Chapter 48: Next Generation - NGN

While the nurse conducts a comprehensive cultural assessment on a client with metastatic colon cancer the client states, "The pain with this cancer is God's way of punishing me for all the drinking and bad things I did in the military. I lost so many friends in the war that I look forward to having a few beers with them after I die." The nurse will use questions to explore the client's statement.

Health Beliefs/Practices >How much alcohol do you use daily? >How do you control your pain? Cultural Sanctions/Restrictions >Have you experienced flashbacks to your military years? >Are you part of a faith community? >How do you express emotions or feelings? Explanation: The nurse listens to the client responses and asks more specific questions to gain understanding of the client's cultural and health beliefs and practices. Health beliefs and practices influence nursing care. These factors help the nurse recognize client's health-seeking behaviors and activities that promote, maintain, and restore health. Specific questions may be used to assess health beliefs and practices. Cultural sanctions/restrictions are a means of encouraging individuals belonging to a specific culture to conform to cultural norms. To obtain information about cultural sanctions/restrictions, the nurse may ask clients about their culture, such as military service or how they express emotions.

The nurse reviews the medical records of several clients scheduled for routine follow-up at the gynecology clinic. The nurse determines that a conventional Papanicolaou (Pap) test is indicated for which client(s)?

45-year-old client who had a negative Pap test 4 years ago 21-year-old client who has never had a Pap test done before 25-year-old client who has never had sex 32-year-old client who has been vaccinated with human papillomavirus and has never had a Pap test done Explanation: A conventional Pap test, also known as a liquid-based cytology test, is a test used in determining cellular cervical changes. It is helpful in detecting cervical cancer. The test is indicated for women from 30 to 65 years old; the test should be done every 3 years. Because the client is 45 years old and has had the latest Papanicolaou (Pap) test 4 years ago, the client is due for another test. Women 21 years of age and older are encouraged to have a conventional Pap test done every 3 years until age 29. Therefore, the 21-year-old client who has never had a Pap test done is due to be tested during this visit. Women 21 years of age and older are encouraged to have a conventional Pap test done every 3 years until age 29. Therefore, the 21-year-old client who has never had a Pap test done is due to be tested during this visit. A conventional Pap test is recommended to be performed every 3 years for women 21 to 29 years of age regardless of sexual history. Clients who have received a human papillomavirus vaccine should still receive a regular Pap test based on the guidelines. Because the client has not had a Pap test done before, the client is due to receive the test during this visit. Women older than 65 years of age who have had negative Pap test results on three consecutive tests are no longer required to have one. For women 30 to 65 years old, a conventional Pap test should be done every 3 years. Since the client had her Pap test done 2 years ago, she is due for another test in a year.

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system.

Cardiac >Provide verbal stimulation. Respiratory >Assess skin color. Neurologic >Gently touch the client. Explanation: Providing verbal stimulation helps to expel anesthetic gases, facilitate an increase in consciousness, and subsequently increase blood pressure. Skin color can be assessed as a determinant of efficient or deficient oxygenation of tissues. The nurse can verbally reorient the client following anesthesia using a gentle touch and addressing the client by name. Noting the response to stimulation is a means of assessing a client's neurologic status. Monitoring urinary function will help to determine renal function. The nurse can help to prevent aspiration or airway obstruction by placing lethargic or uncounscious clients in a sidelying position. Constant reorientation in the postoperative period helps to provide psychologic comfort. Pupillary response is an assessment used to determine neurologic status. Bowel sounds are an indicator of bowel motility that must be established prior to the client taking food or drink by mouth. Monitoring muscle strength is a means of assessing neurologic status. Interventions such as monitoring reflexes will help the nurse to identify when anesthetics are wearing off. Assessing the dressing for drainage can be an indicator of fluid loss which can adversly affect cardiovascular function. The performance of leg exercises helps to promote circulation. Provision of a warm blanket helps to reduce shivering, which can contribute to hemodynamic stress and cardiac disturbances. Monitoring laboratory values, for example hematocrit, to help assess circulatory status.

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity.

Circulation >pallor >temperature Motor Function >paralysis >pain Sensation >numbness Explanation: When assessing for circulation, the nurse will check the color, temperature, pulses, and capillary refill. The nurse can assess motor function or movement of the extremity by asking the client to move the extremity. Pain with movement is a sign of neurovascular impairment. Paralysis, or the inability to move the extremity, is another sign of impairment. Assessing for sensation is an important part of a neurovascular assessment. The presence of parasthesias, such as numbness or tingling, is a sign of neurovascular damage.

The hospice nurse is caring for a client who is dying. Which intervention(s) should be included in the plan of care?

