Med Surg FINAL EXAM

A nurse should be able to differentiate between the typical and atypical antipsychotics. Which are classified as typical antipsychotics? (Select all that apply.) Lithium (Eskalith) Aripiprazole (Abilify) Chlorpromazine (Thorazine) Haloperidol (Haldol) Fluphenazine (Prolixin)

Chlorpromazine (Thorazine) Haloperidol (Haldol) Fluphenazine (Prolixin)

Which medication is used to prevent alcohol withdrawal symptoms? Lorazepam (Ativan) Clonidine (Catapres) Folic acid (Folate) Naltrexone (ReVia)

Lorazepam (Ativan) Safe withdrawal usually is accomplished with the administration of benzodiazepines, such as lorazepam, chlordiazepoxide, or diazepam, to suppress the withdrawal symptoms.

What are common skin reactions that a nurse should warn a client about when they are initiated on antipsychotic therapy? (Select all that apply.) Urticaria Stevens-Johnson syndrome Photosensitivity Hyperpigmentation Toxic epidermal necrolysis

Urticaria Photosensitivity Urticaria and photosensitivity are common skin reactions that a nurse should warn a client about when they are initiated on antipsychotic therapy.

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's father states that he's going to have his son declared legally incompetent. Which response by the nurse is most therapeutic? "Your son is ill and can't make decisions about himself and his safety right now, but this situation is temporary." "You don't have the right to declare your son incompetent. He has rights, too." "I'll help you contact the hospital legal representative for help with the paperwork." "If you become your son's guardian, you'll be responsible for his finances and for paying for his treatment."

"Your son is ill and can't make decisions about himself and his safety right now, but this situation is temporary." The client is temporarily unable to make decisions about his health care and safety. After receiving emergency care and treatment, he'll probably be able to safely manage his daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting his civil rights. A guardian doesn't assume financial responsibility.

A nurse should monitor a client taking donepezil (Aricept) for which adverse effects? (Select all that apply.) Anorexia Dizziness Headache Constipation Bradycardia

Anorexia Dizziness Headache Generalized adverse reactions to cholinesterase inhibitors like donepezil (Aricept) include: anorexia, nausea, vomiting, diarrhea, dizziness, and headache and therefore should be monitored for by the nurse.

During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting during what time frame? Within 24 hours Between 24 and 48 hours At the beginning of the third day Beginning on day 4 or day 5

Beginning on day 4 or day 5 Beginning on the fourth or fifth post-burn day, potassium ions shift from the extracellular fluid into cells, leading to a potassium deficit.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. Which initial assessment data would the nurse anticipate? Select all that apply. Decreased respiratory rate Dyspnea on exertion Barrel chest Shortened expiratory phase Clubbed fingers and toes Fever

Dyspnea on exertion Barrel chest Clubbed fingers and toes COPD is one of the most common lung diseases making it difficult to breathe. Severity of the illness varies. Typical findings for clients with COPD include dyspnea on exertion, a barrel chest, and clubbed fingers and toes. Clients with COPD are usually tachypneic with a prolonged expiratory phase. Fever is not associated with COPD, unless an infection is also present.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Endotracheal suctioning Encouragement of coughing Use of a cooling blanket Incentive spirometry

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

Which finding would indicate a decrease in pressure with mechanical ventilation? Kinked tubing Increase in compliance Decrease in lung compliance Plugged airway tube

Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

Which are considered physiological signs the nurse expects to observe in a grieving individual? Select all that apply. Hypersomnia Weight gain Indigestion Palpitations Lack of energy

Indigestion Palpitations Lack of energy The client may experience indigestion, palpitations, and lack of energy due to grief. While experiencing grief, the client may sleep more than usual throughout the day rather than during one specific time of day. Grief may suppress the client's appetite resulting in weight loss and not weight gain.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery

Intubate the client and control breathing with mechanical ventilation A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A 25-year-old woman with a history of systemic lupus erythematosus was admitted with a severe viral respiratory tract infection and diffuse petechiae. Based on these data, it is most important that the nurse further evaluate the client's recent: quality and quantity of food intake. type and amount of fluid intake. extent of weakness and fatigue. Length and amount of menstrual flow.

Length and amount of menstrual flow. A recent viral infection in a female client between the ages of 20 and 30 with a history of systemic lupus erythematosus and an insidious onset of diffuse petechiae are hallmarks of idiopathic thrombocytopenic purpura. It is important to ask whether the client's recent menses have been lengthened or are heavier. Determining her ability to clot can help determine her risk of increased bleeding tendency until a platelet count is drawn. Petechiae are not caused by poor nutrition. Because of poor food and fluid intake or weakness and fatigue, the client may have gotten bruises from falling or bumping into things, but not petechiae.

When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply. Measure drainage at the end of each shift. Assess chest tube dressing for bleeding. Maintain wall suction at a low setting so there is intermittent bubbling. Position the client in the prone or supine position to permit optimal drainage. Ensure all connections are securely taped.

Measure drainage at the end of each shift. Assess chest tube dressing for bleeding. Ensure all connections are securely taped. It is important to ensure that chest tube connections are secure so there are no air leaks. In addition, postoperative considerations include checking the chest tube dressing. The drainage would also be measured at the end of each shift. These are primary considerations postoperatively after a lobectomy. Wall suction must be continuously bubbling to ensure there is active suction in the pleural space. The client needs to be in the Fowler's position to promote effective breathing. Prone or supine would not be appropriate.

A 20-year-old client arrives at the emergency department by ambulance. The client is unconscious, with slow respirations and pinpoint pupils. There are "tracks" visible on the client's arms. The friend who came with the client reports that the client had just "shot up" heroin when the client became unconscious. Which medication would the nurse most likely expect to administer? Naloxone Naltrexone Bupropion Varenicline

Naloxone Naloxone, an opioid antagonist, is given to reverse respiratory depression, sedation, and hypertension. Naltrexone is used to treat alcohol dependence. Bupropion and varenicline are used to promote smoking cessation.

A client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation in the anteroseptal leads and T-wave inversion in leads V3 to V5. Which medication should the nurse prepare to administer? Lidocaine Procainamide Nitroglycerin Epinephrine

Nitroglycerin The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to order an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs, which may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or asystole, a physician may order epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects.

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention? Partial pressure of arterial oxygen (PaO2) of 69 mm Hg Partial pressure of arterial carbon dioxide (PaCO2) of 51 mm Hg pH of 7.29 Bicarbonate (HCO3-)of 28 mEq/L

Partial pressure of arterial oxygen (PaO2) of 69 mm Hg In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in discharge teaching? Select all that apply. Provide humidity at home. Follow a bland diet. Learn how to suction. Have communication rehabilitation with a speech pathologist Attend a smoking cessation program.

Provide humidity at home. Learn how to suction. Have communication rehabilitation with a speech pathologist Attend a smoking cessation program. Home care for a client with a total laryngectomy should include a high-humidity environment, laryngectomy tube care and suctioning, speech rehabilitation, and smoking cessation. The client is not restricted to a bland diet.

A client has been prescribed naltrexone for treatment of alcohol dependence. The nurse has explained the drug's purpose to the client. The nurse determines that the client has understood the instructions when the client identifies which about the drug? Causes itching if alcohol is consumed Produces the euphoria of alcohol Reduces the appeal of alcohol Improves appetite and nutritional status

Reduces the appeal of alcohol Naltrexone's effect is unknown. Reports from successfully treated clients suggest three kinds of effects: (1) can reduce craving (the urge or desire to drink), (2) can help maintain abstinence, and (3) can interfere with the tendency to want to drink more if a recovering client slips and has a drink.

While the nurse is providing morning hygiene for a patient who has a chest tube, the patient has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? Submerge the end of the tube in sterile water Clamp the tube near the end and also near the insertion point Place the end of the tube on a sterile surface and seek help promptly Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit

Submerge the end of the tube in sterile water If a chest tube becomes disconnected from the drainage unit, the nurse should submerge the end of the tube in a bottle of sterile water, thus preventing a pneumothorax but still allowing air to escape.

High doses of alcohol produce which effect? Vomiting Decreased muscle tension Increased inhibitions Calmness

Vomiting An overdose, or excessive alcohol intake in a short period, can result in vomiting, unconsciousness, and respiratory depression.

A client diagnosed with schizophrenia is being discharged on aripiprazole 5 mg every night. When developing the teaching plan about the most common adverse effects, which information should the nurse include? Select all that apply. headaches transient mild anxiety insomnia torticollis pill rolling movements

headaches transient mild anxiety insomnia Headaches, transient anxiety, and insomnia are the most common adverse effects of aripiprazole. Torticollis and pill rolling are more common with the older antipsychotics.

The nurse is caring for a client who had a kidney transplant 4 months ago. What symptom would be indicative of an acute transplant rejection? Select all that apply temperature >100.8°F (38.7°C) weight gain increased blood urea nitrogen level decreased serum creatinine weight loss

temperature >100.8°F (38.7°C) weight gain increased blood urea nitrogen level Fever, increased blood urea nitrogen level, and weight gain are all indicative signs of a transplant rejection. A decreasing serum creatinine is not an indicator; creatine levels will rise in this scenerio.

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: suctioning the tracheostomy tube frequently. using a cuffed tracheostomy tube. using the minimal-leak technique with cuff pressure less than 25 cm H2O. keeping the tracheostomy tube plugged.

using the minimal-leak technique with cuff pressure less than 25 cm H2O. To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.

A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. The jaws are wired. Which items should always be available at this client's bedside? Select all that apply. nasogastric tube wire cutters oxygen cannula suction equipment code cart

wire cutters suction equipment Following surgery for a fractured mandible, the client's jaws will be wired. The nurse should be prepared to intervene quickly in case the client develops respiratory distress or begins to choke or vomit. Wire cutters or scissors should always be available in case the wires need to be cut in a medical emergency. Suction equipment should be available to help clear the client's airway if necessary. It is not necessary to keep a nasogastric tube or oxygen cannula at the client's bedside. Cardiopulmonary arrest is unlikely, so a code cart is not needed at the bedside.

A client loses control and throws two chairs toward another client. What should the nurse do next? Ask the client to go to the quiet area and talk about the behavior. Administer an oral PRN tranquilizer, and prepare for a show of determination. Process the incident with the client and discuss alternative behaviors. Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer.

Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer. The client is in the crisis phase of the assault cycle. Therefore, the nurse must act immediately, using restraints and an intramuscular tranquilizer to prevent injury to others or further property damage. It is too late to ask the client to go to a quiet area to talk because the client's behavior is past the triggering phase. Giving the client an oral tranquilizer and preparing for a show of determination are nursing interventions used in the escalation phase. Processing the incident with the client and discussing alternative behaviors are interventions used in the postcrisis phase.

A client with systemic lupus erythematosus reports palpitations, dyspnea on exertion, and leg swelling. The client's symptoms may indicate: cardiomyopathy. pericarditis. thrombophlebitis. Buerger's disease.

