananas Explanation: Bananas are high in potassium. Apples, fish, and rice are not high in potassium.

The nurse is caring for a client who is scheduled to receive a local anesthetic. The nurse understands that vital signs should be monitored at what point? After the procedure During the procedure Before, during, and after the procedure Before the procedure

Before, during, and after the procedure Explanation: Vital signs are monitored before, during, and after a procedure when local anesthetic is used.

A client is in the clinic to have blood drawn to assess theophylline levels. The client appears to being responding well to the medication and is not experiencing any adverse effects. What serum level will the nurse expect the client to have? Between 40 and 50 mcg/mL Between 25 and 35 mcg/mL Between 0.5 and 5 mcg/mL Between 10 and 20 mcg/mL

Between 10 and 20 mcg/mL Explanation: Therapeutic theophylline levels should be between 10 and 20 mcg/mL. A level between 0.5 and 5 mcg/mL would be low and would not produce a therapeutic effect. Levels between 25 and 50 mcg/mL would be too high and could cause serious adverse effects.

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? Increased anterior-posterior (AP) diameter Shallow respirations Bilateral wheezes Bradypnea

Bilateral wheezes Explanation: The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's AP diameter does not normally change.

A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. The complications for which the nurse should monitor the client include which of the following? Pulmonary edema Left ventricular hypertrophy Bleeding at insertion site Peripheral edema

Bleeding at insertion site Explanation: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include left ventricular hypertrophy because this problem takes an extended time to develop and is not emergent. Bleeding is a more likely and more serious complication than edema.

An older adult client who is taking metformin has just been seen in the clinic. The health care provider prescribes metoprolol for angina. What assessment data should the nurse prioritize due to this drug combination? Urine specific gravity Blood glucose White cell differential Intake and output

Blood glucose Explanation: Metformin is an antidiabetic drug, and the nurse should monitor the client's blood glucose frequently throughout the day because the client may not have the usual signs and symptoms of hypoglycemia or hyperglycemia. Urine specific gravity, leukocyte counts, and intake and output are less likely to be affected by this drug-drug combination.

What sign is most indicative of dehydration in a patient taking diuretics? Body weight Bradycardia Dry cough Decreased hematocrit

Body weight Explanation: Obtain an accurate body weight, to provide a baseline to monitor fluid balance. The other options would not indicate dehydration.

Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement? A. Instructing the client to breathe slowly into a paper bag. B. Administering low-flow oxygen. C. Encouraging the client to cough and deep breathe. D. Nothing, because these ABG values are within normal limits.

C. Encouraging the client to cough and deep breathe. The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler's position. These measures improve lung ventilation and reduce or prevent airway obstruction associated with the accumulation of mucus.

Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client? A. Sodium level B. Magnesium level C. Potassium level D. Calcium level

C. Potassium level Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Most cases of hypokalemia result from gastrointestinal (GI) or renal losses. Renal potassium losses are associated with increased mineralocorticoid-receptor stimulation such as occurs with primary hyperreninism and primary aldosteronism.

Nursing interventions for a patient with hyponatremia include: A. Administering hypotonic IV fluids. B. Encouraging water intake. C. Restricting fluid intake. D. Restricting sodium intake.

C. Restricting fluid intake Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated. In the presence of fluid excess or SIADH, fluid restriction is indicated while in the presence of hypovolemia, volume losses are replaced with isotonic saline, or, on occasion, hypertonic solution when hyponatremia is life-threatening.

The thyroid gland produces and secretes which in direct response to serum calcium levels? Insulin Calcitonin Erythropoietin Aldosterone

Calcitonin Explanation: Calcitonin is produced and secreted by the thyroid gland. Aldosterone is an adrenocorticoid hormone that is released in response to ACTH. Erythropoietin is released by the juxtaglomerular cells in the kidney in response to decreased pressure or decreased oxygenation of the blood flowing into the glomerulus. Insulin is produced by the pancreas in response to varying blood glucose levels.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? Inform the nurse manager. Call the health care provider immediately. Administer an analgesic. Sit with the client for a few minutes.

