Adult Health Review

Which clients can the nurse assign to the same room? Select all that apply 1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis 2. A 41 year old male with nausea, vomiting, and diarrhea and a 62 year old male with neutropenia 3. A 41 year old male with Methicillin-resistant Staphylococcus aureus (MRSA) infection and a 42 year old male with Clostridium difficile 4. A 14 year old two days postoperative splenectomy and an 80 year old female with Parkinson's disease 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma Hint: Ask yourself which groups of clients have something in common.

1 & 5. Correct: Both the client with a postoperative appendectomy and the client with nephrolithiasis will need frequent pain assessments. Also neither client has an infection that could be transmitted to the other client.These 2 clients can be assigned to the same room. The clients with asthma and COPD are noninfectious respiratory diseases, so they also can be assigned to the same room. 2. Incorrect: The client with neutropenia has a low number of neutrophils which are a common type of white blood cell important to fighting off infections. The client should be assigned to a single-client room. In addition the other client could be contagious depending on the causative factor of the nausea,vomiting and diarrhea. The client with neutropenia should not be assign with this client since their diagnosis has not been identified. 3. Incorrect: MRSA and C difficile require contact isolation due to different causative organisms. Both of these clients should be assigned to a single-client room. In the healthcare setting it is recommended that clients requiring Contact Precautions should be assigned a single-client room. 4. Incorrect: Think about it an adolescent and an older adult in the same room. The 14 year old client is in the early adolescent stage. Since an admission to the hospital is a stressful situation, the client may exhibit "immature" behaviors and be embarrassed about the healthcare team seeing their bodies. There is a wide gap between a 14 year old and a 80 year old developmental stage. The 80 year old is experiencing developmental changes for older adult client. In addition, this client is exhibiting symptoms of Parkinson's disease.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries

3. Correct: Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber. 1. Incorrect: People with hypothyroidism have a slow metabolism and do not need high protein but a well balanced diet. Almonds are high in protein. 2. Incorrect: Cheese and crackers are high in sodium. This client is at risk for CAD, so sodium should be limited. 4. Incorrect: This client does not need high potassium, which fried sweet potatoes have. The high potassium dietary approaches to stop hypertension (DASH) diet is only for healthy clients with hypertension.

The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Slightly swollen eyelid 2. Slight discomfort of the eye 3. "Bloodshot" appearance of the eye 4. Extreme pain in the eye

4. Correct. The postoperative cataract client usually experiences little to no pain, and it can be managed with mild analgesics. If the pain is severe, there may be an increase in intraocular pressure, hemorrhage, or infection, and the surgeon should be notified. 1. Incorrect. Slight swelling of the eyelid is considered a normal finding following cataract surgery. 2. Incorrect. The postoperative cataract client usually experiences little to no discomfort following surgery. This is a normal finding. 3. Incorrect. Slight redness is an expected finding. Pay attention to the word "slight". Increased redness is cause for concern. Compare it to the non-operative eye.

In what order will the nurse provide instructions to a client on using a cane? 1) Advance weaker leg forward toward the cane. 2) With cane on stronger side of body, support body weight with both legs. 3) Move cane forward 6-10 inches (15 - 25 cm). 4) Advance stronger leg forward toward cane.

First, with cane on stronger side of body, support body weight with both legs. This will support the even distribution of weight away from the weaker side to promote a normal gait. Second, move cane forward 6-10 inches (15-25 cm). Moving the cane the approximate distance of a normal gait helps with stability. Third, advance weaker leg forward toward the cane. This allows the weight to be supported by the cane and the stronger leg. Fourth, advance stronger leg forward toward the cane. This allows the weight to be supported by the can and weaker leg.

A client has been admitted to the orthopedic floor following application of a long leg cast for a fractured femur. What nursing action takes priority? 1. Perform neurovascular checks of the extremities. 2. Cover the edge of the cast near the groin area. 3. Instruct client not to insert anything into cast. 4. Use palms of hands to lift and position the cast.

1. Correct: The most vital aspect of care for clients with a fracture and/or cast is frequent neurovascular checks. Circulation can quickly become compromised secondary to edema from the injury or application of the cast, leading to permanent nerve and tissue damage. Neurovascular checks are performed every two hours for the first 24 hours, or more often per hospital protocols, and both extremities must be compared when looking for problems. 2. Incorrect: While this is a vital action by the nurse, it is not the initial priority. Because this client has a long leg cast for a fractured femur, there is the potential for urine to contaminate the cast close to the groin. That would impair the integrity of the cast, or potentially cause an infection. The nurse definitely needs to cover the upper edges of the cast near the groin with water proof material, but there is another action to complete first. 3. Incorrect: Clients must always be instructed on self care or equipment function as part of the recovery process. Proper cast care following discharge is essential and, in particular, the importance of not placing anything down inside the cast. Clients tend to complain of itching skin beneath a cast and may put baby powder, corn starch or other objects inside the cast to scratch. All these can cause serious complications, and the nurse must provide specific teaching to prevent such problems. However, those instructions are not the most immediate priority for the nurse at this time. 4. Incorrect: Casting material can take up to 24 hours to dry hard enough to protect the client's injury. In the meantime, careful handling of the cast when positioning the client is crucial. The nurse is aware that the cast must be lifted using only the palms of the hands to prevent indentations which could injure the client's skin beneath the casting material. These instructions must also be relayed to any personnel providing care to the client; however, this is not the first priority. Remember: Think about all the things that can go wrong following a fracture with cast application. There is always swelling as a result of the injury, and that can impair circulation. Although immobilization provided by the cast would prevent further muscle spasms, this client will still be experiencing pain. But because the cast is inflexible, the extremity can keep swelling inside the cast. That is a problem! Recite in your mind all you can remember about such an injury - tissue or nerve damage, circulatory impairment, diminished mobility, and, in the case of a femur, the potential for shock or a fat embolus. So many complications make neurovascular checks crucial in the prevention or immediate treatment of complications. Remember that neurovascular checks include pulses, skin temperature and color, sensation, movement, and capillary refill. In the nursing process, assessment comes before implementation!

