PrepU - Exam 2

saturated fats

lipids that contain as much hydrogen as their molecular structure can hold and are generally solid. S

anorexia

loss of appetite

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?

loss of urine without any identifiable pattern or warning

Paramedics arrive in the emergency department with a victim of a motor vehicle collision. The paramedic reports the driver was restrained, the car was traveling about 30 miles per hour (48 Km/hour), and the air bags were not deployed. The paramedic continues to report the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?

"All of the victims got themselves out of the car?"

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Can you tell me why your physician sent you here to be admitted?"

Which documentation example best reflects the complexity of client teaching by the nurse?

"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse educator that intervention is needed?

"Do you have any questions about your cholecystectomy?"

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching?

"Having sexual relationships does not put a woman at risk for developing a UTI."

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?

"How frequently do you urinate each day?"

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn?

"I am having difficulty breathing."

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

"I know this is hard for you. Is there any way I can help?"

The nurse is discussing the use of the patient-controlled analgesia pump with the postoperative patient. Which of the following statements by the patient indicate a need for additional education?

"I should not press the button more often than every 3-4 hours."

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this."

The nurse is providing education for a client that will be providing self-care at home. The client states, "I just don't think I can do all of this. It's too much to learn." What is the best response by the nurse?

"I understand that you feel overwhelmed with all of the information. Tell me what I can do to help."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse?

"I use cotton-tipped applicators daily to remove cerumen." To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicatosr because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.

A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? (Select all that apply.)

"I will rinse with water when I cannot brush." "I will increase my intake of calcium." "I will not chew ice cubes or crushed ice." The client should brush teeth twice daily, rinse with water when brushing cannot be accomplished, avoid soda of any kind, increase calcium intake, and refrain from chewing ice.

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A nurse is caring for a client with multiple chronic conditions and some physical disabilities. The nurse is using "people-first" language with the following statement during end-of-shift report: -"Last evening, Mr. Rudd, a 44-year-old patient with diabetes was admitted to the unit." -"I admitted another diabetic patient last evening; his name is Mr. Rudd." -"A new diabetic admit came to the floor last night during my shift. He is 44 and his name is Mr. Rudd." -"Mr. Rudd is a 44-year-old diabetic patient who was admitted last evening."

"Last evening, Mr. Rudd, a 44-year-old patient with diabetes was admitted to the unit." -important to all people, both those with and those without disabilities, that they not be equated with their illness or physical condition. Therefore, it is important to refer to all people using "people-first" language.

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?

"Let me talk to your health care provider about a condom catheter."

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?

"Let's review the types of fluids that your child drinks in the morning."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants."

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?

"My name is Sue Smith, RN and I am calling regarding Mrs. Jones in room 356 at Jefferson hospital."

The nurse and client are looking at a client's heel pressure injury. The client states, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "This is normal tissue." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "Necrotic tissue is devitalized tissue that must be removed to promote healing."

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?

"Only if the stool has not been contaminated by urine."

The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?

"Tell me about what signs of infection you will report to the health care provider."

A 56-year-old executive meets with the nurse for education about recently diagnosed atrial fibrillation. He verbalizes concerns about the time he will spend away from his work, and that he is not sure it is necessary to have blood tests every week. He feels it is a waste of time when he does not have any symptoms. Which is the best motivational statement by the nurse for this client?

"The medicine and blood work for atrial fibrillation can help prevent blood clots that have the potential to cause debilitating strokes. What have you heard about warfarin therapy?"

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

When the preoperative client tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:

"The thought of having surgery is keeping you awake."

A nurse has developed strong rapport with the wife of a client who has been receiving rehabilitation following a debilitating stroke. The wife has just been informed that her husband will be unlikely to return home and will require care that can only be provided in a facility with constant nursing care. The client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?"

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?

"Those are senile lentigines and are common in older adults."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it."

A client who is blind and has a guide dog is hospitalized. The nurse states -"Someone needs to stay with you at all times to walk the dog outside." -"What can I do to assist you in keeping your dog with you?" -"Your dog must stay in a corner of the room." -"You are unable to have your guide dog here."

"What can I do to assist you in keeping your dog with you?"

A 70-year-old female client had a cholecystectomy four days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask the client in order to assess the her orientation?

"What day of the week is it?"

The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse?

"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6." Many children achieve daytime bowel and bladder control between 2 and 3 years. They usually stay dry through the night by 4 years, but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.

The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions?

"Why did the health care provider prescribe this medication for you?"

The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left him immobile. As the nurse enters the home, the client braces his hands on the arms of his chair to rise and uses crutches to walk across the room. What is the best response by the nurse?

"You have made an amazing recovery."

A grandmother visits the pediatric clinic with her daughter and 18-month-old granddaughter. The grandmother states, "I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants." What is the best response the nurse can make?

"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained." Many children achieve daytime bowel and bladder control between age 2 and 3 years. They usually stay dry through the night by 4 years. but some children still wet the bed at night until 6 years, after which time nursing intervention may be necessary.

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

fat-soluble vitamins

(A, D, E, and K) are stored in the body as reserves for future needs.

water-soluble vitamins

(B complex and C) are eliminated with body fluids and so require daily replacement.

malnutrition

(a condition resulting from a lack of proper nutrients in the diet).

megadoses

(amounts exceeding those considered adequate for health)

protein complementation

(combining plant sources of protein) helps a person to acquire all essential amino acids from non-animal sources

complete proteins

(proteins that contain adequate amounts and proportions of all the essential amino acids)

calorie

(the amount of heat that raises the temperature of 1 g of water by 1°C) ( used to describe the energy of food)

projectile vomiting

(vomiting that occurs with great force)

A client with multiple sclerosis is being discharged. The nurse understands that living with chronic conditions imposes many challenges, including the need for which accomplishments? Select all that apply. -Validate individual self-worth -Return to a better state of health than prior -Ignore threats to identity -Validate family functioning -Alleviate and manage symptoms

-Alleviate and manage symptoms -Validate individual self-worth -Validate family functioning

A client with multiple sclerosis is being discharged. The nurse understands that living with chronic conditions imposes many challenges, including the need for which accomplishments? Select all that apply. -Validate individual self-worth -Validate family functioning -Return to a better state of health than prior -Ignore threats to identity -Alleviate and manage symptoms

-Alleviate and manage symptoms -Validate individual self-worth -Validate family functioning -challenges of living with chronic conditions include the need to accomplish the following: alleviate and manage symptoms, validate individual self-worth and family functioning, manage threats to identity, and die with dignity and comfort.

What are common in older adults?

-Senile lentigines (brown, flat patches on the face, hands, and forearms) -Benign skin lesions such as seborrheic keratoses (tan to black raised areas)

An older adult in the hospital with a fractured hip is being prepared for surgical repair. The bilateral hearing aids were forgotten at the client's home and the client is having difficulty hearing. To promote communication, which of the following actions should the nurse perform? Select all answers that apply. -Ask the client to repeat what was stated. -Talk directly to the client. -Use a deeper tone of voice. -Allow the television to remain on while talking to the client. -Speak in a loud voice.