Call the health care provider immediately. Explanation: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? Call the physician to review the procedure with the client. Explain the procedure clearly to the client and her family. Have the client sign the informed consent and place it in the chart. Provide the client with a pamphlet explaining the procedure.

Call the physician to review the procedure with the client. Explanation: While the nurse may ask the client to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the client giving consent. The surgeon must also inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the physician. The consent formed should not be signed until the client understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the client about the surgical procedure, but will not substitute for the information provided by the physician.

Which of the following foods should the nurse instruct the client who is taking spironolactone to avoid? Cantaloupe Green beans Bread Squash

Cantaloupe

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? Fluid and electrolyte balance Seizure activity Pain Cardiac and respiratory status

Cardiac and respiratory status Explanation: Acute care begins with managing ABCs. Clients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.

The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. What is the best response? "Cardiac catheterization is usually done to evaluate cardiovascular response to stress." "Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are." "Cardiac catheterization is most commonly done to evaluate cardiac electrical activity." "Cardiac catheterization is most commonly done to detect how efficiently a client's heart muscle contracts."

Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are." Explanation: Cardiac catheterization is usually used to assess coronary artery patency to determine if revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after stress. An ECG shows the electrical activity of the heart.

A client being prepared for surgery has been prescribed antibiotics as prophylaxis. Which medication would the nurse anticipate being ordered? Penicillin G Amoxicillin Doxycycline Cephalosporin

Cephalosporin Explanation: Clinical indications for the use of cephalosporins include surgical prophylaxis and treatment of infections of the respiratory tract, skin and soft tissues, bones and joints, urinary tract, brain and spinal cord, and bloodstream (septicemia). In most infections with streptococci and staphylococci, penicillins are more effective and less expensive.

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem? Dysfunction of the medulla Cerebellar dysfunction A lesion in the pons A hemorrhage in the midbrain

Cerebellar dysfunction Explanation: The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX to XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

A client receiving treatment for hypernatremia is being monitored for signs and symptoms of complications of therapy. The nurse would assess this patient for which of the following? Cellular dehydration Renal shutdown Cerebral edema Red Blood Cell (RBC) destruction

Cerebral edema

A client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action should the nurse take first? Elevate the arm. Document the findings. Medicate with an additional dose of an opioid. Check for paresthesia and paralysis of the right arm.

Check for paresthesia and paralysis of the right arm.

A client is wearing a continuous cardiac monitor which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen what is the priority action of the nurse? Call a code blue. \Call the healthcare provider. Check the client status and lead placement. Press the recorder button on the ECG.

Check the client status and lead placement.

Prostaglandins are: Chemical mediators released in the periphery, which prevent sensitization of pain receptors to various chemical substances released by damaged cells. Chemical mediators found in most body tissues; they participate in the inflammatory response. Sensitized pain receptors; they participate in the inflammatory response. Chemical mediators which produce chronic, painful, inflammatory disorders that affect the synovial tissue of hinge-like joints.

Chemical mediators found in most body tissues; they participate in the inflammatory response. Explanation: Prostaglandins are chemical mediators found in most body tissues; they help regulate many cell functions and participate in the inflammatory response. They are formed when cellular injury occurs and phospholipids in cell membranes release arachidonic acid.

Much of the sodium in the filtrate is reabsorbed in the proximal convoluted tubule to the peritubular capillaries. As the sodium is moved out of the filtrate, what does it take with it? Potassium ions Magnesium Chloride ions Calcium

Chloride ions Explanation: As sodium is actively moved out of the filtrate, it takes chloride ions and water with it. Sodium does not take calcium, magnesium, or potassium ions with it.