A client with Hepatitis C has returned from surgery with a total laryngectomy. The nurse knows that what personal protective equipment is necessary when providing trach care? Select all that apply 1. Face mask 2. Shoe covers 3. N-95 mask 4. Goggles 5. Gloves 6. Gown

1, 4, 5 and 6. CORRECT: The client has had a total laryngectomy which will initially produce large amounts of thick, bloody mucus from frequent coughing and suctioning. Hepatitis C is transmitted through blood and body fluids. During trach care, the nurse needs to be protected by specific personal protective equipment (PPE's). For this procedure, the nurse should utilize gown, gloves, goggles and face mask. 2. INCORRECT: Tracheostomy care is completed in close proximity to the client. Splattering of blood and body fluids on the floor is unlikely, so shoe covers are unnecessary. 3. INCORRECT: The N-95 face mask is a specially fitted mask used by nurses when providing care for clients with active tuberculosis. It is not necessary for a client with Hepatitis C.

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's disease. What signs should the nurse include? Select all that apply 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1. & 2. Correct: Early warning signs of Alzheimer's disease include mild disorientation and difficulty with words and numbers. This client may have difficulty recognizing numbers or doing basic calculations. The person may begin to have trouble with words. 3. Incorrect: Poor personal hygiene occurs as Alzheimer's disease progresses due to ongoing loss of neurons. 4. Incorrect: Behavioral manifestations occur later in the disease process as a result of changes that take place within the brain. They are not intentional or controllable by the person with this disease. 5. Incorrect: With progression of this disease, additional cognitive impairments are noted, including visual agnosia, which is the inability to recognize objects by sight. 6. Incorrect: Dysgraphia is defined as difficulty communicating via writing and occurs during disease progression.

A nurse assessing a client who is one day post thyroidectomy and identifies an arrhythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. Which interventions are the priority? Select all that apply 1. Initiate seizure precautions 2. Monitor potassium level 3. Monitor BUN and creatinine 4. Restrict calcium-rich foods 5. Check for airway patency

1. & 5. Correct: The parathyroid glands can accidentally be removed with a thyroidectomy. Low calcium causes rigid and tight muscles. 2. Incorrect: What about potassium? Is this the problem chemical? No, calcium is. But, can calcium cause an arrhythmia? Yes, it can! See, the NCLEX Lady thought you would see arrhythmia and say that must be potassium, but don't let them get you off track. Remember, no doubts or hesitation. But, what other chemical should you think about with calcium? Phosphorous, because we just said they have an INVERSE relationship. 3. Incorrect: What about BUN and creatinine? Are my kidneys involved, no not here. 4. Incorrect: The client is hypocalcemic. You would not restrict calcium rich foods. Instead you would provide a diet high in calcium rich foods.

A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

1. Correct: A lacto-ovo vegetarian diet is a vegetarian diet that does not include meat, but does contain eggs and dairy. The client can eat milk and dairy products along with grain products on this diet. 2. Incorrect: Dairy products and eggs are allowed on this diet. Milk, cheese and yogurt can be consumed on a lacto-ovo vegetarian diet. 3. Incorrect: The client does not consume meats. Meats should not be provided as a snack. 4. Incorrect: The client can consume milk and eggs as well as fresh fruits and vegetables. Milk and eggs can be consumed on a lacto-ovo vegetarian diet.

Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."

1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications. 2. Incorrect: The appearance of the retina provides important information about the severity and duration of hypertension. Manifestations of severe retinal damage include blurred vision, retinal hemorrhage, and loss of vision. 3. Incorrect: Intermittent claudication is a complication of peripheral vascular disease (PVD). Hypertension speeds up the process of PVD. 4. Incorrect: Lifestyle modifications include dietary sodium reduction, weight reduction, Dietary Approaches to Stop Hypertension (DASH) eating plan, moderation of alcohol consumption, regular physical activity, avoidance of tobacco use, and management of psychosocial risk factors.

Which intervention would the nurse recommend to a client with rheumatoid arthritis to best help relieve joint stiffness? 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.

1. Correct: Warm water may provide muscle relaxation, increase blood flow, and reduce stiffness. 2. Incorrect: A mild analgesic may be taken before activity or exercise to decrease pain and inflammation. 3. Incorrect: Weight reduction may be recommended to relieve stress on joints but does not address joint stiffness. 4. Incorrect: Apply cold compresses for 15-20 minutes at a time. Longer than 20 minutes may cause tissue damage.

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? Select all that apply 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.

1., 2. & 4. Correct: HIV infected clients are considered to have a (+) TB skin test with an induration of 5 millimeters or more. An induration of 10 millimeters or more is considered positive in recent immigrants (less than five years) from high-prevalence countries such as Haiti, and in children less than 4 years of age. 3. Incorrect: An induration of 10 millimeters or more is considered positive for residents and employees of high-risk congregate settings. 5. Incorrect: An induration of 15 millimeters or more is considered positive in any person with no known risk factors for TB.

A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the nursing assessment reveals hard, mottled, bluish-white toes bilaterally, and the client reports being unable to feel the toes. Which actions should the nurse initially take? Select all that apply 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.

1., 2., & 3. Correct: Wet clothing is removed to eliminate continued exposure to the cold and allow the warming process to begin. Swelling is common so anything, such as clothing or jewelry that could cause constriction to blood flow should be removed. A controlled and rapid re-warming process is accomplished using a continuous flow of warm water until flushing is noted in the affected areas. Antiseptics or antibiotics are often used, and each digit is wrapped individually with sterile gauze (not constricting) to minimize the risk of infection and assist in the warming process. The core should be re-warmed first to prevent "afterdrop" which is a further drop in core temperature caused by cold peripheral blood returning to the central circulation. 4. Incorrect: Movement of frostbitten areas can cause ice crystals to form in the tissue and cause further damage. In addition, lack of sensation places the client at risk for falls or other injury. 5. Incorrect: External heat such as heating pads, fireplaces, etc. should not be used because this is a safety issue! Don't pick that on NCLEX! The extreme heat can damage the skin or, even worse, cause irregular heartbeats so severe that they can cause the heart to stop. 6. Incorrect: Initial rubbing or massage of the frostbitten digits is an absolute contraindication as it can cause further tissue damage. Gentle handling is required to prevent stimulation of the cold myocardium because excessive, vigorous or jarring movements may trigger cardiac arrest.. Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. Hypothermia occurs as body temperature drops below 95ºF (35ºC). When body temperature drops, the heart, nervous system and other organs can't work normally. Left untreated, hypothermia can lead to complete failure of the heart and respiratory system resulting in death. Hypothermia is most often caused by exposure to cold weather or immersion in a cold body of water. Treatment methods include warming the body back to a normal temperature.