Cardiomyopathy Dilated cardiomyopathy is accompanied by dyspnea on exertion and when lying down. The client experiences fatigue and leg swelling and may also have palpitations and chest pain. When a client's medical history includes disorders that are bacterial or viral in origin, a family history of early cardiac deaths, or any of several other conditions that correlate with heart involvement, the possibility of cardiomyopathy is considered. Pericarditis usually is secondary to endocarditis, myocarditis, chest trauma, or MI (heart attack), or develops after cardiac surgery. Clients with thrombophlebitis often complain of discomfort in the affected extremity. With Buerger's disease, the client notes that one or both feet are always cold and may report numbness, burning, and tingling in some areas of the feet.

A nurse is interviewing a rape victim who was assaulted 6 month ago. Which questions should the nurse ask the client to know the extent of physical symptoms of PTSD? Select all that apply. "Are you having trouble sleeping?" "Have you felt irritable or experienced outbursts of anger?" "Do you have heart palpitations or sweating?" "Do you feel numb emotionally?" "Do you ever feel as you are reliving the event?"

"Are you having trouble sleeping?" "Have you felt irritable or experienced outbursts of anger?" "Do you have heart palpitations or sweating?" "Do you ever feel as you are reliving the event?" To learn whether the client is having physical symptoms of PTSD, the nurse should ask the client if she is having trouble sleeping and whether she is emotionally stable or given to bursts of irritability. The nurse should also find out if the client experiences heart palpitations or sweating. Reliving the event is called flashback and is a physical response to the event. Asking the client if she is feeling numb emotionally assesses the presence of avoidance reactions, not physical manifestation of PTSD. The nurse should ask the client whether she has upsetting thoughts and nightmares to assess for the presence of intrusive thoughts.

A 13-year-old is being evaluated for lupus. The teen asks who is at risk for this condition. What information can be provided by the nurse? Select all that apply. "Females are at a higher risk than males." "There are certain groups such as Hispanics and African Americans who are at an increased risk for the disease." "Excessive sun exposure is linked to the development of lupus." "Family history does not seem to play a factor for this condition." "Some clients will have had a recent infection."

"Females are at a higher risk than males." "Excessive sun exposure is linked to the development of lupus." "Some clients will have had a recent infection." Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder that affects both humoral and cellular immunity. SLE can affect any organ system, so the onset and course of the disease are quite variable. There are some identified risk factors including female gender. Groups such African Americans or those of Asian descent have a higher incidence of lupus. Hispanics are not at an increased risk. Family history does have a role in this condition. A recent infection may be reported by some diagnosed with the condition.

A client has been rehospitalized with a severe exacerbation of lupus. Her husband approaches the nurse and says, "My wife is scaring me. She says she does not want to live with this illness anymore. Our kids are grown, and she feels useless as a mother and a wife." Which statements are the most appropriate responses to the husband? Select all that apply. "I will have a talk with your wife to see if she is suicidal." "You need to be strong and optimistic when you are with her." "I am glad you shared this with me. I can imagine that this is scary for you." "I am sure she will feel differently when we get this episode under control." "We can talk about what you can say to her that may help."

"I will have a talk with your wife to see if she is suicidal." "I am glad you shared this with me. I can imagine that this is scary for you." "We can talk about what you can say to her that may help." Suicide is a risk with chronic illnesses. The husband needs validation of his feelings and support, as well as suggestions for helping his wife with her concerns. Telling him to be strong and optimistic ignores the client's needs. It is false to assume that the client will no longer be suicidal when the lupus is under control.

A 68-year-old client is admitted to the addiction unit after treatment in the emergency department for an overdose of oxycodone. Her son calls the unit and expresses intense anger that his mother is being treated as a "common street addict." He says she has severe back pain and was given that prescription by her health care provider (HCP). "She just accidentally took a few too many pills last night." Which reply by the nurse is most therapeutic? "I understand that your mother may not have intentionally taken too many pills. This medication can cause one to forget how many have been taken." "It may be appropriate for your mother to be referred to a pain management program." "Unfortunately, it is fairly common for clients with pain to increase their use of pain pills over time." "I can hear how upset you are. You sound very concerned about your mother."

"I can hear how upset you are. You sound very concerned about your mother." Acknowledging the client's son's feelings is the most therapeutic intervention because he is not likely to hear the nurse's information until his anger and other feelings are addressed and subside. Then it is important to acknowledge that oxycodone, especially in older clients, can interfere with remembering how many pills were taken. It is common for clients with chronic pain to inadvertently overuse or become addicted to pain medications. Pain management programs help clients to withdraw from the offending medication and start on a multifaceted system for controlling the pain.

A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. "My hands get pale, bluish, and feel numb and painful when I'm really stressed." "I can't continue to wash dishes and do my cleaning because of this problem." "I don't need to report any other skin problems with my fingers or hands to my practitioner." "I probably got this disorder because I have lupus." "This problem is caused by a temporary lack of circulation in my hands." "Medication might help treat this problem."

"My hands get pale, bluish, and feel numb and painful when I'm really stressed." "I probably got this disorder because I have lupus." "This problem is caused by a temporary lack of circulation in my hands." "Medication might help treat this problem." Raynaud's phenomenon causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when the client is exposed to cold or stress. It is caused by episodic vasospasm in the small peripheral arteries and arterioles and can affect the feet as well as the hands. The phenomenon is commonly associated with connective tissue diseases such as lupus and may be alleviated by calcium channel blockers or adrenergic blockers. It does not limit the client's ability to function, although the symptoms are bothersome. Keeping the hands warm and learning to manage stressful situations effectively reduces the frequency of episodes. The disorder can progress to skin ulcerations and even gangrene in some clients, so all skin changes should be reported to the practitioner promptly.

A client with end-stage liver disease is scheduled to undergo a liver transplant. The client tells the nurse, "I am worried that my body will reject the liver." Which statement is the nurse's best response to the client? "You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." "You would not be scheduled for a transplant if there was a concern about rejection." "The problem of rejection is not as common in liver transplants as in other organ transplants." "It is easier to get a good tissue match with liver transplants than with other types of transplants."

"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the client's anxiety.

The nurse is preparing an assessment guide for the emergency department staff regarding assessment of clients are admitted with burn injuries. What should the nurse be sure to include in the assessment guide for primary emergency assessment of burns? Airway assessment Depth of the burn/s Presence of edema Percentage of body burned Pulse strength

Airway assessment Presence of edema Pulse strength The primary survey includes evaluation of the child's airway, breathing, and circulation. The secondary survey focuses on evaluation of the burns and other injuries.

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Acute respiratory distress syndrome Lung cancer Bronchitis Tracheobronchitis

ARDS Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

A nurse is teaching a group of families who have members experiencing addiction about this problem. Which of the following, if stated by the families, indicates that the teaching was successful? Addiction results from a defect in the person's character. A single factor is usually responsible for development of addiction. Addiction is not a result of a person having moral faults. Addiction rarely results in the person experiencing relapse.

Addiction is not a result of a person having moral faults. Addiction is not a defect in character or a moral fault. It results from a combination of factors, such as values, beliefs, family and personal norms, spiritual convictions, and conditions of the current social environment. Even with treatment, relapse, which is considered part of the illness process, can occur.

A physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result helps to confirm an SLE diagnosis? Increased total serum complement levels Negative antinuclear antibody test Negative lupus erythematosus cell test An above-normal anti-deoxyribonucleic acid (DNA) test

An above-normal anti-deoxyribonucleic acid (DNA) test Laboratory results specific for SLE include an above-normal anti-DNA test, a positive antinuclear antibody test, and a positive lupus erythematosus cell test. Because the anti-DNA test rarely is positive in other diseases, this test is important in diagnosing SLE. (The anti-DNA antibody level may be depressed in clients who are in remission from SLE.) Decreased total serum complement levels indicate active SLE.

A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he's scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next? Contact the physician and apply physical restraints as instructed by the physician. Apply physical restraints to protect the client, then contact the physician for orders. Place the client in seclusion and contact the physician for further orders. Call security to restrain the client and put him in seclusion for the safety of the unit.

Apply physical restraints to protect the client, then contact the physician for orders. A nurse may place a client in physical restraints if he poses a threat to himself or others and all less-restrictive interventions have failed. A nurse may place a client in restraints without a physician's order but must obtain an order within 1 hour of restraint application. Secluding the client, with or without security involvement, doesn't protect him from injury.

The nurse is caring for a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which information would be included in a teaching plan that focuses on home care? Select all that apply. Avoid exposure to sunlight. Keep exercise to a minimal level. Report development of a butterfly rash on the face. Avoid over-the-counter (OTC) medications unless approved by the physician. Take rest periods as needed.

Avoid exposure to sunlight. Keep exercise to a minimal level. Avoid over-the-counter (OTC) medications unless approved by the physician. Take rest periods as needed. The client who suffers from SLE has a tendency toward photosensitivity; therefore, the client would avoid exposure to sunlight. The client would also be advised to keep exercise to a minimum, to avoid OTC medications unless directed by the physician, and to rest as needed. Because the butterfly rash associated with lupus is an initial sign, the client would already have the rash and would not be reporting its development after discharge.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply. Base-bicarbonate deficit Elevated hematocrit level Potassium deficit Sodium deficit Magnesium deficit

Base-bicarbonate deficit Elevated hematocrit level Sodium deficit At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. There is a loss of bicarbonate ions accompanying sodium loss, which results in metabolic acidosis (base-bicarbonate deficit).

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? Acute pain Septicemia Bleeding Seizures

Bleeding Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.

The mental health nurse should focus on preventative efforts including educational interventions related to the abuse of prescription drugs on which client group? Chronically ill females regardless of age Both genders between the age of 12 and 17 Cognitively impaired, 60 years of age and older Males between the age of 25 and 50

Both genders between the age of 12 and 17 Prescription drug abuse among youth 12 to 17 years of age has been increasing at an alarming rate, so the mental health nurse concentrates assessments and educational interventions related to the abuse of prescription drugs on both genders between the age of 12 and 17.

The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply. Vomiting Burns Diarrhea Dehydration Trauma

Burns Dehydration The internal (fluid shift) causes of hypovolemic shock include hemorrhage, burns, ascites, peritonitis, and dehydration. The external (fluid loss) causes of hypovolemic shock include trauma, surgery, vomiting, diarrhea, diuresis, and diabetes insipidus.

Which clients would be appropriate candidates for total parenteral nutrition? Select all that apply. Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body A client with peptic ulcer disease Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa Client who is having shoulder surgery

Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa A client with severe burns, as well as a client who has had gastric surgery, would both be a candidate for total parenteral nutrition. TPN is designed for clients who are severely malnourished who will not be able to eat for a long period. A client with anorexia nervosa would also be an appropriate candidate for TPN. A client who has peptic ulcer disease will be able to eat after initiation of a medication regimen. A client who is having shoulder surgery will likely be able to return to a normal diet within a short time frame.