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified? Inactivity, stress, gender, and smoking Gender, obesity, family history, and smoking Stress, family history, and obesity Cholesterol levels, hypertension, and smoking

Cholesterol levels, hypertension, and smoking Explanation: Four modifiable risk factors-cholesterol abnormalities, tobacco use, hypertension, and diabetes-are established risk factors for CAD and its complications. Gender and family history are risk factors that cannot be controlled.

A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize? Smoking up to three cigarettes weekly is generally allowable. Minor respiratory infections are considered to be self-limited and are not treated with medication. Activities of daily living (ADLs) should be clustered in the early morning hours. Chronic inhalation of indoor toxins can cause lung damage.

Chronic inhalation of indoor toxins can cause lung damage. Explanation: Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all clients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit clients to perform these without excessive distress.

While assessing a new client on the unit, the nurse notes the following: productive cough, respiratory rate of 22, oxygen saturation of 90%, afebrile, and increased secretions. The client has a 20-year history of smoking 1.5 packs of cigarettes daily. What diagnosis is most likely? Pneumonia Cystic fibrosis Chronic obstructive pulmonary disease (COPD) Pleural effusion

Chronic obstructive pulmonary disease (COPD) Explanation: Chronic obstructive pulmonary disease (COPD) is a permanent, chronic obstruction of airways, often related to cigarette smoking. It is caused by two related disorders, emphysema and chronic bronchitis, both of which result in airflow obstruction on expiration, as well as overinflation of the lungs and poor gas exchange. Emphysema is characterized by loss of the elastic tissue of the lungs, destruction of alveolar walls, and resultant alveolar hyperinflation with a tendency to collapse with expiration. Chronic bronchitis is a permanent inflammation of the airways with mucus secretion, edema, and poor inflammatory defenses. Characteristics of both disorders often are present in the person with COPD. Pneumonia would likely cause a fever. Because of the client's smoking history, COPD is more likely than pleural effusion. Cystic fibrosis is a genetic disease of excessive pulmonary tract secretions and GI tract involvement.

A nurse is caring for a client taking a beta-blocker and a nitrate to treat angina. The nurse recognizes the need for careful monitoring because of what comorbidity? Rheumatoid arthritis (RA) Irritable bowel syndrome (IBS) Chronic obstructive pulmonary disease (COPD) Chronic urinary tract infection (UTI)

Chronic obstructive pulmonary disease (COPD) Explanation: The nurse should assess for COPD, because the effect of beta-blockers in reducing effects of the sympathetic nervous system could exacerbate the respiratory condition. RA, IBS, and chronic UTI are not affected by the use of beta-blockers or nitrates to treat angina.

A clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what he could have done to minimize the risk of contracting this disease. What should the nurse describe as the most significant risk factor? Inadequate exercise Exposure to dust and pollen Cigarette smoking Exposure to occupational toxins

Cigarette smoking Explanation: The most important risk factor for COPD is cigarette smoking. Lack of exercise and exposure to dust and pollen are not risk factors for COPD. Occupational risks are significant but are far exceeded by smoking.

Microscopic, hair-like projections of the nasal cell membranes transport foreign substances toward the throat. What structures perform this role? Goblet cells Cilia Alveolar sacs Sinuses

Cilia Explanation: Cilia are found in the epithelial cells of the lining of the nasal cavity and are constantly in motion directing mucus and trapped substances down toward the throat. Goblet cells are found in the epithelial lining and produce mucus, which traps foreign substances. Alveolar sacs are located in the lower respiratory tract and are considered the functional units of the lung. Sinuses are air-filled passages through the skull, which open into the nasal cavity.

Which nursing action is the best example of the principle of nonmaleficence as an ethical consideration and pain management? Client seems excessively sedated but continues to ask for morphine, so the nurse can ask further assessment and seeks alternative to opiate medication. Client has no known disease disorders and no objective signs of poor health or energy, but reports severe pain, so nurse advocates for pain medicine. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages client to verbalize personal goals for pain management. Client repeatedly refused his pain medication but she was grimacing and reluctance to move, so the nurse explains the benefit of taking pain medication.