What should the nurse consider when caring for a client who is receiving total parenteral nutrition (TPN)? Select all that apply 1. Will need a central line. 2. TPN requires a dedicated line. 3. Weigh the client daily. 4. Check the urine for protein. 5. TPN can only be hung for 12 hours

1., 2., & 3. Correct: Yes, you will need a central line, remember TPN is very irritating to a vein because of the high glucose content and can only be safely administered through a central line. TPN is incompatible with most other solutions so administer through a dedicated line. Daily weights will help you evaluate effectiveness of the TPN. 4. Incorrect: I bet you thought, "Well, I know that we check the urine for something?" But if you chose that option, then you will miss the question. You may want to check the urine for ketones and glucose. 5. Incorrect: TPN can be hung for 24 hours.

What signs and symptoms of ovarian cancer should a nurse include when educating women? Select all that apply 1. Urinary frequency. 2. Menorrhagia with breast tenderness. 3. Watery vaginal discharge. 4. Increasing abdominal girth. 5. Fullness after a heavy meal.

1., 2., & 4. Correct: Signs and symptoms of ovarian cancer include irregular menses, increasing premenstrual tension, menorrhagia with breast tenderness, early menopause, abdominal discomfort, dyspepsia, pelvic pressure and urinary frequency. Flatulence, fullness after a light meal, and increasing abdominal girth are significant symptoms. 3. Incorrect: Watery, vaginal discharge is a sign of advanced cervical cancer. 5. Incorrect: A sense of fullness occurs after ingesting a light meal.

The nurse providing palliative care to a client would include which outcomes in the teaching plan? Select all that apply 1. Maintaining the client's quality of life 2. Minimizing family caregiver stress 3. Managing the client's pain 4. Managing the client's and family's emotional needs 5. Attending to the client's spiritual needs 6. Ensuring the client understands that disease focused treatments will cease

1., 2., 3., 4. & 5. Correct: Palliative care includes supporting the client's and family's quality of life. Palliative care includes managing pain and symptoms. Palliative care includes managing the client's and family's emotional needs and attending to their spiritual needs. 6. Incorrect: Palliative care is broader than hospice care and aims to support best possible quality of life regardless of stage of disease. Palliative care includes treatment of discomfort, symptoms, and stress of serious illness. Disease focused treatments will not cease.

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? Select all that apply 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1., 2., 3., 5., & 6. Correct: Classic features of RA include joint pain, swelling, and tenderness worsened by movement and stress placed on joint. Morning stiffness that often lasts for one hour or more and limited movement in joints are common manifestations as well. The Rheumatoid Factor is present in 80% of adults who have rheumatoid arthritis. The ESR blood test is elevated with RA and is used to determine if an abnormal level of inflammation exists in the body. The cyclic citrullinated peptide antibody, if present, helps to confirm the diagnosis of RA and may indicate the risk of having severe symptoms. Levels that are at a moderate to high level may indicate that the client is at increased risk for damage to the joints. 4. Incorrect: Dupuytren's contractures are a type of hand deformity where a layer of tissue under the skin in the palms of the hands is affected. Hard knots form in the palm areas and eventually create a thick cord that can pull one or more of the fingers into a bent position. However, this is not associated with RA.

Which prevention measure should the nurse include when instructing a client on avoidance of otitis externa? 1. Gently cleaning the ear canal with a cotton tipped applicator daily. 2. Use of astringent drops after bathing. 3. Taking preventative antibiotics prior to swimming in lakes or ponds 4. Routine use of nasal saline to clear the sinuses and eustachian tubes.

2. Correct: Prevention and avoidance measures for otitis externa include thorough ear canal drying and use of acidifying or astringent drops after swimming or bathing. 1. Incorrect: Clients should be taught to NEVER stick objects, including cotton tipped applicators, into the ear canal. This could result in rupture of the tympanic membrane. 3. Incorrect: Taking preventative antibiotics is unnecessary and increases the risk for antibiotic resistance. 4. Incorrect: Use of saline may be useful in keeping the sinuses cleared thereby reducing accumulation in the eustachian tubes. While this might be beneficial for otitis media, it would serve no benefit in otitis externa.

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis? Select all that apply 1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 3. Decrease fluid intake to 1 liter/day. 4. Advise client that urine may change color with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, fever.

1., 2., 4., & 5. Correct: With pyelonephritis urine will be dark, cloudy and foul smelling due to the bacteria. Anytime a client has a renal problem, that client should be placed on I&O. Nitrofurantoin, an antibiotic, will turn the urine brown. Monitor for septic shock, a complication of pyelonephritis. S/S include hypotension, tachycardia, and fever. 3. Incorrect: Fluid intake should be increased to 2-3 liters/day unless contraindicated. Acute pyelonephritis is an infection of the renal pelvis and kidney that usually results from ascent of a bacterial pathogen up the ureters from the bladder to the kidneys. The classic presentation in clients include: Fever - This is not always present, but when it is, it is not unusual for the temperature to exceed 103°F (39.4°C); Costovertebral angle pain - Pain may be mild, moderate, or severe; flank or costovertebral angle tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present; Nausea and/or vomiting - These vary in frequency and intensity, from absent to severe; anorexia is common in clients with acute pyelonephritis. Blood pressure is usually within the reference range, unless the client has underlying hypertension; in cases of underlying hypertension, the pressure may be elevated above the patient's baseline. A systolic blood pressure below 90 mm Hg suggests shock secondary to sepsis.

Which of the following should the nurse teach regarding nutrition for a client with celiac disease? Select all that apply 1. Gluten is a protein found in wheat and oats. 2. A gluten intolerant person can eat foods that are made with barley or rye. 3. Fruits can be eaten on a gluten free diet. 4. Gluten causes inflammation of the large intestines of people with celiac disease. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

1., 3., & 5. Correct: A gluten-free diet is used in the treatment of celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. All products containing these grains are to be avoided. Rice and corn may be used. Fruits, vegetables, nuts, diary products and meats not prepared with gluten containing ingredients can be eaten. Accidentally ingesting food with gluten may result in abdominal pain and diarrhea. 2. Incorrect: The main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and Tapioca. The gluten intolerant clients can not eat barley and rye. Gastrointestinal pain and diarrhea may occur. 4. Incorrect: Gluten causes inflammation in the small intestines of people with celiac disease. Eating a gluten-free diet helps people control their signs and symptoms and prevent complications.

