Med Surg Test 2 Ch's 34, 39, 44, 45, 46, 47

Integrated Process: Nursing Process (Implementation) 14. The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

A Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Implementation) 18. A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client? a. "Clean your toothbrush with laundry bleach daily." b. "Bathe every other day with antimicrobial soap." c. "Wash your hands after changing pet litter boxes." d. "Use an electric razor when you shave your face."

A The client at risk for septic shock should be instructed to clean his or her toothbrush daily, either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at higher risk for bleeding disorders. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Teaching/Learning 7. A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action? a. Palpate the area over the bladder for distention. b. Place the client in the Trendelenburg position. c. Administer oxygen via a nasal cannula. d. Perform bilateral carotid massage.

A The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Analysis) 10. A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago is brought to the intensive care unit. Which prescribed medication does the nurse prepare to administer? a. Tissue plasminogen activator b. Heparin sodium c. Gabapentin (Neurontin) d. Warfarin (Coumadin)

A The client who has had a thrombotic stroke has a 3-hour time frame from the onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for administration of this therapy. The other medications do not assist in the re-establishment of blood flow for a client with a confirmed thrombotic stroke. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 13. A client has experienced a stroke resulting in damage to Wernicke's area. Which clinical manifestation does the nurse monitor for? a. Inability to comprehend spoken words b. Communication with rote speech only c. Slurred speech d. Inability to make sounds

A The client with damage to Wernicke's area cannot understand spoken or written words. If the client speaks, the language is meaningless, with the client using made-up words. Damage to Wernicke's area does not cause slurred speech, nor will the client communicate with habitual speech only. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations)

Integrated Process: Nursing Process (Implementation) 2. The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? a. Elevate the head of the bed and apply oxygen. b. Listen to the client's lung sounds. c. Pull the call bell out of the wall socket. d. Assess the client's pulse oximetry.

A The client's immediate need is to have oxygen applied. The nurse should then assess the client's pulse oximetry. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Teaching/Learning 15. A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client? a. Sudden onset of shortness of breath b. Swelling of the lower extremities c. Lower abdominal tenderness d. Decreased urinary output

A The complication to be alert for is pneumothorax or hemothorax. The nurse monitors the client for chest pain, sudden onset of shortness of breath, diminished chest wall expansion, decreased breath sounds, restlessness, and changes in vital signs. The other symptoms are not likely to occur or are not related to removal of the thymus. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Teaching/Learning 8. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

A The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 991 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 26. What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a. Ask the client to point to words on a board. b. Ask the client to blink for "yes" and "no." c. Have the client mouth words slowly. d. Teach the client some simple sign language.

A The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Implementation) 16. The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question? a. Enoxaparin (Lovenox) 40 mg subcutaneous twice daily b. Transfusion of 2 units of fresh frozen plasma c. Regular insulin intravenous drip per protocol d. Cefazolin (Ancef) 1 g IV every 6 hours

A Therapy during the second (late) phase of septic shock is aimed at enhancing the blood's ability to clot. Enoxaparin would increase the client's risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client's blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Assessment) 2. A client with aphasia presents to the emergency department with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke? a. Two episodes of speech difficulties in the last month b. Sudden loss of motor coordination c. A grand mal seizure 2 months ago d. Chest pain and nuchal rigidity

A Thrombotic stroke is characterized by a gradual onset of symptoms that often are preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction. Two episodes of speech difficulties would correlate with TIAs. The other manifestations are not related to a thrombotic stroke. DIF: Cognitive Level: Comprehension/Understanding REF: Table 47-1, p. 1006 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 18. A hospitalized client with late-stage Alzheimer's disease says that breakfast has not been served. The nurse witnessed the client eating breakfast earlier. Which statement made to this client is an example of validation therapy? a. "I see you are still hungry. I will get you some toast." b. "You are confused about mealtimes this morning." c. "You ate your breakfast 30 minutes ago." d. "You look tired. Maybe a nap will help."

A Use of validation therapy involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Teaching/Learning 22. A client who has a local infection of the right forearm is being discharged. The nurse teaches the client to seek immediate medical attention if which complication occurs? a. Dizziness on changing position b. Increased urine output c. Warmth and redness at site d. Low-grade temperature

A When a local infection becomes systemic, the client develops a high-grade temperature, decreased urine output, and increased respiratory rate. Because of tachycardia and low blood pressure, the client may exhibit orthostatic hypotension. This is a subtle sign of systemic infection that requires further evaluation by the health care provider. The other signs are not manifestations of complications. Warmth and redness are expected with local infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Planning) SHORT ANSWER 1. A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units per hour is the client receiving? __________ units/hr

500 25,000 units/250 mL = X units/hr/(5 mL/hr) 250X = 125,000 X = 500 units/hr DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation)

Integrated Process: Nursing Process (Assessment) COMPLETION 1. The nurse is preparing to administer a prescribed dose of intravenous dexamethasone (Decadron) to a client after craniotomy. The pharmacy supplies dexamethasone 40 mcg in 20 mL normal saline to be administered over 15 minutes. The nurse sets the IV pump at a rate of _____ mL/hr.

80 20 mL/15 min = x mL/60 min 15x = 1200 x = 80 mL/hr DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation)

Integrated Process: Nursing Process (Assessment) 21. The nurse is planning discharge education for a client who had an exploratory laparotomy. Which nursing statement is appropriate when teaching the client to monitor for early signs of shock? a. "Monitor how much urine you void and report a decrease in the amount." b. "Take your temperature daily and report any below-normal body temperatures." c. "Assess your radial pulse every day and report an irregular rhythm." d. "Monitor your bowel movements and report ongoing constipation or diarrhea."

A A decrease in urine output is a sensitive indicator of early shock. In severe shock, urine output is decreased (compared with fluid intake) or even absent. Alterations in temperature, irregular rhythms, and changes in bowel movements are not early signs of shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 3. The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

A A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS. DIF: Cognitive Level: Comprehension/Understanding REF: p. 988 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 4. The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client? a. Impaired proprioception b. Aphasia c. Agraphia d. Impaired olfaction

A A stroke to the right cerebral hemisphere causes impaired visual and spatial awareness. The client may present with impaired proprioception and may be disoriented as to time and place. The right cerebral hemisphere does not control speech, smell, or the client's ability to write. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 3. A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy. Which postprocedure instructions does the nurse provide before discharge? a. "You should begin an exercise routine which includes walking every day." b. "You must sleep in a supine position until the bandage is removed." c. "You may feel numbness or tingling in the legs for 24 hours." d. "You will need to wear a lumbar brace for 1 week."

A After this minimally invasive surgery, clients typically go home the same day or the day after surgery. Clients should be taught to begin the prescribed exercise program immediately after discharge, which includes walking every day. The client should not be restricted to one sleeping position. Clients generally have less pain with this procedure and do not experience numbness or tingling. The client may have a clear or gauze dressing but will not need to wear a lumbar brace. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 3. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? a. Monitor the client's oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding.

A Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Intervention) 24. The nurse is assessing a client who has septic shock. The following assessment data were collected: Baseline Data Today's Data Heart rate 75 beats/min 98 beats/min Blood pressure 125/65 mm Hg 128/75 mm Hg Respiratory rate 12 breaths/min 18 breaths/min Urinary output 40 mL/hr 40 mL/hr The nurse correlates these findings with which stage of shock? a. Early b. Compensatory c. Intermediate d. Refractory

A An increase in heart and respiratory rates (heart rate first) from the client's baseline and a slight increase in diastolic blood pressure may be the only objective manifestations of early shock. These findings do not correlate with other stages of shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

1. The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best response? a. "Shock occurs when oxygen to the body's tissues and organs is impaired." b. "Shock is a serious condition, but it is not a life-threatening emergency." c. "Shock progresses slowly and can be stopped by the body's normal compensation." d. "Shock is a condition that affects only specific body organs like the kidneys."

A Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death. DIF: Cognitive Level: Knowledge/Remembering REF: p. 809 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Analysis) 13. A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

A Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

Integrated Process: Communication and Documentation 6. The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for? a. Automatisms b. Intermittent rigidity c. Sudden loss of muscle tone d. Brief jerking of the extremities

A Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, patting, and picking at clothing. The other manifestations do not correlate with absence seizures. DIF: Cognitive Level: Comprehension/Understanding REF: p. 932 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Teaching/Learning 17. The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching? a. "I will change positions slowly." b. "I will avoid wearing cotton socks." c. "I will use an electric razor." d. "I will use a heating pad on my feet."

A Autonomic dysfunction causes orthostatic hypotension. The client should change positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause peripheral polyneuropathy, so the client should be taught to wear socks and shoes at all times and not to use a heating pad. The disorder does not cause bleeding; therefore the client can use any type of razor. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 11. A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? a. Obtain two sets of blood cultures. b. Administer the prescribed IV vancomycin (Vancocin). c. Obtain central venous pressure (CVP) measurements. d. Administer the prescribed IV norepinephrine (Levophed).

A Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Analysis) 4. The nurse is assessing a client with a cluster headache. Which clinical manifestation does the nurse expect to find? a. Ipsilateral tearing of the eye b. Exophthalmos c. Abrupt loss of consciousness d. Neck and shoulder tenderness

A Cluster headache is usually accompanied by ipsilateral tearing, rhinorrhea or nasal congestion, ptosis, eyelid edema, facial sweating, and miosis. The other manifestations are not associated with cluster headaches. DIF: Cognitive Level: Comprehension/Understanding REF: p. 931 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 2. The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer

A Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma. The other clients are at risk for hypovolemic and cardiogenic shock. DIF: Cognitive Level: Comprehension/Understanding REF: p. 812 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 15. The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed? a. Heparin sodium b. Vitamin K c. Corticosteroids d. Hetastarch (Hespan)

A During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Expected Actions/Outcomes)

1. The nurse is providing health education at a community center. Which instruction does the nurse include as part of client education for the prevention of low back pain? a. "Participate in a regular exercise program." b. "Purchase a soft mattress for sleeping comfort." c. "Wear high-heeled shoes only for special occasions." d. "Keep your weight within 20% of your ideal body weight."

A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 17. The nurse is caring for a hospitalized client with Alzheimer's disease who has a history of agitation. Which intervention does the nurse implement to help prevent agitation and aggressive behavior in this client? a. Provide undisturbed sleep. b. Orient the client to reality. c. Leave the television turned on. d. Administer hypnotic drugs as needed.

A Fatigue from disturbed sleep increases confusion and behavioral manifestations, such as aggression and agitation. Reality orientation is inappropriate for clients in a later stage of the disease. Constant noise from the TV most likely would agitate the client. Sedation should be used as a last resort. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Implementation) 22. The nurse is caring for a client who is disoriented as the result of a stroke. Which action does the nurse implement to help orient this client? a. Ask the family to bring in pictures familiar to the client. b. Turn on the television to a 24-hour news station. c. Maintain a calm and quite environment by minimizing visitors. d. Provide auditory and visual stimulation simultaneously.

A For the client with disorientation, the nurse can request that the family bring in pictures or objects that are familiar to the client. The nurse explains what the object or picture represents in simple terms. These stimuli can be presented several times daily. Visitors can also be familiar stimuli to reorient the client. Too much stimuli and constant stimuli can lead to further confusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Analysis) 6. The nurse notes that the left arm of a client who has experienced a brain attack is in a contracted, fixed position. Which complication of this position does the nurse monitor for in this client? a. Shoulder subluxation b. Flaccid hemiparesis c. Pathologic fracture d. Neglect syndrome

A Hypertonia causing contracture or flaccidity can predispose the client to subluxation of the shoulder. Contractures are stiff and immobile—not flaccid. Contractures are not caused by fractures or neglect syndrome. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Implementation) 13. The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs.

A If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment)

Integrated Process: Nursing Process (Analysis) 17. The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr

A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Teaching/Learning 20. The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication? a. Draw up the medication using a filtered needle. b. Have injectable naloxone (Narcan) prepared and ready at the bedside. c. Prepare to hyperventilate the client before drug administration. d. Discontinue a barbiturate-induced coma before drug administration.

A Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals. Narcan does not reverse the effects of mannitol. Hyperventilation does not affect administration of this drug, and clients can be given mannitol while in a barbiturate-induced coma. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration)

Integrated Process: Nursing Process (Assessment) 12. The nurse is taking the health history of a client suspected of having bacterial meningitis. Which question is most important for the nurse to ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

A Meningococcal meningitis tends to occur in outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. The other questions do not identify risk factors for bacterial meningitis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

Integrated Process: Nursing Process (Implementation) 16. The nurse is teaching a client who has a spinal cord injury how to prevent respiratory problems at home. Which statement indicates that the client correctly understands the teaching? a. "I will use my incentive spirometer every 2 hours while I'm awake." b. "I will not drink thick fluids to prevent choking." c. "I will take cough medicine to prevent excessive coughing." d. "I will position myself on my right side so I don't aspirate."

A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand her or his lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easy to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high Fowler's position to prevent aspiration. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Communication and Documentation 27. A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a. Stays with the client and replaces the oxygen mask b. Asks the client's spouse to hold the oxygen mask in place c. Restrains the client per facility policy d. Contacts the health care provider and requests sedation

A Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)

Integrated Process: Nursing Process (Assessment) 3. A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips

A, B, C A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions. DIF: Cognitive Level: Comprehension/Understanding REF: p. 671 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Analysis) MULTIPLE RESPONSE 1. The nurse is assessing a client who is in early stages of hypovolemic shock. Which manifestations does the nurse expect? (Select all that apply.) a. Elevated heart rate b. Elevated diastolic blood pressure c. Decreased body temperature d. Elevated respiratory rate e. Decreased pulse rate

A, B, D Heart and respiratory rates increased from the client's baseline level and a slight increase in diastolic blood pressure may be the only objective manifestations of this early stage of shock. DIF: Cognitive Level: Knowledge/Remembering REF: p. 813 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Evaluation) MULTIPLE RESPONSE 1. A client is admitted for evaluation of a cerebral tumor. Which clinical manifestations does the nurse assess this client for? a. Hemiplegia b. Aphasia c. Hearing loss d. Behavior changes e. Nystagmus

A, B, D If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral changes are common. Hearing loss and nystagmus are found with brainstem lesions. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 47-10, p. 1032 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) MULTIPLE RESPONSE 1. A client has just undergone surgery for peripheral nerve trauma. Which interventions does the nurse include in the client's plan of care? (Select all that apply.) a. Immobilization of the affected area with a splint b. Rotation of cold and heat therapy c. Occupational therapy d. Skin care, including hygiene and ointments e. High-fat, low-protein diet

A, C, D Care for the client with peripheral nerve trauma includes immobilization before and after surgery, and skin care to prevent skin breakdown and promote healing. The client may likely require physical or occupations therapy during the recovery process. The client will have decreased sensation, so cold and heat therapy should not be used. The client will require a diet high in protein to promote healing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 2. A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer? ______ mL

0.25 5000 units/20,000 units 1 mL = 0.25 mL DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Dosage Calculation)

Integrated Process: Teaching/Learning 3. A client has septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.) a. Decreased cardiac output b. Increased cardiac output c. Increased blood glucose d. Decreased blood glucose e. Increased serum lactate f. Decreased serum lactate

A, C, E Septic shock manifests with decreased cardiac output, increased blood glucose, and increased serum lactate. The other parameters do not correlate with septic shock. DIF: Cognitive Level: Comprehension/Understanding REF: Table 39-5, p. 823 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 4. The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.

