S3U4(2)

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1. "I am unable to run a mile (1.6 kilometers) now." 2. "I wake up at night short of breath." 3. "My wife says I snore very loudly." 4. "My shoes seem larger lately."

2. "I wake up at night short of breath." Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.

What behavioral findings correspond to intimate partner violence in young adolescents? Select all that apply. 1. Sexually acting out 2. Attempting suicide 3. Pattern of substance abuse 4. Fear of certain people or places 5. Preoccupation with others or one's own genitals

2. Attempting suicide 3. Pattern of substance abuse Adolescent undergoing intimate partner violence may attempt suicide or have patterns of substance abuse. The behavioral findings in children undergoing sexual abuse include sexually acting out, fear of certain people or places, and a preoccupation with genitalia.

A client with heart failure is receiving digoxin and hydrochlorothiazide. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply . 1. Nausea 2. Yellow vision 3. Irregular pulse 4. Increased urine output 5. Heart rate of 64 beats per minute

1. Nausea 2. Yellow vision 3. Irregular pulse Signs and symptoms of digoxin toxicity include bradycardia, headache, dizziness, confusion, nausea, and visual disturbances (blurred vision or yellow vision). In addition, ECG findings may include heart block, atrial tachycardia with block, or ventricular dysrhythmias, all causing an irregular pulse. Increased urine output is an expected effect of the diuretic furosemide; a pulse rate of 64 beats per minute is an acceptable rate when a client is receiving digoxin.

A nurse educates the mother of a four-year-old child about sexual abuse. What behavioral finding explained by the nurse signifies that the child may be a victim of child abuse? 1. The child may attempt suicide. 2. The child may be verbally aggressive. 3. The child may have stress-related concerns. 4. The child may show fear of certain people or places.

4. The child may show fear of certain people or places. A sexually abused child may show fear of certain people or places. Attempting suicide is observed in adolescents or adults who are being abused. Combative, verbally aggressive behavior can be appreciated in older adults who are sexually abused. Stress-related concerns are unrelated to sexual abuse.

A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse? A. Increased blood volume B. Hyperactivity of the heart C. Increased cardiac sufficiency D. Decreased force of contraction

D. Decreased force of contraction A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. A decreased pulse pressure is associated with heart failure or hypovolemia. A decreased blood volume is indicated by a decreased pulse pressure. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.

Which drug should be excluded from the prescription of a lactating mother being treated for heart problems? 1. Tenormin 2. Labetalol 3. Metoprolol 4. Propranolol

1. Tenormin Tenormin is contraindicated for lactating mothers because this drug highly concentrates in breast milk. Labetalol, metoprolol, and propranolol are safe to prescribe to lactating mothers.

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? 1. 1+ 2. 2+ 3. 3+ 4. 4+

1. 1+ A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

A client takes isosorbide dinitrate daily. The client states, "I would like to start taking sildenafil for erectile dysfunction." The nurse explains that taking both of these medications concurrently may result in which complication? 1. Constipation 2. Protracted vomiting 3. Respiratory distress 4. Severe hypotension

4. Severe hypotension Concurrent use of sildenafil and a nitrate, which causes vasodilation, may result in severe, potentially fatal hypotension. Protracted vomiting and respiratory distress are not adverse effects associated with concurrent use of sildenafil and a nitrate. Sildenafil may cause diarrhea; adding a nitrate will not constipation.

A neonate diagnosed with congestive heart failure has been prescribed furosemide. What changes to the dosage or time intervals between doses should be made? 1. The time between doses should be shortened. 2. The time between doses should be lengthened. 3. The dosage should be doubled. 4. The dosage should be cut in half.

2. The time between doses should be lengthened. In neonates, the half-life of furosemide is increased. To avoid toxicity of the drug, the nurse should lengthen the time interval between the doses. If the time interval is shortened or the dosage is doubled, the level of drug circulating in the blood will be increased leading to toxic effects of the drug. Halving the dose is not an appropriate solution.

A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure? 1. Encouraging early ambulation 2. Monitoring the site for bleeding 3. Restricting fluids until the blood pressure has stabilized 4. Comparing blood pressure readings in the lower extremities

2. Monitoring the site for bleeding Hemorrhage is a major life-threatening complication because arterial blood is under pressure and a catheter has been inserted into an artery. The child is kept in bed for 6 to 8 hours after an arterial catheterization. Fluids may be given as soon as they are tolerated. Pulses, not blood pressure, must be compared for quality and symmetry.