Cluster nursing activities. Provide cool foods and fluids. Gently massage the arms and legs. Routinely administer pain medications. Explanation: Dying clients may exhibit sleep disturbance due to several reasons such as anxiety or environmental noise. To promote rest and sleep, the nurse should cluster nursing activities. Due to slowed peristalsis, clients who are dying may experience nausea and vomiting. Cool foods and fluids are preferred to prevent nausea. Due to diminished circulation, clients who are dying may feel cold. Gently massaging the arms and legs help promote ciriculation and transfer heat from the nurse's hands to the client. To prevent causing extreme discomfort, pain medications are administered around the clock. As the client becomes less alert, the need for pain medication continues. Allowing the client to rest is one of the most essential components of end of life care. Frequent, non-intrusive assessments may be performed. Obtaining the client's blood pressure frequently is unnecessary and disrupts rest. Small food portions of favorite foods are recommended over large or normal food amounts to prevent suppression of appetite or nausea. To prevent aspiration, the client's head should be elevated and turned to the side when drooling occurs.

A new prescription has been noted in the medical record for an adult client with chest pain to receive a medication that comes in the form of a transdermal patch. The nurse will consider which precaution(s) to ensure safety with this form of drug use?

May cause injury with defibrillation. Fold the patch in half before disposal. Assess for fever prior to application. Remove the patch prior to magnetic resonance imaging (MRI). Monitor the client for early identification of adverse effects. Explanation: Burns to the skin and smoke may occur if a patch is in place during defibrillation. A transdermal patch should be folded in half after removal to prevent nurse making contact with the medication or inadvertently transferring the medication onto another surface. A fever higher than 102°F (39°C) may be a contraindication to use, because the heat may increase the rate of absorption. A transdermal patch may cause burning to the skin, if the patch is in place while the client is undergoing magnetic resonance imaging (MRI). The use of a transdermal patch carries the same risk as the medication given in other forms. The client should be evaluated accordingly for potential adverse effects. The nurse will follow facility protocols to dispose of a transdermal patch, often in facility-approved containers and sometimes with a second nusre as a witness. Application sites should be rotated with each application to prevent local skin irritation. Direct heat, such as that provided by a heating pad or a sun lamp, should be avoided. Local heat provided by the palm of the hand may be used initially to help facilitate adhesion.

A 2-year-old child with specialized nutritional needs is receiving care in the home. The plan of care includes provision of enteral nutrition through a gastrostomy tube every 3 hours.

Measure the length of the external tube. >reduces the risk of aspiration Elevate the head of bed at least 30 degrees. >facilitates the flow of feeding to the gut Confirm pH of aspirate is less than 5.5. >useful in verifying correct placement Replace all gastric contents following measurment of aspirate. >prevents electrolyte imbalance Explanation: Measuring the length of the external tube helps to confirm proper placement and, therefore, reduce the risk of aspiration. The act of elevating the head of the bed to at least 30 degrees facilitates the flow of enteral feeding into the gut. The act of assessing the pH of aspirate helps to confirm proper placement. For a gastrostomy tube the pH should be less than 5.5. The pH of aspirate in the intestines will be 7.0 and greater than 6.0 indicates the end of the tube may be located in the respiratory tract. After the residual of gastric contents, which is full of electrolytes, is measured the aspirate must be returned to avoid electrolyte imbalances. The risk of bloating can be reduced by clamping the tube immediately after administration of enteral feeding. The act of flushing following administration of enteral feedings helps to prevent blockage of the tube. Capnography can be used to detect carbon dioxide which is a reliable indicator that the tube ends in the airway. The intervention that helps prevent diarrhea is to not administer the feeding too fast. A nurse can help prevent the spread of microorganism by capping the tube when not in use and discarding any enteral feeding not administered by the specified time. Providing education and explaining the procedure helps to enhance compliance of the client. Gastric intolerance can be reduced by ensuring the enteral feeding is at room temperature. Bacterial growth can be reduced by rinsing with water following feedings. If enteral feeding is too hot it can cause burning to the stomach, to avoid this ensure it is room temperature prior to administration. The risk of aspiration can be reduced by confirming placement and elevating the head of bed prior to administration of enteral feedings, but not by returning gastric contents prior to feeding. The nurse can avoid administering contaminated contents by flushing after feeding and checking feeding to ensure it is not outdated. Patency of the tube is assured by the act of flushing with warm water prior to administration of enteral feeding.

The following statements are examples of communication blocks.