Which treatments are common to both systemic lupus erythematosus and juvenile idiopathic arthritis? Select all that apply. Corticosteroids Nonsteroidal anti-inflammatories Antimalarials Antipyretics Antirheumatics

Corticosteroids Nonsteroidal anti-inflammatories Antimalarials are specific to SLE; antirheumatics are specific to JIA. Antipyretics are not typically used for either disorder.

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Disseminated intravascular coagulation (DIC) Septicemia Stevens-Johnson syndrome from the administration of antibiotics

DIC Disseminated intravascular coagulation (DIC) may occur either as a cause or as a complication of shock. In this condition, widespread clotting and bleeding occur simultaneously. Bruises (ecchymoses) and bleeding (petechiae) may appear in the skin. Coagulation times (e.g., prothrombin time [PT], activated partial thromboplastin time [aPTT]) are prolonged. Clotting factors and platelets are consumed and require replacement therapy to achieve hemostasis. The other conditions listed would not result in bleeding simultaneously at multiple sites.

A client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. He's fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Tests reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl (6.9 mmol/L), and potassium level 3.8 mEq/L (3.8 mmol/L). Which nursing diagnosis is most appropriate for this client? Deficient fluid volume related to inability to conserve water Imbalanced nutrition: Less than body requirements related to hypermetabolic state Deficient fluid volume related to osmotic diuresis induced by hypernatremia Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency

Deficient fluid volume related to inability to conserve water The client has signs and symptoms of diabetes insipidus, probably caused by the failure of his renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. Therefore, Deficient fluid volume related to inability to conserve water is the most appropriate nursing diagnosis. The client's hypernatremia is secondary to his water loss. Imbalanced nutrition: Less than body requirements — whether it's related to hypermetabolic state or catabolic effect of insulin deficiency — is an inappropriate nursing diagnosis for this client.

A child with 20% second- and third-degree burns is admitted to the burn center. The child weighs 44 lbs (20 kg). The nurse has started an IV infusion of lactated Ringer solution and inserted an indwelling catheter. Which of the findings indicate that the child is going into shock? Select all that apply. Urinary output is 25 ml/hr. Specific gravity is within normal limits. Pain is 7 on a pain scale of 1 to 10. Heart rate is elevated. Blood pressure is dropping.

Heart rate is elevated. Blood pressure is dropping. The child is observed for shock that can occur following a severe burn. Shock is noted by the increasing heart rate and dropping blood pressure. This child has an adequate urine output (more than 1 ml/kg body weight) and the specific gravity is within normal range. Pain is expected and is not an indicator of shock.

A female client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting? Intellectualization Denial Regression Displacement

Denial Denial is a protective and adaptive reaction to increased anxiety. It involves consciously disowning intolerable thoughts and impulses. This response is commonly seen in victims of sexual abuse. In intellectualization, the client attempts to avoid expressing emotions associated with the stressful situation by using logic, analysis, and reasoning. A client who uses regression reverts to an earlier developmental level in response to stress. With displacement, the client transfers his feelings for one person toward another, less-threatening person.

A client who has used IV heroin every day for the past 10 years says, "I don't have a drug problem. I can quit whenever I want." Which defense mechanism is being used by the client? Denial Repression Compensation Rationalization

Denial The client who says the client can quit a heroin addiction whenever the client wants is utilizing the defense mechanism of denial.

A client with bipolar disorder, manic phase, is yelling at visitors. The client's face is flushed and his fists are clenched. Which nursing action should be taken first? Summon security to escort the client to his room. Administer IM lorazepam. Direct the client to his room for a time-out. Discuss the problem with the client.

Direct the client to his room for a time-out. The client is in the escalation phase of the assault cycle. Applying the principle of the least restrictive alternative, such as a time-out, is the nurse's first action. Calling security to forcibly escorting the client to his room is more restrictive and not indicated at this time because the client has not lost control. Administering IM lorazepam is not indicated because the client has not lost control. The nurse might offer oral lorazepam if the client is having trouble calming down while in time-out. Discussing the problem is not appropriate in the escalation phase but is appropriate in the triggering phase.

When a client is working toward the prevention of an alcohol abuse relapse, the nurse is acting in a therapeutic role when doing what? Helping the client identify positive coping mechanisms Discussing the pros and the cons of alcohol abuse Monitoring the effects of treatment Providing education to the client's family

Helping the client identify positive coping mechanisms When a client is working toward the prevention of an alcohol abuse relapse, the nurse is most therapeutic when helping the client identify positive coping mechanisms.

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child? Encouraging the child to share feelings Grouping nursing care Following guidelines for protective isolation Providing age-appropriate activities

Following guidelines for protective isolation The child with leukemia is susceptible to infection, especially during chemotherapy. Infections such as meningitis, septicemia, and pneumonia are the most common causes of death. To protect the child from infectious organisms, follow standard guidelines for protective isolation. Grouping nursing care to provide rest is important, but not the highest priority. Encouraging the child to share feelings and providing age-appropriate activities are important, but psychological issues are a lower priority than physical.

A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? Handwashing can prevent the spread of the disease to others. The importance of compliance with antibiotic therapy Signs and symptoms of complications, such as meningitis and septicemia The likely need for surgery to prevent scarring of the conjunctiva

Handwashing can prevent the spread of the disease to others. The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Patients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis.

A 53-year-old female hospital patient has received a kidney transplant following renal failure secondary to hypertension. As part of the teaching while she was on the organ wait list, she was made aware that she would need to take anti-rejection drugs for the rest of her life. Which aspect of the immune system underlies this necessity? The lack of identifiable major histocompatibility complex (MHC) molecules will stimulate the innate immune response. Donor organ antibodies will be identified as foreign and stimulate an immune response. Anti-rejection drugs will stimulate the production of familiar MHC molecules. MHC molecules will never develop in the cells of the donor organ and effector cells will be continually stimulated.

MHC molecules will never develop in the cells of the donor organ and effector cells will be continually stimulated. The lack of familiar MHC molecules will stimulate an immune response by effector cells in the absence of anti-rejection drugs. An innate immune response is not central to the response, but rather the adaptive immune system. Lack of known MHC molecules, not foreign antibodies, accounts for the immune response, and familiar MHC molecules will not be produced by the donor kidney cells.

After a long history of intravenous heroin use, a client has expressed willingness to stop using heroin. The nurse would expect the client to receive which medication to decrease the severity of withdrawal? Methadone Gabapentin Amphetamines Ondansetron

Methadone Methadone is given to clients who abuse opioids and synthetic substances to replace their usual substance of abuse because it decreases the severity of withdrawal.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? Administering an analgesic once per shift, as ordered, to prevent drug addiction Positioning the client on the side with the knees flexed Encouraging frequent visits from family and friends Administering frequent oral feedings

Positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

How are psychosocial and environmental factors implicated in the development of substance abuse disorders? Disturbed psychosocial and environmental factors are considered to be causes of substance abuse disorders. Psychosocial and environmental factors increase the client's vulnerability to drug or alcohol abuse. Psychosocial and environmental factors have little influence on the development of substance abuse disorders but are used in treatment. Disturbed psychosocial and environmental factors are a function of the disease process and are not part of the development of a substance abuse disorder.

Psychosocial and environmental factors increase the client's vulnerability to drug or alcohol abuse. Although psychosocial and environmental factors often were considered the cause of substance abuse disorders, recently they have been viewed as operating within the context of "vulnerability" factors in susceptible people.

A nursing student is aware that which accounts for more deaths, illnesses, and disabilities across the life span than any other preventable condition? Motor vehicle accidents Substance abuse disorders Falls Mood disorders

Substance abuse disorders Substance abuse disorders across the life span account for more deaths, illnesses, and disabilities than any other preventable health condition.

A client has completed treatment for an addiction to prescription pain medications. As part of the client's therapy, the family participates in a family therapy program. Which reason would best explain the need for a family system approach to therapy? The family needs to focus on helping the client until equilibrium is regained. The dynamics of the entire family have and will continue to shift to accommodate a change. The family has unresolved issues toward the client. The family needs to learn signs of relapse if the client begins taking pills again.

The dynamics of the entire family have and will continue to shift to accommodate a change. When a family system is affected in some way, the dynamics of that family shift to a new balance. The family reorganizes or begins functioning at a different level than it did prior to the change, disturbance, or intervention. A change in one member affects all members.

A psychiatric-mental health nurse is assessing a client who has been referred for care following a violent assault. Which finding would the nurse most likely document as reflecting the diagnostic criteria for posttraumatic stress disorder (PTSD)? Select all that apply. The client describes oneself as being constantly "on edge." The client states, "All I can think about these days is the attack." The client states that the client has a limited support network. The client states "completely avoiding the neighborhood where the attack occurred." The client admits that recent withdrawal from many of friends.

The client describes oneself as being constantly "on edge." The client states, "All I can think about these days is the attack." The client states "completely avoiding the neighborhood where the attack occurred." Hyperarousal, avoidance of places associated with a trauma, and pervasive reminders of a trauma are criteria for PTSD. The nurse should address the client's social isolation and limited support network, but these are not diagnostic criteria for PTSD.

Which factor would contraindicate the use of disulfiram in the treatment of a client who has an alcohol use disorder? The client has a demonstrated family history of alcoholism. The client engages in binge drinking a few times a week rather than drinking consistently each day. The client uses marijuana in addition to alcohol. The client had six drinks a few hours ago.

The client had six drinks a few hours ago. Disulfiram may not be administered to a client who is acutely intoxicated. A family history of alcoholism, marijuana use, and binge drinking do not preclude the use of the drug.

A nurse is assessing a client with bizzare and aggressive behavior in the emergency department. Upon questioning, the client's partner discloses that the client had been smoking PCP. While in the emergency department, the client continues to exhibit signs of PCP-induced psychosis and has required physical restraints. What nursing outcome should the nurse prioritize in the care of this client? The client will be physically safe and without injury. The client will demonstrate appropriate social skills. The client will establish a balance of rest, sleep, and activity. The client will verbalize acceptance of responsibility for the behavior.

The client will be physically safe and without injury. While the client is actively psychotic and restrained, the need for safety is paramount and would be prioritized over establishing healthy routines, taking responsibility, or demonstrating social skills.

A nurse is teaching the client about CNS medications and how they are addictive. What is primary reason CNS medications are addictive? The medication stimulates the brain's pleasure centers with enhanced neurotransmission of dopamine. The medication stimulates the brain's sleep centers, so the client can sleep more soundly. The medication stimulates the brain's visual centers, so the client sees everything more clearly. The medication decreases the amount of dopamine released into the body, causing feelings of euphoria.

