Questions #5 from Bran////

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include: a. Increased coronary artery blood flow. B. Decreased posterior thoracic curve . C. Decreased peripheral resistance. D. Delayed gastric emptying.

d. Delayed gastric emptying. Reason: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid? A."The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." b."The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration." c "The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach." d. "The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption."

a. "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." Reason: The action of an antacid occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don't work in the large or small intestine or in the esophagus.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? a. Abruptio placentae. B. Placenta Previa. c.Disseminated intravascular coagulation. d. Threatened abortion.

a. Abruptio placentae. B. Placenta Previa. c.Disseminated intravascular coagulation. d. Threatened abortion. c. Disseminated intravascular coagulation Reason: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," firm consistency of the abdomen (abruption) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no complaints of cramping or vaginal bleeding.

Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? A. Activity is resumer gradually, and the client can resume her usual activities in 5 to 6 weeks. b. Activity level is determined by the client's tolerance; she can be as active as she wishes. c. Activity level will be restricted for several months, so she should plan on being sedentary. d. Activity level can return to normal and may include regular aerobic exercises.

a. Activity is resumed gradually, and the client can resume her usual activiites in 5 to 6 weeks. Reason: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume her usual activities in 5 to 6 weeks. Successful healing should allow the client to return to her previous level of functioning.

The nurse is serving on the hospital ethics committee which is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit and without his knowledge. Which of the following should be considered concerning the relationship of ethical and legal standards of behavior? a. Ethical standards are generally higher than those required by law. b. Ethical standards are equal to those required by law. c.Ethical standards bear no relationship to legal standards for behavior. d.Ethical standards are irrelevant when the health of a client is at risk.

a. Ethical standards are generally higher than those required by law. Reason: Some behavior that is legally allowed might not be considered ethically appropriate. Legal and ethical standards are often linked, such as in the commandment "Thou shalt not kill." Ethical standards are never irrelevant, though a client's safety or the safety of others may pose an ethical dilemma for health care personnel. Searching a client's room when they are not there is a violation of their privacy. Room searches can be done with a primary health care provider's order and generally are done with the client present.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? A. Protects the client's right to self-determination in health care decision making. B. Helps the client refuse treatment that he or she does not wish to undergo . c. Helps the client to make a living will regarding future health care required . d. Provides the client with in-depth knowledge about the treatment options available.

a. Protects the client's right to self-determination in health care decision making. Reason: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A. Trendelenburg's b. 30 degree head elevation c. flat d. Side-lyiing

b. 30 degree head elevation Reason: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

A parent brings a 5-year-old child to a vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practices for scheduling missed vaccinations the nurse should: a. Ask the primary care provider. B. Check the website at the Center for Disease Control and Prevention (CDC). c. Read the vaccine manufacturer's insert d. Contact the pharmacist

b. check the website at the Center for Disease Control and Prevention (CDC) Reason: The CDC is the federal body that is ultimately responsible for vaccination recommendations for adults and children. A division of the CDC, the Advisory Committee on Immunization Practices, reviews vaccination evidence and updates recommendation on a yearly basis. The CDC publishes current vaccination catch-up schedules that are readily available on their website. The lack of vaccinations is a strong indicator that the child probably does not have a primary care provider. If consulted, the pharmacist would most likely have to review the CDC guidelines that are equally available to the nurse. Reading the manufacturer's inserts for multiple vaccines would be time consuming and synthesis of the information could possibly lead to errors.

The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about disease process and medications has been effective? A. "His depression is almost cured." b. "He's intelligent and won't need to depend on a pill much longer." c. "it's important for him to take his medication so that the depression will not return or get worse." d."It's important to watch for physical dependency on Zoloft."

c. "it's important for him to his medication so that the depression will not return or get worse." Reason: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addictive.

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect which of the following? A. increased forced exiratory volume b. Normal breath sounds. C. Inspiratory and expiratory wheezing d. Morning headaches.

c. Inspiratory and expiratory sheezing Reason: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations, there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume [forced expiratory flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration] due to bronchial constriction. Morning headaches are found with more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.

Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area? A. The client will be maintained on bed rest for several days. b. Ambulation is restricted by the presence of drainage tubes c. The operative incision is near the diaphragm 4. The presence of a nasogastric tube inhibits deep breathing

c. The operative incision is near the diaphram Reason: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.

When developing a care plan for a client with a do-not-resuscitate (DNR) order , a nurse should: a. withhold food and fluids b. discontinue pain medications. C. ensure access to spiritual care providers upon the client's request d. always make the DNR client the last in prioritization of clients.

c. ensure acess to spiritual care providers upon the client's request. Reason: Ensuring access to spiritual care, if requested by the client, is an appropriate nursing action. A nurse should continue to administer appropriate doses of pain medication as needed to promote the client's comfort. A health care provider may not withhold food and fluids unless the client has a living will that specifies this action. A DNR order does not mean that the client does not require nursing care.

A nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: a. start using insulin. B. start taking an oral antidiabetic drug. c. monitor her urine for glucose d. be taught about diet

d. be taught about diet Reason: The client will need to watch her overall diet intake to control her blood glucose level. The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. Oral antidiabetic drugs aren't used in pregnant clients. Urine glucose levels aren't an accurate indication of blood glucose levels.

Which of the following client statements indicates that the client with hepatitis B understands discharge teaching? A. "I will not drink alcohol for at least 1 year." b. "I must avoid sexual intercourse." c. "I should be able to resume normal activity in a week or two." d. "Because hepatitis B is a chronic disease, I know I will always be jaundiced."

a. "I will not drink alcohol for at least 2 year."Reason: It is important that the client understand that alcohol should be avoided for at least 1 year after an episode of hepatitis. Sexual intercourse does not need to be avoided, but the client should be instructed to use condoms until the hepatitis B surface antigen measurement is negative. The client will need to restrict activity until liver function test results are normal; this will not occur within 1 to 2 weeks. Jaundice will subside as the client recovers; it is not a permanent condition.

The nurse has discussed sexuality issues during the prenatal period with a primigravida who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says: a. " I can resume sexual intercourse when the bleeding stops." b. "I should not get sexually aroused or have any nipple stimulation." c. "I can resume secual intercourse in 1 to 2 weeks." d. "I should not have sexual intercourse until my next prenatal visit."

b. "I should not get sexually aroused or have any nipple stimulation." Reason: This client has already had one episode of preterm labor at 32 weeks' gestation. Sexual intercourse, arousal, and nipple stimulation may result in the release of oxytocin which can contribute to continued preterm labor and early delivery. The client should be advised to refrain from these activities until closer to term, which is 6 to 8 weeks later. Telling the client that intercourse is acceptable after the bleeding stops is incorrect and may lead to early delivery of a preterm neonate. The client should not have intercourse for at least 6 weeks because of the danger of inducing labor. There is no indication when the client's next prenatal visit is scheduled.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? A. Diaphragmatic breathing b. Use of acessory muscles c. Pursed-lip breathing d. Controlled breathing

b. Use of accessory muscles Reason: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following? A. "This doctor has been on our staff for 20 years." b. "I know you are worried, but the doctor has an excellent reputation." c. "You always have an option to change. Tell me about your concerns." d "I take my own children to this doctor."

c. "You always have an option to change. Tell me about your concerns." Reason: Asking the mother to talk about her concerns acknowledges the mother's rights and encourages open discussion. The other responses negate the parent's concerns.

A client is scheduled for an excretory urography at 10 a.m. An order directs the nurse to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at: a. 7:30 AM b. 8:30AM c.9:00 AM d. 9:30 AM

c. 9:00AM d. 9:30AM a. 7:30 AM Reason: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) to anesthetize an insertion site. Therefore, if the insertion is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. The local anesthetic wouldn't be effective if the nurse administered it at the later times.

Which of the following laboratory findings are expected when a client has diverticulitis? a. Elevated red blood cell count b. Decreased platelet count c Elevated white blood cell count d. Elevated serum blood urea nitrogen concentration

c. Elevated white blood cell count. Reason: Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.

A nurse is developing a nursing diagnosis for a client. Which information should she include? A. Actions to achieve goals b.Expected outcomes c.Factors influencing the client's problem

c. Factors influencing the client's problem Reason: A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: a. Hyperalbuminemia. B. Thrombocytopenia. C. Hypokalemia . D. Hypercalcemia.

c. Hypokalemia Reason: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

.Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids? A. Decrease fiber in the diet. B. Take laxatives to promote bowl movements c. Use warm sitz baths d. Decrease physical activity...

c. Use warm sitz baths Reason: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort.

A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival? A. Position the client in a supine position b. Auscultate breach sounds every 4 h c. Monitor the vital signs every 4 h d. Admit the client to a quiet, darkened room

d. Correct answer Admit the client to a quiet, darkened room Reason: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.

A nurse is caring for a client with a diagnosis of Impaired gas exchange. Based upon this nursing diagnosis, which outcome is most appropriate? A. The client maintains a reduced cough effort to lessen fatique. B. The client restricts fluid intake to prevent overhydratoin. c. The client reduces daily activities to a minimum. D. The client has normal breath sounds in all lung fields.

d. The client has normal breath sounds in all lung fields. Reason: If the interventions are effective, the client's breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluids should help thin secretions, so fluid intake should be encouraged.