Nonprofessional Involvement >"I think you should get a second opinion because your health care provider has had a lot of complaints against him." >"My ex-boyfriend did not come pick up the kids again and I did not get much sleep last night." Being Moralistic >"Everybody should be allowed to die if they want to." >"Why did you not use a condom? They are given at the clinic for free." False Reassurance >"Do not worry, this is a minor surgery. You will do great!" >"Injecting insulin is nothing for you to worry about. Even children can do it!" Explanation: The use of therapeutic communication strategies promote a successful nurse-client relationship. Nontherapeutic communication techniques impede effective communication. Comments such as sharing gossip about a provider and encouraging the client to seek a second opinion and sharing personal information about the nurse's home life are examples of nonprofessional involvement. Nonprofessional involvement happens any time the nurse steps outside the boundaries of the therapeutic relationship. The professional relationship should be used to meet the client's needs, not the nurse's needs. Although it is sometimes helpful to reveal small pieces of personal information, this information should be brief and used only for the benefit of the client. Everyone has a right to their own values, including nurses; however, in clinical situations, nurses must be able to put aside their own moral attitude and view the client in objective terms. Providing an opinion on contraception or death and dying is a judgmental approach that infers a preconceived idea about right and wrong. Being moralist is perceived as judging the client's actions by giving approval or disapproval. Providing false reassurances about an upcoming surgery or learning how to give insulin via self-injection is a way to minimize the client's situation. Providing false reassurance violates the client's trust. False reassurance is often done because it is often easier and more pleasant to deal with positive outcomes than negative outcomes.

A nurse is caring for a 3-year-old child that was admitted with pneumonia. The parent expresses concerns about the child's respirations. The nurse is providing education about respiratory-related developmental changes to help the parent differentiate what is normal from what is abnormal.

Normal >respiratory rate of 28/min >irregular respiratory pattern Abnormal >thoracic breathing >inspiration longer than expiration >round thorax Explanation: The normal respiratory rate for a 3-year-old child is between 20 and 32 breaths/min, depending on the source used. It is a normal finding for children up to 5 years of age to have an irregular respiratory pattern. It would be abnormal for a 3-year-old child to have thoracic breathing, because children up to 5 years of age demonstrate irregular breathing patterns. For these children, the parent can expect to find the expiration is longer than the inspiration. The thorax of a 3-year-old child should be eliptical, not round.

The nurse is caring for a 25-year-old client admitted to a medcial surgical unit after an emergency appendectomy. The newly admitted client has been assigned under the nurse's care. As part of the care plan, the nurse sets specific client goals.

Orientation Phase >The client is able to call the nurse by name and demonstrate how to use the call light. Working Phase >The client states, "I know I have to get up and moving so I do not get pneumonia." >The client states, "Using the pillow to splint my abdomen when I cough, really helps." Termination Phase >The client verbalizes understanding of what signs indicate infection and when to contact the health care provider. Explanation: The orientation phase is the initial phase of the nurse-client relationship. During this phase, specific client and nurse roles are discussed, including the duration of the therapeutic relationship. The nurse also orients the client to the room and environment as well as identify oneself by name. After the initial orientation, the client should be able to verbalize understanding of the room including being able to demonstrate how to use the call light and identify the nurse by name. The second phase of the nurse-client relationship is the working phase. Participation and cooperation between the nurse and the client are the highlights of this phase. In addiiton, verbalization of concerns and feelings also occur in the working phase. The nurse takes on the role of teacher during this phase by instructing and motivating the client to implement health-promoting activities meant to facilitate the client's ability to execute the nursing plan. The client 's statements, "I know I have to get up and moving so I do not get pneumonia," and "Using the pillow to splint my abdomen when I cough, really helps" indicates understanding of the nurse's teachings. The last phase of the nurse-client relationship is the termination phase. Evaluation of goals and termination of the therapeutic relationship occur during this phase. This can occur at the end of the nurse's shift or when the client is discharged. The client's ability to verbalize understanding of what signs indicate infection and when to contact their health care provider, allows the nurse to evaluate the client's goal progression as well as assess their readiness for discharge.

A famous actor with bipolar disorder has been admitted in the mental health unit for treatment. A well known news outlet has offered the nurse several thousand dollars to provide information or a picture of the client. The nurse knows that it is their professional duty and legal responsibility to uphold privacy and confidentiality.

Privacy >keeping the door closed while conducting physical assessment >obtaining the client's permission before allowing a student nurse to assist with care Confidentiality >sharing client information only to the caregivers directly assigned to client care >logging off the electronic health record after documenting assessment information >asking the client to sign a medical release form before providing information to the health insurance company Explanation: Privacy requires the nurse to utilize client information appropriately; that is, limiting access to client information to activities that are only directly related to health care. Upholding privacy includes keeping the door closed while conducting physical assessment and obtaining the client's consent before allowing a student nurse to assist with care. Confidentiality involves protecting client health information from public disclosure. Client information should only be shared with health personnel directly involved in the client's care. This includes controlled access to electronic health records; therefore, the nurse should log off the electronic health record after documenting to avoid unauthorized access to the client's information. If client information needs to be divulged, the nurse should first obtain the client's written permission. An example of this is asking the client to sign a medical release form before providing information to the health insurance.