A, C, F Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment)

Integrated Process: Nursing Process (Assessment) 6. The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion exercises.

A, D Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in bed, and the client should perform active range of motion (ROM) if able. If the client is unable to perform active ROM, the nurse should provide passive ROM. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 34-1, p. 663 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Communication and Documentation MULTIPLE RESPONSE 1. The nurse is assessing a client's coping strategies after suffering a traumatic spinal cord injury. Which information related to this assessment is important for the nurse to obtain? (Select all that apply.) a. Spiritual or religious beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

Integrated Process: Nursing Process (Implementation) 25. The nurse is teaching a client who has an unstable thoracic vertebral fracture and is being treated with immobilization before surgery. Which statement does the nurse include in the client's teaching? a. "You will need to apply an immobilizing brace snugly around your waist when out of bed." b. "You will remain strapped to the transport back board until the surgical room is ready." c. "Keep your spine in alignment by not sitting up, arching your back, or twisting in bed." d. "An incentive spirometer will prevent you from having atelectasis and pneumonia after surgery."

C The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially with flexion, extension, or rotation of the trunk. The client will be moved to a more comfortable bed to wait for surgery and will remain on bedrest. Although teaching about how to use an incentive spirometer is important for surgical clients, the incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists the client to breathe deeply. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 18. The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. "Cut all calluses and corns from your feet as soon as you notice them." b. "Your balance will be steadier if you go barefoot while at home." c. "Use a thermometer to check the temperature of bath water." d. "Avoid using lotion on the feet and legs."

C The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 25. The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. d. Suction the client.

C The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests, Treatments, and Procedures)

Integrated Process: Nursing Process (Analysis) 4. A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?"

C The first manifestations of hypovolemic shock result from compensatory mechanisms. Signs of shock are first evident as changes in cardiovascular function. As shock progresses, changes in skin, respiration, and kidney function progress. The other questions would not identify early stages of shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Analysis) 14. A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond? a. "Rehabilitation will reverse any physical deficits caused by the stroke." b. "If you do not have rehabilitation, you may never walk again." c. "Rehabilitation will help you function at the highest level possible." d. "Your doctor knows best and has ordered this treatment for you."

C The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The other responses do not answer the client's question appropriately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

Integrated Process: Nursing Process (Assessment) 13. A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first? a. Insert a Foley catheter to monitor urine output closely. b. Ask the client's family to come to the hospital because death is near. c. Initiate the prescribed dobutamine (Dobutrex) intravenous drip. d. Obtain blood cultures before administering the next dose of antibiotics.

C The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client's pulse pressure is decreasing rapidly. The family should be updated appropriately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Assessment) 2. The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

C The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barré syndrome. DIF: Cognitive Level: Comprehension/Understanding REF: p. 987 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 9. The nurse is caring for a client who has a vertebral fracture. Which intervention does the nurse implement to prevent deterioration of the client's neurologic status? a. Reorient the client to time, place, and person. b. Administer the Mini-Mental State Examination. c. Immobilize the affected portion of the spinal column. d. Reposition the client every 2 hours.

C The nurse keeps the client in optimal body alignment at all times, avoiding flexion and extension at the site of vertebral injury, to prevent further cord injury or irritability from bone fragments. A brace, traction, or external fixation may be used for this purpose. The other interventions would not prevent deterioration of the client's neurologic status. Assessments would assist with the recognition of neurologic changes but would not prevent them. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Analysis) 26. The nurse is planning care for a client who has a spinal cord injury. Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapists, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Consultation with Interdisciplinary Team)

Integrated Process: Nursing Process (Analysis) 10. The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle accident

C The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 24. The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders.

C This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) 18. The nurse is caring for a client who has a moderate head injury. The client's sister asks, "Will my brother return to his normal functioning level when his brain heals?" How does the nurse respond? a. "You should expect a full recovery in all ways by the time of discharge." b. "Usually, someone with this type of injury returns to baseline within 6 months." c. "Your brother may experience many changes in personality and cognitive abilities." d. "Learning complex new skills may be more difficult, but you can expect other functions to return to normal."

C Those with moderate to severe head injuries are never the same as before the injury. They can experience changes in cognition such as memory loss, difficulty learning new information, and limited concentration. Personality alterations such as outbursts of temper and depression also may occur. The other responses do not correctly answer the question and can give false hope. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Teaching/Learning 15. The nurse is teaching bladder training to a client who is incontinent after a stroke. Which instruction does the nurse include in this client's teaching? a. "Decrease your oral intake of fluids to 1 liter per day." b. "Use a Foley catheter at night to prevent accidents." c. "Plan to use the commode every 2 hours during the day." d. "Hold your bladder as long as possible to restore bladder tone."

C To begin a bladder training program, teach the client to use the commode, bedpan, or urinal every 2 hours. If used frequently enough, this will prevent accidents and establish a routine. Fluid intake should be restricted at night, and a Foley catheter should be used only for urine retention. The client should empty his or her bladder when the urge occurs and should not hold the bladder. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Evaluation) 24. The nurse teaches a client who has Guillain-Barré syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching? a. "I can use the button on the pump as often as I want to get more pain medication." b. "Aspirin will provide the best relief from my pain associated with this disease." c. "A combination of morphine and distraction helps bring me relief right now." d. "I should not have any pain as a result of impaired motor and sensory neurons."

C Typical pain from GBS often is not relieved by medication other than opiates. Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects. Patient-controlled analgesia (PCA) pumps should be set with appropriate doses and limits. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 3. The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which actions does the nurse implement during this procedure? (Select all that apply.) a. Use Standard Precautions. b. Wear sterile gloves when handling the specimen. c. Place the specimen on ice. d. Send the specimen in a sealed bag displaying a biohazard symbol. e. Confirm the specimen label with the client's identification band.

A, D, E The Standard Precautions approach is based on the premise that a medical history and a physical examination cannot reliably identify all those infected by pathogens. Consequently, health care workers should consider all human blood and body fluids as potentially infectious and must use appropriate protective measures to prevent possible exposure. Specimens should be labeled appropriately and transported in a sealed bag displaying the biohazard symbol. The nurse should use Standard Precautions when handling the specimen. The nurse should also confirm the identification of the client and the specimen. The nurse does not need sterile gloves, and the specimen should not be iced. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Handling Hazardous and Infectious Materials)

Integrated Process: Teaching/Learning 3. The nurse is assessing the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which values and observations does the nurse correlate as most indicative of viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Normal protein level d. Increased protein level e. Normal glucose level f. Decreased glucose level

A, D, E Viral meningitis does not cause cloudiness or increased turbidity of CSF. Protein levels are slightly increased, and glucose levels are normal. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values)

Integrated Process: Teaching/Learning MULTIPLE RESPONSE 1. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

A, D, F The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. Padded tongue blades may pose a danger to the client during a seizure. Be sure that oxygen and suctioning equipment with an airway are readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

Integrated Process: Nursing Process (Implementation) 17. The nurse is assessing a client at risk for shock. The client's systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first? a. Increase the IV fluid rate. b. Administer oxygen. c. Notify the health care provider. d. Place the client in high Fowler's position.

B Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. The other interventions should be completed after oxygen is administered. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Implementation) 19. A client is prescribed levetiracetam (Keppra). Which laboratory tests does the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

B Adverse effects of levetiracetam (Keppra) include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

Integrated Process: Teaching/Learning 22. The nurse is assessing a client with Huntington's disease. Which motor changes does the nurse monitor for in this client? a. Shuffling gait b. Jerky hand movements c. Continuous chewing motions d. Tremors of the hands during fine motor tasks

B An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson's disease. DIF: Cognitive Level: Knowledge/Remembering REF: p. 956 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

1. The nurse is caring for a client experiencing migraine headaches who is receiving a beta blocker to help manage this disorder. When preparing a teaching plan, which instruction does the nurse plan to provide? a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." b. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines."

B Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss an appropriate use of the medication. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 16. The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client? a. Administering antibiotics every 6 hours b. Positioning the client with the "good lung dependent" c. Making sure that the pilot balloon line on the endotracheal tube is deflated d. Ensuring that the client is able to speak clearly

B Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Teaching/Learning 6. The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client? a. "You may lift items up to 10 pounds." b. "Wear your brace when you are out of bed." c. "You must remain on bedrest for 48 hours after surgery." d. "You will need to take steroids to prevent rejection of the bone graft."

B Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 11. The nurse is assessing a client with a spinal cord injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury? a. Rhinorrhea and epiphora b. Fever and cough c. Agitation and restlessness d. Hip and knee pain

B Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles. The development of fever and cough should alert the nurse to the possibility of pneumonia. The other manifestations are not related to complications from this type of injury. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 28. A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best? a. Call the Rapid Response Team. b. Decrease involvement in care until the episode is past. c. Cluster morning activities to provide long rest periods. d. Space out interventions to provide for periods of rest.

B Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the client's involvement, which is the cause of shortness of breath. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Analysis) 7. The nurse is caring for a client who has experienced a stroke. Which nursing intervention for nutrition does the nurse implement to prevent complications from cranial nerve IX impairment? a. Turn the client's plate around halfway through the meal. b. Place the client in high Fowler's position. c. Order a clear liquid diet for the client. d. Verbalize the placement of food on the client's plate.

B Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 4. The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action? a. Place the client in a high Fowler's position. b. Prepare the client for elective intubation. c. Administer oxygen via a nasal cannula. d. Auscultate for breath sounds.

B Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Teaching/Learning 20. The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock? a. 15-year-old adolescent who plays high school basketball b. 24-year-old computer specialist who has bulimia c. 48-year-old truck driver who has a 40-pack-year history of smoking d. 62-year-old business executive who travels frequently

B Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

1. The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

B In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract. DIF: Cognitive Level: Knowledge/Remembering REF: p. 987 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 8. A client is actively experiencing status epilepticus. Which prescribed medication does the nurse prepare to administer? a. Atropine b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Morphine sulfate

B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atropine and morphine are not administered for seizure activity. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Assessment) 21. The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurse's best action? a. Place the client in high Fowler's position. b. Document the finding. c. Assess the corneal reflex. d. Notify the health care provider.

B Loss of motor and sensory function after complete trigeminal nerve dissection is normal. No intervention is necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 25. The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis? a. "This is the worst type of brain tumor, and surgery is not an option." b. "My tumor can be removed, but I can still have damage because of pressure in my brain." c. "Even after the surgery, I will need chemotherapy to decrease the spread of the tumor." d. "Radiation is never used on brain tumors because of possible nerve damage."

B Meningiomas arise from the coverings of the brain (the meninges) and are the most common type of benign tumor. This tumor is encapsulated, globular, and well demarcated, and causes compression and displacement of nearby brain tissue. Although complete removal of the tumor is possible, it tends to recur and causes irreversible damage to the brain. The tumor is not treated by chemotherapy or radiation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Implementation) 10. A client who experienced a spinal cord injury 1 hour ago is brought to the emergency department. Which prescribed medication does the nurse prepare to administer to this client? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for the client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 7. The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. "I need to see a lawyer because I do not expect to recover from this disease." b. "I will have to take things slowly for several months after I leave the hospital." c. "I expect to be able to return to work in construction soon after I get discharged." d. "I wonder if my family will be able to manage my care now that I am paralyzed."

B Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

Integrated Process: Teaching/Learning 24. The nurse assesses periorbital edema and ecchymosis around both eyes of a client who is 6 hours postoperative for craniotomy. Which intervention does the nurse implement for this client? a. Position the client with the head of the bed flat. b. Apply an ice pack to the affected area. c. Assess arterial blood pressure. d. Notify the health care provider.

B Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should attempt to increase the client's comfort by reducing the swelling with application of ice. The provider does not need to be notified. Lowering the head of the bed and assessing blood pressure will not decrease inflammation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 5. A client who has acidosis resulting from hypovolemic shock has been prescribed intravenous fluid replacement. Which fluid does the nurse prepare to administer? a. Normal saline b. Ringer's lactate c. 5% dextrose in water d. 5% dextrose in 0.45% normal saline

B Ringer's lactate is an isotonic solution that acts as a volume expander. Also, the lactate acts as a buffer in the presence of acidosis. The other solutions do not contain any substance that would buffer or correct the client's acidosis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies)

Integrated Process: Nursing Process (Assessment) 20. The caregiver of a client with advanced Alzheimer's disease states, "She is always wandering off. What can I do to manage this restless behavior?" How does the nurse respond? a. "Allow for a 45-minute daytime nap." b. "Take the client for frequent walks throughout the day." c. "Using a Geri-chair may decrease agitation." d. "Give a mild sedative during periods of restlessness."

B Several strategies may be used to cope with restlessness and wandering. Taking the client for frequent walks may decrease restless behavior. Another strategy is to engage the client in structured activities. The other options would not be as helpful. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

Integrated Process: Nursing Process (Assessment) 10. A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

B Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug. The other medications are not appropriate for complications of this test. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

Integrated Process: Nursing Process (Implementation) 12. The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

B The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex and caloric reflex test would not be appropriate for this client. DIF: Cognitive Level: Knowledge/Remembering REF: p. 992 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Evaluation) 17. The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS) of the relapsing type? a. Absence of periods of remission b. Attacks becoming increasingly frequent c. Absence of active disease manifestations d. Gradual neurologic symptoms without remission

B The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks. The other manifestations do not correlate with a relapsing type of MS. DIF: Cognitive Level: Comprehension/Understanding REF: p. 979 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 8. A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next? a. Check the client's blood pressure and apical heart rate. b. Elevate the back rest to 30 degrees and notify the health care provider. c. Place the client in a supine position with a flat back rest, and observe. d. Assess the client's white blood cell count and differential.

