Principles Ch. 48 NGN

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

45-year-old client who had a negative Pap test 4 years ago; 21-year-old client who has never had a Pap test done before; 25-year-old client who has never had sex; 32-year-old client who has been vaccinated with human papillomavirus and has never had a Pap test done

A middle-aged adult was rushed to the emergency department after sustaining a broken ankle due to a fall. The client only speaks German and the nurse only speaks English. An interpreter was asked to help. Which action(s) should be implemented?

Ask questions that are answerable by a yes or no. Allow adequate time for the interpreter to translate. Choose an interpreter of the same gender and approximate age as the client. Obtain the interpreter's advice when dealing with sensitive or delicate topics.

To facilitate decision-making, the nurse makes use of the ethical principles as a guide. For each nursing intervention, click to specify whether the action upholds the ethical principle of beneficence, nonmalificence or autonomy.

BENEFICIENCE: applying an ice pack to the client's swollen ankle; administering morphine sulfate for the client's abdominal pain NONMALIFICENCE: putting the client's scheduled furosemide on hold because of hypokalemia; informing the health care provider that the client's antipsychotic medications are causing suicidal ideations; reporting an impaired nurse to the nurse supervisor; AUTONOMY: answering all of the client's questions about their care before obtaining consent to proceed; providing information in the client's primary language to ensure the client's full understanding; withholding a medication after the client has refused and notifying the health care provider

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system. Complete the table by selecting the intervention associated with each body system.

CARDIAC: Provide verbal stimulation RESPIRATORY: Assess skin color NEUROLOGIC: Gently touch the client

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity. For each activity, click to specify whether it fulfills the circulation, motor function, or sensation section of the assessment.

CIRCULATION: pallor, temperature MOTOR FUNCTION: paralysis, pain SENSATION: numbness

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

Cluster nursing activities.; Provide cool foods and fluids.; Gently massage the arms and legs.; Routinely administer pain medications.

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

HEALTH BELIEFS/PRACTICES: How much alcohol do you use daily? How do you control your pain? CULTURAL SANCTIONS/RESTRICTIONS: Have you experienced flashbacks to your military years? Are you part of a faith community? How do you express emotions or feelings?

A client has been admitted to the medical-surgical floor for management of a fluid and electrolyte imbalance associated with decreased oral intake and excessive use of laxatives. The nurse analyzes assessment findings to identify those that may be caused by electrolyte imbalances. For each asssessment finding below, click to specify the associated electrolyte imbalance: hypokalemia, hyponatremia, or hypocalcemia. Each finding may support more than 1 disease process.

HYPOKALEMIA: muscle weakness HYPONATREMIA: confusion, muscle weakness, edema HYPOCALCEMIA: seizures, tetany

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

May cause injury with defibrillation.; Fold the patch in half before disposal.; Assess for fever prior to application.; Remove the patch prior to magnetic resonance imaging (MRI).; Monitor the client for early identification of adverse effects.

A 2-year-old child with specialized nutritional needs is receiving care in the home. The plan of care includes provision of enteral nutrition through a gastrostomy tube every 3 hours. For each nursing intervention below, click to specify the associated rationale.Note: Each nursing intervention must have at least one associated rationale.

Measure the length of the external tube = reduces the risk of aspiration Elevate the head of the bed at least 30 degrees = facilitates the flow of feeding to the gut Confirm pH of aspirate is less than 5.5 = useful in verifying correct placement Replace all gastric contents following measurment of aspirate = prevents electrolyte imbalance

The following statements are examples of communication blocks. Click to specify the type of communication block being expressed by the nurse.

NONPROFESSIONAL INVOLVEMENT: "I think you should get a second opinion because your health care provider has had a lot of complaints against him."; "My ex-boyfriend did not come pick up the kids again and I did not get much sleep last night." BEING MORALISTIC: "Everybody should be allowed to die if they want to."; "Why did you not use a condom? They are given at the clinic for free." FALSE REASSURANCE: "Do not worry, this is a minor surgery. You will do great!"; "Injecting insulin is nothing for you to worry about. Even children can do it!"

A nurse is caring for a 3-year-old child that was admitted with pneumonia. The parent expresses concerns about the child's respirations. The nurse is providing education about respiratory-related developmental changes to help the parent differentiate what is normal from what is abnormal. For each assessment finding click to specify if the finding indicates the client's condition is normal or abnormal.

NORMAL: respiratory rate of 28/min, irregular respiratory pattern ABNORMAL: thoracic breathing, inspiration longer than expiration, round thorax

The nurse is caring for a 25-year-old client admitted to a medcial surgical unit after an emergency appendectomy. The newly admitted client has been assigned under the nurse's care. As part of the care plan, the nurse sets specific client goals. For each of the goals set by the nurse, click to specify whether it belongs to the orientation, working or termination phase.

ORIENTATION: The client is able to call the nurse by name and demonstrate how to use the call light. WORKING: The client states, "I know I have to get up and moving so I do not get pneumonia."; The client states, "Using a pillow to help splint my abdomen when I cough, really helps." TERMINATION: The client verbalizes understanding of what signs indicate infection and when to contact the health care provider.