The medication stimulates the brain's pleasure centers with enhanced neurotransmission of dopamine. CNS medications have a high degree of addiction potential because they stimulate the brain's pleasure centers with enhanced neurotransmission of dopamine. CNS stimulants do not promote sleep. CNS stimulants do not change visual acuity. Decreased dopamine does not produce feelings of euphoria.

Which would be the benefit of including a client's family members in the long-term treatment of a client with schizophrenia? The onset of a possible relapse can be detected early and effective treatment can be initiated It shows the client that he/she is loved and so it elevates the client's self-esteem The client's compliance with treatment can be monitored and supported effectively The family can provide more effective care when it is based on an understanding of the disease

The onset of a possible relapse can be detected early and effective treatment can be initiated Family education can help family members deal more effectively with a loved one who has schizohprenia, enabling them to contribute to a better outcome for the client, especially because they may be more able to recognize relapse.

When assessing a client diagnosed with chronic alcoholism, the nurse addresses potential memory dysfunction by reviewing the client's serum level of what? Thiamine Vitamin C Vitamin E Iron

Thiamine Korsakoff's psychosis and Wernicke's encephalopathy both result in memory dysfunction as an outcome of a thiamine deficiency.

A client is admitted to the emergency department for intoxication with alcohol. The client has an unsteady gait, myopathy, and neuropathy and cannot remember past or recent events. When treated with thiamine, the client's symptoms greatly improve. Which condition was the client likely experiencing? Scurvy Wernicke-Korsakoff syndrome Alcohol dependence with memory impairment Alcoholic dementia

Wernicke-Korsakoff syndrome Wernicke-Korsakoff syndrome is the coexistence of Wernicke's encephalopathy and Korsakoff's psychosis. Wernicke's encephalopathy is characterized by ataxia, nystagmus, ophthalmoplegia, and mental status changes. Korsakoff's psychosis involves gait disturbances, short-term memory loss, disorientation, delirium, confabulation, and neuropathy.

A client with pancreatic cancer has been receiving morphine via a subcutaneous pump for 2 weeks. The client is requiring an increased dose of the morphine to manage the pain. The nurse should document that the client is: tolerating the medication well. showing addiction to morphine. developing a tolerance for the medication. experiencing physical dependence.

developing a tolerance for the medication. Tolerance develops from taking opioids over an extended period. It is characterized by the need for an increased dose to achieve the same degree of analgesia. Addiction is characterized by a drive to take the medication for the psychic effect rather than the therapeutic effect. Physical dependence is a response to ongoing exposure to a medication manifested by withdrawal symptoms when discontinued abruptly.

A client's face is flushed. The client is swearing, yelling, and pushing chairs around the day room of a mental health center. The nurse judges the client to be in which phase of the assault cycle? triggering escalation crisis aggressive

escalation The escalation phase of the assault cycle involves agitation, swearing, screaming, demanding, and provocative behaviors with loss of reasoning ability. Some behaviors in the triggering phase involve muscle tension, irritability, restlessness, perspiration, and changes in breathing and voice quality. The crisis phase involves loss of self-control, hitting, scratching, kicking, and throwing things. "Aggressive" is not a phase of the assault cycle.

A 22-year-old woman has received an organ transplant and is on cyclosporine therapy. The nurse will encourage her to avoid crowds and limit social activities while on the medication due to: increased sedation. episodes of extreme dizziness. increased risk of infections. frequent migraine headaches.

increased risk of infections. Cyclosporine therapy suppresses the immune system to limit immune reactions directed toward the new organ; however, the suppression also causes a generalized increased susceptibility to infection. Patients taking cyclosporine should avoid exposure to infections by avoiding crowds and promptly reporting injuries or signs of infection. The drug is not known to cause sedation, extreme dizziness, or migraine headaches.

A physician who fails to obtain informed consent before performing a procedure is subject to liability for: medical battery. assault. false imprisonment. battery.

medical battery Medical battery, intentional and unauthorized harmful or offensive contact, occurs when a client is treated without informed consent. Assault is the threat of unlawful force to inflict bodily injury upon another. False imprisonment is detention or imprisonment contrary to provision of the law. Battery is intentional and unpermitted contact with another.

A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: the flu. malignant hyperthermia. neuroleptic malignant syndrome. septicemia.

neuroleptic malignant syndrome Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection.

An infection or the products of infection carried throughout the body by the blood is called: contamination. infectious disease. septicemia. viral illness.

septicemia Transport of an infection or the products of infection throughout the body by the blood is known as septicemia. Sepsis, a term that means poisoning of tissues, often is used to describe the presence of infection.

Before his hospitalization, a client needed increasingly larger doses of barbiturates to achieve the same euphoric effect he initially realized from their use. From this information, the nurse develops a plan of care that takes into account that the client is likely suffering from problem? tolerance addiction abuse dependence

tolerance Tolerance for a drug occurs when a client requires increasingly larger doses to obtain the desired effect. Therefore, the plan of care would address the client's state of tolerance. The term addiction refers to psychological and physiologic symptoms indicating that an individual cannot control his or her use of psychoactive substances. This term has been replaced with the term dependence. Abuse refers to the excessive use of a substance that differs from societal norms. Drug dependence occurs when the client must take a usual or increasing amount of the drug to prevent the onset of abstinence symptoms, cannot keep drug intake under control, and continues to use even though physical, social, and emotional processes are compromised.

A young adult is hospitalized with a seizure disorder. The client, who is in a bed with padded side rails, has a tonic-clonic seizure. In what order from first to last should the nurse take the actions? All options must be used.

Clear the area around the client. Loosen clothing around the client's neck. Turn the client on his or her side. Suction the airway. The goal of care for a client who is having a seizure is to prevent respiratory arrest and aspiration. The nurse should first clear the area around the client. Next, the nurse should loosen clothing around the client's neck and turn the client on the side. As needed, the nurse can then suction the airway and administer oxygen.

The hospice nurse is visiting a new client. Which assessment questions are appropriate for the nurse to ask a client that has a terminal illness? (Select all that apply.) "Please describe what you have been told about your condition." "What community resources might be of help to you?" "How well do you think those around you are coping?" "Have you had any previous experiences with the death of someone you love?" "Do you have a will?"

"Please describe what you have been told about your condition." "What community resources might be of help to you?" "How well do you think those around you are coping?" "Have you had any previous experiences with the death of someone you love?" Focused assessment for those experiencing loss, grief, and dying is directed toward determining the adequacy of the client's and family's knowledge, perceptions, coping strategies, and resources. Interview questions for these areas would include the following: adequacy of knowledge base ("describe your condition"), perceptions ("previous experience with death of someone you loved"), adequacy of resources ("community resources"), and adequacy of coping ("those around you coping"). Determining if a client has a will, to dispose of personal property, is not a priority assessment for the nurse.

A client with moderate Alzheimer's-related dementia is being prepared for discharge. What statement by the caregiver demonstrates that discharge teaching about client safety has been effective? "I should encourage him to be active and do as much as he can on his own." "Showering by himself is fine as long as he remains seated and holds tightly to the safety rails." "I need to place signs in each room to help remind him where he is." "Someone should supervise him at all times."

"Someone should supervise him at all times." The caregiver stating that someone should supervise the client at all times demonstrates effective teaching. Alzheimer's disease causes progressive psychological and physiological deterioration; someone needs to be in attendance at all times to ensure the client's safety. Allowing the client to do as much as he can and posting signs to orient him to his surroundings are important strategies that help to provide optimal independence and create familiarity in the environment, but they don't specifically contribute to personal safety. Although ensuring that the client remains seated and holds onto safety bars while showering provides a measure of safety, the client shouldn't be allowed to shower without supervision.

A client with a persecutory delusion has been explaining to the nurse the specifics of the conspiracy against the client. The client pauses and says, "I get the feeling that you don't actually believe that what I'm telling you is true." How should the nurse respond? "What you're telling me is difficult for me to believe. This may be real for you, but not me." "What's important to me is that it's real for you." "The conspiracy that you're explaining to me is actually a delusion." "What makes you think that I don't believe you?"

"What you're telling me is difficult for me to believe. This may be real for you, but not me." While an empathic approach is crucial when interacting with persons who have a delusional disorder, this does not involve expressing or implying that the nurse believes the person's delusions are real. If confronted by the client on this fact, this is best stated clearly.

When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds? 5 seconds 10 seconds 15 seconds 20 seconds

15 seconds Suctioning the respiratory tract for prolonged periods depletes the client's oxygen supply and causes hypoxia. It is recommended that each suctioning period not exceed 15 seconds.

The nurse is completing a health history review of a client who has received long term medical steroid therapy for Lupus. Which client data does the nurse recognize as potentially linked to the steroid use? Select all that apply. A 16 pound (7.3 kilogram) weight loss 3 infections over the course of the year Routine symptoms of nausea An increase in client blood pressure Acne noted on the forehead, cheeks, and back

3 infections over the course of the year Acne noted on the forehead, cheeks, and back Suppression of the immune system occurs when a client receives long term steroid therapy making the client more susceptible to infections. Acne is present related to oily skin and also the overproduction of the acne bacterium, Propionibacterium acnes. Also, changes in metabolism occur leading to weight gain, not weight loss. Nausea and hypertension are not commonly seen with steroid use.

The nurse understands that numerous comorbidities can contribute to the development of dementia. Which client may be at risk for dementia? An 87-year-old resident of a long-term care facility who has developed a urinary tract infection (UTI) A 69-year-old client whose lung cancer has metastasized to the bones and liver A 30-year-old client with schizophrenia who has been admitted to the hospital because of psychogenic polydipsia A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS)

A 49-year-old client whose human immunodeficiency virus (HIV) has progressed to acquired immunodeficiency syndrome (AIDS) HIV/AIDS is known to cause dementia. Cancer does not normally result in dementia, and the cognitive changes that may result from a UTI or polydipsia are reversible and thus classified as delirium.

The nurse expects psychiatric hospitalization for which of the clients diagnosed with schizoaffective disorder experiencing delusional thoughts? Select all that apply. A 76-year-old person whose symptoms are acute in nature A 25-year-old person who is having a first delusional experience A 45-year-old person who was arrested for assaulting a policeman A 30-year-old person who also has a diagnosis of depression A 39-year-old person who reports minor side effects from the current medication

A 76-year-old person whose symptoms are acute in nature A 25-year-old person who is having a first delusional experience A 45-year-old person who was arrested for assaulting a policeman A 30-year-old person who also has a diagnosis of depression Hospitalization may be required during acute psychotic episodes or when suicidal ideations are present. This structured environment protects the client from self-harm (e.g., suicidal, assaultive, financial, legal, vocational, or social). Emergency care also is needed during periods of symptom exacerbation. Psychosis, mood disturbance, and medication-related adverse effects account for most emergency situations. The nurse would expect psychiatric hospitalization for the following clients with schizoaffective disorder experiencing delusional thoughts: a 76-year-old person whose symptoms are acute in nature, a 25-year-old person who is having a first delusional experience, a 45-year-old person who was arrested for assaulting a policeman, and a 30-year-old person who also has a diagnosis of depression.