-Talk directly to the client. -Use a deeper tone of voice. -Ask the client to repeat what was stated.

Clients must contend with chronic illness daily. Nurses relate more effectively to clients when they understand the following as characteristics of chronic illness. Choose all that apply. -Chronic illness affects the entire family. -Chronic conditions only involve one phase of a person's life. -Chronic illness involves treating only the medical problems. -The management of chronic conditions is a process of discovery. -Managing chronic conditions must be a collaborative process.

-The management of chronic conditions is a process of discovery. -Managing chronic conditions must be a collaborative process. -Chronic illness affects the entire family.

Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?

Allow ample time for psychomotor skills.

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

eructation

belching

When caring for a client whose oral mucous mem-branes are irritated and sore, which of the following items is best to withhold from the dietary tray? 1. Tomato soup 2. Lime gelatin 3. Canned peaches 4. Rice pudding

1. Tomato soup

A nurse notes that a client coughs and chokes while eating. What initial nursing recommendation is best? 1. Have the dietary department send baby foods from now on. 2. Tell the client to chew his or her food very thoroughly. 3. Advise the client to avoid drinking beverages with meals. 4. Withhold milk and other dairy products in the future.

2. Tell the client to chew his or her food very thoroughly.

Which of the following is the best evidence that a client with anorexia as a result of cancer is responding to the nutritional regimen developed by the nurse and dietitian? 1. The client remains alert. 2. The client gains weight. 3. The client feels hungry. 4. The client is pain free.

2. The client gains weight.

4. When a client on a clear liquid diet asks for some nourishment, which of the following is appropriate for the nurse to provide? 1. Milk 2. Pudding 3. Gelatin 4. Custard

3. Gelatin

The nurse is most correct in recommending which of the following food sources of iron to a client with chronic anemia? 1. Dairy products 2. Citrus fruits 3. Red meat 4. Yellow vegetables

3. Red meat

Which client is most at risk for foot difficulties? 80-year-old man with coronary artery disease 45-year-old woman with type 2 diabetes 91-year-old man with renal insufficiency 34-year-old woman who is paraplegic

45-year-old woman with type 2 diabetes People who are at the greatest risk for foot problems are those with poor circulation and those with diabetes. Older age can also put a person at risk but an active older adult is less at risk. A paraplegic could also be at risk for skin issues in general if the person is not active.

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening

50-year-old client with a family history of polyps

The nurse is caring for four clients. For which client is a sitz bath most appropriate?

51-year old with hemorrhoids

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

Adolescents

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?

A 28-year-old female; works nights, willing to try, asking about insurance coverage of appointment.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? A Penrose drain promotes drainage passively into a dressing. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes drainage passively into a dressing. A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide a sinus tract for drainage. to provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.

A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

A nurse is caring for a client diagnosed with high risk for cardiovascular disease. The nurse should encourage this client to minimize intake of what food?

A client with a high risk of cardiovascular disease should not be given red meat, which is high in cholesterol.

In which of the following situations would the SBAR technique of communication be most appropriate?

A nurse is calling a physician to report a client's new onset of chest pain.

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. What is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views expressed on Facebook are his or hers alone and not the employer's.

During a meeting with the school nurse, a 15-year-old girl has declared her intention to adopt a vegan diet. The nurse should conduct client education to ensure that the girl maintains an adequate intake of:

A vegan diet, unless skillfully planned, can be inadequate in protein, calcium, vitamins B12 and D, iron, zinc, and omega 3 fatty acids. Thus, it is helpful to teach vegans about protein complementation if they are unfamiliar with the practice.

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?

Administer the solution gradually over 5 to 10 minutes.

vitamins

chemical substances necessary in minute amounts for normal growth, the maintenance of health, and the functioning of the body

A client is diagnosed with type 2 diabetes mellitus. The client takes metformin and exenatide and reports adhering to a diet. The glycohemoglobin is 5.9%. According to the stable phase of the Trajectory Model of Chronic Illness, how should the nurse respond? -Acknowledges that the client is performing satisfactorily -Responds, "There are some adjustments to your medications that need to be made" -Advises the client that changes must be made to the diet -States, "The glycohemoglobin is too high"

Acknowledges that the client is performing satisfactorily -Acknowledges that the client is performing satisfactorily

An elderly female client who has dizziness and osteoporosis fell at home and fractured her hip. She underwent surgical intervention for repair of the fractured hip and is now being discharged to a subacute care facility. In the comeback phase of the Trajectory Model of Chronic Illness, the nurse -Teaches the client about osteoporosis -Acknowledges the client's achievement when she walks to the bedside commode with her walker -Discontinues the intravenous needle and changes the surgical dressing prior to discharge from the hospital -Assesses postural blood pressures

Acknowledges the client's achievement when she walks to the bedside commode with her walker -comeback phase of the Trajectory Model of Chronic Illness, the nurse provides positive reinforcement for goals identified and accomplished by the client. This would be acknowledging the client's achievement when she ambulates to the bedside commode with her walker

The client who has the chronic condition of diabetes, reports blurry vision, and admits to nonadherence to the diet and medications. The home health nurse checks the client's fasting blood glucose level, which is 412 mg/dL. What phase of the Trajectory Model of Chronic Illness does the nurse assess this client is in? -Pretrajectory -Comeback -Stable -Acute

Acute -acute phase of the Trajectory Model of Chronic Illness the client has severe and unrelieved symptoms or complications that necessitate hospitalization.

A nurse practitioner would be applying the pre-trajectory model of chronic illness when she: -Explained the significance of a serum glucose level of 160 mg/dL. -Encouraged a post-fracture patient to continue physical therapy. -Advised a woman, whose mother has Huntington's chorea, and who is considering pregnancy, to get genetic testing. -Suggested home health care to a stroke victim.

Advised a woman, whose mother has Huntington's chorea, and who is considering pregnancy, to get genetic testing. -pre-trajectory phase involves the prevention of a chronic illness. For example, the focus of nursing care would be to refer the patient for genetic testing and counseling, if indicated, and provide education about prevention of modifiable risk factors and behaviors.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

After the initial stream is initiated, collect the sample.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition?

An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

A client's risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7% sodium 135 mEq/L

An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure injury. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure injuries due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure injuries.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? avulsion abrasion incision laceration

An incision.. of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves separation of skin and tissue with torn, irregular edges. Therefore, the nurse does not document the finding as an avulsion, abrasion, or laceration.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thicker and stronger than in adults. A child's skin becomes less resistant to injury and infection as the child grows. An individual's skin changes little over the life span.

An infant's skin and mucous membranes are easily injured and at risk for infection.

A nurse is caring for a client whose cancer treatment is resulting in anorexia. What is the best evidence that the client is responding to the diet recommended by the dietitian?

Anorexia is loss of appetite. It is associated with multiple factors: illness, altered taste and smell, oral problems, and tension and depression. If the client feels hungry, it is the best evidence that a client is responding to the nutritional regimen and care.

