Saunders Quiz #4
The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? "A fever on and off is expected and is nothing to worry about." "Even though I am breast/chest-feeding my baby, I still can ovulate." "I can begin abdominal exercises about a month after delivery." "I need to contact my doctor if I am having any feelings of depression."
"A fever on and off is expected and is nothing to worry about." Rationale: A fever in the postpartum period is not expected, and if this occurs, the client needs to contact the primary health care provider because fever is an indication of infection. The client may ovulate in the postpartum period even without menstruating, so breast/chest-feeding would not be considered a form of birth control. Abdominal exercises would not start until 3 to 4 weeks after abdominal surgery to allow for healing of the incision. Postpartum depression is a concern, and the client needs to contact the primary health care provider if having any depressed feelings.
A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms? "Well, a picture paints a thousand words." "You just felt like destroying your textbooks?" "Your parents and teachers are very concerned about your drawings." "I am concerned about you. Are you now or have you ever been abused?"
"I am concerned about you. Are you now or have you ever been abused?" Rationale: The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. The remaining options are insensitive, not focused on the possible sexual abuse, or too indirect to be useful.
The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instruction? "I need to wear panty hose." "I need to wear support hose." "I need to wear flat nonslip shoes that have good support." I need to wear knee-high hose, but I would not leave them on longer than 8 hours."
"I need to wear knee-high hose, but I would not leave them on longer than 8 hours. Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client would be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist in maintaining proper posture and balance and to minimize falls.
The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." "I would ask the client to keep a record and document every time the perineal pad is changed." "I need to weigh the perineal pad before and after use and note the amount of time between each pad change." "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."
"I need to weigh the perineal pad before and after use and note the amount of time between each pad change." Rationale: To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes and the number of pads used also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the information also may not provide accurate data.
The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? "I don't think I can do this on my own. I still need help coping with things. I know I need to keep working with staff, even now that I'm going home." "This has been the hardest thing I've ever had to deal with. I've made progress in learning how to communicate, especially with my family. It's hard to tell them when I need help." "I really tried to listen to what people said in the group sessions. Sometimes it was hard, but I think we really helped each other. I think I've learned it's all right to get disappointed sometimes." "I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility
"I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end." Rationale: Rationalization is substituting acceptable reasons for actual reasons for behavior. In the correct option the client is rationalizing and is minimizing the response to loss. The remaining options indicate that the client is reviewing and evaluating certain valued perceptions of the treatment process before discharge.
An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes, and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the parent indicates an understanding of the care measures? "I will call the doctor if my child has abdominal or left shoulder pain." "I need to keep my child on bed rest for 3 weeks to discourage physical activity." "I will notify the doctor if my child is still feeling tired in 1 week."4 I need to isolate my child so that the respiratory infection is not spread to others."
"I will call the doctor if my child has abdominal or left shoulder pain." Rationale: The parent needs to be instructed to notify the physician if abdominal pain, especially in the left upper quadrant, or left shoulder pain, occurs because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? "I will drink 8 oz of water with each meal." "I will eat three servings of cracked wheat bread each day." "I will eat two saltine crackers before I get up each morning." "I will eat fresh fruits and vegetables for snacks and for dessert each day."
"I will eat fresh fruits and vegetables for snacks and for dessert each day." Rationale: Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums.
The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? "Inner voices tell me to perform my rituals." "My behavior is a conscious attempt to punish myself." "I'm demonstrating control when I engage in my rituals." "My rituals are ways for me to control unpleasant thoughts or feelings."
"My rituals are ways for me to control unpleasant thoughts or feelings." Rationale: In obsessive-compulsive disorder (OCD), the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling and prevent acting on it. This decreases the client's anxiety. OCD is not associated with a need for control or punishment, or with hallucinations.
During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would bestaddress this breach of boundaries? "Thank you, the perfume was a gift." "Your comment is really inappropriate." "Neither my hair nor my perfume is the focus of today's session." "The focus of today's session is on your issues, so let's get started."