A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. 1. Collapsed neck veins 2. Distended abdomen 3. Dependent edema 4. Urinating at night 5. Cool extremities

2. Distended abdomen 3. Dependent edema 4. Urinating at night Right-sided heart failure is associated with increased systemic venous pressures and congestion, as manifested by a distended abdomen, dependent edema, and urinating at night. Distended, not collapsed, neck veins occur in right-sided heart failure. Cool extremities are key features of left-sided heart failure.

A client who had a femoropopliteal bypass graft is receiving clopidogrel postoperatively. What should the nurse teach the client related to the medication? A. Eliminate grapefruit from the diet B. Eat more roughage if constipation occurs C. Report any occurrence of multiple bruises D. Take the medication on an empty stomach

C. Report any occurrence of multiple bruises Clopidogrel is a platelet aggregation inhibitor that decreases the probability of clots forming where the graft was placed, but it also increases bleeding tendencies when the dosage is excessive. Clopidogrel does not interact with grapefruit, which is permitted on the diet. Diarrhea, not constipation, is more likely to occur with clopidogrel. Clopidogrel should be taken with food to decrease the side effects of gastric discomfort, diarrhea, and gastrointestinal bleeding.

A child being treated with cardiac drugs developed vomiting, bradycardia, anorexia, and dysrhythmias. Which drug toxicity is responsible for these symptoms? 1. Digoxin 2. Nesiritide 3. Dobutamine 4. Spironolactone

1. Digoxin Digoxin helps improve pumping efficacy of the heart, but overdose can cause toxicity leading to nausea, vomiting, bradycardia, anorexia, and dysrhythmias. The side effects of nesiritide may include effects like headache, insomnia, and hypotension. Dobutamine does not cause nausea or vomiting but may cause hypertension and hypotension. Spironolactone may cause edema.

A nurse expects that a client with right-sided heart failure will exhibit which of these signs or symptoms? 1. Oliguria 2. Pallor 3. Cool extremities 4. Distended neck veins

4. Distended neck veins Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure.

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse add to the client's plan of care? 1. A glass of water every hour until hydrated 2. Small, frequent intake of juices, broth, or milk 3. Short-term nasogastric (NG) replacement of fluids and nutrients 4. A rapid intravenous (IV) infusion of an electrolyte and glucose solution

2. Small, frequent intake of juices, broth, or milk Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment. Water does not supply the necessary electrolytes, and hyponatremia may result. No data are presented to indicate that the client cannot take fluids orally; an NG tube is not necessary when the client can take fluids by mouth. A rapid IV infusion of an electrolyte and glucose solution is unsafe; rapid correction of a fluid and electrolyte imbalance is dangerous. Therapy should promote a gradual correction.

A toddler is found to have coarctation of the aorta. What does the nurse expect to identify when taking the child's vital signs? 1. Irregular heartbeat 2. Weak femoral pulse 3. Thready radial pulses 4. Increased temperature

2. Weak femoral pulse Coarctation of the aorta is a narrowing of the aorta, usually in the thoracic segment, resulting in decreased blood flow below the constriction and increased blood volume above it. The femoral pulses are weak or absent. An irregular heartbeat and increased temperature are not related to coarctation of the aorta. The radial pulses are bounding in coarctation of the aorta.

A nurse discovers lower extremity pitting edema in a client with right ventricular heart failure. Which information should the nurse consider when planning care? 1. Client has decreased plasma colloid osmotic pressure. 2. Client has increased tissue colloid osmotic pressure. 3. Client has increased plasma hydrostatic pressure. 4. Client has decreased tissue hydrostatic pressure.

3. Client has increased plasma hydrostatic pressure. In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema. Increase in tissue (interstitial) colloid osmotic pressure occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces, pulling fluid and causing edema. In right ventricular heart failure, increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease. Although a decrease in colloid osmotic (oncotic) pressure can cause edema, it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.

A nurse who suspects that a newly admitted infant is the victim of child abuse assesses the parents' interaction with their baby. What parental behaviors might support the diagnosis of child abuse? Select all that apply. 1. Displaying sensitivity about their child care ability 2. Taking the initiative in meeting their child's needs 3. Exhibiting difficulty in showing concern for their child 4. Demonstrating heightened interest in their child's welfare 5. Procrastinating in obtaining treatment for their child's injuries Abusive parents seek gratification of their own needs rather than of their child's needs; they may even project blame for the abuse on their child and find it difficult to conceal their hostility. Abusive parents often delay obtaining help for their child's injuries; the behavior is precipitated by a concern to conceal the injury and a lack of concern for the child. Abusive parents typically have an ill-developed nurturing role and little perception of their parenting inability.