A client underwent surgical repair of a hernia early this morning and has been ordered a clear fluid diet for the first 24 hours following surgery. The client's family members are eager to help with recovery and have asked the nurse about permissible food items to bring for the client. Which of the following items is acceptable at this point in the client's recovery?

Apple juice is acceptable in a clear fluid diet because it contains no solid food particles. Tomato juice and orange juice would be acceptable in a full fluid diet, but not in a clear fluid diet. Yogurt is similarly acceptable in a full fluid diet.

The nurse has just confirmed proper placement of a nasogastric tube. Which action should the nurse take next?

Apply skin barrier to the tip and end of the nose.

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? Contact the surgeon. Apply sterile dressings with normal saline over the protruding organs and tissue. Assess for impaired blood flow to the area of evisceration. Monitor for pallor and mottle appearance of the wound.

Apply sterile dressings with normal saline over the protruding organs and tissue.

When preparing client teaching materials, how does the nurse best assess a client's preferred learning style?

Ask the client, "Do you learn better by seeing how to use an inhaler, believing how the inhaler works, or showing me how to use the inhaler after I show you?"

Which developmental consideration is a nurse assessing when determining that an 8-year-old boy is not equipped to understand the scientific explanation of his disease?

Intellectual development

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview.

What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter?

Avoid irrigation unless needed to relieve an obstruction.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing

Avoid more than 250 mg

The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist?

Interpersonal

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

Be silent and allow the client to continue speaking when ready.

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Before removing the tube, discontinue suction and separate the tube from suction.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which of the following is the most appropriate method the nurse should use to conduct new learning?

Begin the session with a reference to the client's actual experience.

The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?

Blood sugar

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls.

Phosphorus

Buffering action Formation of bones and teeth Eggs Meat Milk

Which symptom will have a great impact on the extracellular fluid for water conservation?

Burns

B3 (Niacin)

Carbohydrate, fat, and protein metabolism Enzyme component Prevention of appetite loss Prevention of pellagra, a condition characterized by cutaneous, gastrointestinal, neurologic, and mental symptoms Lean meat and liver Fish Peas, beans Whole-grain cereals Peanuts Yeast Eggs Liver

The acute care nurse is preparing to bathe a patient and notices that the patient is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which of the following actions by the nurse is most appropriate?

Carefully thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. The gown should be removed without disconnecting the IV equipment or cutting the gown.

The nurse recognizes which disorder as a developmental disability in a patient? -Spinal cord injury -Cerebral palsy -Osteoarthritis -Stroke

Cerebral palsy

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a non-skid floor. The nurse can ensure the client's safety by checking for non-skid strips on the floors of bathtubs and showers, along with strategically placed handles and grab bars that reduce the risk of falls for older adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach of the dominant arm. As the client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs as they increase the risk of falls.

The nurse is caring for a client with diabetes. Which of the following is a characteristic of chronic illness? -Chronic conditions only involve one aspect of a person's life. -One chronic disease never develops into another chronic condition. -Chronic illness affects the entire family. -Managing chronic conditions must be an individual process.

Chronic illness affects the entire family.

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?

Clamp the tube for a brief period and resume at a slower rate.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

A nurse is caring for a client who has been ordered clear liquid diet. Which of the following can be included in the client's diet?

Clear liquid diet consists of water, clear broth, clear fruit juices, plain gelatin, tea, and coffee.

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which of the following?

Client will participate in self-care measures by the end of the week.

An 84-year-old resident of a long-term care home developed the early signs and symptoms of Alzheimer disease several months ago and has experienced a significant decline in food intake as the disease has progressed. What action should the nurse take in order to promote nutrition for this client?

Clients with cognitive deficits may benefit from consistency in the time and place for eating. New and unfamiliar foods are unlikely to appeal to this client and there is no need to completely eliminate seasonings and spices. A minced or pureed diet is easier to chew and swallow, but this unusual texture is unlikely to promote increased interest in eating.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool.

Iron

Component of hemoglobin Assistance in cellular oxidation Liver Egg yolks Meat

Zinc

Constituent of enzymes and insulin Seafood Liver

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

Contact a podiatrist to care for toenails.

A student nurse is attempting to improve their communication skills. Which therapeutic communication skill is appropriate?

Control the tone of the voice to avoid hidden messages.

A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest

Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet?

Custard

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what?

Cut the nail straight across.

The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition. -Coronary artery disease -Type 2 diabetes mellitus -End-stage renal disease -Carcinoma-in-situ

End-stage renal disease

obesity

condition in which a person's BMI equals or exceeds 30 or the triceps skinfold measurement exceeds 15 mm.

Special therapeutic:

consists of foods prepared to meet special needs, such as low in sodium, fat, calories, or fiber

The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: 7-year-old male, diabetes mellitus type 1 with a hemoglobin A1C of 8.3%, BMI of 31.7, BMI percentile of 99. What are the most appropriate learning diagnoses for this first session?

Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance.

A client who is blind is admitted for treatment of a small bowel obstruction and has been vomiting for days. Which nursing diagnosis takes highest priority for this client? -Impaired physical mobility -Activity intolerance -Deficient fluid volume -Risk for injury

Deficient fluid volume

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?

Describe how the walker can improve the client's quality of life.

B6 (Pyridoxine)

Destroyed by heat, sunlight, and air Healthy gums and teeth Red blood cell formation Carbohydrate, fat, and protein metabolism Whole-grain cereals and wheat germ Vegetables Yeast Meat Bananas Black strap molasses

This type of disability represents one that occurs any time from birth to 22 years and results in impairment of physical or mental health, cognition, speech, language, or self-care. -Age-related -Acquired -Developmental -Acute nontraumatic

Developmental -Developmental disabilities occur any time from birth to 22 years and result in impairment of physical or mental health, cognition, speech, language, or self-care. Examples are spina bifida, cerebral palsy, and Down syndrome

Which symptom is a known side effect of antibiotics?

Diarrhea

The nurse is caring for a client with malnutrition due to protein deficiency. Which of the following foods should be included in this client's diet?

Dietary proteins come from animal and plant food sources. Milk, meat, fish, poultry, eggs, legumes (peas, beans, and peanuts), nuts, and components of grains are good sources of proteins.

Clear liquid:

consists of water, clear broth, clear fruit juices, plain gelatin, tea, and coffee; may or may not include carbonated beverages

The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports barriers to each action and continues to smoke. What is the best action of the nurse?

Discuss the client's case with a colleague.

A nursing instructor is discussing the causes of the increasing number of people with chronic conditions. Which of the following would the nurse correctly identify as a cause? -Lowered stress and increased physical activity lifestyles -Early detection and treatment of diseases -Shorter lifespans -An increased mortality rate from infectious diseases

Early detection and treatment of diseases

The nurse needs to understand the teaching-learning process when administering

Educational interventions

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? Exert equal, but not excessive, tension with each turn of the bandage. Wrap distally to proximally. Elevate and support the stump. Keep bandage free from gaps between each turn.

Elevate and support the stump.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube?

Every 4 to 8 hours

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. What is the priority nursing intervention?

Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

nursing diagnoses:

Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: More Than Body Requirements Deficient Knowledge: Nutrition Self-Care Decit: Feeding Impaired Swallowing Risk for Aspiration

The nurse is helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response?

Flossing removes plaque and food debris from the surfaces of teeth that a manual or electric toothbrush may miss. The choice of unwaxed or waxed floss is personal. Waxed floss is thicker and more difficult to insert between teeth; unwaxed floss frays more quickly. The nurse should not share his or her own personal experiences, but rather, educate the patient on the need to use flossing in addition to brushing to maintain good oral hygiene.

Influences on Eating Habits

Food preferences acquired during childhood • Established patterns for meals • Attitudes about nutrition Knowledge of nutrition • Income level • Time available for food preparation • Number of people in the household • Access to food markets • Use of food for comfort, celebration, or symbolic reward • Satisfaction or dissatisfaction with body weight • Religious beliefs

Calcium

Formation of teeth and bones Neuromuscular activity Blood coagulation Cell wall permeability Milk products

Physical Assessment

General appearance Integrity of the mouth Condition of the teeth Ability to chew and swallow Gag reflex Characteristics of skin and hair Joint flexibility Hand strength Attention and concentration

A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis Other definitions: Glossitis is an inflammation of the tongue. Gingivitis is an inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa.

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition."

Hair conditioner coats the hairs and protects the nits. The nurse must intervene to teach the client to only use the pediculicide shampoo; not conditioner. Eggs may attach to hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces, and lice can be spread by direct contact.

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have client rate pain level and reschedule the teaching session.

The nurse has inserted a client's urinary catheter as ordered, but there has been no immediate flow of urine. What is the nurse's most appropriate action?

Have the client take a deep breath to relax the perineal and abdominal muscles.

The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply.

Having blood pressure measurements in the affected arm Getting venipuncture in the affected arm Carrying heavy items including purses or luggage with the affected arm Sleeping with the affected arm under the head or body

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by the one of the participants requires further teaching to ensure understanding? Select all that apply.

Health promotion teaching for hygiene should include proper diet and exercise to promote healthy skin; brushing and flossing teeth regularly and visiting the dentist every six months; keeping hair neat, combed, and brushed regularly; using caution with certain hair care products that can damage the hair; keeping nails clean and neatly trimmed by clipping them straight across and shaping and smoothing with an emery board; bathing and cleansing the skin regularly using lotions and creams while ensuring good cleansing of the axilla and application of deodorant and antiperspirants; and cleaning the perineal areas. Hygiene also promotes a sense of well-being and positive self-image.

H (Biotin)

Heat sensitive Enzyme activity Metabolism of carbohydrates, fats, and proteins Egg yolks Green vegetables Milk Liver and kidney Yeast

E (Alpha-tocopherol)

Heat stable in the absence of oxygen Red blood cell formation Protection of essential fatty acids Important for normal reproduction in experimental animals (ie, rats) Green leafy vegetables Wheat germ oil Margarins Brown rice Pantothenic acid Metabolism Liver Egg yolks Milk

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? transparent films hydrocolloid dressings hydrogels alginates

Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury? Stage I Stage II Stage III Stage IV

IV Stage IV pressure injuries are characterized as exposing muscle and bone, and may have slough and a foul odor. Stage I pressure injuries are characterized by intact, but reddened, skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

The nurse prepares to irrigate a wound and apply antiseptic. The nurse will follow which guideline for performing this procedure? If the wound is closed, clean technique may be used instead of sterile technique. Sterile water is often the solution of choice when irrigating wounds. When the solution from the wound turns light pink, the irrigation should be stopped. If bleeding that was not previously there is noted, the nurse should continue irrigation and then notify the health care provider

If the wound is closed, clean technique may be used instead of sterile technique.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

A 56-year-old woman with a diagnosis of breast cancer is receiving chemotherapy and has been experiencing debilitating nausea throughout the course of treatment. What nursing diagnosis should the nurse assign to this client's health problem?

Imbalanced Nutrition: Less than Body Requirements. Protracted nausea usually results in decreased food intake and consequent malnutrition. Nausea does not directly result in difficulty with the mechanics of swallowing, self-care deficit, or aspiration.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client?

Impaired Skin Integrity related to urinary bladder infection and dehydration

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan

Increase fiber slowly over a period of time to prevent gas.

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

Independent showering

An older adult female client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. She is tearful and verbalizes that she feels lonely and abandoned in the hospital unit. The nurse noticed that family visits daily and that there are flowers and cards in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client?

Ineffective Coping; verbalizes support systems.

What are recommendations that should be given to clients with poor circulation in order to prevent problems with their feet? Select all that apply.

Inspect feet daily. Avoid crossing your feet. A person with poor circulation should never use sharp instruments to cut nails as they can cause damage to the foot itself. Furthermore, they should always wear shoes to protect their feet. Soaking the feet causes them to dry out and can cause cracking.

Which medication causes constipation?

Iron supplements

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? (Select all that apply.)

Keep extra batteries on hand. Do not get hair spray or other chemicals on the hearing aid. Carefully wipe the outer surface of the hearing aid to maintain cleanliness. Extra batteries should be kept, in case the battery of the hearing aid goes out or fails. Avoid exposing the device to extreme heat, water, cleaning chemicals, or hair spray. Clean cerumen that has become embedded in the earpiece with a special instrument that comes with the hearing aid. If this is not available, use a thin needle as a substitute. The outer surface of the hearing aid should be occasionally wiped clean to maintain cleanliness. It is not appropriate for the client to store the hearing aid in a very warm environment or use a small knife to remove the cerumen in the earpiece.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?

Keep hair off the face and wash hair daily.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include

Keep muscles contracted for at least 10 seconds.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile.

Keep the swab and the inside of the culture tube sterile.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients items. Pediculosis is an infestation of lice. The nurse will plan to launder linens, gowns, and bath items separately from items of other clients to prevent the transmission of infection. The other actions are not interventions the nurse would provide.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?

Lecture/discussion

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

Left lateral

A school nurse is conducting a teaching session for the parents of elementary students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups?

Lice are transmitted by head-to-head contact during play and by sharing of personal items.

Potassium

Maintenance of electrolyte balance Neuromuscular activity Enzyme reactions Bananas Oranges Potatoes

Chloride

Maintenance of fluid and electrolyte balance Table salt Processed meat

Sodium

Maintenance of water and electrolyte balance Table salt and Processed meat

A nurse is assessing a 70-year-old client with a reduced appetite. Which of the following contributes to reduced appetite and reduced nutritional intake in older adults?

Medical conditions and adverse medication affect the appetite of older adults.

B1 (Thiamine)

Not readily destroyed by ordinary cooking temperatures Carbohydrate metabolism, Functioning of the nervous system Normal digestion Prevention of beriberi, a condition characterized by neuritis Fish Pork Lean meat and poultry Glandular organs Milk Whole, fortified, and enriched breads, cereals, and grains Peas, beans, and peanuts

A 45-year-old woman has multiple sclerosis. She is able to perform most functions of self-care but recently she has been having problems with balance, which has made it hard to get dressed. Which factor is affecting this client's ability to perform self-care?