B The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted. Assessing vital signs and white blood cell count is not the priority at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 8. The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication? a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.

B The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the client's pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 21. The nurse is preparing a client who has multiple sclerosis (MS) for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include in the teaching plan for the client? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Use physical aids such as walkers as little as possible." d. "Stop using these medications when your symptoms improve."

B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the MS symptoms, assistive devices may be required for safe ambulation, and medication should not be stopped. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Implementation) 6. The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure? a. Tachycardia b. Hypovolemia c. Hyperkalemia d. Hemorrhage

B The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated. The other manifestations are not complications of plasmapheresis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

Integrated Process: Nursing Process (Evaluation) 25. The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis? a. "My neighbor also had Guillain-Barré syndrome." b. "I had a viral infection about 2 weeks ago." c. "I am an artist and work with oil paints." d. "I have a history of a cardiac dysrhythmia."

B The client with GBS often relates a history of acute illness, trauma, surgery, or immunization 1 to 3 weeks before the onset of neurologic symptoms. The other statements do not correlate with GBS. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 11. The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

B The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. Therapeutic massage, passive range of motion, and repositioning will not reduce muscle weakness. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Teaching/Learning 19. The nurse is caring for a client who has undergone peripheral nerve repair. Which priority assessment does the nurse perform postoperatively? a. Evaluate extremity mobility. b. Assess the skin surrounding the cast. c. Test distal extremities for sensation. d. Auscultate bowel sounds.

B The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and color. If the cast is too tight, the nurse notifies the provider immediately. The other assessments should be completed after a circulatory assessment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 20. A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a. Disorientation b. Hemoptysis c. Pulse oximetry reading of 94% d. Chest pain with movement

B The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 7. The nurse is caring for a client with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. What is the nurse's priority action? a. Restrain the client's extremities. b. Turn the client's head to the side. c. Take the client's blood pressure. d. Place an airway into the client's mouth.

B The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. The client should not be restrained nor an airway placed in his or her mouth during the seizure because these actions increase seizure activity and can harm the client. Vital signs are measured in the postictal phase of the seizure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 15. The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action? a. Nothing; this is required during ventilation. b. Inflate the cuff using minimal leak technique. c. Call the Rapid Response Team. d. Increase the tidal volume.

B The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment)

Integrated Process: Nursing Process (Assessment) 3. The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide

B The syndrome of hypovolemic shock results in inadequate tissue perfusion and oxygenation; thus some cells are metabolizing anaerobically. Such metabolism increases the production of lactic acid, resulting in an increase in hydrogen ion production and acidosis. Other laboratory values associated with acidosis include increased creatinine (impaired renal function) and increased partial pressure of arterial carbon dioxide. Urine specific gravity is not associated with acidosis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 812 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values)

Integrated Process: Teaching/Learning 16. The nurse is caring for a client admitted to the intensive care unit after incurring a basilar skull fracture. Which complication of this injury does the nurse monitor for? a. Aspiration b. Hemorrhage c. Pulmonary embolus d. Myocardial infarction

B This type of fracture may cause hemorrhage from damage to the internal carotid artery. The other problems are not complications of this injury. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Evaluation) 12. The nurse is caring for a client who is immobile from a recent stroke. Which intervention does the nurse implement to prevent complications in this client? a. Position the client with the unaffected side down. b. Apply sequential compression stockings. c. Instruct the client to turn the head from side to side. d. Teach the client to touch and use both sides of the body.

B To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneumatic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent complications of immobility. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Analysis) 5. The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b. Urinary output of 10 mL/hr c. Heart rate of 100 beats/min d. Dry cough

B Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Assessment) 2. Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) a. Middle-aged client awaiting surgery b. Older adult with a 20-pack-year history of smoking c. Client who has been on bedrest for 3 weeks d. Obese client who has elevated platelets e. Middle-aged client with diabetes mellitus type 1 f. Older adult who has just had abdominal surgery

B, C, D, F Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting. Diabetes and waiting for surgery are not known risk factors. DIF: Cognitive Level: Knowledge/Remembering REF: p. 663 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Caring 2. The nurse is teaching a client with a spinal cord tumor about the treatment plan. Which statements indicate that the client correctly understands the teaching? (Select all that apply.) a. "Because my symptoms occurred so quickly, I am likely to be cured quickly by surgery." b. "Radiation therapy can shrink the tumor but radiation can cause more problems, too." c. "I am glad you are here to turn me. Lying in one position for a long time makes my pain worse, even if turning is uncomfortable." d. "I have put my affairs in order and purchased a burial plot because this type of cancer is almost always fatal." e. "My family is making some changes at home for me, including moving my bedroom downstairs."

B, C, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Analysis) MULTIPLE RESPONSE 1. Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema

B, C, E Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry cough. DIF: Cognitive Level: Knowledge/Remembering REF: Chart 34-2, p. 664 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Planning) 2. The nurse is preparing a staff in-service program related to restless legs syndrome (RLS). Which potential risk factors of this syndrome does the nurse include? (Select all that apply.) a. Skin rashes b. Polyneuropathies c. Muscle atrophy d. Diabetes mellitus type 2 e. Hypercalcemia

B, D Risk factors for RLS include a possible genetic basis, history of type 2 diabetes mellitus, advanced kidney failure, vitamin and mineral deficiencies, polyneuropathies, peripheral nerve disease, age, lack of exercise, and pinched nerve. Rashes, muscle atrophy, and hypercalcemia are not related. DIF: Cognitive Level: Comprehension/Understanding REF: p. 999 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Teaching/Learning 3. The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about the sexual effects of this injury. Which statement by the client indicates correct understanding of the teaching? (Select all that apply.) a. "I will not be able to have an erection because of my injury." b. "Ejaculation may not be as predictable as before." c. "I will explore other ways besides intercourse to please my partner." d. "I may urinate with ejaculation but this will not cause an infection." e. "I should be able to have an erection with stimulation."

B, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

Integrated Process: Nursing Process (Implementation) 2. The nurse is teaching a client with chronic headaches about headache triggers. Which statements does the nurse include in the client's teaching plan? (Select all that apply.) a. "Increase your intake of caffeinated beverages." b. "Increase your intake of fruits and vegetables." c. "Avoid all alcoholic beverages." d. "Avoid drinking red wine." e. "Incorporate physical exercise into your daily routine." f. "Incorporate an occasional fast into your plan."

B, D, E Triggers for headaches include caffeine, smoking, and ingestion of pickled foods. Clients are taught to eat a balanced diet and to get adequate exercise and rest. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 2. The nurse is providing health education to a client on immunosuppressant therapy. Which instructions does the nurse include in this client's teaching? (Select all that apply.) a. "Wear a facemask at all times." b. "Take your temperature once a day." c. "Drink only bottled water." d. "Avoid any contact with pets." e. "Wash dishes with hot sudsy water." f. "Rinse your toothbrush in liquid laundry bleach."

B, E, F Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Implementation) 19. A client who has a severe head injury is placed in a drug-induced coma. The client's husband states, "I do not understand. Why are you putting her into a coma?" How does the nurse respond? a. "These drugs will prevent her from experiencing pain when positioning or suctioning is required." b. "This medication will help her remain cooperative and calm during the painful treatments." c. "This medication will decrease the activity of her brain so that additional damage does not occur." d. "This medication will prevent her from having a seizure and will reduce the need for monitoring intracranial pressure."