3. Exhibiting difficulty in showing concern for their child 5. Procrastinating in obtaining treatment for their child's injuries Abusive parents seek gratification of their own needs rather than of their child's needs; they may even project blame for the abuse on their child and find it difficult to conceal their hostility. Abusive parents often delay obtaining help for their child's injuries; the behavior is precipitated by a concern to conceal the injury and a lack of concern for the child. Abusive parents typically have an ill-developed nurturing role and little perception of their parenting inability.

The registered nurse is caring for a client with dysrhythmias. Which action should the nurse perform immediately according to priority? 1. Monitoring oxygen saturation 2. Establishing intravenous access 3. Administer oxygen via nonrebreather mask 4. Ensure airway, breathing, and circulation (ABC)

4. Ensure airway, breathing, and circulation (ABC) The client with any life-threatening complication such as dysrhythmias should be assessed for ABCs immediately because the client may suffer with airway obstruction. Oxygen saturation should be monitored during ongoing assessments and after providing the client with initial treatment. Intravenous access should be established after performing initial assessments such as vital signs. After assessing ABCs in a client with dysrhythmias, the client should be provided with oxygen via nasal cannula or nonrebreather mask to maintain oxygen levels.

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? 1. Allows excess tissue fluid to be excreted 2. Helps to control the volume of food intake and thus weight 3. Aids the weakened heart muscle to contract and improves cardiac output 4. Assists in reducing potassium accumulation that occurs when sodium intake is high

1. Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.

Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply. 1. Checking for compliance with the client's drug regimen 2. Monitoring the client's serum potassium and magnesium levels regularly 3. Administering digoxin only through the intramuscular route 4. Calculating the correct dosage form, prescribed amounts, and the prescriber's order 5. Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly

1. Checking for compliance with the client's drug regimen 2. Monitoring the client's serum potassium and magnesium levels regularly 4. Calculating the correct dosage form, prescribed amounts, and the prescriber's order 5. Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly Digoxin may alter the serum potassium and serum magnesium levels, which affects heart function. Calculating the correct dose according to the healthcare provider's orders helps to prevent drug toxicity. Checking for compliance with the client's drug regimen is important so that the child does not have drug to drug interactions. Monitoring and recording drug intake and output, heart rate, blood pressure, daily weight, and respiration rate is a part of general nursing care. Administering digoxin through the intramuscular route is not advised because this method is very painful.

The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? 1. Dependent edema in the evening 2. Chest pain that decreases with rest 3. Palpitations in the chest when resting 4. Frequent coughing with yellow sputum

1. Dependent edema in the evening Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.

An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply. 1. Dyspnea 2. Crackles 3. Hacking cough 4. Peripheral edema 5. Jugular distention

1. Dyspnea 2. Crackles 3. Hacking cough Left-sided heart failure causes impaired tissue perfusion, pulmonary congestion, and pulmonary edema, which also cause signs and symptoms such as dyspnea, crackles, and hacking cough. Peripheral edema and jugular distention are signs of right-sided heart failure.

Sildenafil is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug, which include what? Select all that apply. 1. Flushing 2. Headache 3. Dyspepsia 4. Constipation 5. Hypertension

1. Flushing 2. Headache 3. Dyspepsia Flushing is a common central nervous system response to sildenafil. Headache is a common central nervous system response to sildenafil. Dyspepsia is a common gastrointestinal response to sildenafil. Diarrhea, not constipation, is a common gastrointestinal response to sildenafil. Hypotension, not hypertension, is a cardiovascular response to sildenafil. It should not be taken with antihypertensives and nitrates because drug interactions can precipitate cardiovascular collapse.

A 2.5-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? Select all that apply. 1. "Kids have to learn to be careful on the stairs." 2. "Every time I turn around the kid is falling over something." 3. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs." 4. "I can't understand it. This child didn't have a problem using the stairs without my help before this." 5. "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid."

2. "Every time I turn around the kid is falling over something." 4. "I can't understand it. This child didn't have a problem using the stairs without my help before this." Abusive parents often have a poor understanding of the expected growth and development of children and tend to blame the child. Toddlers generally need supervision and some assistance when climbing stairs, but abusive parents have little understanding of toddlers' abilities. Although "Kids have to learn to be careful on the stairs" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs" is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. Although "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people usually do not have an understanding of children's needs in relation to growth and development.

A nurse is providing discharge instructions to a client who experienced an anterior septal myocardial infarction (MI). Which statement by the client indicates the nurse needs to follow up? 1. "I want to stay as pain-free as possible." 2. "I am not good at remembering to take medications." 3. "I should not have any problems in reducing my salt intake." 4. "I wrote down my dietary information for future reference."

2. "I am not good at remembering to take medications." Not adhering to the treatment regimen may interfere with effective resolution of the MI, and further intervention is necessary. The other statements, such as "I want to stay as pain-free as possible," "I should not have any problems in reducing my salt intake," and "I wrote down my dietary information for future reference," are appropriate responses related to teaching concerning self-care after an MI.