A nurse has been assigned to sit overnight with a client who has been demonstrating unsafe actions. The charge nurse asks the the nurse to monitor the client closely to help identify any deficits in sleep quality.

REM >changes in blood pressure >decrease in muscle mobility >increase in heart rate >increase in body temperature NREM >changes in blood pressure >reduction in metabolism Explanation: The stage of sleep classified as Rapid Eye Movment (REM) is characterized by an immobility of muscles that resembles paralysis. During REM sleep, an increase in physiologic functions such as heart rate takes place. Metabolism is also increased, which results in an increase in body temperature. During the Non-Rapid Eye Movement (NREM) stage of sleep, physiologic functions are slowed down. This includes metabolism, which results in a reduction of temperature. Both REM and NREM sleep stages include variations in blood pressure. During NREM sleep the blood pressure is reduced, whereas in REM sleep blood pressure may increase or flucturate.

The nurse discovers during assessment that the client has an altered temperature.

Radiation: infrared heat waves Conduction: the air itself Evaporation: through sweating Convection: exposure to a fan Explanation: Radiation is heat that is lost to infrared heat waves. It can be accelerated by exposing the skin to the heat waves or prevented by covering the skin. Conduction describes heat that is lost by transfering from one object to the next. For example, heat is lost from the skin to the air or to water. Evaporation consists of heat loss that occurs as water is transformed into a gas, such as with sweating. Convection facilitates heat loss via passing air, such as with a breeze or a fan. Arterioveous shunts may remain open to facilitate the dissapation of heat from the body. A passing breeze facilitates heat loss via convection. In response to the body's temperature the sympathetic nervous system controls the opening and closing of arteriovenous shunts. Shivering is one mechanism for the body to retain heat. Heat can be lost through uncovered body surfaces by the physical process of radiation. Water in the form of a tepid bath or swimming is one way heat loss can occur through conduction. Insensible loss of body fluids is a form of evaporation that takes place on the skin. "Goose bumps" or piloerection is a natural response of the body to retain heat by reducting the surface area of the skin.

After caring for a pediatric client, the nurse is surprised to learn about being named in a malpractice lawsuit.

The client suffered an injury. The nurse has the duty to care for the client. The nurse failed to provide appropriate care. The nurse's lack of action directly resulted in harm. Explanation: Malpractie refers to professional negligence. It stipulates that pprfessionals are accountable for their actions. To prove malpratice, four elements must be present, one of which is damage or injury. The client should have suffered an injury as a result of the nurse's action or inaction. Another element that needs to be established to prove malpractice is duty. The nurse is obligated to provide care for the client concern. Breach of duty, described as the failiure to provide appropriate care, is the third element needed to prove malpractice. The last element is causation, which shows that the nurse's action or inaction caused the injury. Professional liability insurance is required for nurses, because it provides legal and financial services in case of a malpractice lawsuit. Not having professional liability insurance is not, however, an element needed to prove malpractice. Admission of guilt does not establish malpractice. A written legal contract between the nurse and the client or the client's legal guardian is unnecessary. Contracts with clients are usually implied. The nurse is expected to exhibit competence in providing client care. A written contract is not an element needed to prove malpractice.

The charge nurse in the oncology unit is preparing the shift assignments. The unit is fully staffed: unlicensed assistive personnel (UAP), licensed practical nurse (LPN), and registered nurse (RN).

Unlicensed Assistive Personnel (UAP) >calculating the total intake and output for the entire shift >collecting a stool specimen for hemoccult Licensed Practical Nurse (LPN) >administering a pain medication intramuscularly >inserting an indwelling urinary catheter Registered Nurse (RN) >obtaining an admission assessment on a client >administering an intravesical chemotherapy Explanation: The unlicensed assistive personnel (UAP) can perform noninvasive, basic nursing activities such as computing for the intake and output and obtaining a stool specimen for hemoccult. The licensed practical nurse (LPN) can perform all the tasks the UAP can do plus basic nursing skills such as administering oral, intramuscular, subcutaneous, and intradermal medications that have standing prescriptions and inserting indwelling urinary catheters. The registered nurse (RN) is assigned tasks that require advanced training and education. Specialized nursing skills such as administering intravesical chemotherapy should be done by the RN. Tasks that require nursing judgment and assessment such as performing an admission assessment cannot be delegated; hence, should be done by the RN.