"The focus of today's session is on your issues, so let's get started." Rationale: The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse would confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle or those that are a social response and could be misinterpreted by the client.
A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The nurse has explained to the parent the purpose of the blood test. Which comment by the parent indicates the need for further explanation? "This test is used to determine the child's immune status." "This test identifies the specific diagnosis of HIV infection." "This test is a blood test that is used to identify the risk for disease progression." "This test assesses the need for pneumonia prophylaxis after 1 year of age."
"This test identifies the specific diagnosis of HIV infection." Rationale: Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. These counts are measured at 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+counts is indicated when P. jiroveci pneumonia prophylaxis and antiretroviral therapy are recommended. The CD4+ count is not diagnostic of HIV infection.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse? "Why don't you tell your spouse about this?" "What do you find difficult about this situation?" This is not the best time to make that decision." "I agree with you. You should get out of this situation."
"What do you find difficult about this situation?" Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse would not agree with the client, and the nurse would not request that the client provide explanations.
Which statement, if made by the parent of a 1-day-old newborn, indicates an understanding of gastrointestinal system functioning in the infant? Select all that apply. 10 to 20 mL is the stomach capacity of a 1-day-old newborn 30 to 60 mL is the stomach capacity of a 1-day-old newborn 75 to 100 mL is the stomach capacity of a 1-week-old infant 90 to 150 mL is the stomach capacity of a 1-month-old infant 250 to 400 mL is the stomach capacity of a 1-month-old infant
10 to 20 mL is the stomach capacity of a 1-day-old newborn 90 to 150 mL is the stomach capacity of a 1-month-old infant Rationale: The stomach capacity is 10 to 20 mL for a newborn infant, 30 to 60 mL for a 1-week-old infant, 75 to 100 mL for a 2- to 3-week-old infant, and 90 to 150 mL for a 1-month-old infant.
The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? Increased urinary output A fetal heart rate of 90 beats/minute Three contractions occurring within a 10-minute period Adequate resting tone of the uterus palpated between contractions
A fetal heart rate of 90 beats/minute Rationale: A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus would return to resting tone between contractions, and there would be no evidence of fetal distress.
A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? Anxiety A temper tantrum A hypercyanotic episode The need for immediate primary health care provider notification
A hypercyanotic episode Rationale: Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate primary health care provider (PHCP) notification is not required unless other appropriate nursing interventions are unsuccessful. Anxiety and a temper tantrum are unrelated to tetralogy of Fallot.
The nurse determines that which client is at highest risk for suicide? A lawyer who is 47 years old and recently divorced A 25-year-old homemaker who cares for cares for 2-year-old and 3-year-old children A 39-year-old single parent who dropped out of high school and whose children are both in medical school An 18-year-old who abuses both alcohol and drugs and who will not meet the requirements for graduation
An 18-year-old who abuses both alcohol and drugs and who will not meet the requirements for graduation Rationale: Some risk factors associated with suicide include previous suicide attempts, mental disorders, co-occurring mental and alcohol and substance abuse disorders, family history of suicide, and impulsiveness or aggressive tendencies. The 18-year-old who is abusing substances is at highest risk because of the developmental potential for addiction and the adolescent trait of impulsiveness. High-risk groups include those who are 19 years of age or younger and those who are 45 years of age or older (especially older clients, age 65 years or older).
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction would the nurse provide? Strict bed rest is required after the procedure. Hospitalization is necessary for 24 hours after the procedure. An informed consent needs to be signed before the procedure. A fever is expected after the procedure because of the trauma to the abdomen.
An informed consent needs to be signed before the procedure. Rationale: Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the primary health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.