Client seems excessively sedated but continues to ask for morphine, so the nurse can ask further assessment and seeks alternative to opiate medication.

What is the best indicator of decreased nausea after administering ondansetron (Zofran) IV? Blood pressure 110/64 Heart rate 64 bpm Client is hungry Client states, "I feel less nauseated."

Client states, "I feel less nauseated." Explanation: Monitor patient response to the drug (relief of nausea and vomiting). Nausea is a subjective symptom. The patient telling you that they are less nauseated would be the best indication the drug is working.

A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this client's care, what desired outcome should the nurse identify? Client is able to describe modifiable risk factors for hypertension. Client's BP remains consistently below 140/90 mm Hg. Client denies signs and symptoms of hypertensive urgency. Client takes medication as prescribed and reports any adverse effects.

Client takes medication as prescribed and reports any adverse effects. Explanation: The most appropriate expected outcome for a client who is given the nursing diagnosis of risk for ineffective health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the client's role in the treatment regimen.

The nurse is planning care for a client with AIDS who has developed chronic severe diarrhea secondary to adverse effects of the antiviral drugs prescribed. What goal should the nurse prioritize during this client's care? Client will remain free of electrolyte disturbances. Client will show improved nutritional status evidenced by weight gain. Client will be able to demonstrate the effectiveness of the teaching plan. Client will state that comfort and safety measures are effective and show compliance with the regimen.

Client will remain free of electrolyte disturbances. Explanation: Severe chronic diarrhea is likely to result in malnutrition and weight loss along with potential alterations in fluid and electrolyte balance. Of these, electrolyte imbalances are the most acute threat. Electrolyte imbalances would be prioritized over comfort and education because of their serious consequences.

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? Body rigidity Urinary incontinence Epileptic cry Confusion

Confusion Explanation: In the postictal state (after the seizure), the client is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

A 91-year-old client is being discharged on the diuretic spironolactone. What assessment finding would the nurse attribute to adverse effects of this medication? Blood pressure of 160/109 mm Hg Confusion and irregular heart rate Polyuria and polyphagia Diarrhea and positive stool for occult blood (FOB) test

Confusion and irregular heart rate Explanation: The most common adverse effect of potassium-sparing diuretics is hyperkalemia, which can cause lethargy, confusion, ataxia, muscle cramps, and cardiac arrhythmias. Diarrhea, GI bleeding, and hypertension are not recognized as adverse effects of spironolactone. Polyuria is expected, but polyphagia is atypical.

A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? Dilated bronchioles Relaxed muscular walls of the urinary bladder Decreased peristaltic movement Constricted pupils

Constricted pupils Explanation: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client that angina is most often attributable to what cause? Decreased cardiac output Decreased cardiac contractility Infarction of the myocardium Coronary arteriosclerosis SUBMIT ANSWER

Coronary arteriosclerosis Explanation: In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances? A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypernatremia

Correct Answer: A. Hypokalemia Aldosterone is secreted in response to fluid loss. Aldosterone causes sodium reabsorption and potassium elimination, further exacerbating hypokalemia. Aldosterone causes sodium to be absorbed and potassium to be excreted into the lumen by principal cells. In alpha intercalated cells, located in the late distal tubule and collecting duct, hydrogen ions and potassium ions are exchanged. Hydrogen is excreted into the lumen, and the potassium is absorbed.

A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? Inspiratory wheezes Expiratory wheezes Crackles Rhonchi

Crackles Explanation: Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.