An older adult was admitted to the cardiac unit following an emergency room visit for chest pain. To personalize education, the nurse is reviewing the chart to identify the client's risks of coronary vascular disease (CVD). The nurse will use this information to develop a teaching plan that will assist the client in altering factors that increase the risk of CVD. Click to highlight the findings below that the would be included in the education. Progress Note: The client is a 70-year-old male. Family history includes a mother who died of a myocardial infarction and a paternal grandparent who suffered from multiple strokes prior to death. The client is verbal and pleasant and oriented × 4. Socially the client reports a high level of stress after having to recently take in a grandchild to raise . Respirations are even unlabored. The client reports shortness of air with minimal exertion and reports reports a 40-pack-year history of tobacco use . Cardiac rate and rhythm regular and within normal limits. Bowel sounds positive × 4 quadrants. The client reports walking at least one mile per day for exercise , but cannot seem to get BMI below 36 . Current medications include metformin and insulin .

a high level of stress after having to recently take in a grandchild to raise reports a 40-pack-year history of tobacco use but cannot seem to get BMI below 36 Current medications include metformin and insulin Explanation: The teaching plan is focused on providing education on factors that can be altered (modifiable). Nonmodifiable risk factors cannot be altered. Stress is associated with cardiac complications such as high blood pressure, angina, and myocardial infarction. It also causes an elevation in lipids and contributes to increased clotting. Cigarette smoking is a modifiable risk factor associated with coronary vascular disease (CVD) due to its effects on the heart, including elevated heart rate, elevated blood pressure, and arteriole constriction. It also reduces the oxygen-carrying capacity of blood and can cause irregular heart rhythms. Obesity increases one's risk factor of CVD because of its ability to increase blood pressure, triglycerides, and cholesterol. A client is said to be obese if the body mass index (BMI) is 30 kg/m2 or more. The client has diabetes mellitus as indicated by current medications of metformin and insulin. Diabetes increases the risk of CVD because it elevates the level of sugar and cholesterol in the blood, and it raises blood pressure. The age and gender of the client are not modifiable factors and, therefore, are not included in education associated with altering health factors. A familial history of heart disease is not something within the client's ability to alter. Being verbal, pleasant, and oriented × 4 are normal neurologic findings that do not have an impact on CVD. Respirations that are even and unlabored are normal respiratory findings. Shortness of air with exertion is a finding that is physiologic in nature and cannot itself be remedied. The client will need to modify other factors to attempt to reduce the work of breathing. A regular rate and normal rhythm of the heart is an expected finding that is not indicative of CVD. Gastrointestinal findings that include positive bowel sounds in all four quadrants are a normal finding. Physical inactivity, as opposed to regular exercise, is a risk factor for CVD.

A nurse is providing care for an older adult who is unable to get out of bed. Intake and output records indicate a possible alteration in urinary elimination. Client is alert and oriented × 4. Client is verbal, but with dysphasia, as associated with recent cerebrovascular accident. Client reports a high level of stressassociated with recent social changes. Respirations even and unlabored. Continued reports of sneezing that is slightly improved with the use of antihistamines for seasonal allergies. Cardiac rhythm is regular and rate within normal limits. Edema of 2+ to bilateral feet, improved from 3+ following a.m. diuretic administration and elevation of bilateral lower extremities. Bowel sounds positive x 4, denies diarrhea or constipation.

cerebrovascular accident high level of stress antihistamines Edema of 2+ to bilateral feet diuretic administration Explanation: Impaired neurologic function caused by disorders such as cerebrovascular accidents, tumors of the brain, or spinal injury can reduce the perception of bladder fullness. A high level of stress can either cause a strong need to urinate or it could contribute to urinary retention. Anticholinergic medications such as antihistamines and tricyclic antidepressants can cause urinary retention. Anticholinergic medications such as antihistamines and tricyclic antidepressants can cause urinary retention. A cognition of alert and oriented × 4 is a positive factor and normal finding that would not alter elimination. The ability to verbally communicate effectively does not impair or alter the function of the genitourinary system. Social changes may be positive or negative and are not associated with altered urinary output. Even and unlabored respirations are normal factors that would not alter urinary function. Sneezing is a respiratory symptom associated with allergies but not with urinary function. A regular cardiac rhythm and rate are positive and normal findings not associated with urinary elimination. The presence of edema is a consequence of fluid overload, which can be reduced with elevation, but does not directly alter the production of urine. Gastrointestinal findings such as positive bowel sounds or the lack of diarrhea or constipation are normal findings that would not affect urinary output.