What nursing interventions should the nurse initiate in a client who experiences sundowning? Select all that apply 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.

1., 3., 4., & 6. Correct: Sundowning occurs when the client becomes more confused and agitated in the late afternoon or evening. Behaviors commonly seen include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Limit naps because too much daytime napping may interfere with sleeping at night. Light therapy may reduce agitation and confusion so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure. 2. Incorrect: Watching television for this client may lead to restlessness, agitation, and confusion. Calming and more restful activities are better for the evening. 5. Incorrect: Lights should be on during the day but turned off at night (except for low lighting or nightlights so the client can see).

The nurse is caring for a client in the emergency department who presents with hematemesis. What information is most important for the nurse to obtain during the initial assessment? Select all that apply 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness

1., 4., & 5. Correct: A set of vital signs and assessment for hypovolemic shock take priority for this client. S/S of shock include thready, rapid pulse, decreased LOC, shortness of breath, cold and clammy skin, and decreased urinary output. 2. Incorrect: Will this assess the current problem? No. History of prior bleeding episodes is important but does not address the immediate problem. 3. Incorrect: Will knowing medications fix the problem? No. Medication history is important, but the nurse must first determine whether or not the client is in shock.

A nurse is educating the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? Select all that apply 1. Give 30 minutes to eat 2. Serve finger foods 3. Serve one dish at a time 4. Do not worry about neatness

2, 3, & 4. Correct: Too many foods at once may be overwhelming. Simplify by serving one dish at a time. For example, mashed potatoes followed by meat. Serve finger foods, which are foods easy to pick up to eat. Do not worry about neatness. Let the person feed self as much as possible. Consider plates with suction, built-up rims and no spill glasses to allow users to more easily place food on their utensils. 1. Incorrect: Give the person plenty of time to eat. Remind client to chew and swallow carefully. Keep in mind that it may take an hour or longer to finish eating.

A community health nurse prepares a presentation about decreasing the risk of the spread of influenza in the community. Which information should the nurse include in the presentation? 1. The flu is spread via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing. 3. Tissues are the most effective means to decrease the spread of the influenza. 4. Antibiotics are effective in treating influenza.

2. Correct: A shirtsleeve should be used as a barrier when coughing or sneezing. This prevents germs being spread via the hands. 1. Incorrect: The flu vaccine contains a dead virus that is not capable of causing the flu. Clients may experience flu-like symptoms from the flu vaccine, but they won't contract the virus. 3. Incorrect: Tissues are effective in decreasing the spread of the flu if disposed of in the trash after use. Hand washing is also very important in decreasing the spread of germs. 4. Incorrect: Antibiotics are not effective in treating the flu. The flu is treated with antipyretics, fluids, and rest. Antibiotics are used for infections, not viruses.

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? Select all that apply 1. Anti-embolic stockings 2. Smoking cessation 3. Moderate exercise 4. Application of heat 5. Low cholesterol diet 6. Decrease blood pressure

2., 3., 5. & 6. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Smoking is a major risk factor in developing PAD by contributing to arterial constriction. Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. A low cholesterol, heart healthy diet with more fruits and vegetables helps reduce cholesterol while decreasing blood pressure, both important goals towards controlling PAD. 1. Incorrect: Increasing arterial blood flow is important in the prevention or management of peripheral artery disease; however, anti-embolic stockings are designed to improve venous return in clients with decreased mobility. The use of these stockings would actually hinder arterial flow in lower extremities. 4. Incorrect: Clients with PAD often complain of cold extremities secondary to decreased arterial blood flow. But the application of heat such as use of a heating pad is unsafe and is always contraindicated in the elderly with PAD. Inability to sense temperature extremes may result in serious burns to lower extremities. Additionally, clients with PAD do not heal as well from injuries or wounds. Too many senior adult clients accept certain problems or disease processes as "part of getting old". However, research has shown it is possible to slow or even stop the buildup of plaque in arteries with a few simple lifestyle changes. A community presentation aimed at this group of individuals is a great way to improve their quality of life and decrease many painful symptoms. Remember when presenting information to non-medical individuals, simple and direct facts are more likely to be understood and accepted. What do you recall about peripheral artery disease? You know that plaque builds up in the arteries, impairing blood flow to extremities and placing the client at risk for multiple health issues. Once atherosclerosis sets in, the arterial lumens narrow and it is very difficult to reverse damage. Obviously, prevention is the key.

A client has been trying to implement a low fat diet for prevention of heart disease and enhancement of weight loss. He further reports that his wife shows her love by preparing rich foods and pastries. Which action should the nurse make? 1. Suggest that the client prepare all meals at home. 2. Schedule a meeting with husband and wife to discuss diet and health. 3. Suggest that the client limit intake to one serving of each food at meals. 4. Ask the client to give his wife a cookbook with low fat recipes.

2. Correct: The meeting with the wife and husband together may help to gain the support of the wife. She may not realize that meal preparation is actually serving as a barrier to successful change. Also, the importance of the opinions and behaviors of the wife are important to the client as he tries to engage in long-term behavioral change. 1. Incorrect: This intervention may actually increase barriers to change because the wife's feeling and support are necessary to maintain long-term change. 3. Incorrect: While this practice may reduce the intake of fat, the issue of spousal support should be addressed. 4. Incorrect: Open discussion with the wife about the need for low-fat meals is essential.

The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks

2. Correct: The nurse is using the expertise of other team members by requesting that the dietician visit the client. This is the most important measures to address the client's nutritional needs. The problem may be that the client simply does not like the foods that have been served and the dietician is the best one to address these issues. 1. Incorrect: An appointment with the primary healthcare provider may not be necessary. It is the best to first utilize available team members such as the dietician. The nurse would then notify the primary healthcare provider of any pertinent findings. 3. Incorrect: To simply monitor weight loss for a month would not be an appropriate intervention. There could be significant weight loss within a month. This is much too long to wait before taking measures to ascertain the reason for the client consuming fewer calories. 4. Incorrect: The nurse should monitor intake and weight over the next couple of weeks; however, there is a more immediate action that is appropriate. The nurse takes action by asking the dietician to see the client.