The nurse is assessing a postoperative client whom the nurse suspects may have developed atelectasis. What assessment finding by the nurse best supports this suspicion? Hemoptysis (blood-tinged sputum) Oral temperature of 37.4°C (99.3°F) Chest pain on exertion Crackles on lung auscultation

Crackles on lung auscultation Explanation: Clients with atelectasis may present with crackles, dyspnea, fever, cough, hypoxia, and changes in chest wall movement. This client's temperature is within normal ranges. Hemoptysis and chest pain are not normally associated with atelectasis.

Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium? A. A 14-year-old who is taking diuretics. B. A 16-year-old with ileostomy. C. A 16-year-old with metabolic acidosis. D. An 18-year-old who has renal disease.

D. An 18-year-old who has renal disease. Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be hypokalemic and should be encouraged to eat foods high in potassium. Encourage intake of carbohydrates and fats and low potassium food such as pineapple, plums, strawberries, carrots, cauliflower, corn, and whole grains. Reduces exogenous sources of potassium and prevents metabolic tissue breakdown with the release of cellular potassium.

Respiratory regulation of acids and bases involves: A. Hydrogen B. Hydroxide C. Oxygen D. Carbon dioxide

D. Carbon dioxide Respiratory regulation of acid-base balance involves the elimination or retention of carbon dioxide. Arterial blood gas interpretation is best approached systematically. Interpretation leads to an understanding of the degree or severity of abnormalities, whether the abnormalities are acute or chronic, and if the primary disorder is metabolic or respiratory in origin.

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance? A. Skin turgor B. Intake and output C. Osmotic pressure D. Cardiac rate and rhythm

D. Cardiac rate and rhythm Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake, and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important. Tachycardia and hypertension are common manifestations. Tachypnea is usually present with or without dyspnea. Elevated CVP may be noted before dyspnea and adventitious breath sounds occur. Hypertension may be a primary disorder or occur secondary to other associated conditions such as heart failure.

Which of the following findings would the nurse expect to assess in a patient with hypokalemia? A. Hypertension B. pH below 7.35 C. Hypoglycemia D. Hyporeflexia

D. Hyporeflexia Hyporeflexia is a symptom of hypokalemia. Significant muscle weakness occurs at serum potassium levels below 2.5 mmol/L but can occur at higher levels if the onset is acute. Similar to the weakness associated with hyperkalemia, the pattern is ascending in nature affecting the lower extremities, progressing to involve the trunk and upper extremities, and potentially advancing to paralysis.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. Increased total body water Decreased renal blood flow Decreased excretion of potassium Decreased kidney mass Increased conservation of sodium

Decreased kidney mass Decreased renal blood flow Decreased excretion of potassium Explanation: Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

When the nurse administers a beta-adrenergic blocker to a client with angina, the nurse expects the drug will help to control angina. What other effect does a beta-adrenergic blocker have? Decreased strength of heart muscle contraction Increased heart rate Increased oxygen consumption Decreased urinary output

Decreased strength of heart muscle contraction Explanation: Beta-blockers competitively block beta-adrenergic receptors in the heart and kidneys, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart. As a result, it decreases the strength of cardiac contraction, reducing cardiac output, which results in lowered blood pressure and decreased cardiac workload. It does not impact urinary output.

The nurse provides client teaching related to medication and lifestyle changes the client can make to reduce serum lipid levels. One month later, the nurse evaluates the client teaching as having been effective based on what data? Select all that apply. Weight loss of 8 lb Decreased low-density lipoprotein (LDL) Decreased total cholesterol level Decreased blood pressure Decreased high-density lipoprotein (HDL)

Decreased total cholesterol level Decreased low-density lipoprotein (LDL) Decreased blood pressure Weight loss of 8 lb Explanation: For most clients, desirable outcomes include increased HDL, decreased LDL, and decreased total cholesterol. Weight loss and blood pressure control are also positive outcomes.

