Question Set 2 From Bran//////
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs hand washing and dons clean gloves. Which of the following should the nurse do next? A. place the non-dominant hand above the symphysis pubis and the dominant hand at the umbilicus b. ask the client to assume a side-lying position with the knees flexed c. perform massage vigorously at the level of the umbilicus if the fundus feels boggy d. place the client on a bedpan in case the uterine palpation stimulates the client to void
D - The nurse should place the non-dominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents the uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.
A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When she informs him that the physician has ordered a wound care nurse to examine his foot, the client asks why he should see anyone other than this nurse. He states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." What is the nurse's best response? a. "we're very concerned about your foot and we want to provide the best possible care for you" b. "This is a big deal and you need to recognize how serious it is" c. "This is the physician's recommendation. The wound care nurse will see you today" d."You could lose your foot if you don't see the wound care nurse"
a - The client's response indicates that he's in denial and needs further insight and education about his condition. Letting the client know that the nurse has his best interests in mind helps him accept the wound-care nurse. Although telling the client that his condition is serious and that the wound care nurse will see him that day are true statements, they're much too direct and may increase client resistance. Telling the client he could lose his foot is inappropriate and isn't therapeutic communication.
A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: a. An isotonic dextrose solution b. a hypertonic dextrose solution. C. a hypotonic dextrose solution d. a colloidal dextrose solution
b - The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy? A. decrease in appetite b. drowsiness c. spasms of the diaphragm d. couth and shortness of breath
d - Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.
Which of the following is an early symptom of glaucoma? A. Hazy vision. B. Loss of central vision. C. Blurred or "sooty" vision D. Impaired peripheral
d - In glaucoma, peripheral vision is impaired long before central vision is impaired. Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts. Loss of central vision is consistent with senile macular degeneration but it occurs late in glaucoma. Blurred or "sooty" vision is consistent with a diagnosis of detached retina.
Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct? A. an infant should ride in a front=facing car seat until he wights 20 lb (9.1kg) and is 1 year old. b. An infant should ride in a rear-facing car seat until he weights 25 lb. (11.3kg) or is 1 year old. c. An infant should ride in a front facing car seat until he weight 30lb. (13.6kg) or is 2 years old d. An infant should ride in a rear-facing car seat until he weights 20 lb and is 1 year old.
d - Until the infant weighs 20 lb and is 1 year old, he should ride in a rear-facing car seat.
A multigavid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probably fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely? A. early deceleration pattern b. sinusoidal pattern c. variable deceleration pattern d. late deceleration pattern
B - The fetal heart rate of a multipara diagnosed with Rh sensitization and probably fetal hydrops and anemia will most likely demonstrate a sinusoidal pattern that resembles a sine wave. It has been hypothesized that this pattern reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. This client will most likely requires a cesarean delivery to improve the fetal outcome. Early decelerations are associated with cord compression; and late deceleration are associated with poor placental perfusion
A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. He admits drinking excessively over the previous 48 hours. This behavior is an example of: a. alcoholism b. manic episode c. situational crisis d. depression
C - A situational crisis results from a specific event in the life of a person who is overhwlemed by the situation and reacts emotional. Fatigue, insomnia, and inability to make decisions are common signs and symtpoms. The situations crisis may precipitate behavior that causes a criss (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episodes is characterized by euphoria and labile effect. Symptoms of depression are usually present for 2 or more weeks.
A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock? A. Tachycardia. B. Dry, flused skin. C. Increased uring output d. Loss of consciousness. d. Loss of consciousness.
a - In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should: a. Administer TPN through a nasogastric or gastrostomy tube b. handle TPN using strict aseptic technique c. auscultate for bowel sounds prior to adminstering TPN d. designate a peripheral intravenous (IV) site for TPN administration
a - TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered
A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying: a. Concreteness. b. Flight of ideas. c. Depersonalization d. use of neologisms
b - The client is demonstrating flight of ideas, or the rapid, unconnected, and often illogical progression from one topic to another. Concreteness involves interpreting another person's words literally. Depersonalization refers to feelings of strangeness concerning the environment or the self. A neologism is a word made up by a client.