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

PRIVACY: keeping the door closed while conducting physical assessment; obtaining the client's permission before allowing a student nurse to assist with care CONFIDENTIALITY: sharing client information only to the caregivers directly assigned to client care; logging off the electronic health record after documenting assessment information; asking the client to sign a medical release form before providing information to the health insurance company

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

Prescription for warfarin Diagnosis of periodontitis Current chemotherapy treatment Low platelet count

The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss.

RADIATION: infrared heat waves CONDUCTION: the air itself EVAPORATION: through sweating CONVECTION: exposure to a fan

A nurse has been assigned to sit overnight with a client who has been demonstrating unsafe actions. The charge nurse asks the the nurse to monitor the client closely to help identify any deficits in sleep quality. For each characteristic, click to specify if it is consistent with the Rapid Eye Movement (REM) and/or the Non-Rapid Eye Movement (NREM) stage of sleep. Each characteristic may support more than one stage.

REM: Changes in blood pressure, decrease in muscle mobility, increase in heart rate, increase in body temperature NREM: changes in blood pressure, reduction in metabolism

A nurse on a medical-surgical unit is completing the admission assessment on a 38-year-old client. The client is feeble and unable to get out of bed and at times they slide down and require assistance for repositioning. They respond to verbal commands, but cannot accurately express discomfort and have no sensation in the left lower extremity. The client is only able to make frequent, but slight, changes in extremity position. The client has no control over their bowel or bladder and subsequently requires linen changes at least twice per shift. When fed, the client generally eats 50% or less of each meal. Using the Braden Scale, identify the appropriate score and description associated with the client's risk factors.

Sensory Perception = Slightly Limited-3 Moisture = Constantly Moist-1 Mobility = Slightly Limited-3

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

The nurse determines that the client believes in the *holistic* cause of illness as manifested by *believing one can be cured of cancer by limiting work hours*

The charge nurse in the oncology unit is preparing the shift assignments. The unit is fully staffed: unlicensed assistive personnel (UAP), licensed practical nurse (LPN), and registered nurse (RN). For each of the nurse activities, click to specify whether they should best be assigned to the unlicensed assistive personnel (UAP), licensed practical nurse (LPN), or registered nurse (RN).

UAP: calculating the total intake and output for the entire shift; collecting a stool specimen for hemoccult LPN: administering a pain medication intramuscularly; inserting an indwelling urinary catheter RN: obtaining an admission assessment on a client; administering an intravesical chemotherapy

An older adult was admitted to the cardiac unit following an emergency room visit for chest pain. To personalize education, the nurse is reviewing the chart to identify the client's risks of coronary vascular disease (CVD). The nurse will use this information to develop a teaching plan that will assist the client in altering factors that increase the risk of CVD. Click to highlight the findings below that the would be included in the education. Progress Note: The client is a 70-year-old male. Family history includes a mother who died of a myocardial infarction and a paternal grandparent who suffered from multiple strokes prior.....

a high level of stress after having to recently take in a grandchild to raise; reports a 40-pack-year history of tobacco use; but cannot seem to get BMI below 36; Current medications include metformin and insulin

A nurse is providing care for an older adult who is unable to get out of bed. Intake and output records indicate a possible alteration in urinary elimination. Click to highlight the findings that can impair the amount of urinary output. Client is alert and oriented × 4. Client is verbal, but with dysphasia, as associated with recent cerebrovascular accident. Client reports a high level of stress associated with recent social changes. Respirations even....

cerebrovascular accident; high level of stress; antihistamines; diuretic administration

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

guilt; inability to live up to devout practices disengagement from faith community

A parent brings a child into the pediatric office with reports of an itchy red rash with fluid filled blisters. Two siblings at home are reported to have the same rash. Drag words from the choices below to fill in each blank in the following sentence. The nurse knows that since the parent had the same virus during childhood they will have _________ immunity in the form of __________.

humoral; antibodies

A nurse is caring for a client who has urinary incontinence associated with a flaccid neurogenic bladder. Drag words from the choices below to fill in each blank in the following sentence. The nurse will implement _________________ because the client has _________________ urinary incontinence.

in-and-out catheterization; reflex

A client with a medical history of valvular dysfunction is admitted to the medical floor for management of heart failure exacerbation. The nurse reviews the client's chart to identify related findings. Complete the following sentence by choosing from the lists of options. The nurse would differentiate ______________ and elevated _______________ as being associated with heart failure, because they are both a result of _____________.

lower extremity edema; B-type natriuretic peptide; fluid volume excess

A 19-year-old male college student accompanies the pregnant partner to the emergency department. The client states, "My parents are not aware that I am having a child with my partner. If they do, they might not send me to school anymore. What is the best thing to do?" The nurse responds,"What do you think is the best thing to do?" Complete the following sentence by choosing from the lists of options. The therapeutic communication technique employed by the nurse is ___________ as evidenced by _______________.

reflection; directing the client's response back to the client

The school nurse is providing health education about sexuality and reproduction to a group of young adolescents. The male sexual response is included in the teaching plan. Select three physical changes that occur during the plateau phase.

secretion of pre-ejaculatory fluid; increased heart rate and blood pressure; penile circumference at the coronal ridge thickens

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

transactional; task-and-reward orientation

A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client? Select all that apply.

yogurt broccoli tofu