A nurse is caring for a client who had abdominal thoracic surgery 16 hours ago. What interpretation should the nurse make based on the results of the client's arterial blood gases (ABGs)? pH - 7.32 PaO2 - 93% PaCO2 - 48 HCO3 - 24 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

2. Correct: The pH is 7.32 (normal 7.35-7.45) which means acidosis. The paCO2 of 48 (normal 35-45) indicates a respiratory problem. The arterial blood gas results indicate that the client is in respiratory acidosis. 1. Incorrect: This is a respiratory problem. The bicarb is within normal limits, eliminating a metabolic problem. 3. Incorrect: The pH is low which indicates acidosis. The bicarb is within normal limits, eliminating a metabolic problem. 4. Incorrect: The pH is low, which indicates acidosis.

After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

2. Correct: This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the PICC line being removed or a portion of the line breaking off before removal. 1. Incorrect: This is not the most important information that needs to be documented. There are no client safety issues with charting the client's tolerance of the procedure. 3. Incorrect: This would be charted so the intake and output could be calculated. This is not the most important data that needs to be documented related to the removal of the PICC line. 4. Incorrect: This would need to be documented because a dressing is applied to the insertion site after removal. However, this is not the most important data that would need to be documented after this procedure.

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? Select all that apply 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2., & 4. Correct: Contact isolation will be needed to prevent the spread of infection. Also the electronic equipment for vital signs must not be used in the room. The client will need a disposable stethoscope, BP cuff and thermometer dedicated for use in that patient room. 1. Incorrect: Precautions should be instituted and a stool sample sent for any client with persistent diarrhea. Isolation should be in place with suspected c. diff. 3. Incorrect: Soap and water must be used to clean the hands. Alcohol based foams do not have enough alcohol in them to destroy the c diff spores. 5. Incorrect: Medications to stop diarrhea will not be prescribed with c. diff. because they cause even further irritation.

The nurse is preparing a seminar for a group of clients diagnosed with irritable bowel syndrome. Which points should the nurse include? Select all that apply 1. Teach about a low fiber diet. 2. Schedule meals at regular times. 3. Fluid should be taken with meals. 4. Become active in yoga classes. 5. Keep a food diary for 2 weeks.

2., 4. & 5. Correct: Eating at regular intervals and chewing foods slowly and thoroughly will help to manage symptoms. Additional strategies include maintaining good dietary habits with avoidance of food triggers. Although adequate fluid intake is necessary, fluid should not be taken with meals because this results in abdominal distention. Alcohol use and cigarette smoking are discouraged. Stress management via relaxation techniques, yoga, or exercise are recommended. Identify irritating foods by keeping a food diary for 1-2 weeks. 1. Incorrect: This client needs a high soluble fiber diet to help control diarrhea and constipation. 3. Incorrect: Although adequate fluid intake is necessary, fluid should not be taken with meals because this results in abdominal distention.

A nurse has taught a group of teenage girls about breast self-awareness. Which statements by the teens would indicate to the nurse that teaching was effective? Select all that apply 1. "I should have a clinical breast exam every 5 years starting at the age of 18." 2. "Doing a monthly breast self-exam will help me learn what is normal for me." 3. "It is important to know my maternal health history." 4. "Signs I should not ignore include dimpling of the skin, and nipple discharge." 5. "Self-breast exam should be done a few days before my menstrual cycle begins."

2., & 4. Correct: The purpose of breast self-exam is to determine what is normal. This will allow the client to recognize when there is a change in breast tissue. S/S of breast cancer includes dimpling of the skin, nipple discharge, tenderness, change in appearance, retracted nipple, hard lump and itchy or scaly skin. 1. Incorrect: Clinical breast exams are recommended every 3 years starting at age 20, and every year starting at age 40. 3. Incorrect: Talk to both sides of the family to learn about your family health history. 5. Incorrect: The breast self-exam should be done after the menstrual cycle (day 7-12) for a better exam. The breasts will be too tender just prior to the period. There are 4 parts to breast cancer awareness. 1st - Know your risk by talking to both sides of your family to learn about your family health history. 2nd - Get screened. Have a mammogram every year starting at age 40 if at average risk. Have a clinical breast exam at least every 3 years starting at age 20, and every year starting at age 40. 3rd - Know what is normal for you. See a primary health care provider if any breast changes occur. 4th - Make healthy lifestyle choices. Maintain a healthy weight; Add exercise into routine; Limit alcohol intake; Limit menopausal hormone use; Breastfeed, if possible.

A client's absolute neutrophil count (ANC) is 750/mm3. Which measures should the nurse take to protect the client? Select all that apply 1. Prohibit the client from shaving. 2. Instruct the client to wear a mask when leaving the hospital room. 3. Remove fresh flowers and plants from the client's room. 4. Ask visitors to perform hand hygiene before entering the client's room. 5. Instruct client to avoid flossing of teeth.

2., 3. & 4. Correct: If a client's ANC is less than 1000/mm3, the client is at risk for infection. Instructing the client to wear a mask outside of the hospital room protects the client from infection. The soil in fresh flowers and plants can carry bacteria and fungi, which can cause infection. Performing hand hygiene is the best way to prevent the spread of infection. 1. Incorrect: Not allowing the client to shave would be an appropriate intervention for someone with a low platelet count. 5. Incorrect: Not allowing the client to floss the teeth would be an appropriate intervention for someone with a low platelet count. The client needs good oral care to prevent infections in the mouth.

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? Select all that apply 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2., 3., & 5. Correct. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Observe for color changes in skin, lips, and nail beds and for edema, induration, inflammation, pain and sensory impairment. If they occur, discontinue the procedure and notify the primary healthcare provider. Chilling AEB by shivering can increase metabolism and body needs. 1. Incorrect: Check the client's temperature every 15 minutes. If the client is cooled too quickly, chilling, increased metabolism, and adverse reactions may occur. 4. Incorrect: The blanket will not immediately return to room temperature and will continue to cool the client even after it is turned off. Turning it off shortly before the goal temperature is achieved will prevent altering the client's core temperature beyond the desired outcome. Remember: Well, we know that a cooling blanket is one method used to decrease a client's temperature. Generally, it is reserved for use when the temperature does not decrease with other conservative methods. The blanket is most commonly used to maintain normal temperature during surgery or shock; inducing hypothermia during surgery to decrease metabolic activity and thereby reduce oxygen requirements; reducing intracranial pressure; controlling bleeding and intractable pain in clients with amputations, burns, or cancer. So the key here is to remember safety. We don't want to drop the temperature too rapidly or cause shivering. Shivering increases body metabolism and elevates body temperature.