Neuromuscular

Magnesium

Neuromuscular activity Activation of enzymes Formation of teeth and bones Whole grains Milk Meat

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the client's lenses after removal?

Normal saline

B2 (Riboflavin)

Not destroyed by heat except in the presence of alkali Formation of certain enzymes Normal growth Light adaptation in the eyes Eggs Green leafy vegetables Lean meat Milk Whole grains Dried yeast

A (Retinol)

Not destroyed by ordinary cooking temperatures Growth of body cells Promotion of vision, healthy hair and skin, and integrity of epithelial membranes Prevention of xerophthalmia, a condition characterized by chronic conjunctivitis Animal fats: butter, cheese, cream, egg yolks, whole milk, Fish, liver oil and liver, Dark green leafy vegetables; deep orange fruits and vegetables

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings.

A nurse prepares a diabetes prevention health seminar for community residents. Her teaching points should emphasize the most important factor influencing metabolic syndrome (pre-diabetes). What is that factor? -Smoking -Obesity -Stress -Sedentary lifestyle

Obesity

A client who is hearing impaired and communicates through sign language only is scheduled for an endoscopy. She does not read lips. It would be best for the nurse to -Obtain a sign interpreter. -Continue with the procedure without someone to interpret. -Talk to the client while also writing messages for the client. -Ask a family member to interpret.

Obtain a sign interpreter. -

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? Contact the surgeon for debridement. Using sterile technique, debride the wound. Off-load pressure from the heel. Place a TED hose on the client's leg.

Off-load pressure from the heel.

A nurse needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer?

Oil-retention

A pediatric nurse provides education to numerous clients in their care. Which group of children benefits most from being involved in the teaching-learning process?

School-age children

A nurse is caring for a client who has been experiencing frequent nausea. Which food should the nurse first recommend to the client when the nausea is relieved?

Once nausea is relieved, assisting the client to resume fluid intake and nourishment becomes a priority. The nurse starts this process gradually, offering sips of clear fluids, such as fruit juices first. Liquids such as soup and milk and bland foods, such as boiled vegetables, can be given later.

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

Orientation phase

The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship?

Orientation phase

When caring for a psychiatric client, a formal contract is made with the client during which phase of the nurse-client relationship

Orientation phase

When caring for a psychiatric client, a formal contract is made with the client during which phase of the nurse-client relationship?

Orientation phase

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?

Palpation

A nurse is talking on the phone with a doctor and states, "I am calling you about Mrs. Nye, my client with cancer in room 213." This is an example of what type of language that is important to all people? -Nursing speak -People-first -First nation -Medical jargon

People-first

Which medical diagnosis is most likely to necessitate testing for fecal occult blood

Peptic Ulcer

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in the bilateral knees. The nurse knows this client does not want to be a burden on his family, and he remains stoic even though he reports the pain as severe. He avoids the topic of surgery and attends church weekly. His family is supportive of any decisions he makes regarding his health. Which of the assessment data are most important to forming an individualized education plan for this client concerning treatment for his osteoarthritis?

Personal perception of health and aging

A client has lost mobility following a stroke. The nurse has established interventions that include providing direct care to the client, teaching, making referrals, and managing the case, to meet the goal. The next step is to -Instruct the client what he or she must do. -Plan with the client how to incorporate the regimen into the client's activities of daily living. -Refer the client to physical therapy for ambulation exercise two times a week. -Assist the familly in obtaining equipment that would help the client to walk.

Plan with the client how to incorporate the regimen into the client's activities of daily living.

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure?

Position the client in a supine position.

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation?

Prime the tubing with the solution.

K (Menadione)

Production of prothrombin Liver Eggs Green leafy vegetables Synthesized in the gastrointestinal tract by bacteria

B9 (Folic acid)

Protein metabolism Red blood cell formation Normal intestinal tract functioning Green leafy vegetables Glandular organs Yeast

B12 (Cyanocobalamin)

Protein metabolism Red blood cell formation Healthy nervous system tissues Prevention of pernicious anemia, a condition characterized by decreased red blood cells Liver and kidney Dairy products Lean meat Milk Salt water fish and oysters

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

Providing a backrub before bed A backrub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? R/t the inability to recognize the need to urinate or defecate R/t right-sided weakness R/t the inability to perform bathing independently R/t impaired mobility

R/t right-sided weakness Self-care deficit: Bathing is related to lack of motor skills, coordination, mental status, and endurance when performing bathing activities. Right-sided weakness is an appropriate statement about why this problem exists. A person's inability to perform bathing independently is more of a sign or symptom in the "as evidenced by (AEB)" statement of a nursing diagnosis. Related to impaired mobility is a nursing diagnosis and cannot be used as a "related/to" statement.

C (Ascorbic acid)

Readily destroyed by cooking temperatures Healthy bones, teeth, and gums Formation of blood vessels and capillary walls Proper tissue and bone healing Facilitation of iron and folic acid absorption Prevention of scurvy, a condition characterized by bleeding and abnormal bone and teeth formation Citrus fruits and juices Tomatoes Berries Cabbage Green vegetables Potatoes

A nurse is caring for a client with chronic anemia. Which of the following should be included in the diet of this client?

Red meat is a source of iron. It, therefore, should be included in the diet of a client with chronic anemia.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding?

Reddened perineal skin

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? Serous Sanguineous Serosanguineous Purulent

Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

Iodine

Regulation of body metabolism Promotion of normal growth Seafood Iodized salt

D (Calciferol)

Relatively stable with refrigeration Absorption of calcium and phosphorus Prevention of rickets, a condition characterized by weak bones Fish liver oils, salmon, tuna, Milk, Egg yolks, Butter, Liver, Oysters, Formed in the skin by exposure to sunlight

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. Which is an internal resource that the client has to help her attain her self-care goals

She has motivation to participate in self-care. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her

A 43-year-old woman is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with her treatment. Self-care activities have been very hard for her to complete. Which is an internal resource that the client has to help her attain her self-care goals?

She has motivation to participate in self-care. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.

A nurse may attempt to help a client solve a situational crisis during what type of counseling session?

Short-term counseling

The nurse is providing teaching for a client in a wheelchair. How will the nurse provide teaching? -Sitting down in a chair during the teaching. -Standing next to the client during the teaching. -Providing modified teaching materials. -Providing alternative communication devices.

Sitting down in a chair during the teaching.

What type of bath is preferred to decrease the inflammation after rectal surgery?

Sitz bath A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth or rectal surgery, or to decrease inflammation of hemorrhoids.