A nurse is providing care for an older adult who is unable to get out of bed. Intake and output records indicate a possible alteration in urinary elimination. Click to highlight the findings that can impair the amount of urinary output. Client is alert and oriented × 4. Client is verbal, but with dysphasia , as associated with recent cerebrovascular accident . Client reports a high level of stress associated with recent social changes. Respirations even and unlabored. Continued reports of sneezing that is slightly improved with the use of antihistamines for seasonal allergies. Cardiac rhythm is regular and rate within normal limits. Edema of 2+ to bilateral feet , improved from 3+ following a.m. diuretic administration and elevation of bilateral lower extremities. Bowel sounds positive x 4, denies diarrhea or constipation.

cerebrovascular accident high level of stress antihistamines diuretic administration Explanation: Impaired neurologic function caused by disorders such as cerebrovascular accidents, tumors of the brain, or spinal injury can reduce the perception of bladder fullness. A high level of stress can either cause a strong need to urinate or it could contribute to urinary retention. Anticholinergic medications such as antihistamines and tricyclic antidepressants can cause urinary retention. Anticholinergic medications such as antihistamines and tricyclic antidepressants can cause urinary retention. A cognition of alert and oriented × 4 is a positive factor and normal finding that would not alter elimination. The ability to verbally communicate effectively does not impair or alter the function of the genitourinary system. Social changes may be positive or negative and are not associated with altered urinary output. Even and unlabored respirations are normal factors that would not alter urinary function. Sneezing is a respiratory symptom associated with allergies but not with urinary function. A regular cardiac rhythm and rate are positive and normal findings not associated with urinary elimination. The presence of edema is a consequence of fluid overload, which can be reduced with elevation, but does not directly alter the production of urine. Gastrointestinal findings such as positive bowel sounds or the lack of diarrhea or constipation are normal findings that would not affect urinary output.

The nurse is providing education to a group at a local community center on how to improve sleep quality. The nurse associates each intervention suggested with an example of how it can improve sleep. The nurse suggests that the clients____ because ____.

get up after 30 minutes of sleeplessness it helps the mind to associate the bedroom with sleep Explanation: To improve sleep patterns and quality, clients should get out of bed after 20 to 30 minutes of an inability to fall asleep. Clients should go into another room and perform a nonstimulating activity such as reading. Limiting the bed or bedroom to only resting or sexual activity helps to train the mind to associate the area with sleep. Sleep hygiene education should include the need to reduce evening meals to a lighter, versus heavier, proportion. Heavier meals can contribute to heartburn and delay or impair sleep. Clients should be informed that it is necessary to get up at the same time each morning, even if they did not sleep well or went to bed later the night before. This practice helps to maintain the circadian rhythm. Clients also should be instructed to perform physical activity each day, but not prior to going to bed. Both rest and sleep impairment are associated to physical activities that occur prior to bedtime. The only appropriate intervention suggested is to get out of bed after 30 minutes of an inability to fall asleep. This action will not reduce heartburn, but it can be reduces by consuming a lighter evening meal. Getting up after not being able to fall asleep will not help to maintain the circadian rhythm; however, clients can do this by ensuring they get out of bed at the same time each morning. Fatigue and sleepiness will not be increased, if clients get out of bed after 30 minutes of not being sleepy. Increased fatigue or sleepiness at bedtime may be associated with undertaking at least some physical activity each day.

A middle-aged female client visits the clinic to confirm pregnancy. "I cannot believe this is happening. I cannot be pregnant. My parents will kill me. I was raised in a strict Roman Catholic home. I was not supposed to get pregnant before marriage." The client is exhibiting signs of spiritual ____ related to the ____.

guilt disengagement from faith community Explanation: The client is exhibiting spiritual guilt related to the inability to live up to devout practices. Because the Roman Catholic doctrine prohibits getting pregnant before marriage, the client feels that they have betrayed their family and their religion. Spiritual anger pertains to feelings of outrage or frustration against an ultimate or higher power. Spiritual alienation refers to feelings of separation or estrangement from a supreme power or being. Clients experiencing spiritual alienation may feel that they are detached from their faith source. Birth control and abortion are prohibited in the Roman Catholic religion. These rules may make the client feel disengaged from their faith if this situation is making the client reconsider their options related to pregnancy. The feeling of questioning their belief and value systems is characteristic of spiritual anxiety. The client's comments indicate that the client has not yet fully accepted the pregnancy. The client is displaying risk factors characteristic of spiritual pain because the client is unable to reconcile being pregnant before marriage and the religious teachings.