Nurses may commit both intentional and unintentional torts when practicing within the profession. What intentional torts may occur in nursing practice? Select all that apply. A nurse forgets to put the side rails up on a crib and the toddler falls out. A nurse does not report a change in client condition in a timely manner. A nurse threatens to hit an older client who has dementia and is screaming. A nurse seeks employment in a hospital after falsifying credentials on a resume. A nurse places a client who is a fall risk in restraints without an order from the health care provider. A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI).

A nurse threatens to hit an older client who has dementia and is screaming. A nurse seeks employment in a hospital after falsifying credentials on a resume. A nurse places a client who is a fall risk in restraints without an order from the health care provider. A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI). Torts may be intentional or unintentional acts of wrongdoing. Some of the intentional torts for which nurses may be held liable include assault and battery. Examples of intentional torts would include a nurse threatening to hit an older client who has dementia and who is wailing; a nurse seeking employment in a hospital after falsifying credentials on a resume; a nurse placing a client who is a fall risk in restraints without the proper order; a nurse making disparaging remarks to the staff about a client who has a sexually transmitted infection. A nurse forgetting to put the side rail up on a crib would be an example of an unintentional tort, as would a nurse not reporting a change in client condition in a timely manner.

A patient with thoracic trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A chest tube A tracheostomy An endotracheal tube A feeding tube

A tracheostomy In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea. The other listed tubes would neither resolve the subcutaneous emphysema nor the consequent airway constriction.

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis

Acute respiratory distress syndrome Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C and D are incorrect.

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply. Epiglottitis Acute respiratory distress syndrome Pneumonia Pulmonary edema Cardiac tamponade

Acute respiratory distress syndrome Pneumonia Pulmonary edema Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung's passageways. They can be classified as fine or course. They may be present on auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade.

At night, an elderly client with senile dementia wanders into other clients' rooms, awakening them. What is the best nursing intervention for dealing with this client's insomnia and nocturnal roaming? Administer a benzodiazepine at bedtime as ordered. Administer a low-dose antipsychotic at bedtime as ordered. Administer a barbiturate at bedtime as ordered. Lock the client's door at bedtime.

Administer a low-dose antipsychotic at bedtime as ordered. In elderly clients, low-dose antipsychotics are preferred for sedation and improvement in thinking. Benzodiazepines are usually avoided because of the risk of addiction, cardiovascular complications, and impaired motor coordination. Barbiturates also are avoided because they may cause delirium, confusion, excitement, and addiction. Locking the door is inappropriate and would violate the client's rights.

A nurse is conducting an in-service program for a group of hospice nurses. When describing the grief response in adults and older adults as compared to children, which would the nurse most likely include? Select all that apply. The grief of adults and older adults is less intense. Adults and older adults grieve more continuously. Children need to go through the same grief reactions as adults do Adults and older adults do not seek an immediate replacement for the lost loved one. Middle-age adults usually cope well with loss.

Adults and older adults grieve more continuously. Children need to go through the same grief reactions as adults do Adults and older adults do not seek an immediate replacement for the lost loved one. In contrast to children, adults tend to grieve more intensely and more continuously, but for a relatively shorter period of time. Furthermore, adults usually do not seek an immediate replacement for the lost loved one but rather may move toward this after achieving some resolution of their grief. Middle-age adults who have a relatively stable lifestyle and adequate support systems usually cope well with loss.

The nurse is caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which items will the nurse obtain to respond appropriately to accidental disconnection of the chest tube from the drainage device? An unopened bottle of sterile water A Heimlich valve Two rubber-tipped clamps A spare chest tube insertion kit

An unopened bottle of sterile water Keep bottle of sterial saline or water at bedside. If chest tube disconnects from drainage unit, submerge end in water.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. What should the nurse request in SBAR communication with the health care provider? Portable chest X-ray Antibiotic therapy Intubation and mechanical ventilation Arterial blood gasses

Antibiotic therapy Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. With the symptoms of infection, antibiotic therapy would be recommended. Nothing in the question demonstrates a need for chest X-ray, intubation, or ABGs.

A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found in the bed. As the registered nurse is directing the health care team, place the actions of the registered nurse in the correct order. All options must be used.

Apply an occlusive dressing over the puncture site Tape the dressing on three sides Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care provider. Assess the client's respiratory status. Assess vital signs and await further medical orders A chest tube is a flexible, hollow tube placed through the chest wall and in to the pleural space. The chest tube is able to relieve trapped air and fluid. If a chest tube is dislodged and comes out, the nurse would immediately apply an occlusive dressing such as Vaseline gauze (many times kept in the client's room). The dressing is taped on three sides. The first action always focuses on the client. The nurse would direct another licensed nurse to immediately notify the health care provider. The nurse would then assess the respiratory status. The nurse would obtain vital signs and await further orders.

The nurse is caring for a child who has had an endotracheal tube placed and is hooked to a ventilator. When assessing the child, the nurse notes that they child is exhibiting signs of poor oxygenation. What should the nurse do? Select all that apply. Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly. Assess for decreased body temperature.

Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly. If the child begins to exhibit signs of poor oxygenation, perform a quick assessment. Auscultate the lungs for equal air entry and determine the heart rate. Are the breath sounds equal? Is the heart rate normal for age? Perform a quick survey of the equipment and look for any disconnected tubes or kinks in the tubing. Determine oxygen saturation levels via pulse oximeter and evaluate the end-tidal CO2 color. Use the mnemonic "DOPE" for troubleshooting when the status of a child who is intubated deteriorates: D = Displacement. The tracheal tube is displaced from the trachea. O = Obstruction. The tracheal tube is obstructed (e.g., with a mucous plug). P = Pneumothorax. Usually a pneumothorax results in a sudden change in the child's assessment. The signs of a pneumothorax include decreased breath sounds and decreased chest expansion on the side of the pneumothorax. Subcutaneous emphysema may be noted over the chest. In the case of tension pneumothorax, there may be a sudden drop in heart rate and blood pressure. E = Equipment failure. Relatively simple problems as previously discussed, such as a disconnected oxygen supply, can cause the child to deteriorate. Culprits such as a leak in the ventilator circuit or a loss of power are other types of equipment failure that may be responsible.

A client with a diagnosis of lung cancer is seen in the clinic for follow-up care. Which nursing interventions are essential to include in this client's plan of care to address grief? Select all that apply. Assist the client to form a support system. Help the client establish coping strategies. Promote good nutrition and sleep habits. Encourage participation in religious rituals. Urge the client to continue a usual routine.

Assist the client to form a support system. Help the client establish coping strategies. Promote good nutrition and sleep habits. Encourage participation in religious rituals. Nursing interventions used to help clients move through grief include helping the client mobilize a support system. The nurse can also help the client establish coping behaviors used in the past. Other interventions to include when helping clients move through grief are promoting good nutrition and sleep habits. The nurse should encourage the client to participate in religious rituals that are important to him. The nurse should not urge the client to continue his usual routine because it may not include healthy behaviors. For example, the nurse should not encourage use of alcohol, drugs, and caffeine during the grief process.

Which ventilator mode provides full ventilatory support by delivering a preset tidal volume and respiratory rate? IMV SIMV Assist control Pressure support

Assist-control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A firefighter is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the firefighter reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply. Monitor for fever. Prepare the chest for chest tube insertion. Auscultate the lungs for adventitious breath sounds. Assess for increased pulse rate. Monitor for increased anxiety levels.

Auscultate the lungs for adventitious breath sounds. Monitor for increased anxiety levels. Assess for increased pulse rate. More than half of all clients with pulmonary involvement following inhalation injury do not immediately demonstrate pulmonary signs. Any client with possible inhalation injury must be observed for at least 24 hours for possible respiratory complications. Maintaining increased oxygen saturation levels is essential, especially following a carbon monoxide inhalation injury, to prevent the development of carboxyhemoglobin, which competes with oxygen for available hemoglobin. The client does not typically develop a fever with inhalation injury, but may progress to acute respiratory syndrome with bilateral lung infiltrates, cardiac involvement with tachycardia, and increasing anxiety due to oxygen starvation. A chest tube is not indicated.

The nurse is caring for a client who has been intubated and on a mechanical ventilator and has been restrained with soft wrist restraints. The client no longer requires the restraints, so the nurse removes them. What type of ethical decision making does the nurse display? Fidelity Autonomy Beneficence Nonmaleficence

Beneficence Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities. Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition. Nonmaleficence is the duty to do no harm to the client.

A client was recently in a motor vehicle accident, which resulted in an amputation of the right leg. The client is withdrawn, doesn't want to get out of bed, and has been crying a lot. What behaviors is the client demonstrating? Anticipatory grief Bereavement Mourning Anger

Bereavement The client is exhibiting a symptom of bereavement which includes emotional, physical, social, and cognitive responses.

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

Butterfly rash 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. Patients with SLE do not typically experience jaundice or skin sloughing.

The nurse is caring for a client who is on a ventilator. The nurse is bathing the client and talking to him as she is carrying out care, as well as telling the client what is going to happen next. The nurse speaks to the client in a soothing manner. The nurse is acting in which role? Select all that apply. Caregiver Decision-maker Communicator Educator Client advocate

Caregiver Communicator Educator The nurse is fulfilling the role of caregiver by providing the care and speaking to the client in a soothing manner. The nurse is also acting as a communicator by talking to the client, even if the client can't respond. The nurse is also acting as an educator by informing the client of the care that will be performed. The nurse is not assisting in making any decisions or speaking on behalf of the client.

A newly admitted client with an acute exacerbation of psychotic symptoms of schizophrenia is having trouble deciding whether to live in a group home or a supervised apartment. Based on the client's current cognitive functioning, which activity is most appropriate for the nurse to ask the client to do initially? List the pros and cons of each housing option. Choose between apple and orange juice for breakfast. Identify why the client cannot live in an unsupervised apartment. Decide which staff member the client would like to have today.

Choose between apple and orange juice for breakfast. The client is in an acute psychotic state and cannot process complex decisions or explain complex situations. Therefore, the nurse would focus on decision making involving simple choices. Listing the pros and cons of each housing option and identifying why the client cannot live in an unsupervised apartment involve complex decision-making skills. Deciding which staff member to have today is a difficult and threatening decision for a client who is psychotic.

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? Cleaning the client's mouth with chlorhexidine daily Maintaining the client in a high Fowler's position Ensuring that the client remains sedated while intubated Turning and repositioning the client every 4 hours

Cleaning the client's mouth with chlorhexidine daily The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP) Increases oxygen consumption Prevents aspiration

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP) An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber? Remove the chest tube. Document the finding. Contact the Rapid Response Team. Remind the client to remain stationary in bed to stop the bubbling.