A client with asthma has been prescribed an anti-inflammatory medication. How does an anti-inflammatory drug reduce this client's bronchoconstriction? Decreases formation of mucus secretions Decreasing airway hyperreactivity to stimuli Increasing uptake of corticosteroids to medication Increasing ability to metabolize medication

Decreasing airway hyperreactivity to stimuli Explanation: Bronchodilators, or antiasthmatics, are medications used to facilitate respirations by dilating the airways. They are helpful in symptomatic relief or prevention of bronchial asthma and for bronchospasm associated with chronic obstructive pulmonary disease (COPD). Reducing inflammation prevents and reduces bronchoconstriction by decreasing airway hyperreactivity to various stimuli that decreases mucosal edema and formation of mucus secretions that narrow airways. Anti-inflammatory drugs do not increase the ability to metabolize medication or increase uptake of steroids.

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of heart failure and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent what complication? Aortitis Thoracic aortic aneurysm Deep vein thrombosis Raynaud disease

Deep vein thrombosis Explanation: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aortitis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

A client with liver failure due to cirrhosis comes to the clinic complaining of a swollen abdomen and dizziness upon standing. The client is pale with weak radial pulses, delayed hand vein filling, and distended abdomen. The nurse develops a care plan identifying which of the following nursing diagnoses? Excess fluid volume: extravascular related to hormonal disturbances Deficient fluid volume: intravascular related to third space fluid shifts Deficient fluid volume: extravascular related to hormonal disturbances Excess fluid volume: intravascular related to third space fluid shifts

Deficient fluid volume: intravascular related to third space fluid shifts

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? Uncertainty Depression Disassociation Confusion

Depression Explanation: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? Dexamethasone Furosemide Dextromethorphan Solumedrol

Dexamethasone Explanation: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

When describing gas exchange, the nurse should teach a client that oxygen and carbon dioxide enter and leave the body by what method? Active transport Diffusion Passive transport Osmosis

Diffusion Explanation: The alveolar sac holds the gas, allowing needed oxygen to diffuse across the respiratory membrane into the capillary, whereas carbon dioxide, which is more abundant in the capillary blood, diffuses across the membrane, and enters the alveolar sac to be expired.

A client presents to the emergency department (ED) having an acute asthma attack and has been prescribed epinephrine. The nurse should assess what therapeutic effect of this drug? Decreased inflammatory response in the airways Dilation of the bronchi with increased rate and depth of respiration Reduced surface tension within the alveoli allowing for gas exchange Inhibition of histamine and slow-reacting substance of anaphylaxis (SRSA) to prevent the allergic asthmatic response

Dilation of the bronchi with increased rate and depth of respiration Explanation: Epinephrine will cause the bronchi to dilate and also cause the rate and depth of respiration to increase. Inhaled steroids decrease the inflammatory response, and lung surfactants reduce the surface tension within the alveoli. Mast cell stabilizers inhibit the release of histamine and SRSA to prevent the allergic response.

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? Acute flank pain Cool, clammy skin Diminished deep tendon reflexes Tachycardia

Diminished deep tendon reflexes Explanation: To gauge a client's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a client's room. The nurse asks the client when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take? Add a small amount of normal saline to moisten the specimen. Immediately take the sputum specimen to the laboratory. Discard the specimen and assist the client in obtaining another specimen. Refrigerate the sputum specimen and submit it once it is chilled.

Discard the specimen and assist the client in obtaining another specimen. Explanation: Sputum samples should be submitted to the laboratory as soon as possible. Allowing the specimen to stand for several hours in a warm room results in the overgrowth of contaminated organisms and may make it difficult to identify the pathogenic organisms. Refrigeration of the sputum specimen and the addition of normal saline are not appropriate actions.

While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? Ignore the comment because the patient is unconscious. Realize that humor is needed in the workplace. Report the comment immediately to a supervisor. Discourage the colleague from making such comments.

Discourage the colleague from making such comments. Explanation: Clients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the client and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Loss of corneal reflex Disorientation and restlessness Decreased pulse and respirations Projectile vomiting

Disorientation and restlessness Explanation: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.