The nurse obtains a health history interview on a client with lung cancer. The client states, "I became too focused at work; I did not have time to rest. I usually work 8 hours per day but, for the past few months, I have been spending at least 12 hours per day at the office. That is probably the reason why I was diagnosed with cancer. Maybe when I try to go back to my usual schedule, the cancer will go away. I did not want to be here but my wife is insistent. I do not think medications work. My brother-in-law died of cancer. He took a lot of medicines and prayed really hard, but he died just the same." The nurse determines that the client believes in the ____ cause of illness as manifested by____.

holistic believing one can be cured of cancer by limiting work hours Explanation: The holistic perspective presupposes that health is achieved when an individual is in harmony or in balance with the internal/external environment; illness is caused by any imbalance or disharmony. Believing that the cancer will be cured if the client cuts back on work hours is a means of restoring balance and harmony; thus, supports the holistic perspective of health. The biomedical perspective relies on empirical findings to explain health and illness. Believing in the effectiveness of medications supports the biomedical model. This perspective does not apply because the client is skeptical about relying on medications to cure the cancer. The client states, "I do not think medications work" and comments about how the brother-in-law took "a lot of medicines" and still died. The belief that supernatural forces influence health and illness supports the magico-religious perspective. Exhibiting confidence in the power of prayer to alleviate and/or cure illnesses falls under the magico-religious belief. The client comments that the brother-in-law died even though the brother-in-law prayed "really hard," which leads the nurse to believe the client does not hold the belief that prayer will cure the illness.

A parent brings a child into the pediatric office with reports of an itchy red rash with fluid filled blisters. Two siblings at home are reported to have the same rash. The nurse knows that since the parent had the same virus during childhood they will have ____ immunity in the form of ____.

humoral antibodies Explanation: Humoral immunity consists of antibodies that are formed in response to exposure to an antigen. Artificial immunity would be obtained via a vaccine, whereas lymphocytes are considered part of cellular immunity. Cellular immunity is stimulated upon exposure to an antigen (foreign material) and results in the lymph system producing T-cells to attack the antigen. Passive immunity is acquired from another individual, for example a pregnant client to a fetus or through a blood transfusion. T-cells are part of cellular immunity that is activated upon response to an antigen.

A client with a medical history of valvular dysfunction is admitted to the medical floor for management of heart failure exacerbation. The nurse reviews the client's chart to identify related findings. The nurse would differentiate ____ and elevated ____ as being associated with heart failure, because they are both a result of ____.

lower extremity edema B-type natriuretic peptide fluid volume excess Explanation: Lower extremity edema is associated with the venous pooling caused by heart failure. The cardiac biomarker associated with heart failure is B-type natriuretic peptide, which is released when the heart is stretched by the excess fluid volume of heart failure. Fluid volume excess is a common presenting characteristic of heart failure, which is a result of ineffective cardiac pumping ability and fluid retention. Yellow sputum is associated with an infection of the lungs. During heart failure exacerbation, the client may develop pulmonary edema and associated frothy pink sputum. Nerve damage, specifically peripheral neuropathy, is not a common symptom of heart failure, but is common with diabetes. Radiating pain is characteristic of cardiac muscle damage and infarction. Generalized weakness can be a symptom with multiple conditions, but is not specific to heart failure or associated with fluid volume excess. Fluid volume excess is not associated with red blood cell production. An elevated red blood cell count may be a result of polycythmia, which is an overproduction of blood cells. Troponin is a cardiac biomarker that is elevated with cardiac muscle damage and is used to identify or rule out myocardial infarction. Another cardiac biomarker used to measure muscle damage of the heart is creatine kinase, elevation is not associated with heart failure nor fluid volume excess. Elevated platelets are associated with hypercoagulation and are a result of a condition called thrombocytosis. Fluid volume excess is a primary concern in the client suffering an exacerbation of heart failure. Inability to swallow may be associated with pain or compression, stricture, or blockage of the espophagus, but is not correlated with heart failure. Difficulty with self-care or altered physical mobility are not associated with elevated laboratory findings nor any specific symptoms of heart failure. Elevated infection risk would be indicated by an increased or significantly reduced white blood cell account. Another assessment finding associated with elevated infection risk might include fever, chills, or swollen lymph nodes.

The nurse is providing care to a client who had abdominal surgery yesterday. Click to highlight the items in the scenario that break the cycle of infection between the infectious agent and reservoir. The nurse enters the room, performs hand hygiene and confirms the client's identity . Using a scanner system the nurse accesses the medication adiministration record and hangs prescribed intravenous antibiotics . The nurse then prepares a sterile field on which sterile items are aseptically placed . The soiled dressing is removed and both the wound and the dressing are assessed. The nurse removes the soiled gloves and then dons sterile gloves to clean the wound and applies a new sterile dressing.