Document the finding. Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.

A client is admitted to the psychiatric unit with acute onset of schizophrenia. His physician orders the phenothiazine chlorpromazine, 100 mg by mouth four times per day. Before administering the drug, a nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects? Guanethidine Droperidol Lithium carbonate Alcohol

Droperidol When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. Guanethidine, lithium carbonate, and alcohol do not increase the risk of extrapyramidal effects.

The nurse is planning care for a child with a pneumothorax. The nurse adds the nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube" to the care plan. When writing the care plan, what should the nurse be sure to include as interventions? Keep dry gauze at the bedside Ensure a pair of hemostats are at the bedside Monitor pulse oximetry readings Assess lungs as directed by the physician or as the client's condition warrants Maintain chest tube bottle in an upright position and below the level of the chest

Ensure a pair of hemostats are at the bedside Monitor pulse oximetry readings Assess lungs as directed by the physician or as the client's condition warrants Maintain chest tube bottle in an upright position and below the level of the chest If the tube becomes dislodged from the child's chest, the nurse must apply Vaseline gauze and an occlusive dressing to prevent air leakage into the pleural space. A pair of hemostats should be kept at the bedside to clamp the tube should it become dislodged from the drainage container. Pulse oximetry and lung assessments help ensure proper placement of the chest tube. To maintain proper drainage, the bottle must be kept upright and below the level of the chest.

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? Ensure that suction apparatus is set up at the bedside. Pad the patient's bed rails. Maintain bed rest whenever possible. Provide several small meals each day.

Ensure that suction apparatus is set up at the bedside. Because of the patient's risk of aspiration, it is important to have a suction apparatus at hand. Bed rest should be generally be minimized, not maximized, and there is no need to pad the patient's bed rails or to provide multiple small meals.

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. Facilitate removal of an upper airway obstruction Establish an airway for ventilation Decrease tracheobronchial secretions Allow connection to a manual resuscitation bag Prevent aspiration into the lungs

Establish an airway for ventilation Allow connection to a manual resuscitation bag Prevent aspiration into the lungs Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions.

The nurse is caring for a client with a left chest tube to drain a pleural effusion. The nurse notes that the water is below the required level in the water seal chamber of the closed chest drainage system. What is the priority assessment that the nurse needs to make? Check for bloody drainage in the collection chamber. Ensure that the tubing is free of any occlusions. Evaluate the client for the presence of a pneumothorax. Determine whether there has been an increase in suction.

Evaluate the client for the presence of a pneumothorax. Atmospheric pressure is greater than the pressure inside the pleural space. Without the necessary amount of water in the water seal chamber, air would enter the pleural space and collapse the lung, resulting in a pneumothorax. The water seal does not affect the amount of suction used. The water seal is separate from the drainage collection chamber. The tubing does not affect the level of water in the water seal chamber.

A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client? Intubation and mechanical ventilation Face mask with nonrebreather Oxygen cannula at 6 L/minute Venturi mask at 35%

Intubation and mechanical ventilation The client?'s respiratory status is severely compromised and has developed signs of respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is administered under continuous positive airway pressure or with mechanical ventilation with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not deliver the concentration or ventilatory support that an endotracheal tube with mechanical ventilation will provide.

After having a lobectomy for lung cancer, a client receives a chest tube connected to a three-chamber chest drainage system. The nurse observes that the drainage system is functioning correctly when noting which of the following? Select all that apply. Fluctuations in the water-seal chamber occur when the client breathes. Crepitus forms at the chest tube insertion site. Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in the suction control chamber. Drainage is collecting in the drainage chamber.

Fluctuations in the water-seal chamber occur when the client breathes. Intermittent bubbling occurs in the water-seal chamber. Gentle bubbling occurs in the suction control chamber. Drainage is collecting in the drainage chamber. Fluctuations in the water-seal compartment (or tidal movements) indicate normal function of the system as the pressure in the tubing changes with the client's respirations. There also should be intermittent bubbling in the water-seal chamber, indicating that air is being removed from the pleural cavity by the system. Gentle bubbling in the suction control chamber indicates that the proper suction level has been reached. Drainage is expected to collect in the drainage chamber after a lobectomy. Crepitus indicates that air is leaking into the subcutaneous tissues. The physician should be notified of this finding.

What is the key sign of onset of acute respiratory distress syndrome? Tachypnea Stridor Hypoxemia Chest pain

Hypoxemia The key sign of the onset of acute respiratory distress syndrome (ARDS) is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Intermittent mandatory ventilation (IMV) Assist control Synchronized intermittent mandatory ventilation (SIMV) Pressure support

IMV IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A client with dementia of Alzheimer's disease is prescribed rivastigmine. Which instruction should the nurse include in the teaching plan for the client? Select all that apply. Avoid food with spices and seasonings. Immediately report occurrence of adverse reactions. Keep all appointments with primary health care provider. Do not take any nonprescription drug. Avoid taking the drug on an empty stomach.

Immediately report occurrence of adverse reactions. Keep all appointments with primary health care provider. Do not take any nonprescription drug. The nurse should instruct the client to immediately report any occurrence of adverse reactions, such as nausea, vomiting, diarrhea, anorexia, dyspepsia, fatigue, and insomnia; keep all appointments with the primary health care provider, and not take any nonprescription drugs. The nurse need not ask the client to avoid food with spices and seasonings or avoid taking the drug on an empty stomach; the use of rivastigmine tartrate is not affected by these factors.

The nurse is repositioning a client with a chest tube in bed when the chest tube accidentally becomes disconnected from the chest tube container. What is the nurse's priority action at this time? Encourage the client to breathe slowly while the wound is covered. Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing. Call for assistance and then cover the wound with a sterile dressing. Call for assistance and cover the insertion site with clean, dry gauze.

Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing. Instructing the client to exhale forces air out and allows the space to be covered before a sucking chest wound occurs. The wound needs to be covered with an occlusive dressing to prevent leak of air. Breathing slowly will still allow air re-entry.

The nurse is discussing end-of-life decisions with a patient who has terminal cancer. Which statements describe the patient's options? (Select all that apply.) Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. In a living will, a patient appoints an agent that he or she trusts to make decisions if he or she becomes incapacitated. The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. The status of advance directives varies from state to state. Nurses are legally responsible for arranging for a durable power of attorney for all terminal patients. Legally, all attempts must be made by the health care team to resuscitate a terminal patient.

Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. The Patient Self-Determination Act of 1990 requires all hospitals to inform their patients about advance directives. The status of advance directives varies from state to state. Advance directives, including living wills, helps the patient to make decisions concerning their end-of-life care. Appointing an agent for care involves identifying a durable power of attorney for healthcare, which is the responsibility of the patient, family, or significant others. If a patient has advance directives, resuscitation is not warranted.

A nurse is caring for a client recently diagnosed with cancer and experiencing situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply. Maintain a calm, nonthreatening environment. Explain relevant aspects of chemotherapy. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Provide distractions for the client during periods of stress. Teach the stages of grieving to the client.

Maintain a calm, nonthreatening environment. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. During periods of acute stress, interventions that help the client regain control will help master this new threat. Providing a calm, nonthreatening environment and encouraging verbalization of concerns will help the client face the unknown. Relaxation techniques have a physiologic and psychological effect in calming the client, which in turn allows further exploration of thoughts and feelings as well as problem solving. The ability to learn is limited during extreme stress, so teaching the client about grief and chemotherapy would not be effective at this stage. Providing distractions would be ineffective at this point in the grief process.

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. Monitor serum creatinine and blood urea nitrogen levels. Administer a sedative. Keep the head of the bed flat. Administer humidified oxygen. Auscultate the lungs.

Monitor serum creatinine and blood urea nitrogen levels. Administer humidified oxygen. Auscultate the lungs. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death? Endotoxins in the system Limited gas exchange Brain death Multiple organ failure

Multiple organ failure In the irreversible stage of shock, significant cells and organs are damaged. The client's condition reaches a "point of no return" despite treatment efforts. Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) pH Bicarbonate (HCO3-)

Partial pressure of arterial oxygen (PaO2) In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A nurse is performing nasotracheal suctioning on a client who has pneumonia. In what order should the nurse perform the steps of the procedure? Place in order from first to last. All options must be used.

Place the client in a sitting position. Pass the catheter into the trachea. Apply suction. Apply oxygen with a face mask. Nasotracheal suctioning is used to remove secretions from clients who cannot cough them up. After explaining the procedure to the client, the nurse should first assist the client to an upright position. Next, the nurse should pass the catheter into the trachea and assure that the catheter is in the trachea by listening for air at the end of the catheter. The nurse should then apply suction. After suctioning, the nurse should disconnect the catheter from the suction source and administer oxygen by face mask. The nurse can repeat the procedure if needed and then withdraw the catheter while applying suction.

A client is admitted to the postsurgical unit after wiring of a fractured jaw. When the nurse completes an assessment, noisy, shallow breathing is noted and the oxygen saturation level is now 90%. What is the appropriate action by the nurse? Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed. Position in Fowler's position to assist in breathing and give oxygen as ordered. Insert an airway, suction, and position in the supine position. Encourage deep breathing, position in the prone position, and give oxygen as ordered.

Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed. Sims position is indicated for clients in the initial postoperative period. Sims position helps ensure patency of the airway by allowing secretions and blood to pool in the cheek and drain out the side of the mouth. If secretions are accumulating too quickly, suctioning may be required. Oxygen is given to improve oxygen saturation levels. If positioned in Fowlers, there will be more likelihood of swallowing the bloody secretions and becoming nauseated. The client's jaw is wired, so the airway cannot be inserted. If the client is positioned supine, he/she could aspirate. If positioned prone, there is more compression on the chest cage that could contribute to more shallow breathing.

A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Chronologically arrange the nursing interventions to prioritize care. All options must be used.

Position the client upright at a 45°angle. Administer oxygen via nasal cannula at 2 L/minute. Prepare suctioning equipment at the bedside. Call the physician. Administer furosemide (Lasix) 40 mg intravenously STAT. Insert an indwelling urinary catheter. The order of priority moves from the simple to the complex for bedside interventions when a client is in respiratory distress. The nurse would first attempt to maximize respiratory excursion as much as possible by sitting the client up, and then provide supplemental oxygen to minimize impending hypoxia. It is also important to have suction equipment readily available because the client may choke on oral secretions due to the pulmonary edema. After performing these interventions, the nurse would notify the physician and anticipate orders for administration of a diuretic (such as furosemide) and insertion of an indwelling urinary catheter to measure eventual output.

A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. Provide frequent mouth care. Apply mineral oil to the lips. Arrange for suctioning to remove mucus. Change the client's position every two hours. .Assist the client to a lateral position.

Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position When caring for a client who cannot swallow or expectorate, the nurse should provide frequent mouth care, arrange for suctioning to remove mucus, and assist the client to a lateral position to keep the mouth and throat free of accumulating secretions. Mineral oil is applied to the lips of the client to overcome dryness caused by oxygen therapy. The client's position should be changed every 2 hours to promote comfort and circulation.