C When intracranial pressure cannot be controlled by other means, clients may be placed in a barbiturate coma to decrease cerebral metabolic demands, decrease formation of vasogenic edema, and produce a more uniform blood supply to the brain. The other responses do not correctly explain the reason for a medication-induced coma. Pain medication should be administered when the client is comatose. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Assessment) 5. The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy.

C, D, E The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment)

Integrated Process: Nursing Process (Analysis) 9. The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway.

D An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the client's lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 10. The nurse is caring for a client who has had an anaphylactic event. Which priority question does the nurse ask to determine whether the client is experiencing distributive shock? a. "Is your blood pressure higher than usual?" b. "Are you having pain in your throat?" c. "Have you been vomiting?" d. "Are you usually this swollen?"

D Anaphylaxis damages cells and causes release of large amounts of histamine and other inflammatory chemicals. This results in massive blood vessel dilation and increased capillary leak, which manifests as swelling. The other clinical manifestations do not relate to anaphylaxis or distributive shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 23. Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure? a. Measurement of sensation using the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid (CSF) sampling d. Venipuncture for autoantibody analysis

C A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)

Integrated Process: Nursing Process (Implementation) 19. The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action? a. Determine whether an air leak is present in the client's endotracheal tube cuff. b. Have the respiratory therapist check the pressure settings. c. Assess the client's oxygenation. d. Manually ventilate the client with a resuscitation bag.

C A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests, Treatments, and Procedures)

Integrated Process: Nursing Process (Planning) 27. The nurse is discussing advanced directives with a client who has amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How does the nurse respond? a. "You will need to discuss that with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "What would you like to be done if you begin to have difficulty breathing?" d. "You will be on the ventilator only until your muscles get stronger."

C ALS is an adult-onset upper and lower motor neuron disease, characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must include in the advance directives what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Ethical Practice)

Integrated Process: Nursing Process (Evaluation) 16. A client with Alzheimer's disease is admitted to the hospital. Which psychosocial assessment is most important for the nurse to complete? a. Ability to recall past events b. Ability to perform self-care c. Reaction to a change of environment d. Relationship with close family members

C As the disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important for a client with Alzheimer's disease. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations)

Integrated Process: Teaching/Learning 25. The nurse is caring for a client who has chronic migraine headaches. Which complementary health therapy does the nurse suggest? a. "Place a hot compress on your forehead at the onset of the headache." b. "Wear dark sunglasses when you are in brightly lit spaces." c. "Lie down in a darkened room when you experience a headache." d. "Do not sleep longer than 6 hours at one time."

C At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Analysis) 21. The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment.

C Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Analysis) 14. The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock? a. 25-year-old man who has irritable bowel syndrome b. 37-year-old woman who is 20% above ideal body weight c. 68-year-old woman who is being treated with chemotherapy d. 82-year-old man taking beta blockers for hypertension

C Certain conditions or treatments that cause immune suppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock. The other client situations do not increase the client's risk for septic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 21. A client who has Alzheimer's disease is being discharged home. What safety instructions does the nurse include in the teaching plan for the client's caregiver? a. "Keep exercise to a minimum." b. "Place a padded throw rug at the bedside." c. "Install deadbolt locks on all outside doors." d. "Keep the lights off in the bedroom at night."

C Clients with Alzheimer's disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client may need or want lights on in the bedroom at night. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

1. The nurse is obtaining a health history for a client admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic stroke? a. Seizures b. Psychotropic drug use c. Atrial fibrillation d. Cerebral aneurysm

C Clients with a history of hypertension, heart disease, atrial fibrillation, diabetes, obesity, and hypercoagulopathy are at risk for embolic stroke. The other disorders are not risk factors for an embolic stroke. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1012 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

Integrated Process: Nursing Process (Implementation) 11. A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? a. Repeated syncope b. New-onset confusion c. Spontaneous ecchymosis d. Abdominal distention

C Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

Integrated Process: Nursing Process (Implementation) 23. The nurse is planning the discharge of a client who has sustained a moderate head injury and is experiencing personality and behavior changes. The client's wife states, "I am concerned about how different he is. What can I do to help with the transition back to our home?" How does the nurse respond? a. "Be firm and let him know when his behavior is unacceptable." b. "Minimizing the number of visitors will help stabilize his personality." c. "Developing a routine will help provide him with a structured environment." d. "He will return to his normal emotional functioning in 6 to 12 months."

C Developing a home routine that provides structure and repetition is recommended because clients with personality and behavior problems respond best to this type of environment. The client's personality and emotional functioning will never return to normal. The client may be aggressive, and family members must be aware of potential client reactions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Family Dynamics)

Integrated Process: Nursing Process (Implementation) 6. The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication? a. Decrease in blood pressure b. Increase in heart rate c. Increase in cardiac output d. Decrease in mean arterial pressure

C Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is not a desired response but often occurs as a side effect. DIF: Cognitive Level: Comprehension/Understanding REF: p. 818 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 9. The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to prevent complications? a. Administer prescribed analgesics to promote pain relief. b. Cluster nursing procedures together to avoid fatiguing the client. c. Monitor neurologic and vital signs closely to identify early changes in status. d. Position with the head of the bed flat to enhance cerebral perfusion.

C Early detection of neurologic, blood pressure, and heart rhythm changes offers an opportunity to intervene in a timely fashion. Evidence is not yet sufficient to recommend a specific back rest elevation after stroke. Analgesics are often held during the first 72 hours to ensure that the client's neurologic status is not altered by pain medications. Preventing fatigue is not a priority in the first 72 hours. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 18. The nurse is assessing a client with an early onset of multiple sclerosis (MS). Which clinical manifestation does the nurse expect to see? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. The other manifestations are later signs of MS. DIF: Cognitive Level: Comprehension/Understanding REF: p. 979 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Teaching/Learning 2. The nurse is assessing a client with a history of migraines. Which clinical manifestation is an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura. DIF: Cognitive Level: Comprehension/Understanding REF: p. 928 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 20. A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which clinical manifestation alerts the nurse to an adverse effect of this medication? a. Periorbital edema b. Black tarry stools c. Bradycardia d. Vomiting after meals

C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. The other manifestations are not adverse effects of fingolimod. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications//Side Effects/Interactions)

Integrated Process: Teaching/Learning 2. The nurse is caring for a client who has low back pain (LBP) from a work-related injury. Which measures does the nurse incorporate into the client's plan of care? a. Apply moist heat continuously to the affected area. b. Use ice packs or ice massage for 1 to 2 hours over the affected area. c. Apply heat packs for 20 to 30 minutes at least four times daily. d. Advise the client to avoid hot baths or showers.

C Heat increases blood flow to the affected area and promotes healing of injured nerves. However, continuous application of moist heat can promote skin breakdown. DIF: Cognitive Level: Comprehension/Understanding REF: p. 962 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Evaluation) 7. The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client? a. Administer an aminoglycoside. b. Initiate a dopamine hydrochloride (Intropin) drip. c. Administer crystalloid fluids. d. Initiate an intravenous heparin drip.

C IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies)

Integrated Process: Nursing Process (Implementation) 5. A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt? a. Palpable distal pulses b. A pink, warm extremity c. The presence of a bruit d. Shunt pressure higher than 25 mm Hg

C Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures)

Integrated Process: Nursing Process (Analysis) 11. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.