performs hand hygiene and hangs prescribed intravenous antibiotics prepares a sterile field on which sterile items are aseptically placed Explanation: The cycle of infection includes several specific components including the infectious agent and the reservoir. The infectious agent is a potentially disease-causing microorganism, such as a bacterium, fungus, parasite, prion, or virus. The reservoir is a place of growth and reproduction for the infectious agent. A reservoir can be living, such as another human or an animal, or environment, such as air, food, water, or contaminants. By performing hand hygiene the nurse reduces the presence of infectious agents that can potentially enter the reservoir. By hanging antibiotics as prescribed, the nurse helps stregnthen the immune defense of the reservoir. The use of sterile supplies from a sterile field assist in preventing entry of organisms into the reservoir. Confirming the client's identity will not interupt the cycle of infection but will be essential in avoiding administering the wrong treatment to the client. Using a scanner system also ensures the correct client and treatment are matched with each other, but the action does not interrupt the cycle of infection. Wearing gloves while removing a soiled dressing will help to interrupt the infectious cycle link that occurs between the portal of exit from reservoir and the means of transmission of the pathogenic organism. Assessing the wound and the dressing will not interrupt the cycle of infection but will assist the nurse in documentation and clinical judgment. Changing the gloves after removing a soiled dressing disrupts the cycle at the point between means of transmission and portal of entry. The wound is a portal of entry, donning sterile gloves interrupts the means of transmission into the portal. Cleaning the wound and applying a sterile dressing again breaks the chain between a portal of exit and the means of transmission.

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply.

prescription for warfarin diagnosis of periodontitis current chemotherapy treatment low platelet count Explanation: Warfarin is in a class of drugs known as anticoagulants, which interrupt the clotting ability of blood. The use of anticoagulants increase the risk of bleeding. Periodontitis is inflammation of the gums and may be associated with swollen, painful, or bleeding gums. Chemotherapy can result in sensitive mucous membranes and bleeding gums. Platelets are blood cells that are necessary for adequate clotting. When the level of platelets are decreased the blood is not able to clot effectively and the risk of bleeding increases. An unwitnessed fall may be a sign of unnoticed blood loss or bleeding, but it is not likely to be the cause of oral bleeding. Shortness of air, or dyspnea on exertion, is not associated with increased bleeding, especially of the gums. Beta-blockers such as carvedilol are not associated with increased risk for bleeding. The qualities of mental status--intact, altered, or decreased--have no bearing on tissue integrity or the body's ability to clot effectively.

The nurse works in a unit where the staff nurses can pick their own work schedule in exchange for being on call at least one weekend in a month. However, once the staff nurse refuses to come in when called in to work, the staff nurse loses the flexibility to choose their work schedule for the next 2 months. The institution implements a ____ leadership style as evidenced by the ____.

transactional task-and-reward orientation Explanation: The transactional leadership style makes use of the task-reward system. Individuals concur to a favorable work condition on the off chance that the institution too gets something in return. In the scenario, the nurses are given the option to choose their work schedule provided that they agree to be on call for a weekend. With transformational leadership, the provision of a stimulating and supportive environment foster professional and personal growth. The given scenario lack cues that promote transactional leadership. Autocratic leadership, otherwise referred to as directive or aurthoritarian leaadership, does not provide opportunity for its members to make independent decisions. The autocratic leadreship is not applicable in the scenario because the nurses were given the flexibility to choose their own schedule, although they are also expected to be on call one weekend in a month. In the provided scenario, the nurse was not offered the opportunity of shared decision making which is the foundation of the democratic leadership style. With this style of leadership, decisions and activities are shared, thereby creating a sense of equality among leadership and employees. The adoption of self scheduling methods indicates the organizations use of technology and ability to recognize its members as a collective being. This is an example of quantum leadership theory, which views the organization and its members as an interconnected, collaborative being that can prove useful when dealing with unpredictable events and changes.

The nurse works in a unit where the staff nurses can pick their own work schedule in exchange for being on call at least one weekend in a month. However, once the staff nurse refuses to come in when called in to work, the staff nurse loses the flexibility to choose their work schedule for the next 2 months. The institution implements a____ leadership style as evidenced by the ____.

transactional task-and-reward orientation Explanation: The transactional leadership style makes use of the task-reward system. Individuals concur to a favorable work condition on the off chance that the institution too gets something in return. In the scenario, the nurses are given the option to choose their work schedule provided that they agree to be on call for a weekend. With transformational leadership, the provision of a stimulating and supportive environment foster professional and personal growth. The given scenario lack cues that promote transactional leadership. Autocratic leadership, otherwise referred to as directive or aurthoritarian leaadership, does not provide opportunity for its members to make independent decisions. The autocratic leadreship is not applicable in the scenario because the nurses were given the flexibility to choose their own schedule, although they are also expected to be on call one weekend in a month. In the provided scenario, the nurse was not offered the opportunity of shared decision making which is the foundation of the democratic leadership style. With this style of leadership, decisions and activities are shared, thereby creating a sense of equality among leadership and employees. The adoption of self scheduling methods indicates the organizations use of technology and ability to recognize its members as a collective being. This is an example of quantum leadership theory, which views the organization and its members as an interconnected, collaborative being that can prove useful when dealing with unpredictable events and changes.