Child maltreatment is suspected in a 3-year-old girl admitted to the hospital with many poorly explained injuries. Which statement by the mother further supports this suspicion? 1. "When I get angry, I take her for a walk." 2. "I have no problems with any of my other children." 3. "When she misbehaves, I send her to her room alone." 4. "I make her stand in the corner when she doesn't eat her dinner."

2. "I have no problems with any of my other children." Identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt suspicions of physical abuse and warrant further investigation. Taking a walk is helpful for both the mother and the child and does not indicate abuse. Sending a child to his or her room alone is an acceptable punishment for misbehavior. Although making a child stand in the corner is demeaning, it is not physical abuse.

A client who has been diagnosed with a myocardial infarction is receiving morphine for pain. The client takes digoxin and fluoxetine at home. Docusate sodium is prescribed. What drug does the nurse identify as a risk factor for straining due to constipation? 1. Digoxin 2. Morphine 3. Docusate 4. Fluoxetine

2. Morphine Morphine is an opioid. Opioids decrease peristalsis, which may precipitate constipation; straining at stool should be avoided to prevent the Valsalva maneuver, which increases demands on the heart. Digoxin is unrelated to intestinal peristalsis and the potential for constipation. Docusate sodium is a stool softener which would relieve, not cause, constipation. A side effect of fluoxetine is diarrhea, not constipation.

The nurse is assessing a client with the diagnosis of left ventricular failure. Which assessment finding does the nurse expect to identify? 1. Crushing chest pain 2. Dyspnea on exertion 3. Jugular vein distention 4. Extensive peripheral edema

2. Dyspnea on exertion Pulmonary congestion and pulmonary edema occur because of fluid shift from the pulmonary capillary bed to the alveoli, resulting in difficult breathing. Crushing chest pain is a hallmark of myocardial infarction; it is caused by inadequate oxygen supply to the myocardium. Jugular vein distention results from increased pressure in the right atrium associated with right ventricular failure, not left ventricular failure. Extensive peripheral edema is a sign of right, not left, ventricular failure; a weakened right ventricle causes venous congestion in the systemic circulation.

What is the professional nurse's legal responsibility regarding child abuse? 1. Honor the request of the parents not to report the suspected abuse. 2. Report any suspected abuse to local law enforcement authorities. 3. Return the child to the legal parent even if he or she is suspected of abuse. 4. Provide the parents with a copy of the child's medical record.

2. Report any suspected abuse to local law enforcement authorities. Nurses and primary healthcare providers are legally responsible for reporting suspected or actual abuse. Child protective services may obtain a court order to grant temporary guardianship if it is found that the child is in immediate danger. The other answer options do not fulfill the nurse's duty to report suspected child abuse.

A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? 1. Atropine 2. Epinephrine 3. Amiodarone 4. Sodium bicarbonate

3. Amiodarone Amiodarone suppresses ventricular activity; therefore, it is used for treatment of premature ventricular complexes (PVCs). It works directly on the heart tissue and slows the nerve impulses in the heart. Atropine blocks vagal stimulation; it increases the heart rate and is used for bradycardia, not PVCs. Epinephrine increases myocardial contractility and heart rate; therefore, it is contraindicated in the treatment of PVCs. Sodium bicarbonate increases the serum pH level; therefore, it combats metabolic acidosis.

When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress? 1. Getting up from bed in the morning 2. Walking to visit the next-door neighbor 3. Climbing a flight of stairs to the bedroom 4. Leaving the table immediately after a meal

3. Climbing a flight of stairs to the bedroom Stair climbing increases oxygen consumption and therefore increases the workload of the heart; this results in dyspnea and fatigue. Getting up from bed in the morning may cause orthostatic hypotension; the oxygen demands of the body are not significantly increased when sitting up. Walking short distances on level surfaces will not place as much strain on the cardiovascular system as does climbing stairs against gravity. Although moving from a sitting to a standing position during digestion increases the demand on the heart, it is not as demanding or sustained an activity as is climbing stairs.

A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which physical parameters should the nurse consider to determine the safe resumption of sexual activity? 1. When the client and partner are not fearful of sexual intimacy 2. When the client feels emotionally ready to resume sexual activity 3. The point at which two flights of stairs can be climbed without dyspnea 4. Laboratory data showing that enzyme results have returned to preinfarction levels

3. The point at which two flights of stairs can be climbed without dyspnea The point at which two flights of stairs can be climbed approximates the energy expended during sexual activity. Emotionally, the client or partner may never be ready; studies have shown that individuals fear resumption of sexual activity. The client may be emotionally ready to resume sexual activity before being physically ready. Enzyme studies, such as creatine kinase (CK), creatine kinase myoglobin (CK-MB), lactate dehydrogenase (LDH), and aspartate transaminase (AST), return to expected levels after 3 to 14 days, which may be too soon to resume sexual activity.