What should a nurse include when teaching a client diagnosed with shigellosis regarding how to prevent the spread of the infection to others? Select all that apply 1. Wash hands three times a day with alcohol. 2. Do not return to work until authorized by local health department. 3. Do not prepare food for others while you are sick. 4. Avoid swimming until fully recovered. 5. No sex until several days after diarrhea has stopped.

2., 3., 4., & 5. Correct. These are correct actions to prevent the spread of infection. Shigella germs are present in the stools of infected persons while they have diarrhea and for up to a week or two after the diarrhea has gone away. Shigella is very contagious; exposure to even a tiny amount of contaminated fecal matter—too small to see-- can cause infection. Transmission of Shigella occurs when people put something in their mouths or swallow something that has come into contact with stool of a person infected with Shigella. 1. Incorrect. Wash your hands with soap carefully and frequently, especially after using the toilet. Shigellosis is an infectious disease caused by a group of bacteria called Shigella (shih-GEHL-uh). Most who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. Shigellosis usually resolves in 5 to 7 days. Some people who are infected may have no symptoms at all, but may still pass the Shigella bacteria to others. The spread of Shigella can be stopped by frequent and careful handwashing with soap and taking other hygiene measures.

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? Select all that apply 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung. 5. Incorrect: Client tends to lean forward (orthopnea) and uses accessory muscles of respiration to breathe.

The nurse is making an initial homecare visit to a client following a stroke. The client has right arm weakness and a limp in the right leg. While evaluating the client's ability to prepare food, the nurse is most concerned about what actions? Select all that apply 1. Uses skid-proof shoes when walking in kitchen. 2. Pours boiling water from pan into cup of tea. 3. Heats food in microwave instead of the oven. 4. Uses electric chopper to dice up vegetables. 5. Prepares and cooks large casserole in oven.

2., and 5. CORRECT: The nurse is evaluating client safety at home following a stroke, observing for any actions that might be unsafe. With right arm weakness and instability of the right leg, pouring boiling water directly from a pan into a cup is dangerous. Pouring liquid from an open pan could easily spill or splash hot water on the client. Additionally, placing a large, filled casserole into a hot oven could throw the client off balance, again leading to burns. 1. INCORRECT: The nurse would not be concerned about the client using skid-proof shoes, particularly in a kitchen where there could be food or liquids on the floor. This is safe action when cooking food. 3. INCORRECT: Because of physical disabilities, it is safer for the client to use a microwave than the oven. The microwave has a small opening and no overwhelming heat when the door is opened. The smaller plates or bowls used are easier and safer for the client to handle. 4. INCORRECT: An electric chopper is far safer than trying to manage a knife with a weakened hand. Placing vegetables into the chopper and closing the lid prevents the client from being exposed to an open knife blade. There are several clues in the question you must keep in mind. The client has had a stroke which resulted in right arm weakness and ambulation issues because of a right leg limp. There is no indication of actual paralysis or how weak the right arm is, but you realize safety is a huge issue! You also know the client will move slower and a bit unsteady, despite being returned to the home environment. There is no mention of family members available to help, so you cannot assume. Remember the nurse is evaluating whether the client can safely prepare food in the home setting. When you are looking for potential safety hazards in each option, keep in mind the physical limitations of the client.

A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room.

3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.

A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massage the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Acupuncture may provide great improvement in symptoms.

3. Correct: Even though all are educational points that need to be provided to the client, this is the most important point. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 1. Incorrect: Physical therapy will be needed, however care to prevent eye injury takes priority. 2. Incorrect: This can be done once the client's facial sensitivity to touch decreases and the client can tolerate touching the face. Preventing eye injury takes priority. 4. Incorrect: Acupuncture may provide a potential small improvement in function. The priority however, is protection of the eye.

The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.

3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first. 1. Incorrect: Administration of 500 mL of fluid over one hour is possible if the client were in shock. The stem of the question, however, does not indicate this client is in shock. 2. Incorrect: Monitoring BUN and creatinine does not help identify diabetes insipidus. 4. Incorrect: Decadron can cause fluid retention, not increased urinary output.

Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? 1. Reduction of anxiety 2. Referral to community resources 3. Identification of lifestyle changes 4. Verbalization of energy-conservation techniques

3. Correct: On admission, the best starting point is to survey what is good and what needs to be changed. 1. Incorrect: No, people need some anxiety to change. 2. Incorrect: Not yet.This may be done, but it is not the most important thing right now. 4. Incorrect: For cardiac rehab we want to exercise, not conserve, at this point. Conserving energy is for times of hypoxia or angina.

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Midabdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea

3. Correct: Pain in the lower left quadrant with abdominal rigidity indicates the client is experiencing a perforated diverticuli and is a medical emergency. Abdominal rigidity indicates either perforation or internal bleeding. Both of these symptoms are considered an "acute abdomen" and are emergencies. 1. Incorrect: Midabdominal pain radiating to the shoulder is a common s/s for a client with cholecystitis but is not a medical emergency. 2. Incorrect: Nausea and vomiting periodically for several hours is often seen with diverticulitis but is not a medical emergency. 4. Incorrect: Elimination pattern of constipation alternating with diarrhea indicates a partial bowel obstruction and may require further investigation, but this is not a medical emergency. Diverticulitis is defined as an inflammation of one or more diverticula, which are small pouches created by herniation of the mucosa into the wall of the colon. The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Presenting signs/symptoms include: left lower quadrant pain; change in bowel habits; nausea and vomiting; constipation; diarrhea; flatulence; bloating.

While suctioning a client's endotracheal (ET) tube, the nurse notes that the client's heart rate has gone from 78 to 44. The nurse stops suctioning the ET tube. What is the nurse's best action? 1. Deflate the ET tube cuff. 2. Have the client cough several times in a row. 3. Oxygenate the client with 100% oxygen. 4. Notify the primary healthcare provider.

3. Correct: The drop in pulse rate indicates acute hypoxia, which can be caused by suctioning. The nurse should stop suctioning and oxygenate with 100% oxygen. 1. Incorrect: There is no indication to deflate the ET cuff. Routine ET cuff deflation is not recommended. 2. Incorrect: This is a vagal maneuver that can be done to increase parasympathetic tone and decrease the conduction of the electrical impulses to the heart, usually done for treatment of supraventricular tachycardias. 4. Incorrect: The primary healthcare provider does not have to be called unless the client does not respond to oxygen.