During which phase of the Trajectory Model of chronic illness is the focus of nursing care on reinforcing positive behaviors and offering ongoing monitoring? -Trajectory onset -Stable -Unstable -Pretrajectory

Stable -Stable phase, the focus of nursing care is on reinforcing positive behaviors and offering ongoing monitoring

The nurse is with a client who has a chronic illness and is reinforcing positive behaviors and teaching about health promotion. For which phase of the trajectory model of chronic illness are these nursing actions appropriate? -Stable -Comeback -Downward -Acute

Stable -stable phase indicates that the symptoms and disability are under control or managed. -acute phase is characterized by sudden onset of severe or unrelieved symptoms or complications that may necessitate hospitalization for their management. -comeback phase is the period in the trajectory marked by recovery after an acute period. -downward phase occurs when symptoms worsen or the disability progresses despite attempts to control the course through proper management.

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? Stage I Stage II Stage III Stage IV

Stage III Explanation: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Store the hearing aid in cool environment.

When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?

Talk with animation and vocal inflection to stimulate the client aurally.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin

Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

A client is reluctant to learn to do finger sticks for home INR monitoring. What is the best statement by the nurse?

Tell me what you know about these tests.

The physician has ordered laboratory tests that will be used to inform an assessment of an obese client's daily fat intake. Which of the following tests would the nurse include in the list?

The cholesterol test along with triglyceride and lipoprotein levels needs to be conducted to adjust the amount of fats a client consumes. Complete blood count, serum albumin, and transferrin level tests will not help in estimating the amount of fat the client eats.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?

The client and the nurse are equal participants.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?

The client describes signs and symptoms of hypoglycemia.

The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor should the nurse notify the provider about that will prevent administration of this type of enema? Select all that apply

The client has a history of chronic renal failure. The client has an elevated phosphorus level. The client has a history of left sided heart failure.

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?

The client has an enlarged prostate.

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?

The client is dehydrated.

A nurse has been caring for a client who suffered a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how he feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

The nurse is providing instrcutions to a client about performance of breast self-examination. What outcome does the nurse evaluate regarding this education?

The client will use the self-examination for breast cancer detection and prevention.

A nurse is developing a contractual agreement with a client. Which statement is true of a contractual agreement?

The contract serves to meet the client's learning outcomes.

When a nurse is planning for learning, who must decide who should be included in the learning sessions?

The nurse and the client

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.

The nurse fails to accept that clients have the right to change their minds. The nurse uses medical jargon frequently when discussing the teaching plan. The nurse ignores the restrictions of the client's environment.

A nurse who is caring for newborn infants delivers care by utilizing the sense that is most highly developed at birth. Which example of nursing care achieves this goal?

The nurse gently strokes the baby's cheek to facilitate breastfeeding.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?

The nurse must value and support the client becoming independent in care.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A nurse observes that a client occasionally coughs when eating. What instructions should the nurse provide for this client?

The nurse should suggest that the client chew the food thoroughly and encourage repeated swallowing attempts.

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives?

The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which of the following as a characteristic of an adult learner?

Their readiness to learn is often related to a developmental task or social role.

A 77-year-old female client experienced a stroke several weeks ago that has left her with several motor and sensory deficits, including dysphagia. Because of her difficulty swallowing, the client is receiving a diet with a modified texture that is easier to chew and swallow. What nursing action should the nurse perform in order to maintain this client's safety during feeding?

To ensure safety, suction equipment must be at the bedside while feeding a dysphagic client. The client should be seated upright and multiple, smaller feedings may be necessary throughout the day. It is unnecessary to cue a client to hold his or her breath while attempting to swallow.

When collecting data on a client, the nurse implements which nonverbal communication form as one of the most effective to express feelings?

Touch

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True False

True

Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

A client is hospitalized with a traumatic brain injury following an automobile accident. The client has difficulty processing information and needs information to be repeated. A consulting physician enters the room. The nurse -Leaves the room -Communicates with the daughter while the physician talks with the client -Turns off the television -Removes unnecessary items from the beside table while the physician meets with the client

Turns off the television

A nurse is performing an admission assessment with a non-English speaking client. Which actions can the nurse take to enhance communication? (Select all that apply.)

Use an electronic translator. Contact a telephone-based medical interpreter. Request assistance from an agency interpreter.

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

Use electric razor for shaving purposes. Anticoagulant therapy increases the risk of bleeding. Using an electric shaver, and a soft bristle toothbrush will reduce bleeding during care of skin and gums.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.

Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.

Which of the following modifications to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers. Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation.

The nurse has completed teaching. Which client behavior demonstrates understanding within the cognitive domain? Select all that apply.

Verbalizes key points of a brochure about diabetes that was read. Provides a description of what appropriate wound healing should look like.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

A client with constipation has been instructed to increase the intake of foods high in fluid. Which food(s) will the nurse include in the client's education? Select all that apply.

Watermelon Strawberries Cantaloupe Lettuce Cucumber

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk for injury?

Wearing disposable gloves

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.

A nurse is collecting objective data from a client during the physical assessment. What piece of anthropometric data about the client is documented by the nurse?

When recording anthropometric data, the nurse records the clothing the client wears along with the date and time, and the type of scale.

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

Which statement best describes the client most motivated to learn?

a 70-year-old female; learning care so spouse can come home

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

lipoproteins

a combination of fats and proteins

protein

a component of every living cell, is a nutrient com-posed of amino acids, or chemical compounds composed of nitrogen, carbon, hydrogen, and oxygen.

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis

vomiting

a loss of stomach contents through the mouth)

Which of the following nurses most likely is the best communicator?

a nurse who easily developed a rapport with clients

triceps skinfold measurement

adds additional data for estimating the amount of subcutaneous fat deposits

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

age 50 and older a positive family history a history of inflammatory bowel disease

Regular or general:

allows unrestricted food selections

flatus

as formed in the intestine and released from the rectum when eructation does not occur.

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse she is afraid of waking up during surgery. The best response by the nurse is to:

ask the client why she thinks she will wake up during surgery.

A graduate nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the graduate nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to:

ask to speak to the night shift nurse in private and explain how the comment made her feel.

A nurse is on his lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. The nurse recognizes one of the physicians as being in charge of his clients. The nurse witnesses the physician point at the nurse and state, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address any disrespectful remarks or behaviors.

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse will develop a cause and effect by:

asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

A nurse is completing a health history on a client who has a hearing impairment. Which actions should the nurse take first to enhance communication?

assess how the client would like to communicate

diet history

assessment technique for obtaining facts about a client's eating habits and factors that affect nutrition.

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP) Assessments and wound care must be done by the RN.

back massage

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable

black red = dressing changes yellow=cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's education?

blocking 30 minutes of time for skill teaching

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

regurgitation

bringing stomach contents to the throat and mouth without the effort of vomiting)

Before starting the education process, the nurse should determine the preferred learning style, age and developmental level, capacity to learn, motivation level, readiness to learn, and learning needs of the client. How does this help the nurse in the client's health education?

by implementing effective teaching

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake.

A student nurse studying human anatomy knows that a structure of the large intestine is the:

cecum

A nurse is caring for an older adult client who is weak and unable to care for his glasses and dentures. When assisting with cleaning the dentures, the nurse should:

clean the dentures over a plastic basin or towel.