The nurse is caring for a child diagnosed with erythema infectiosum (fifth disease). Which clinical manifestation would the nurse expect to note in the child? An intense fiery red edematous rash on the cheeks Pinkish-rose maculopapular rash on the face, neck, and scalp Reddish and pinpoint petechiae spots found on the soft palate Small bluish-white spots with a red base found on the buccal mucosa
An intense fiery red edematous rash on the cheeks Rationale: Fifth disease is characterized by the presence of an intense fiery red edematous rash on the cheeks, which gives an appearance that the child has been slapped. Options 2 and 3 are manifestations related to rubella (German measles). Koplik's spots (option 4) are found in rubeola (measles).
Which is the appropriate nursing intervention to address poor nutritional intake demonstrated by a client diagnosed with depression? Weigh the client 3 times per week before breakfast. Explain to the client the importance of good nutritional intake. Report the nutritional concern to the psychiatrist, and obtain a nutritional consultation as soon as possible. Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.
Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served. Rationale: Offering small meals at several different times during the day may be less overwhelming for the client. Being available during the meals can add to the social atmosphere of eating. Weighing the client does not address how to increase nutritional intake. The client is experiencing poor concentration and is unlikely to benefit from a nutrition lecture. The option of reporting to the psychiatrist and consulting with the nutritionist is to some degree correct but does not present a method to increase food intake.
The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? Assess for signs and symptoms of labor. Assess the client's temperature every 2 hours. Schedule a daily ultrasound to assess fetal movement. Schedule a nonstress test every 4 hours to assess fetal well-being.
Assess for signs and symptoms of labor. Rationale: As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.
A type 1 diabetic birthing client delivered a 4400-gram newborn 3 hours ago. The client has already initiated breast/chest-feeding. What would the nurse plan to do to maintain euglycemia in this client? Administer the prepregnancy dose of metformin. Assess the blood glucose before administering any glucose-lowering medications. Administer 20 units of long-acting insulin, as sufficient time has elapsed since delivery. Keep NPO (nothing by mouth) for an additional 4 hours to allow the blood glucose to normalize.
Assess the blood glucose before administering any glucose-lowering medications. Rationale: Frequently, after delivery, blood glucose is maintained for several days at a relatively low level, especially when the parent is breast/chest-feeding, as the placental hormones have been depleted. It is not necessary to keep this parent NPO, and not feeding the client may actually be harmful to the client. No medications to alter blood glucose should be administered to this client without having assessment data about the current blood glucose level.
The postpartum unit nurse has provided information on performing a sitz bath to a postpartum client after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action? Numb the tissue. Stimulate a bowel movement. Reduce the edema and swelling. Assist in healing and provide comfort.
Assist in healing and provide comfort. Rationale: Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort, promote healing, and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to numb the tissue and reduce edema. Promoting a bowel movement is best achieved by ambulation.
The nurse has reviewed the primary health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. What would the nurse expect to do next to assist in confirming the diagnosis? Collect a 24-hour urine sample. Perform a neurological assessment. Assist with a bone marrow aspiration. Send to the radiology department for a chest x-ray.
Collect a 24-hour urine sample. Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. In cases of neuroblastoma, a urine sample will indicate an elevated vanillylmandelic acid level. A bone marrow aspiration will assist in determining marrow involvement, but is not specific in diagnosing neurblastoma. A neurological examination and a chest x-ray may be performed but will not confirm the diagnosis.
The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? Chest pain A rigid abdomen A soft and boggy uterus Complaints of severe abdominal pain
Complaints of severe abdominal pain Rationale: Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting.
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? Psychosis Repression Conversion disorder Dissociative disorder
Conversion disorder Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.
The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action would the nurse take? Document the findings. Contact the primary health care provider (PHCP). Apply an oxygen mask to the newborn infant. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.
Document the findings. Rationale: The normal respiratory rate for a newborn is 30 to 60 breaths per minute. On assessment, if the nurse noted a respiratory rate of 50 breaths per minute, the nurse would document these findings because they are normal. Contacting the PHCP, applying an oxygen mask to the newborn, and covering the newborn in blankets are inappropriate or unnecessary nursing actions.