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? 1. Serum sodium of 139 mEq/L (139 mmol/L) 2. Serum chloride of 100 mEq/L (100 mmol/L) 3. Serum calcium of 10.2 mg/dL (2.55 mmol/L) 4. Serum potassium of 7.2 mEq/L (7.2 mmol/L)

4. Serum potassium of 7.2 mEq/L (7.2 mmol/L) Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).

A healthcare provider prescribes milrinone for a client with a diagnosis of congestive heart failure who was unresponsive to conventional drug therapy. What is most important for the nurse to do first? 1. Administer the loading dose over 10 minutes. 2. Monitor the ECG continuously for dysrhythmias during infusion. 3. Assess the heart rate and blood pressure continuously during infusion. 4. Have the prescription, dosage calculations, and pump settings checked by a second nurse.

4. Have the prescription, dosage calculations, and pump settings checked by a second nurse. Accidental overdose can cause death. Another nurse should verify accuracy of the prescription, dose, and pump settings to prevent harm to the client. Although administering the loading dose over 10 minutes is an appropriate intervention, it is not the first thing the nurse should do. Although monitoring for dysrhythmias is important because they are common with this medication and may be life threatening, it is not the first thing the nurse should do. Although taking the vital signs continuously during the infusion is important because the dose needs be slowed or discontinued if the blood pressure decreases excessively, it is not the first thing the nurse should do.

A client's cells are deprived of oxygen during a cardiac arrest. What medication should the nurse be prepared to administer? 1. Regular insulin 2. Calcium gluconate 3. Potassium chloride 4. Sodium bicarbonate

4. Sodium bicarbonate In the absence of oxygen, the body derives its energy anaerobically; this results in buildup of lactic acid. Sodium bicarbonate, an alkaline drug, will help neutralize the acid, raising the pH. Insulin is used to treat diabetes; it lowers blood sugar by facilitating transport of glucose across cell membranes. Calcium gluconate is used to treat hypocalcemia. Although potassium is essential for cardiac function, it will not correct acidosis. With acidosis, serum hydrogen ions will exchange with intracellular potassium, leading to a temporary hyperkalemic state; therefore, potassium chloride is contraindicated until acidosis is corrected.

A client is admitted for chest pain and a myocardial infarction. The nurse caring for the client is preparing to apply nitroglycerin ointment. Before applying the ointment, what action will the nurse take? 1. Assess the client's pulse rate. 2. Prepare the site with an alcohol swab. 3. Shave the client's chest in the area for application. 4. Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount.

4. Use the dose measuring application paper and spread the ointment in a thin layer to the prescribed amount. The nurse should use the dose measuring application paper supplied with the ointment and spread in a thin layer to the prescribed amount and place side down on the desired skin. The nurse should assess blood pressure reading, not pulse rate. There is no need to clean the site with alcohol before administration. Shaving is not recommended; a hairless site on the chest, back, abdomen, or anterior thigh should be selected.

What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain? A. Unchanged by rest B. Precipitated by light activity C. Described as a knifelike sharpness D. Relieved by sublingual nitroglycerin

D. Relieved by sublingual nitroglycerin Relief by sublingual nitroglycerin is a classic reaction because it dilates coronary arteries, which increases oxygen to the myocardium, thus decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.

A 13-year-old who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychologic testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. Which is the best response by the nurse? 1. Refer the mother to the psychiatrist. 2. Explain to the mother the results of the tests. 3. Suggest that the mother call the psychologist. 4. Teach the mother about the tests that were administered.

1. Refer the mother to the psychiatrist. It is the responsibility of the psychiatrist, who is the primary healthcare provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered.

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what? 1. Tissue necrosis 2. Venous thrombosis 3. Pulmonary infarction 4. Respiratory infection

1. Tissue necrosis The body's inflammatory response to myocardial necrosis causes an elevation of temperature as well as leukocytosis within 24 to 48 hours after the event. Venous thrombosis and pulmonary infarction are not expected findings after a myocardial infarction. Respiratory infection is not common after myocardial infarction.