What is the nurse's priority when preparing a client for a paracentesis? 1. Place client in the prone position. 2. Position the client supine with right arm behind the head. 3. Ask the client to empty bladder. 4. Obtain client's vital signs immediately prior to the procedure.

3. Correct: The nurse knows this is a lower abdominal puncture, and the bladder should be empty to avoid puncturing the bladder. 1. Incorrect: The prone position would completely obstruct the area where the procedure is done. The optimal position for paracentesis is HOB up to allow fluid to pool in one spot for paracentesis. 2. Incorrect: The optimal position for paracentesis is HOB up to allow the fluid to pool in one spot for paracentesis. Supine would put the client at risk for the bladder getting punctured during the procedure. 4. Incorrect: Obtaining a set of vital signs immediately prior to the procedure is important as well, but remember, pick the answer that is most life threatening when answering priority questions. Puncturing the bladder is more life threatening than obtaining vital signs.

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms? Select all that apply 1. Headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse

3., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. When cardiac output goes down, perfusion to the brain goes down. Dyspnea is difficulty breathing. There is a lack of oxygen reaching the lungs. The heart muscle is irritable and leads to arrhythmias. 1. Incorrect: Headaches do not commonly occur with MI. 2. Incorrect: The client having an MI, will develop hypotension and possibly cardiogenic shock due to decreasing cardiac output. Remember, dead tissue doesn't pump well. The skin would be cool and clammy rather than warm, dry, and flushed. If you assume the worse when you see the clue "chest heaviness", what should you think is happening to the client? The client is having an MI. This question wants to know if the test taker can identify additions signs and symptoms of an MI. Keep in mind that not everyone presents with the classic signs and symptoms. Common heart attack symptoms and warning signs may include: Chest discomfort that feels like pressure, fullness, or a squeezing pain in the center of the chest that lasts for more than a few minutes, or goes away and comes back. Pain and discomfort that extend beyond the chest to other parts of the upper body, such as one or both arms, back, neck, shoulder, stomach, teeth, and jaw. Unexplained shortness of breath, with or without chest discomfort, dyspnea and tachypnea. Other symptoms, such as cold sweats, cool and clammy skin, nausea or vomiting, lightheadedness, anxiety, restlessness, indigestion, unexplained fatigue, irregular pulse.

What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? Select all that apply 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches

3., 5., & 6. Correct: Guillain-Barre' Syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It is characterized by ascending, symmetric paralysis affecting the cranial and peripheral nerves. S/S include paresthesia, hypotonia, areflexia, muscle aches, cramps, orthostatic hypotension, hypertension, bradycardia, facial flushing, facial weakness, dysphagia, and respiratory distress. 1. Incorrect: Opisthotonos- Spasm of the muscles causing backward arching of the head, neck, and spine, as in severe tetanus, some kinds of meningitis, and strychnine poisoning. This is seen with tetanus, not with GBS. 2. Incorrect: Seizures can be associated with many neuromuscular problems but are not typical with GBS. Look for seizures with such problems as increasing ICP, infections of the brain, high fever, epilepsy. 4. Incorrect: Hemiplegia, paralysis on one side of the body, is not seen. There is symmetrical paralysis and weakness begins in the feet and progresses upward. The client gets better in reverse order.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins. 1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies. 2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies. 3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies.

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

4. Correct: The blood gases confirm respiratory alkalosis. Why? The pH is 7.49 (normal 7.35-7.45). This pH indicates alkalosis since it is high. Which other chemical says alkalosis? The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. The HCO3 is normal. This means that the client is in respiratory alkalosis. 1. Incorrect: The blood gases confirm respiratory alkalosis. The HCO3 is normal, so the problem is not metabolic. 2. Incorrect: The blood gases confirm respiratory alkalosis. The PaCO2 of 29 (normal 35-45) is low which indicates alkalosis. For this client to be in respiratory acidosis, the PaCO2 would be greater than 45. 3. Incorrect: The blood gases confirm respiratory alkalosis. The HCO3 is normal, so the problem is not metabolic.

A 68-year-old client with a history of angina presents to the emergency department (ED) reporting flu like symptoms progressively worsening over the past 24 hours.What action is most important for the nurse to initiate? CC: "I have the flu. I have been vomiting every couple of hours, running a fever and my chest hurts." V/S: HR - 132 bpm RR - 26 rpm BP - 94/60 mmHg T - 101.3° F orally Capillary refill - 4 sec. Orders: - Rapid Influenza Diagnostic Test - NS 1 L at 250 mL/hour, then NS at 100 mL/hour - Chest X-ray - Acetaminophen 500 mg PO now 1. Administer acetaminophen. 2. Initiate IV of NS at 250 mL/hour. 3. Notify radiology and lab of diagnostic test prescriptions 4. Discuss IV prescription with primary healthcare provider

4. Correct: This client likely has the flu and is dehydrated as evidenced by the rapid heart rate, fever, temperature, BP, and capillary refill. So, the client needs fluid. But did you notice that this client is elderly and has a history of cardiac problems? I hope so, because giving this client NS rapidly could throw our heart client into pulmonary edema, which would be a bad thing! Talk to the primary healthcare provider. 1. Incorrect: Acetaminophen needs to be administered but it is not the most important thing for the nurse to do. Clarification regarding the IV fluid prescription is necessary here to prevent a possible complication. 2. Incorrect: If this client receives an isotonic IV solution at this rapid rate, the client will be at increased risk of developing FVE and pulmonary edema. 3. Incorrect: Again, the radiology and lab departments can be notified of the test prescriptions to be completed. However, the nurse can assign this task to the unit secretary.

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

In systolic heart failure, the left ventricle becomes weak and can't contract and work the way it should. 2., 3. & 6. Correct: Normal CVP is 2-6 mm Hg. This CVP is within normal range so treatment is effective. Weight loss indicates that fluid is being removed and a urine output of 50mL/hour indicates that renal perfusion is adequate. All three assessents indicate improvement. 1. Incorrect: 3+ pedal edema would indicate that the client is not better. 4. Incorrect: Purse-lip breathing is seen when client is still short of breath. 5. Incorrect: Pale conjuctiva, nail beds, buccal mucosa are signs of impaired gas exchange.