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery? A. Peritonitis b. Thrombophebitis c. ascites d. inguinal heria
b - After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.
A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: a. "Do you have the pain all the time" b. "Can you describe the pain?" c. "Where does it hurt the most?" d."Is the pain stabbing like a knife?"
b - Asking an open-ended question such as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in his own words. The other options are likely to elicit less information because they're more specific and would limit the client's response.
A pregnant client in her third trimester is started on chlorpromazine (Thorazine) 25 mg four times daily. Which of the following instructions is most important for the nurse to include in the client's teaching plan? A."Don't drive because there's a possibility of seizures occurring" . b. "Avoid going out in the sun without a sunscren with a sun protection factor of 25" . c. "Stop the medication immediately if constipation occurs." d. "Tell your doctor if you experience an increase in blood pressure."
b - Chlorpromazine is a low-potency antipsychotic that is likely to cause sun-sensitive skin. Therefore the client needs instructions about using sunscreen with a sun protection factor of 25 or higher. Typically, chlorpromazine is not associated with an increased risk of seizures. Although constipation is a common adverse effect of this drug, it can be managed with diet, fluids, and exercise. The drug does not need to be discontinued. Chlorpromazine is associated with postural hypotension, not hypertension. Additionally, if postural hypotension occurs, safety measures, such as changing positions slowly and dangling the feet before arising, not stopping the drug, are instituted.
A 7 year old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an intravenous (IV) line of D5 1/2 NS + 20 meq KCL/L running at 60 ml/hr. Vital signs are a temperature of 38 degrees C, heart rate of 120, respiratory rate of 28, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for: a. Rectal diazepam (diastat) b. IV lorazepam (Ativan) c. Rectal acetaminophen (Tylenol) d. IV fosphenytoin
b - IV ativan is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter, stopping seizure activity. If an IV line is not available, rectal Diastat is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: a. "dows water ever get into the baby's ears during shampooing?" b. "Do you give the baby a bottle to take to bed?" c. "Have you noticed a lot of wax in the baby's ears?" d. "Can the baby comgine two words when speaking?"
b - In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.
The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which of the following responses by the nurse is most appropriate? a, "maybe she's just mad at you. Did you have an argument? " b."She may have stopped taking her medications. I'll check on her" c."Don't worry about this. It happens sometimes." d."Go over to her apartment and see what's going on"
b - Noncompliance with medications is common in the client with chronic undifferentiated schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms.
The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? A. G 4, P 1 client who is breastfeeding her infant b. G 3, P 3 client who is breastfeeding her infant c. G 2, P 2 ceasarean client who is bottle-feeding her infant . d. G 3, P 3 client who is bottle feeding her infant
b - The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain.
A nurse is monitoring a client receiving tranylcypromine sulfate (Parnate). Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? A. Hypotensive episodes b. Hypertensive crisis c. Muscle faccidity d. Hypoglycemia
b - The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high doses. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.
Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations? A. two nurses in the cafeteria are discussing a client's condition b. the health care team is discussing a client's care during a formal care conference c. a nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor d. a nurse talks with her spouse about a client's condition
b - To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a client's condition with one's spouse.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? A. the client sees his physician for a check-up yearly b. the client has never traveled outside of the country c. the client had a liver transplant 2 years ago d. the client works in a health care insurance office
c - A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? A. shock b. encephalitis c. increased intracranial pressure (ICP) d. status epilepticus
c - When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.
The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? A. Have the client wear eyeglasses at all times b. lightly tape the eyelid shut c. instill artificial tears once every shift d. clean the eyelid with a washcloth every shift
c. instill artificial tears once every shift d. clean the eyelid with a washcloth every shift b - when the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wears eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.
A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, "I can't talk about that bastard right now. I just need to destroy something." Which of the following should the nurse do next? a. Tell her to write her feelings in her journal. b. Urge her to talk with the nurse now . c. Ask her to calm down or she will be restrained. d. Offer her a phone book to "destroy" while staying with her
d - At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappropriate and could lead to an escalation of her anger.
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? a. phimosis b. hydrocele c. epispadias d. hydrospadias
d - The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.