A client is admitted to the hospital with chest pain and a diagnosis of myocardial infarction. How would the nurse expect the client to describe the chest pain? 1. Severe, intense 2. Burning and of short duration 3. Mild, radiating toward the abdomen 4. Squeezing, relieved by nitroglycerin

1. Severe, intense Blockage of myocardial blood supply causes accumulation of unoxidized metabolites in the muscle; this affects nerve endings and causes severe, intense chest pain. Burning chest pain is not the type of pain associated with a myocardial infarction. Mild chest pain, radiating toward the abdomen, is not the type of pain associated with a myocardial infarction. Nitroglycerin relieves pain associated with angina, not pain associated with myocardial infarction.

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes what important components? Select all that apply. 1. Planning for future safety 2. Normalizing victimization 3. Validating the experiences 4. Promoting access to community services 5. Providing housing for the victim

1. Planning for future safety 3. Validating the experiences 4. Promoting access to community services Planning for the client's future safety needs, validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim's relationship and failing to respond to the disclosure of the abuse. The advocate role would include information and resources for housing if needed, but not necessarily provide it.

A nurse caring for a pregnant client at 28 weeks' gestation and her partner suspects intimate partner violence. Which assessments support this suspicion? Select all that apply. 1. The woman has injuries to the breasts and abdomen. 2. The partner refuses to come into the examination room. 3. The partner answers questions that are asked of the woman. 4. The woman has visited the clinic several times in the last month. 5. The partner is excessively attentive while the health history is being taken.

1. The woman has injuries to the breasts and abdomen. 3. The partner answers questions that are asked of the woman. 4. The woman has visited the clinic several times in the last month. During pregnancy, batterers may concentrate their anger at the pregnancy itself and focus their assaults on the breasts, buttocks, and abdomen. It is common for the abuser to control the conversation by answering for the client. Women who are battered are at risk for stress illnesses such as gastrointestinal distress and chest pain. They are also more likely to suffer from frequent headaches and depression. Control is a primary concern of the abuser, so it would be highly unlikely for him to leave the client alone with the care provider. Excessive attentiveness while the health history is being taken is not typical behavior of an abusive person.

The primary healthcare provider has prescribed a stat chest x-ray exam and electrocardiogram for a client with a history of heart failure. The pulse oximeter has changed from 90% to 86% oxygen saturation. Which immediate actions will the nurse take? Select all that apply. 1. Tell a staff member to get the electrocardiogram machine. 2. Notify the x-ray department that a chest x-ray exam must be done stat. 3. Have a staff member notify the nursing supervisor of the change in client status. 4. Notify the healthcare provider of the change in the oxygen saturation to ask what to do. 5. Tell the certified nursing assistant to get a prescription from the healthcare provider to increase the oxygen. 6. Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider.

1. Tell a staff member to get the electrocardiogram machine. 2. Notify the x-ray department that a chest x-ray exam must be done stat. 3. Have a staff member notify the nursing supervisor of the change in client status. 6. Increase the supplemental oxygen without a prescription from 2 L nasal cannula to 4 L nasal cannula and notify the healthcare provider. A staff member can get the electrocardiogram machine and start the procedure. Ancillary personnel are trained to do electrocardiograms even if they are not able to interpret the results. Anyone can notify the x-ray department that the chest x-ray exam must be done. It is important to delegate the tasks to a specific person. Increasing the oxygen without a prescription is appropriate in the short term, but the nurse must obtain a prescription when notifying the healthcare provider. Notifying the healthcare provider of the change in oxygen saturation is appropriate, but it would be expected that nursing judgment had taken place and the oxygen already was increased from 2 L/min. Telling the certified nursing assistant (CNA) to get a prescription is an inappropriate action as a CNA is not allowed to take medical prescriptions. Taking a medical prescription is a nursing role.

The mother of an infant with a congenital heart defect who was admitted to the pediatric unit with heart failure asks why her baby must be weighed each morning. The nurse explains that the baby's treatment is based on changes in the daily weight. What complication can be prevented if treatment is successful? 1. Renal failure 2. Fluid retention 3. Digitalis toxicity 4. Protein malnutrition

2. Fluid retention Fluid retention is reflected by an excessive weight gain in a short period of time; inadequate cardiac output decreases blood flow to the kidneys, which leads to increased intracellular fluid and hypervolemia. Daily weights are appropriate if renal disease or hypovolemia is present; however, other assessments such as hourly urine output, blood urea nitrogen, and creatinine values provide a more accurate assessment of kidney function. Weight is helpful in determining medication dosages, but daily weights are not used to diagnose digitalis toxicity. Weight gain or loss resulting from nutritional intake is gradual and will not vary on a day-to-day basis.