The nurse is planning a social skills training group for clients with schizophrenia. Which techniques should be used to help the clients gain social skills? Provide rewards for small approximations of the desired behaviors. Use positive reinforcement when a client demonstrates the behavior. Use negative reinforcement when a client demonstrates unacceptable behavior. Withdraw reinforcement when a client demonstrates undesirable behavior.

Provide rewards for small approximations of the desired behaviors. People respond to achieve something rewarding or to avoid something aversive. In operant conditioning, the response precedes the stimulus. Clients would learn that socially appropriate behavior leads to certain rewards from staff. Thus, they increase that behavior to subsequently increase those positive events. It would be unrealistic for the client to perform the behavior entirely before receiving any reward. Learning is more effective with the use of positive rewards than negative reinforcement.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing Cyanosis

Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

Which of the following assessments made by a nurse during a morning assessment of a client would require immediate intervention? Select all that apply. Ten respirations per minute by a sleeping patient Rattling sound in the pharynx of an unconscious patient Coughing and expectorating large amounts of thick mucus Slight shortness of breath after returning from the bathroom Vomiting of large amount of bright red hemoptysis

Rattling sound in the pharynx of an unconscious patient Vomiting of large amount of bright red hemoptysis Rattling would indicate that mucus is in the airway. Suctioning may be necessary to maintain a patent airway because an unconscious patient cannot voluntarily cough. Highest priority is based on ABCs and then level of consciousness. Vomiting large amounts of bright red blood could lead to hemorrhage. Ten respirations per minute by a sleeping patient is an expected finding. Coughing and expectorating large amounts of thick mucus and slight shortness of breath after returning from the bathroom would not require immediate attention.

The nurse is caring for a client who has late stage dementia. Prior to administering oral medications, what is the appropriate nursing action? Change medication route to intramuscular. Mix the drug with pudding. Request that the provider obtain a speech therapist's evaluation. Administer medication with water to drink.

Request that the provider obtain a speech therapist's evaluation. To prevent aspiration, the nurse will ask the provider to consult with a speech therapist for evaluation of dysphagia. The nurse cannot convert order for medications to a different route. Water or pudding may increase the risk for aspiration if a dysphagia evaluation has not been completed.

The nurse is performing routine tracheostomy care. Which step would be appropriate for the nurse to include in the performance of the procedure? Remove the inner cannula every 2 hours for cleaning. Secure the tracheostomy ties with a square knot. Use cut gauze under the neck plate to protect the skin. Suction the inner cannula on completion of the procedure.

Secure the tracheostomy ties with a square knot. When performing tracheostomy care, it is important that the tracheostomy ties be securely tied to prevent dislodgment of the tube. It is not necessary to remove the inner cannula every 2 hours for cleaning. Routine cleaning is usually performed every 8 hours. The nurse should use precut tracheostomy dressings under the neck plate to protect the skin surrounding the stoma. Cutting and using a gauze dressing can cause loose gauze fibers to enter the airway. The inner cannula should be suctioned before cleaning, not afterward.

The nurse should be cautious and closely monitor clients receiving donepezil (Aricept) with which medical condition? (Select all that apply.) Hyperthyroidism Seizure disorder Renal disease Asthma GI bleeding

Seizure disorder Renal disease Asthma GI bleeding Cholinesterase inhibitors, like donepezil (Aricept), are used cautiously in clients with renal or hepatic disease, bladder obstruction, seizure disorder, sick sinus syndrome, GI bleeding, history of ulcer disease, and asthma.

The nurse is caring for a client admitted to a medical surgical unit. Which of the following situations would indicate a professional nurse's boundary violation? Select all that apply. Sharing a personal experience with a client that is very similar to the situation the client is experiencing Speaking to the client's family about a diagnosis without permission from the client Being concerned about a client's welfare and seeking ways to protect them Having well-intentioned behaviors that detract from achievable health outcomes for clients Reminding a client who has dementia that certain sexual touch behaviors are not acceptable

Sharing a personal experience with a client that is very similar to the situation the client is experiencing Speaking to the client's family about a diagnosis without permission from the client Having well-intentioned behaviors that detract from achievable health outcomes for clients Professional boundaries focus on the provision of professional care that assists clients in achieving health outcomes. When the professional nurse becomes overinvolved in care, then it may affect those outcomes. Sharing a personal experience with a client that is very similar to the situation the client is experiencing is not appropriate because it places the focus on the nurse, not the client. Speaking to a client's family without permission violates confidentiality. Being concerned about a client's welfare and seeking ways to protect them and reminding a client who has dementia that certain sexual touch behaviors are not acceptable would not compromise professional boundaries.

A client, with systemic lupus erythematosus (SLE) has been on corticosteroid therapy for the last 2 years. The nurse should assess for which of the following? Select all that apply. Hypoglycemia and cognitive changes Skeletal muscle atrophy and osteoporosis Hyponatremia and hypokalemia Hyperpigmentation of the skin and itching Hyperglycemia and fluid retention

Skeletal muscle atrophy and osteoporosis Hyperglycemia and fluid retention Long-term corticosteroid administration results in significant changes. Two long-term effects of corticosteroid administration are muscle atrophy and osteoporosis. Hyperglycemia and fluid retention is another serious side effect that can occur, so clients must be monitored for edema. Hypoglycemia, hyponatremia, hypokalemia, and hyperpigmentation are not side effects of this category of medication.

The nurse is caring for older adult in an assisted care facility. What information about the older adult client should the nurse consider when caring for this population of client? (Select all that apply.) Some clients with dementia may experience sundowning syndrome and safety is a priority. Delirium experience by a client is a permanent state of confusion Observe for symptoms of depression since many clients go undiagnosed. All older adults experience delirium when they are hospitalized Medication should be closely monitored for polypharmacy A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences.

Some clients with dementia may experience sundowning syndrome and safety is a priority. Observe for symptoms of depression since many clients go undiagnosed. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. Several of the statements listed are true statements. Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark. Depression is a prolonged or extreme state of sadness occurring in many older adults. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. There were three statements that were not true. First, delirium is not a permanent state of confusion occurring in older adulthood. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. Polypharmacy does not look at the number of pharmacies used to obtain prescriptions but the amount of drugs prescribed by health care providers for a variety of medical conditions. Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Complicated regimens need careful review to minimize risks and complications and maximize benefits.

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? Call the physician. Remove the malfunctioning cuff. Add more air to the cuff. Suction the client, withdraw residual air from the cuff, and reinflate it.

Suction the client, withdraw residual air from the cuff, and reinflate it. After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? Clean the wound around the tube and inner cannula at least every 24 hours. Assess a newly inserted tracheostomy every 3 to 4 hours. Use gauze dressings over the tracheostomy that are filled with cotton. Suction the tracheostomy tube using sterile technique.

Suction the tracheostomy tube using sterile technique. Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

The young child had a chest tube placed during cardiac surgery. Which findings may indicate the development of cardiac tamponade? Select all that apply. The chest tube drainage had been averaging 15 to 25 mL out per hour and now there is no drainage from the chest tube. The child's heart rate has increased from 88 beats per minute to 126 beats per minute. The child's right atrial filling pressure has decreased. The child is resting quietly. The child's apical heart rate is strong and easily auscultated.

The chest tube drainage had been averaging 15 to 25 mL out per hour and now there is no drainage from the chest tube. The child's heart rate has increased from 88 beats per minute to 126 beats per minute. Abrupt cessation of chest tube output and an increased heart rate are indicators that the child may have developed cardiac tamponade. The child's right atrial filling pressure will increase. The child may be anxious and their apical heart rate may be faint and difficult to auscultate.

The nurse provides frequent and ongoing assessments for the child who is intubated and on mechanical ventilation. What assessment findings would be concerning for the nurse? The chest rises with each breath of the ventilator The child's pulse oximeter ranges from 85% to 90% The child's heart rhythm is sinus tachycardia The breath sounds are greater on the right side The child's nail beds are pink with capillary refill

The child's pulse oximeter ranges from 85% to 90% The breath sounds are greater on the right side The assessment of breath sounds unilaterally would indicate the need to further asses the child for displacement of the tracheal tube. In addition, the oxygen saturation level should be 95% or higher. The other findings are normal/expected.

Assessment of violence potential is an important part of nursing care on the inpatient unit. Which is an indicator that the client with schizophrenia may be at high risk for violence while in the hospital? The client has never used drugs or alcohol. The client assaulted an officer prior to admission. The client reports feeling that everyone on the unit is "out to get me." The client is suspicious of the nursing staff.

The client assaulted an officer prior to admission. The client's potential for violence is indicated by a history of violent or suicidal behavior, extreme social isolation, feelings of persecution or being "controlled" by others, auditory hallucinations that tell the client to commit violent acts, concomitant substance abuse, medication noncompliance, or feelings of anger, suspiciousness, or hostility.

The nurse is caring for a client with severe depression. In which conditions would the nurse anticipate the use of electroconvulsive therapy (ECT)? Select all that apply. The client also has dementia. The client cannot tolerate monoamine oxidase inhibitors (MAOIs) The client has not responded to conventional therapy. The client is undergoing a stressful life change. The client is having acute suicidal thoughts.

The client cannot tolerate monoamine oxidase inhibitors (MAOIs) The client has not responded to conventional therapy. The client is having acute suicidal thoughts. ECT is used to treat acute depressive illnesses in an attempt to rapidly reverse a life-threatening situation, such as disturbing delusions, agitation, and attempted suicide or when conventional therapies have been unsuccessful. It is also used when the client cannot tolerate antidepressants, since other medication regimens for depression can take weeks to become fully effective. ECT is usually not indicated for situational depression caused by intense stress. Clients with dementia are not given ECT because ECT may further exacerbate cognitive impairment. The decision to use ECT is not based on where the client lives.

The nurse is seeing a client who has a diagnosis of schizophrenia with episodic depression. The nurse should be concerned that the client's risk for completing suicide is higher if what factors are present? Select all that apply. The client has been drinking alcohol The client has been hearing voices more often The client experiences anxiety before seeing a support worker The client is a female The client has mobility problems

The client has been drinking alcohol The client has been hearing voices more often Auditory hallucinations increase the risk for suicide because of the possibility of individuals impulsively responding to "voices" directing them to kill themselves. Substance abuse increases the likelihood that suicidal ideation will result in both parasuicidal and suicidal behaviors. Although panic attacks increase the likelihood of suicidal behavior in adolescents, social anxiety in adults does not increase the risk of attempting suicide. Being female does not increase the risk of completing suicide, however, females do make more attempts. A client with mobility problems is much less likely to be able to access lethal means to complete suicide, therefore, this condition does not serve to heighten the client's risk.