The nurse must instruct a 35-year-old client with Down syndrome about use of an albuterol rescue inhaler. Which of the following demonstrates individualization of the education plan for this client?

client understanding of illness, motor skills and developmental stage assessed, clarification provided

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?

cloudy, foul odor

A 20-year-old client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need of a balanced diet and its relationship with a quick recovery. Which domain correctly identifies the client's learning style?

cognitive domain

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which of the following learning domains does the client's learning style fall?

cognitive domain

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This is an example of what learning theory?

cognitive learning theory

Soft:

contains foods soft in texture; is usually low in residue and readily digestible; contains few or no spices or condiments; provides fewer fruits, vegetables, or meats than a light diet

Full liquid:

contains fruit and vegetable juices, creamed or blended soups, milk, ices, ice cream, gelatin, junket, custards, and cooked cereals

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply.

dark brown light brown

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence. evisceration.

dehiscence Dehiscence is a total or partial disruption in wound edges.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Desiccation Maceration Necrosis Evisceration

desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

Down syndrome is categorized as a(n) -acquired disability. -developmental disability. -age-related disability. -acute nontraumatic disorder.

developmental disability.

Light or convalescent:

differs from regular diet in preparation; typically omits fried, fatty, gas-forming, and raw foods and rich pastries

dysphagia

difficulty swallowing)

The nurse is preparing to place a Foley catheter for a female client who will soon have surgery. Into what position will the nurse place the client?

dorsal recumbent

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

empathy

A pregnant female client presents to the emergency department with vaginal bleeding. A transvaginal ultrasound is performed and the health care provider informs the client that there are normal fetal heart tones noted on the study. When the nurse observes the client's facial expression, she is:

evaluating the client's nonverbal response to the findings.

A nurse is discharging a client terminates the nurse-client relationship. Which action should the nurse perform in this phase?

examine goals of the relationship to determine whether they were achieved

emaciation

excessive leanness

vegans

exclusively on plant sources for protein.

When assessing a client's nonverbal communication, the nurse will assess which characteristic as the most expressive part of the body?

facial expressions

The client is an 18-month-old in the pediatric intensive care unit. He is scheduled to have a subgaleal shunt placed tomorrow, and his mother is quite nervous about the procedure. The nurse feels for the mother and tells her that the surgeon "has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?

false reassurance

A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition?

fecal impaction

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spiral-reverse turn spica turn figure-of-eight turn

figure-of-eight turn (for joints)

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample

first thing in the morning

cachexia

general wasting of body tissue

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

giving false reassurance

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work.

midarm circumference

helps determine skeletal muscle mass. This technique, combined with other body meas-urements, helps assess a client's nutritional status.

An older adult client is reporting dry, itching skin. The nurse should assess:

how often the client is bathing. Frequent bathing for the older client can dry skin and contribute to skin breakdown.

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

hypertonic saline

The nurse is conducting a teaching session regarding HIV/AIDS for hotel workers in the community. Which nursing actions are appropriate for the adult learning? Select all that apply.

identifying the length of the session beginning with basic concepts about HIV/AIDS providing adequate lighting and comfortable temperature identifying the time, place, and content for the next teaching session

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation. Bathing increases circulation and helps maintain muscle tone and joint mobility.

abdominal circumference

indirect measurement of fatty (adi-pose) tissue that is distributed in and about the viscera of the abdomen

kilocalorie

kcal;1,000 cal, or the amount of heat that raises the temperature of 1 kg of water by 1°C).

anthropometric data

measurements of body size and composition

When communicating with clients nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology.

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?

medications listed on the client's medication administration record (MAR) Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety.

unsaturated fats

missing some hydrogen. They are a healthier form of fats and are liquid at room temperature or congeal slightly when refrigerated.

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce his risk for cancer, improve his respiratory status, and enhance the quality of his life. The nurse also shares her story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses his feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client?

motivational counseling

The nurse notices multiple caries upon inspecting a client's mouth. When asked if the client has dental pain, the client responds, "No, my teeth and gums never hurt." Which structural damage does the nurse anticipate?

nerve Nerve damage has occurred if the client does not feel sensation or pain. Enamel, root, and gingiva damage do not cause decreased sensation or pain.

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

neurogenic bladder.

minerals

noncaloric substances in food that are essential to all cells)

body mass index

numeric data used to compare a person's size in relation to norms for the adult population

fats

nutrients that contain molecules composed of glycerol and fatty acids called glycerides, are part of a family of compounds known collectively as lipids.

carbohydrates

nutrients that contain molecules of car-bon, hydrogen, and oxygen, and are generally found in plant food sources.

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?

oil

A nurse enters the client's room and introduces himself stating, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and I will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." He then gives the client a printed card with this information. In the helping relationship, what does this represent?

orientation phase

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter

vegetarian

people who restrict their consumption of animal food sources, modifying their diets for religious or personal reasons.

The nurse is preparing to teach a client about postsurgical care after a laparoscopic cholecystectomy. What determining factors demonstrates that the client is ready and able to learn?

physical condition

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:

physiologic or lifestyle changes in the client.

A nurse is caring for a client who suffered a head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's mother is at the bedside in tears. The mother states, "I just want him to know I am here with him." To address the needs of the mother and the client, the nurse should:

place a chair next to the bed and encourage the mother to hold the son's hand.

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?

positive feedback

Mrs. Shields is a 46-year-old obese woman diagnosed with hypertension and type 2 diabetes. She tells the nurse that she knows she needs to lose weight. She recently visited her local fitness club, obtained a membership and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is Mrs. Shields in related to her weight loss?

preparation

nonessential amino acids

protein components manufactured within the body; these amino acids are not dependent on dietary intake, not that they are unnecessary for health.

essential amino acids

protein components that must be obtained from food because the body cannot synthesize them.

incomplete proteins

proteins that contain insufficient quantities of one or more essential amino acids; come from plant sources .

A nurse assisting a new mother in the act of breastfeeding is represented by which form of learning?

psychomotor

A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:

remain honest, open, and frank.

Mechanical soft:

resembles a light diet but is used for clients with chewing difficulties; provides cooked fruits and vegetables and ground meats

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?

return demonstration

A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client?

sit-down shower with shower chair

The nurse-client relationship is dependent on communication. Effective communication between the nurse and the client includes which of the following? Select all that apply.

spoken words sight touch observation

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress

nausea

sually precedes vomiting and is produced when gastrointestinal sensations, sensory data, and drug effects stimulate a portion of the medulla that contains the vomiting center.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell herself to "remain calm" and remember that she was trained to perform this skill.

retching

the act of vomiting without producing vomitus

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound? There is an infection present. The client has wound dehiscence. There is evidence of evisceration. The client has fistula formation.

the client has fistula formation A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?

the importance of completely finishing the prescribed treatment When educating about pediculosis, the nurse must stress the importance of finishing the treatment. Many times the client will shampoo the hair once and not follow through with a second washing.

nutrition

the process by which the body uses food.

metabolic rate

the speed at which the body uses calories)

emesis

the sub-stance that is vomited

vomitus

the sub-stance that is vomited

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

the working phase

In order to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

therapeutic communication

cellulose

type of fiber in the stems, skins, and leaves of fruits and vegetables, which forms intestinal bulk to promote bowel elimination

trans fats

unsatu-rated fats that have been hydrogenated, a process in which hydrogen is added to the fat. Hydrogenation changes the unsaturated fat to a more saturated form that remains solid at room temperature.