An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply. 1. Demonstrating concern for the injured child 2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 4. Asking questions about the injury and the child's prognosis 5. Giving an explanation of how the injury occurred that is not consistent with the injury

2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 5. Giving an explanation of how the injury occurred that is not consistent with the injury The child is often made the scapegoat in the situation; the parents blame the child because they have unrealistic expectations of the child. Discrepancies or inconsistencies in the history result from attempts to present a story that is not based in fact. Discrepancies between the parental explanation for the child's injuries and the physical findings or discrepancies in the history that each parent gives are common because the information that is being provided is not based in fact. Abusive parents usually do not ask questions about the injury or prognosis and demonstrate little or no interest in their child's well-being.

A home care nurse makes an initial visit to a 60-year-old client with heart failure. The client lives with her daughter, who is addicted to drugs and a single parent of seven children. When the nurse enters the home, the client is feeding a 6-month-old granddaughter and preparing dinner for the rest of the family. A 14-year-old grandson, disabled and in a wheelchair, states that his mother is sleeping. What should the nurse do? 1. Sit down with the client and exchange identifying data. 2. Accept coffee when offered by the client and socialize for a few minutes. 3. Ask the client whether it is all right to look around the apartment and evaluate environmental conditions. 4. Question the client to determine whether there is a private place to take a health history and perform an examination.

4. Question the client to determine whether there is a private place to take a health history and perform an examination. Collecting a health history, performing a physical assessment, and developing a nurse-client relationship are accomplished best if the environment is quiet and private. This is not the setting for sitting down with the client and exchanging identifying data because there are too many distractions and a lack of privacy. Accepting coffee may be an imposition and is not the best way to develop trust. Assessment of the environment can be done less obviously while interacting with the client.

The school nurse is conducting a teacher's in-service on signs that may indicate that a child is a victim of bullying. Which sign should the nurse include in the teaching session? 1. The child wants to try out for the basketball team. 2. The child asks for extra work to make better grades. 3. The child is participating in several extracurricular activities after school. 4. The child asks to go to the nurse's office frequently with vague complaints.

4. The child asks to go to the nurse's office frequently with vague complaints. Signs that may indicate a child is being bullied are similar to signs of other types of stress, including nonspecific ailments or complaints. Spending inordinate amounts of time in the school nurse's office with vague complaints is a sign that should be included in the teaching session. Withdrawal and deteriorating school performance are often signs of bullying. The child's wanting to participate on the basketball team, asking for extra work, and participating in extracurricular activities are not signs of withdrawal or deterioration in school performance.

The parents inform the nurse that their preschooler's teachers often complain about the child's bullying behavior in school. The parents are surprised, because they say the child is well behaved at home. What could be the reason for this inconsistency in the child's behavior? 1. The parents are lying about the child being well behaved. 2. The parents are inconsistent in their disciplining methods. 3. The child's parents do not spend enough time with the child. 4. The child is scared of the parents and displaces anger on others.

4. The child is scared of the parents and displaces anger on others. If the child is scared of the parents, the child will displace the anger that is experienced on others, especially peers and authority figures. The child is likely well behaved at home out of fear, but not out of respect for the parents. The parents are not lying about the child being well behaved at home if the child does behave in a disciplined manner out of fear. The parents may be very strict but not lack consistency in this scenario. Not spending enough time with the child does not result in aggressive behavior but may increase feelings of loneliness.

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema? A. Encourage frequent coughing. B. Elevate the client's lower extremities. C. Prepare for modified postural drainage. D. Place the client in the orthopneic position.

D. Place the client in the orthopneic position. The orthopneic, or tripod position, allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Excessive coughing and mucus production are characteristic of pulmonary edema and do not need to be encouraged. Elevation of the extremities should be prevented because it increases venous return, placing an increased workload on the heart. Positioning for postural drainage does not relieve acute dyspnea; furthermore it increases venous return to the heart.

A client comes to the emergency department with pressure in the chest and shortness of breath. The client is admitted for observation after receiving a tentative diagnosis of a myocardial infarction. Which assessment finding should the nurse monitor for in this client that supports this diagnosis? 1. Vomiting 2. Bradycardia 3. Severe headache 4. Pain radiating to the abdomen

1. Vomiting Nausea and vomiting are clinical manifestations that are associated with a myocardial infarction. The heart rate will increase, not decrease, in an attempt to meet oxygen demands of the body. Headaches are associated with a stroke, not with a myocardial infarction. Chest pain associated with a myocardial infarction may radiate to the jaw, back, or left shoulder and arm, not the abdomen.

A nurse is interviewing a mother accused of physical child abuse. When speaking with this mother, what does the nurse expect her to do? 1. Attempt to rationally explain her behavior. 2. Reveal the belief that her child needed to be disciplined. 3. Offer a detailed explanation of how her child was injured. 4. Ask how she can arrange to visit her child on the pediatric unit.