An older client comes to the clinic for a yearly physical exam. During the assessment, the client tells the nurse that the client sometimes has begun feeling anxious about the client's forgetfulness. The nurse notes the client may have mild dementia. Which finding would lead the nurse to conclude this? The client reports having delusions The client exhibits confusion The client has difficulty finding words The client reports an inability to perform complex tasks

The client has difficulty finding words The nurse suspects the client may have mild dementia as the client is reporting difficulty in finding words during conversation, along with anxiety over the client's forgetfulnesss. Confusion and the inability to perform complex tasks are possible indicators of moderate dementia. Delusions are typically experienced by client's suffering from severe dementia.

A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? Select all that apply. The client will need ventilator support. The client will be unable to independently ambulate. The client will have no control of the bladder. The client will need assistance with feeding. The client will be unable to speak. The client will be cognitively impaired.

The client will be unable to independently ambulate. The client will have no control of the bladder. The client with a spinal cord transection (complete tear) at the thoracic 4 location will be a paraplegic with no control of the body below mid chest. The client will need assistance to ambulate (wheelchair) and assistance with urination. The client will be able to breathe independently, speak, feed themselves and have normal cognitive function.

The nurse is teaching a client with terminal cancer who is interested in hospice care. Which home hospice benefits will the nurse explain? Select all that apply. The nurse and physician are on call 24 hours, every day of the week. Medications to treat cancer are provided. Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included.

The nurse and physician are on call 24 hours, every day of the week. Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included. Among the many available services, hospice services include on-call nurses and physicians (24 hours per day, 7 days per week), counselors, pain management techniques, and homemaker services. Patients receiving hospice care are not actively being treated for cancer, but rather are receiving palliative care.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? The patient will be extubated and another endotracheal tube will be inserted. The patient will be extubated and a nasotracheal tube will be inserted. The patient will have an insertion of a tracheostomy tube. The patient will begin the weaning process.

The patient will have an insertion of a tracheostomy tube. Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011).

Which of the following demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion? Monitor the client's temperature after the procedure. Use sterile gloves during the procedure. Use povidone-iodine to clean the inner cannula when it is removed. Place the client in the semi-Fowler's position.

Use sterile gloves during the procedure. The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection. Monitoring the client's temperature is not reflected in application of this question. Povidone-iodine destroys new cellular growth, so it is not to be use on open wounds. The client should be in high Fowler's, not semi-Fowler's position.

The nurse has received a change-of-shift report. The nurse should assess which client first? a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 a 36-year-old with chest tube due to spontaneous pneumothorax with current respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal cannula a 28-year-old who is 2 days postappendectomy with discharge prescriptions written and whose husband is waiting to take her home a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose hemoglobin is 13.8 g/dL (138 g/L)

a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 The nurse should closely monitor the client admitted with an elevated blood alcohol level for several hours for signs and symptoms of withdrawal, administering sedation as needed; delirium tremens, the most severe form of withdrawal, usually peaks at 48 to 72 hours following the last drink. The client with the chest tube is not in any distress and has no pressing needs. For an older client who has had GI bleeding, a hemoglobin of 13.8 g/dL (138 g/L) is within normal limits. After assessing all clients' needs, the nurse will prepare the client who had an appendectomy for discharge as soon as possible.

A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should: administer pain medication and delay client activity. tell the client why lung expansion is important. arrange a care schedule that includes rest periods. teach the client how to use an incentive spirometer.

administer pain medication and delay client activity. Administering pain medication and delaying any activity until the medication takes effect will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and acts as a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort.

A nurse is conducting a program for a local community support group about grieving. The nurse would describe grief as fulfilling which function? Select all that apply. allowing the outer reality of loss to become internally accepted altering the emotional attachment to that which was lost permitting the bereaved person to become unattached to others preparing the client for the loss without warning allowing the person to avoid the experience of the loss more fully

allowing the outer reality of loss to become internally accepted altering the emotional attachment to that which was lost Grief has several important functions: to make the outer reality of the loss into an internally accepted reality; to alter the emotional attachment to the lost person or object; and to make it possible for the bereaved person to become attached to other people or objects. Grief does not prepare the client for the loss nor does it allow the person to avoid the experience the loss more fully. Grief is a necessary and normal reaction to loss.

A nursing student is learning about drugs that affect the central nervous system. The student knows that some clien'ts with schizophrenia are given which drugs? Select all that apply. antipsychotic drugs antidepressants neuroleptics antispasmodics

antipsychotic drugs neuroleptics Drugs used to treat psychotic disorders are called neuroleptics and antipsychotics. Antidepressants are a different classification used for mood disorders. Antispasmodics are used to treat muscle spasms.

The nurse is caring for a client diagnosed with dementia. Which behaviors would the nurse most likely assess? Select all that apply. asking questions repeatedly stable mood socially inappropriate behavior wandering irritabilty

asking questions repeatedly socially inappropriate behavior wandering irritabilty Behavioral findings associated with dementia include: asking questions repeatedly, emotional lability, socially inappropriate behavior, wandering and irritability.

A multipara gives birth to a neonate at 24 weeks' gestation. After 12 hours, the neonate's condition deteriorates, and death appears likely within the next few minutes. The parents are Roman Catholic, and they request that the neonate be baptized. The nurse should: contact the hospital chaplain to perform the baptism. alert the hospital's director that a neonatal death is imminent. find a health care provider who is Roman Catholic to perform the baptism. baptize the neonate, regardless of the nurse's own religious beliefs.

baptize the neonate, regardless of the nurse's own religious beliefs. Tenets of the Roman Catholic Church hold that it is acceptable for anyone, regardless of his or her religious beliefs, to baptize a neonate. For Roman Catholic families, baptism ensures entry into heaven. Local practice may vary, and in some situations, the parents may prefer to have a Roman Catholic person perform the rites; however, the priest may not be available until after the death.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: lobar pneumonia. empyema. Pneumocystis carinii pneumonia. infected chest tube wound site.

empyema. Any condition that produces fluid accumulation or sequestration of fluid with infective properties can lead to empyema, an accumulation of pus in a body cavity, especially the pleural space, as a result of bacterial infection. An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed. Pneumonia typically causes a productive cough. An infected chest tube wound would cause redness and pain at the site, not turbid drainage.

A 62-year-old woman with a history of asthma and alcoholism is beginning drug therapy for Alzheimer's disease. The physician has ordered an acetylcholinesterase enzyme inhibitor. Which part of the health history data is most important for the nurse to consider? age. gender. history of alcoholism. history of asthma.

history of asthma. The fact that the client has a history of asthma is likely to have the greatest impact on the physician's decision to include an acetylcholinesterase enzyme inhibitor, since drugs that increase cholinergic activity should be used with care in clients with a history of asthma or obstructive pulmonary disease. The client's age, gender, and history of alcoholism, although important factors that need to be assessed, will not have as great an implication in this case as the history of asthma.

A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for: initiating IV sedation. starting a high-protein diet. providing pain medication. increasing the ventilator rate.

initiating IV sedation. The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.

The nurse is suctioning the tracheostomy of a child. The nurse should: insert the catheter with the suction port of the catheter closed. keep the catheter straight as it is removed from the tracheostomy tube. use clean technique while suctioning. insert the catheter slightly beyond the end of the tracheostomy tube.

insert the catheter slightly beyond the end of the tracheostomy tube. To prevent damage to the carina, the catheter should only be inserted just slightly beyond the end of the tracheostomy tube. The catheter should be inserted with the suction port open, then removed while turning the catheter with the suction port closed. The catheter should be rotated as it is removed to better clear secretions from the airway. In acute care settings, tracheostomy suctioning in children is an aseptic procedure. In some circumstances, it can be a clean procedure in the home.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. kidney failure disseminated intravascular coagulation acute respiratory distress syndrome hypoglycemia GERD

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

When providing care to a client with dementia, which interventions would be most appropriate? Select all that apply. maintain levels of sensory stimulation that are tolerable ensuring the use of assistive sensory devices employing reality orientation using validation therapy continually correcting the client for mistakes

maintain levels of sensory stimulation that are tolerable ensuring the use of assistive sensory devices using validation therapy Maintaining levels of sensory stimulation that are tolerable for a person with dementia minimizes confusion and fatigue. Appropriate sensory appliances (glasses and hearing aids) assist older adults in interacting appropriately with their environments. An inexpensive, handheld amplifier serves as an excellent alternative for communicating with clients who are hard of hearing and do not have an available hearing aid. Reality orientation can be useful for orienting people with reversible confusional states (e.g., delirium). In the latter stages of irreversible dementia, reality orientation is less successful and often causes agitated or angry responses. At this latter point, validation therapy (Feil, 2002) may be an effective strategy. In addition, the nurse should avoid criticizing, correcting, or arguing with the client.

A client is admitted with a diagnosis of dementia becomes agitated, violent, and has bizarre thoughts. The nurse is reviewing the client's medication record. Which ordered medication would be expected to reduce agitation? tacrine ergoloid diazepam risperidone

risperidone Risperidone is ordered for severe agitation and has a rapid response. Ergoloid and tacrine stabilize and may improve the cognitive functioning of clients with dementia. Diazepam is an antianxiety agent that would not have the desired effect on the severe agitation, violence, and bizarre thoughts.

Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? septic shock chronic obstructive pulmonary disease asthma heart failure

septic shock The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

The nurse is seeing a school-aged child who has been the victim of physical abuse by a parent. The nurse recognizes that the client is more likely to experience which mental health issues in adulthood? Select all that apply. substance misuse anorexia major depressive disorder schizophrenia bipolar disorder

substance misuse anorexia major depressive disorder Adverse events during childhood increase risk of alcohol and drug dependence, eating disorders, affective disorders, posttraumatic stress disorder (PTSD), and suicidal behavior. There is no evidence that supports the correlation of childhood abuse and schizophrenia and bipolar disorder. These mental health problems are caused by multiple factors; however, a genetic predisposition is one of the strongest factors.

The nurse has responsibility for several clients. Based on the information provided, which of these clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the evening shift? the 70-year-old client who had a total laryngectomy the previous day the 40-year-old client with diabetes who had a fasting blood sugar of 110 mg/dL (6.1 mmol/L) an elderly client who has Alzheimer's disease and periods of confusion a 20-year-old with a spontaneous pneumothorax who had a chest tube inserted earlier in the day whose vital signs are stable

the 70-year-old client who had a total laryngectomy the previous day Based on the information provided, the client who is on day 1 after a total laryngectomy would be the priority client for the nurse to evaluate. This client is at risk for swelling or pressure on the trachea and should be monitored closely. Clients with acute conditions that can affect their respiratory status are a high priority for nursing care. The client with diabetes has a normal fasting blood sugar and will not require immediate intervention. The client with Alzheimer's disease is not in immediate danger and, therefore, does not require immediate evaluation. There is no evidence that the client with pneumothorax is in immediate need of evaluation.