C One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Safe Use of Equipment)

Integrated Process: Nursing Process (Analysis) 6. A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response? a. "You should try to rest more during the day." b. "You should try to lie flat for short periods of time." c. "You need to stay in the hospital for further evaluation." d. "You can take medication at night so you can sleep."

C Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 15. A client with paraplegia is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How does the nurse respond? a. "If you do not want to participate in the rehabilitation program, I will cancel the order." b. "Your doctor has helped many clients with your injury and has ordered a rehabilitation program to help you." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet the client's needs. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Analysis) 22. The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention? a. Pain at the chest tube insertion site b. Fluctuation in the water seal chamber with breathing c. Puffiness of the skin around the chest tube insertion site and a crackling feeling d. Dullness to percussion on the affected side

C Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site, fluctuation in the water seal, and dullness to percussion are all expected. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Analysis) 12. The nurse notes reddened areas over the hips and sacrum of a client with paraplegia from a spinal cord injury. Which action does the nurse implement? a. Massage the reddened areas with a barrier cream. b. Perform hip flexion and extension range-of-motion (ROM) exercises. c. Reposition the client so that the reddened area does not bear weight. d. Ensure that the client sits in a chair at least once each shift.

C Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. ROM exercises are used to prevent contractures. The reddened areas should be assessed for blanching. If the skin does not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve pressure on these areas through positioning, assistive devices, and skin protection should then be used. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Analysis) 17. A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately? a. Pupil response b. Motor function c. Respiratory status d. Short-term memory

C Respiratory derangements (e.g., hypoxemia, hypercarbia, alterations in pH) can contribute to secondary brain injury in this scenario. Therefore, the important priority is assessment of respiratory status so that secondary brain injury conditions are avoided. The other assessments should be performed after effective respiratory functions have been established. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 20. The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe? a. Excruciating pain b. Decreased mobility c. Controllable facial twitching d. Increased talkativeness

C Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking, smiling, eating, or attending to hygienic needs. Sensory and mobility deficits are not associated with trigeminal neuralgia. DIF: Cognitive Level: Knowledge/Remembering REF: p. 1000 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Alterations in Body Systems)

Integrated Process: Nursing Process (Evaluation) 9. The nurse is preparing to administer sodium nitroprusside (Nipride) to a client. Which important action related to the administration of this drug does the nurse implement? a. Assess the client's respiratory rate. b. Administer the medication with gravity tubing. c. Protect the medication from light with an opaque bag. d. Monitor for hypertensive crisis.

C Sodium nitroprusside (Nipride) must be protected from light to prevent degradation of the drug. It should be delivered via pump. This medication does not have any effect on respiratory rate. Hypertension is a sign of milrinone (Primacor) overdose. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies)

Integrated Process: Nursing Process (Assessment) 3. The nurse is reviewing a client's prescription for sumatriptan succinate (Imitrex). Which condition in this client's medical history does the nurse report to the health care provider? a. Bronchial asthma b. Gonorrhea c. Prinzmetal's angina d. Chronic kidney disease

C Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal's angina. The other conditions would not affect the client's treatment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)

Integrated Process: Nursing Process (Implementation) 19. The nurse is providing community education for clients at risk for dehydration. One client states, "We are not at risk because we live in a hot and dry climate." What is the nurse's best response? a. "You are still at risk but not as high a risk as those who live in hot and humid climates." b. "Any type of heat can cause peripheral vasoconstriction, which causes the body to lose water." c. "In a hot and dry environment, the body can lose an increased amount of water without your knowledge." d. "Even though you are not at risk, you should drink adequate fluids when you exercise."

C Teach everyone to prevent dehydration by having adequate fluid intake during exercise or when in a hot and dry environment. Insensitive water loss increases in this type of environment. Heat causes vasodilation as well, also contributing to water loss. The other statements are not accurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

Integrated Process: Nursing Process (Assessment) 13. The nurse is talking to the family of a client who has Parkinson's disease. Which statement indicates that the family has a good understanding of the changes in motor movement associated with this disease? a. "I can never tell what she's thinking. She hides behind a frozen face." b. "She drools all the time so I just can't take her out anywhere." c. "I think this disease makes her nervous. She perspires all the time." d. "She has trouble chewing so I will offer bite-sized portions."

D A masklike face, drooling, and excess perspiration are common in clients with Parkinson's disease. Changes in facial expression or a masklike facies in a Parkinson's disease client can be misinterpreted. Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. The other statements indicate poor understanding of the disease process. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

Integrated Process: Nursing Process (Assessment) 23. The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a. Administering antianxiety medications PRN b. Administering a medication to help the client sleep c. Telling the client to relax and let the ventilator do the work d. Making sure the client is breathing spontaneously

D A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Safe Use of Equipment)

Integrated Process: Nursing Process (Implementation) 4. A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? a. Irrigate the Foley. b. Administer an antibiotic. c. Clamp the Foley. d. Notify the health care provider.

D Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Teaching/Learning 23. The nurse is teaching a client who is receiving carbamazepine (Tegretol) for chronic trigeminal neuralgia. Which statement indicates that the client correctly understands the teaching? a. "This drug will prevent seizures, which can occur because of trigeminal disease." b. "I expect to have surgery soon, so I can stop taking this drug now." c. "This medication is very successful in relieving pain. I am glad to be taking it." d. "I will avoid drinking alcohol because it can add to the side effects of this medicine."

D Carbamazepine is thought to interfere with the transmission of pain through slow fibers. It may decrease the paroxysmal afferent impulse that causes trigeminal pain. Trigeminal disease does not cause seizures. Drowsiness, dizziness, confusion, and risk for falls are adverse effects of this medication. Alcohol consumption increases these risks; therefore the client should not drink alcohol when taking this medication. Seizure disorders may occur in clients who stop taking this medication. The dose should be decreased gradually. Pain relief varies with the person; some people find that this medication provides at least some relief. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 5. A client who had a stroke combs her hair only on the right side of her head and washes only the right side of her face. How does the nurse interpret these actions? a. Poor left-sided motor control b. Paralysis or contractures on the right side c. Limited visual perception of the left fields d. Unawareness of the existence of her left side

D Clients who have experienced a right hemisphere stroke often have neglect syndrome, in which they are unaware of the existence of the paralyzed side, or the left side. This injury would not have an effect on the client's sight. This is not related to poor motor control or paralysis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1011 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Potential for Alterations in Body Systems)

Integrated Process: Nursing Process (Analysis) 3. The nurse is caring for an 80-year-old client who presented to the emergency department in a coma. Which question does the nurse ask the client's family to help determine whether the coma is related to a brain attack? a. "How many hours does your mother usually sleep at night?" b. "Did your mother complain recently of weakness in her lower extremities?" c. "Is any history of seizures known among your mother's immediate family?" d. "Does your mother drink any alcohol or take any medications?"

D Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic disturbances, can cause profound changes in level of consciousness (LOC) when accompanied by a brain attack. Alcohol abuse and medication toxicity can be especially problematic in older adults. The other manifestations are related to a stroke but would not increase the client's risk of coma. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 9. A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After teaching the client about this treatment regimen, the nurse assesses the client's understanding. Which statement indicates that the client understands the teaching? a. "I must drink at least 2 liters of water daily." b. "This will stop me from getting an aura before a seizure." c. "I will not be able to be employed while taking this medication." d. "Even when my seizures stop, I will take this drug."