2. Reveal the belief that her child needed to be disciplined. An abusive parent often indicates that he or she was trying to improve the child's behavior with physical consequences for behavior the parent considered unacceptable. Such parents usually do not admit their behavior, so they do not have a need to rationalize it. These parents offer many vague explanations of how the child was injured; rarely is the explanation detailed. Asking how she can arrange to visit her child on the pediatric unit is an unusual request because the abusive parent usually does not ask to see the child.

A woman comes to the emergency department reporting signs and symptoms that are determined by the primary healthcare provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? Select all that apply. 1. Severe fatigue 2. Sense of unease 3. Choking sensation 4. Chest pain relieved by rest 5. Pain radiating down the left arm

1. Severe fatigue 2. Sense of unease A myocardial infarction in women may be asymptomatic, atypical, or mild. Unique symptoms include overwhelming fatigue, a sense of uneasiness, indigestion, and shoulder tenderness. A sense of unease is a unique characteristic of a myocardial infarction in women. The client knows something is not right but cannot identify what it is. This uneasiness often is disregarded by the client. A choking sensation occurs in both men and women with a myocardial infarction. Chest pain relieved by rest occurs in both men and women with angina; it is caused by coronary artery spasms leading to myocardial ischemia. Angina frequently is a precursor to a myocardial infarction. Pain radiating down the left arm occurs in both men and women. It can radiate also to the neck, lower jaw, left arm, left shoulder, and, less frequently, the right arm and back.

The nurse is caring for a client hospitalized with a myocardial infarction. Which analgesic is the drug of choice for this client? 1. Diazepam 2. Meperidine 3. Flurazepam 4. Morphine sulfate

4. Morphine sulfate For myocardial infarction, morphine sulfate is the drug of choice because it relieves pain quickly and reduces anxiety while decreasing cardiac workload. Diazepam is a muscle relaxant that may be used for its sedative effect; it is not effective for the pain of a myocardial infarction. Although meperidine is effective, it is not the drug of choice. Flurazepam is a hypnotic that may be used to reduce fear and restlessness; it is not effective for the pain of a myocardial infarction.

A client with myocardial infarction is admitted in the emergency department, and the primary health care provider recommended the placement of a stent. The client is incompetent to understand the situation. What model does the nurse manager think would be beneficial in this situation? 1. Decision model 2. Autonomy model 3. Social justice model 4. Patient-benefit model

4. Patient-benefit model The patient-benefit model uses substituted judgment such as determining what the client would want for himself or herself if capable of making these issues known, and thereby facilitates decision making for incompetent clients. The decision model is used for nurses; it depends on specific circumstances to know if the situation is routine and predictable or complex and uncertain. The autonomy model facilitates decision making for competent clients. The social justice model considers broad social issues and is accountable to the overall institution.

A nurse suspects sexual child abuse in a preschooler who has come for a routine check-up. What physical findings lead to the nurse's suspicion? Select all that apply. 1. The nurse finds signs of immersion burns. 2. The nurse finds hematomas and bruises at various stages of resolution. 3. The nurse finds injuries and trauma inconsistent with reported cause. 4. The nurse finds that the preschooler has difficulty walking and sitting. 5. The nurse finds that the child has pain, itching, or unusual odor in genital area.

4. The nurse finds that the preschooler has difficulty walking and sitting. 5. The nurse finds that the child has pain, itching, or unusual odor in genital area. Physical findings of child sexual abuse in children include difficulty sitting and walking and pain, itching, or an unusual odor in the genital area. Signs of immersion burns, hematomas, bruises at various stages of resolution and injuries and trauma inconsistent with reported cause are the physical findings of sexual abuse in adolescents or older adults.

A child with pulmonary edema is treated with opioids and furosemide. Which nursing interventions should be performed to promote safe drug administration? Select all that apply. A. Following the principle of atraumatic care B. Administering oral drugs with food or snacks C. Documenting the client's age, weight, and height D. Exposing the child to sunlight for healthy growth E. Administering medications if the client reports dizziness or drowsiness

A. Following the principle of atraumatic care B. Administering oral drugs with food or snacks C. Documenting the client's age, weight, and height A local anesthetic should be applied at the injection site to promote atraumatic care. Administering drugs with food reduces gastric discomfort. The client's age, weight, and height should be documented to help ensure correct calculation of the drug dose. A child who is undergoing treatment with diuretics should not be exposed to sunlight because this can cause fluid volume loss and exhaustion. If the client reports dizziness or drowsiness, medications should not be administered until an order is prescribed by the primary healthcare provider.

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history? A. Cystitis as an adult B. Pleurisy as an adult C. Childhood strep throat D. Childhood German measles

C. Childhood strep throat Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.