The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." "The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy." "The low levels of estrogen and progesterone increase the release of the follicle-stimulating hormone and luteinizing hormone." "The high levels of estrogen and progesterone promote the release of the follicle-stimulating hormone and luteinizing hormone."
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?"Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." "The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy." Rationale: Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation. All other options are incorrect.
The nurse is conducting staff in-service training on von Willebrand's disease. Which would the nurse include as characteristics of von Willebrand's disease? Select all that apply. Easy bruising occurs. Gum bleeding occurs. It is a hereditary bleeding disorder. Treatment and care are similar to that for hemophilia. It is characterized by extremely high creatinine levels. The disorder causes platelets to adhere to damaged endothelium.
Easy bruising occurs.2Gum bleeding occurs.3It is a hereditary bleeding disorder.4Treatment and care are similar to that for hemophilia.5 The disorder causes platelets to adhere to damaged endothelium. Rationale: Von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of, or a defect in, a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder. Treatment and care is similar to other bleeding disorders, such as hemophilia.
Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? Limit fluid intake. Maintain the client in a supine position. Ask family members to care for the newborn. Encourage the client to take pain medication as prescribed.
Encourage the client to take pain medication as prescribed. Rationale: Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. If the client's pain is relieved, they will be more likely to participate in newborn care. Asking family members to care for the newborn will not facilitate client participation in newborn care.
A postpartum client is diagnosed with cystitis. The nurse would plan for which priority action in the care of the client? Providing sitz baths Encouraging fluid intake Placing ice on the perineum Monitoring hemoglobin and hematocrit levels
Encouraging fluid intake Rationale: Cystitis is an infection of the bladder. The client need to consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.
The nurse would monitor a child with Hirschsprung disease for which associated health problem? Pruritus Diaphoresis Enterocolitis Appendicitis
Enterocolitis Rationale: Hirschsprung disease occurs from a congenital anomaly that leads to mechanical obstruction through decreased motility in the intestine. The most serious problem that can occur is enterocolitis, or inflammation of the intestine. Appendicitis occurs with inflammation of the appendix, pruritus is an itching sensation throughout the body, and diaphoresis is sweating, typically of an unusual amount.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? Hemoglobin of 11 g/dL (110 mmol/L) Fetal heart rate of 180 beats per minute Maternal pulse rate of 85 beats per minute White blood cell count of 12,000/mm3 (12 × 109/L)
Fetal heart rate of 180 beats per minute Rationale: A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000/mm3 (11 to 15 × 109/L) up to 18,000/mm3 (18 × 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000/mm3(25 to 30 × 109/L) because of increased leukocytosis that occurs during delivery.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F (37.8° C). What is the priority nursing action? Document the findings. Retake the temperature in 15 minutes. Notify the primary health care provider (PHCP). Increase hydration by encouraging oral fluids.
Increase hydration by encouraging oral fluids. Rationale: The client's temperature needs to be taken every 4 hours while awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which would bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the PHCP is not necessary.
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How would the nurse interpret this behavior as a cue to modify the treatment plan? Suggesting a reduction of medication Allowing increased "in-room" activities Increasing the level of suicide precautions Allowing the client off-unit privileges as needed
Increasing the level of suicide precautions Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm self. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.
A child's fasting blood glucose levels range between 100 and 120 mg/dL (5.7 and 6.9 mmol/L) daily. The before-dinner blood glucose levels are between 120 and 130 mg/dL (6.9 and 7.4 mmol/L), with no reported episodes of hypoglycemia. Mixed insulin is administered before breakfast and before dinner. The nurse would make which interpretation about these findings? Exercise should be increased to reduce blood glucose levels. Insulin doses are appropriate for food ingested and activity level. Dietary needs are being met for adequate growth and development. Dietary intake need to be increased to avoid hypoglycemic reactions.