D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can continue to work while taking this medication. The medication will not stop an aura before a seizure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 15. The daughter of a client with Alzheimer's disease asks, "Will the medication my mother is taking improve her dementia?" How does the nurse respond? a. "It will help your mother live independently once more." b. "It is used to halt the advancement of Alzheimer's disease but will not cure it." c. "It will provide a steady improvement in memory but not in problem solving." d. "It will not improve dementia but can help control emotional responses."

D Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Teaching/Learning 23. The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis? a. Check blood glucose levels every 4 hours. b. Monitor intake and urinary output twice each shift. c. Decrease ventilator rate and tidal volume. d. Administer prescribed low-dose corticosteroids.

D During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should include administration of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Teaching/Learning 14. The nurse is caring for a client with Parkinson's disease. Which intervention does the nurse implement to prevent respiratory complications in the client? a. Keep an oral airway at the bedside. b. Ensure fluid intake of at least 3 L/day. c. Teach the client pursed-lip breathing techniques. d. Maintain the head of the bed at 30 degrees or greater.

D Elevation of the back rest will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson's disease. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 14. A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation? a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Administering daily tap water enemas d. Implementing a consistent daily time for elimination

D For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client, which includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. The other interventions do not assist this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Teaching/Learning 22. Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, and this leads to respiratory compromise. DIF: Cognitive Level: Comprehension/Understanding REF: p. 984 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 13. The nurse is caring for a client with a lower motor neuron lesion who wishes to achieve bladder control. Which intervention does the nurse implement to effectively stimulate the initiation of voiding for this client? a. Stroking the inner aspect of the thigh b. Intermittent catheterization c. Digital anal stimulation d. The Valsalva maneuver

D In clients with lower motor neuron problems, such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. The other interventions do not initiate voiding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Assessment) 22. A client with trigeminal neuralgia is about to undergo surgery for pain relief. The client asks, "How will this surgery relieve my pain?" How does the nurse respond? a. "The surgeon will cut the connection between the cranial nerves." b. "The surgeon will use an electrode to bypass the trigeminal nerve conduction." c. "An incision is made into the nerve itself, and an anesthetic is applied to the area." d. "A small artery compressing the nerve will be relocated."

D In some clients, a small artery compresses the nerve as it enters the pons. By relocating this nerve, pain relief is obtained and sensation is spared. The other responses do not answer the client's question appropriately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Teaching/Learning 4. The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nurse? a. "I am feeling tired." b. "My mouth is so dry." c. "I can't seem to relax and rest." d. "I am unable to urinate."

D Inability to void may indicate damage to the sacral spinal nerves. The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Analysis) 18. The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. d. Assess the client's oxygenation.

D Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests, Treatments, and Procedures)

Integrated Process: Nursing Process (Assessment) 23. The nurse is planning to bathe a client diagnosed with meningococcal meningitis. In addition to gloves, what personal protective equipment does the nurse use? a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask

D Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis)

Integrated Process: Nursing Process (Implementation) 24. A client is scheduled for magnetic resonance imaging (MRI). Which action does the nurse implement before the test? a. Ensure that the person does not eat for 8 hours before the procedure. b. Discontinue all neuroactive medications 3 hours before the procedure. c. Make sure that the client has an identification bracelet that cannot be removed. d. Replace the client's gown with metal snaps with one that has cloth ties.

D Metal objects are a hazard because of the magnetic field used in the MRI procedure. The other actions are not necessary for MRI. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

Integrated Process: Nursing Process (Assessment) 19. A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Nursing Process (Implementation) 21. A client with a head injury is being given midazolam (Versed) while on mechanical ventilation. Which action does the nurse implement for this client? a. Monitor for seizures. b. Assess for urinary output. c. Provide a clear liquid diet. d. Administer an analgesic.

D Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should be given with pain medication. This medication does not increase the risk of seizures and does not decrease urinary output. Clients should not be fed when being mechanically ventilated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)

Integrated Process: Teaching/Learning 11. The nurse assesses for which clinical manifestations in the client with suspected encephalitis? a. Fever of 101° F (38.3° C) b. Nausea and vomiting c. Hypoactive deep tendon reflexes d. Pain on flexion of the neck

D Nuchal rigidity is associated with meningeal irritation and is frequently present in clients with encephalitis. The other manifestations are not associated with encephalitis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 940 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 16. A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver? a. Technique for therapeutic massage to the lower extremities b. Administration of morphine sulfate via an IV pump c. Instructions for preparing thin, puréed foods d. Cardiopulmonary resuscitation (CPR)

D Respiratory compromise is a common occurrence with myasthenia gravis. The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home. The other interventions are not a priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 5. A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity? a. Atonic seizure b. Absence seizure c. Myoclonic seizure d. Tonic-clonic seizure

D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. The other seizures do not manifest in this manner. DIF: Cognitive Level: Comprehension/Understanding REF: p. 932 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Assessment) 9. The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

D Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels. The other laboratory results are not associated with myasthenia gravis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 992 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

1. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin.

D The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Pharmacological Agents)

Integrated Process: Nursing Process (Analysis) 12. The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurse's priority action? a. Assess hemoglobin. b. Administer ferrous sulfate. c. Assess muscle strength. d. Consult with the registered dietitian.

D The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Implementation) 14. Which assessment finding of a client requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw

D The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Analysis) 5. The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital? a. Pain at the incision site b. Decreased appetite c. Slight redness and itching at the incision site d. Clear drainage from the incision site

D The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 8. Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? a. Level of consciousness and orientation b. Heart rate and rhythm c. Muscle strength and reflexes d. Respiratory pattern and airway

D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 12. The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's shock is caused by sepsis? a. Hypotension b. Pale clammy skin c. Anxiety and confusion d. Oozing of blood at the IV site

D The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Teaching/Learning 10. The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen? a. "I will not drink any alcoholic beverages." b. "I will wear a medical alert bracelet." c. "I will let my doctor know about all of my prescriptions." d. "I can skip a couple of pills if they make me ill."

D The nurse must emphasize that antiepileptic drugs must be taken even if seizure activity has stopped. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 8. A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? a. Increase the oxygen. b. Administer an antianxiety medication. c. Administer a bronchodilator. d. Assist with relaxation techniques.

D The nurse should assess the client's oxygenation; however, this client's arterial blood gas documents that the client's hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if the client were hypoxic. The client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 24. A client diagnosed with the Huntington gene but who has no symptoms asks for options related to family planning. Which is the nurse's best response? a. "Most clients with the Huntington gene do not pass on Huntington disease to their children." b. "I understand that they can diagnose this disease in embryos. Therefore you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease." c. "The need for family planning is limited because one of the hallmarks of Huntington disease is infertility." d. "Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider."

D The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogate mother options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other options are not accurate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Analysis) 30. The nurse auscultates the following lung sound in a client with a respiratory disorder. What is the nurse's best action? (Click the media button to hear the audio clip.) a. Have the client use an incentive spirometer. b. Have the client cough and deep breathe. c. Suction the client after auscultating the lower lobes of the lungs. d. Call for the Rapid Response Team.

D The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion. The client's airway is in jeopardy and immediate intervention is necessary. Using the spirometer or coughing and deep breathing will not help the client in this situation. The nurse needs to call the Rapid Response Team. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Medical Emergencies)

Integrated Process: Nursing Process (Implementation) 29. The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg

D This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests)

Integrated Process: Nursing Process (Assessment) 7. A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas.

D When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)