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention

A nurse is caring for a client with an ostomy pouch. When should the nurse ask the client to empty the pouch?

when the pouch is one-third to one-half full

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

working phase

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be:

yellow.

Document feedings

• Type of diet • Percentage of food consumed • Tolerance of food • Client's ability to participate • Problems encountered with chewing or swallowing • Approaches taken to resolve problems

Gerontologic Considerations

■Age-related changes are usually gradual; therefore, include evaluation of nutritional status in annual examinations or more frequently if indicated by weight gain or loss of 10% within 6 months or 5% within 1 month.

Pharmacologic Considerations

■Anorexic clients such as those with cancer may experience a stimulation in appetite by using medical marijuana, which can be purchased in states where it is legally available, orby taking its prescription form, dronabinol (Marinol), in states where possession of the natural marijuana plant is illegal.

Pharmacologic Considerations

■Avoiding gas-forming food in the diet is one of the first steps in preventing the accumulation of stomach and intestinal gas. However, there are several nonprescription products available for this purpose. For example, Beano contains an enzyme that breaks down vegetables containing polysaccharides that are difficult to digest and helps reduce the formation of gas in the colon. Another option is to take one of several products containing simethicone such as Gas-X, Flatulex, Mylicon, and Mylanta Gas.

Pharmacologic Considerations

■Currently, the only FDA-approved medication for promoting weight loss or preventing weight gain following weight loss is orlistat (Xenical, and a reduced strength form called Alli). Weight loss occurs by decreasing the number of dietary calories by blocking the absorption of dietary fat. The action is a result of inhibiting the enzyme lipase. The function of lipase is to break down ingested fat into an absorbable form. The unabsorbed fat is excreted in stool. Due to a reduction in absorbed fat, it is essential to supplement fat-soluble vitamins 2 hours before or several hours after taking orlistat. There are several drug-drug interactions that can occur with drugs for diabetes and anticoagulants, for example. Some side effects include oily spotting of stool in underwear, flatulence, urgent bowel movements, and bowel incontinence. ■The Mayo Clinic (2010) reports that one can only expect modest weight loss when taking this drug. Modest weight loss is defined as 5 to 7 lb greater than diet and exercise after 1 year of taking Xenical or 3 to 5 lb with Alli.

Gerontologic Considerations

■Diminished senses of smell and taste, which may occur with normal aging, can interfere with appetite and intake. ■When attempting to increase an older client's intake, nutritional supplements should be evaluated. Protein-based liquid supplements will not provide the needed fiber and should not be relied on as the main source of protein. ■Decreased exercise may lead to decreased appetite among sedentary older adults. Sitting exercises may be indicated if balance or functional abilities decline.

Gerontologic Considerations

■Dry mouth (xerostomia), a common problem in older adults and often results from medications or the effects of disease. It interferes with chewing, swallowing, and enjoying meals. Encourage people with dry mouth to drink adequate no caffeinated and nonalcoholic beverages or to chew sugarless gum to promote salivation. ■Oral infections, poorly fitting dentures, or vitamin deficiencies can cause a painful or burning tongue, ulcers on the gums, or other difficulties that interfere with eating.

Gerontologic Considerations

■Dysphagia among older adults often results from neurologic conditions including stroke, esophageal disorders, or increased pressure from abdominal disorders. Swallowing studies may allow for the appropriate teaching of strategies to promote swallowing effectiveness.

Gerontologic Considerations

■Male and female adults who are 60 years and older are four times and six times more likely, respectively, than younger adults to have metabolic syndrome (Ervin, 2009). ■The escalating incidence of this syndrome indicates the critical need to control the epidemic of obesity in the United States.

Gerontologic Considerations

■Medical conditions, adverse medication effects, functional impairments, and psychosocial conditions (eg, dementia, depression, social isolation) commonly affect the nutritional status of older adults. ■Oral and dental problems are common in older adults, which interfere with adequate nutrition. Encourage older adults to get dental care every 6 months and to practice good dental hygiene daily. Malfitting dentures may contribute to weight change.

Gerontologic Considerations

■Older adults are likely to have chronic conditions such as arthritis and sensory impairments that affect their ability to meet their nutritional needs. Modifications such as plates with sides and large-handled utensils may help the older person maintain self-care ability in feeding.

Gerontologic Considerations

■Older adults often consume diets high in carbohydrates. Reasons include changes in taste; changes in the ability to prepare or obtain foods; or financial considerations of paying for medications, groceries, and living expenses on a fixed income.

Gerontologic Considerations

■Older adults require fewer calories and, therefore, should be taught to select nutrient-dense foods such as meat, fruits, vegetables, dairy products, and whole-grain breads and cereals.

Gerontologic Considerations

■Psychosocial impairments such as dementia or depression interfere with food preparation, consumption, and enjoyment. An important initial sign of these changes may be weight loss. ■Homebound older adults may benefit from home-delivered meals. The nutrition of older adults who are isolated, depressed, or cognitively impaired may improve with participation in a group meal program. Home-delivered meals and group meal programs are widely available and are funded through the Older Americans Act. The National Eldercare Locator (800-667-1116) provides information. ■Refer low-income older adults to their local Council on Aging for assistance in obtaining food stamps.

Pharmacologic Considerations

■Short-term bouts of nausea and vomiting can be treated with OTC nonprescription drugs such as Pepto-Bismol. Although prescription chlorpromazine (Thorazine) and prochlorperazine (Compazine) have been used for many years to relieve vomiting, many prescribers now are using drugs like metoclopramide (Reglan) and granisetron (Kytril) for a variety of conditions that are accompanied by vomiting, such as emesis due to cancer chemotherapy.

Gerontologic Considerations

■Some older adults have difficulty obtaining and preparing nutritious meals because of socioeconomic barriers such as low income and an inability to get to the grocery store. In addition, appropriate food storage (including food expiration dates, proper storage temperature, and access to cup-boards if arthritic changes are present) should be evaluated.

Pharmacologic Considerations

■Taking multiple medications increases the incidence of food-drug interactions. Some medications cause constipation, diarrhea, a loss of appetite, and other problems that interfere with nutrition. Teaching regarding medication dosage should include the potential side effects as well as the recommended timing of administration in relation to food intake. Also, over-the-counter (OTC) or herbal therapies can interfere with nutrient absorption.

Gerontologic Considerations

■The circumference of the abdomen may be a more accu-rate anthropometric measurement for older adults, but standardized norms have not been established for specific age groups.

Pharmacologic Considerations

■There are many drugs whose side effects include weight gain. However, the drug megestrol (Megace) is prescribed for the primary purpose of promoting weight gain. Its prescription is generally reserved for clients who are cachectic (emaciated due to a serious illness like cancer or AIDS).