Insulin doses are appropriate for food ingested and activity level. Rationale: Blood glucose levels are a measure of the balance among diet, medication, and exercise. Options 1 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here.
The nurse is assessing the fundus in a postpartum client and notes that the uterus is soft and spongy and not firmly contracted. The nurse would prepare to implement which interventions? Select all that apply. Massaging the uterus Pushing gently on the uterus Assisting the client to urinate Rechecking the uterus in 1 hour Checking for a distended bladder Calling the delivery room to schedule an abdominal hysterectomy
Massaging the uterus Assisting the client to urinate Checking for a distended bladder Rationale: If the uterus is soft and spongy and not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse would then check for a distended bladder and assist the client to urinate. Pushing on an uncontracted uterus could invert it, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in excessive blood loss. The primary health care provider (PHCP) will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. In addition, the nurse should not schedule an operative procedure.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions would be included in the plan of care? Select all that apply. Avoid stimulation. Decrease fluid intake. Expose all of the newborn's skin. Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.
Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches. ationale: Phototherapy (bili-light or bili-blanket) is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn may have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide stimulation in the environment. Provide reality orientation as appropriate. Maintain NPO (nothing by mouth) status.
Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate. Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.
The nurse is providing education to a client who is pregnant and has gestational diabetes about the signs and symptoms of hyperglycemia. The nurse determines that the client understands the teaching if the client identifies which clinical manifestations as signs or symptoms of hyperglycemia? Nausea Diarrhea Vomiting Abdominal pain Excessive thirst6Fruity breath odor
Nausea Vomiting4Abdominal pain5Excessive thirst6Fruity breath odor Submit Rationale: Hyperglycemia is an elevated blood glucose level. Signs and symptoms include nausea and vomiting, excessive thirst and dry mouth, weakness, abdominal pain, and a fruity breath odor. Diarrhea is not a manifestation; constipation is more likely to occur.
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? Document the findings. Reassess the client in 2 hours. Encourage increased oral intake of fluids. Notify the primary health care provider (PHCP).
Notify the primary health care provider (PHCP). Rationale: Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the PHCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.
The nurse is teaching the parent of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? Selective placement of the infant Periodic well-baby examinations Phenylketonuria (PKU) testing at birth Administration of an antibiotic for an umbilical cord staphylococcal infection
Periodic well-baby examinations Rationale: Primary prevention activities are actions that are designed to prevent a disease from occurring or to reduce the probability of occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, and genetics. Selective placement of the infant is vague and does not provide any specific information. PKU testing at birth is an example of secondary prevention because it relates to early diagnosis and treatment. Antibiotic administration identifies an actual treatment.
The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning care for the client, which action by the nurse would receive priority? Speaks slowly to the client Projects an attitude of calmness Bargains to prevent the violent episodes Moves quietly when approaching the client
Projects an attitude of calmness Rationale: If a client has the potential for episodes of violence, the nurse would avoid bargaining or making promises to the client. Additionally, the nurse would not judge or criticize the client. Speaking softly to the client and moving quietly when nearing the client identify appropriate nursing actions in the care of the client who has the potential for violence. However, projecting calmness is the priority and encompasses the other two options.
The postpartum nurse is caring for a client who just delivered a healthy newborn. The nurse would be mostconcerned about the presence of subinvolution if which occurs? Afterpains Retained placental fragments from delivery An oral temperature of 99.0° F (37.2° C) following delivery Increased estrogen and progesterone levels as noted on laboratory analysis
Retained placental fragments from delivery Rationale: Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. The presence of afterpains and a temperature of 99.0° F (37.2° C) after delivery are expected findings. Hormonal levels are not a cause of subinvolution and are unrelated to the subject of the question.
What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget? Escort the client to a private, low-stimulus room. Engage the client in a nonthreatening conversation. Allow the client to pace unless the behavior becomes aggressive. Share the observation with the client so that the behavior can be recognized.