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. Client's tracheostomy needs to be suctioned. The water seal chamber is empty in a client's closed chest drainage unit. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria. UAP reports a heart rate of 40/min in a client.

The client with the highest need is the client who has a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. The next client to be seen is the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can create a breathing problem. The purpose of the water seal chamber is to allow air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. The fourth client to be seen is the client on bedrest for a DVT. If the client gets up and ambulates, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented.

A nurse is educating a group of community citizens about risk factors for developing peripheral neuropathy. Which risk factors should the nurse include? Select all that apply 1. Uncontrolled diabetes 2. Alcohol abuse 3. Vitamin A deficiency 4. Rheumatoid arthritis 5. Varicella-zoster virus

The peripheral nervous system connects the nerves from the brain and spinal cord to the rest of the body. This includes the arms, hands, feet, legs, internal organs, mouth, and face. The job of these nerves is to deliver signals about physical sensations back to the brain. Peripheral neuropathy is a disorder that occurs when these nerves malfunction because they're damaged or destroyed. This disrupts the nerves' normal functioning. They might send signals of pain when there's nothing causing pain, or they might not send a pain signal even if something is causing pain. There are three types of peripheral nerves: sensory nerves, which connect to the skin; motor nerves, which connect to muscles; and autonomic nerves, which connect to internal organs. Peripheral neuropathy can affect one nerve group or all three. 1., 2., 4. & 5. Correct: All are risk factors for peripheral neuropathy. Glucose fluctuations kill nerves. We said alcohol abuse leads to poor eating which means the client does not have enough of their B vitamins which can cause neuropathy. Deficiencies of vitamins E, B-1, B-6, and B-12, are essential to nerve health and functioning. Rheumatoid arthritis is an autoimmune disorder that is characterized by inflammation, pain, and loss of function in the joints. The most common neurologic manifestation of RA is a mild, primarily sensory peripheral neuropathy, usually more marked in the lower extremities. Shingles (from the varicella-zoster virus) occurs along peripheral nerve lines and can damage those nerves resulting in neuropathy. 3. Incorrect: Vitamin A deficiency can result from inadequate intake, fat malabsorption, or liver disorders. Deficiency impairs immunity and hematopoiesis and causes rashes and typical ocular effects (e.g., xerophthalmia, night blindness). Vitamin B deficiency can cause peripheral neuropathy.

A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately? BP 90/40 HR 125 RR 30 and labored + jugular venous distention (JVD) subcutaneous emphysema noted to right shoulder area Select all that apply. 1. Apply occlusive dressing to chest. 2. Initiate large gauge IV line. 3. Prepare for chest tube placement. 4. Administer high flow oxygen. 5. Position client on right side.

There are several indications that this trauma client sustained a severe injury to the heart or lungs, such as jugular vein distention, elevated respiratory rate in the presence of low blood pressure, and sub-Q emphysema. The client most likely has a tension pneumothorax. 2., 3. & 4. Correct: Based on the assessment data recorded by the nurse, the client most likely has a tension pneumothorax secondary to blunt force trauma from the fall. Immediate actions must focus on preventing tracheal deviation and a fatal outcome. The need for intravenous fluids and medications in any trauma requires at least one large bore IV line or more. This client will need immediate chest tube placement to relieve increasing intrathoracic pressure. While preparing the client for this procedure, high-flow oxygen should be administered via nonrebreather mask because of the client's respiratory distress. 1. Incorrect: There is no indication in the question of an open chest wound, or that a dressing is needed. The occlusive chest dressing will be placed over the insertion site of the chest tube after placement is completed. 5. Incorrect: This trauma client will be secured to a back board, most likely with a cervical collar in place, until x-rays confirm there has not been a cervical spine injury. Placing the client on the right side is counterproductive and in fact could further impair respiratory efforts.

The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. What should be the nurse's first action? 1. Defibrillate at 200 joules x 2 2. Administer amiodarone IV 150 mg over 10 minutes 3. Infuse 500 mL NS with 40 mEq KCL (40 mmol/L) at 100 mL/hour 4. Begin 2 person cardiopulmonary resuscitation

What electrolyte should the nurse worry about when these clues are seen? Low potassium. The client has been vomiting, so the electrolytes losses are potassium, hydrogen, and chloride. The anorexia further complicates the condition because we get potassium from the foods we eat. Knowing this, you would be concerned that ventricular tachycardia or ventricular fibrillation could occur. 2. Correct: The one electrolyte we worry about with arrhythmias is potassium. The first line medication is amiodarone. 1. Incorrect: Pulseless v-tach and v-fib require defibrillation. 3. Incorrect: KCL is needed but we need to treat the short run of v-tach first. 4. Incorrect: Not indicated. Treat short run of v-tach and increase potassium.

What is the nurse's first priority when treating a client with a chemical burn? 1. Attach client to a cardiac monitor. 2. Apply a sterile bandage. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing.

What is a chemical? A form of matter that causes irritation and destruction to human tissue by direct contact with the substance or from the fumes. So what should be the nurse's first priority when there is a substance on the body that can burn? 3. Correct: The first action in treating a chemical burn is to rinse the affected area with large amounts of cool water. 1. Incorrect: This is necessary with electrical burns. 2. Incorrect: This may come later, not first priority. 4. Incorrect: This can be accomplished while you are rinsing them with water.

Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? Select all that apply 1. Bradypnea 2. Flaccid muscle tone 3. Flushed and warm skin 4. Positive Trousseau's sign 5. Leg cramps 6. Decreased deep tendon reflexes

With post radical neck surgery, the nurse should worry about bleeding and accidental parathyroid removal. When parathyroids are removed, the PTH goes down, which means that serum calcium will go down. When calcium level drops, muscles become rigid and tight. 4., & 5. Correct: A positive Trousseau's sign indicates that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia. Hypocalcemia will cause muscle twitching and painful muscle cramps. 1. Incorrect: The respiratory rate will decrease with hypermagnesemia and hypercalcemia. 2. Incorrect: Weak, flaccid muscle tone is seen with hypercalcemia. 3. Incorrect: Flushed and warm skin would be seen with hypermagnesemia due to vasodilation. 6. Incorrect: Decreased deep tendon reflexes would occur with hypermagnesemia or hypercalcemia.