Share the observation with the client so that the behavior can be recognized. Rationale: Sharing observations with the client may help the client recognize and acknowledge feelings. Allowing the client to pace may also allow the client to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize their behaviors and feelings.
The nurse is preparing a pregnant client for a transvaginal ultrasound examination. The nurse would tell the client that which will occur? Some pain will be felt during the procedure. A side-lying position is needed for the procedure. Some pressure may be felt when the vaginal probe is moved. It is necessary to drink 2 quarts of water before the procedure to attain a full bladder.
Some pressure may be felt when the vaginal probe is moved. Rationale: Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most clients because it alleviates the need for a full bladder to perform the test. The client is placed in a lithotomy position or with the pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the client may feel pressure as the probe is moved.
A 4-year-old child diagnosed with Legg-Calves-Perthes disease underwent magnetic resonance imaging (MRI), and radiographic findings showed aseptic necrosis of the femoral capital epiphysis with degenerative changes. The nurse recognizes this finding as indicative of which stage? Stage I Stage II Stage IV Stage III
Stage I Rationale: Legg-Calve-Perthes disease occurs from avascular necrosis of the femoral head from a disturbance of blood circulation to the femoral capital epiphysis. The bone weakens and gradually breaks apart. The cause is unknown. Onset of the disease presents with limping, especially with increased activity; hip soreness; aching; and stiffness. The diagnosis of Legg-Calves-Perthes disease and its stages is determined by radiographic studies. In stage I, aseptic necrosis of the femoral capital epiphysis with degenerative changes is present. For stage II, capital bone resorption with fragmentation and revascularization is occurring. Stage III reveals new bone formation with calcification and ossification of increased density. Stage IV shows gradual reformation of the head of the femur.
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The contractions are regular. The membranes have ruptured. The cervix is dilated completely. The client begins to expel clear vaginal fluid. The Ferguson reflex is initiated from perineal pressure.
The cervix is dilated completely. The Ferguson reflex is initiated from perineal pressure. Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The client has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? The client is a 35-year-old primigravida. The client has a history of cardiac disease. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). The client is a 20-year-old primigravida of average weight and height.
The client has a history of cardiac disease. Rationale: Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetrical problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.
The nurse evaluates the ability of a hepatitis B-positive parent to provide safe bottle-feeding to the newborn during postpartum hospitalization. Which action best exemplifies the parent's knowledge of potential disease transmission to the newborn? The parent requests that the window be closed before feeding. The parent holds the newborn properly during feeding and burping. The parent tests the temperature of the formula before initiating feeding. The parent washes and dries their hands before and after self-care of their perineum and asks for a pair of gloves before feeding.
The parent washes and dries their hands before and after self-care of their perineum and asks for a pair of gloves before feeding. Rationale: Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce complications. The correct option provides the best evaluation of parental understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.
A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth? Infection Paralysis Pressure ulcer Uneven leg growth
Uneven leg growth Rationale: The epiphyseal line is the area that is responsible for longitudinal bone growth. A fracture affecting this area places the child at risk for uneven future growth if proper healing does not occur. The epiphyses are located at the proximal and distal ends of a bone and are the insertion sites for muscles. The diaphysis is the shaft or main longitudinal portion of a long bone. The metaphysis is an area of flaring of bone, located between the epiphysis and the diaphysis. Paralysis, pressure ulcer, and infection are not priority concerns for future growth. Paralysis and neurovascular status are priority concerns during the immediate period post-injury, but not during future growth.
A client with an anxiety disorder is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat? Using open-ended questions and silence Sharing personal preferences regarding food choices Documenting reasons why the client does not want to eat Offering opinions about the necessity of adequate nutrition
Using open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are unhelpful to the client because they do not encourage the client to express feelings. The nurse would not offer opinions and would encourage the client to identify the reasons for the behavior.