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Archer Review Missed Questions

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The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply. A. "Battery is an intentional touching of another's body without the other's consent." B. "Assault is when the nurse makes a verbal or physical threat." C. "Unintentional torts include negligence and malpractice." D. "Defamation is presenting false credentials for employment." E. "Occurrence reports reduce the liability for a negligent tort."

A. "Battery is an intentional touching of another's body without the other's consent." B. "Assault is when the nurse makes a verbal or physical threat." C. "Unintentional torts include negligence and malpractice." Assault is a threat or an attempt to do bodily harm. This may include verbal or gestures intended to cause intimidation. Battery is intentionally touching another's body without the other's consent. An example of assault is threatening to give a client an injection without the client's consent; if the nurse gives the injection, this would be battery. Unintentional torts, including negligence or malpractice.

The nurse is teaching a client who is breastfeeding and has developed mastitis. Which of the following statements by the nurse would be appropriate to make? Select all that apply. A. "Continue to breastfeed your child normally." B. "Empty each breast at each feeding." C. "Complete the entire course of the prescribed antibiotic." D. "Wear a supportive bra without an underwire." E. "Wean breastfeeding during the infection."

A. "Continue to breastfeed your child normally." B. "Empty each breast at each feeding." C. "Complete the entire course of the prescribed antibiotic." D. "Wear a supportive bra without an underwire." It is essential to educate mothers with mastitis to continue breastfeeding. The infection will not be passed to their child, and they do not need to worry about adverse effects on their infants. The clogged milk ducts should become unclogged by continuing to breastfeed, and mastitis should improve. The client should be instructed to empty the breast completely at each feeding. Further, the prescribed antibiotic should be continued until it is gone (usually 7-10 days). Wearing a supportive bra but one without an underwire is appropriate educational advice for a mother with mastitis. The support will help with the pain and tenderness in the breasts, but an underwire could cause clogged milk ducts, so it should be avoided.

The nurse is performing an assessment on a client who is suspected of having preeclampsia. Which question would be appropriate for the nurse to ask to determine if the client has preeclampsia? A. "Does the light bother you?" B. "Are you having any back aches?" C. "Are you having any vaginal discharge?" D. "Are you noticing any bleeding in your gums?"

A. "Does the light bother you?" Targeting an assessment to a client who is suspected of having preeclampsia would include questions such as "Does the light bother you?" because headache and photosensitivity are clinical manifestations associated with this condition. Other pertinent questions that are useful in determining if the client may have preeclampsia include - "Do you have any abdominal pain?" as severe preeclampsia may cause epigastric pain. "Is your vision blurred?" as blurred vision may support a diagnosis of preeclampsia.

The nurse is teaching a group of students about renal disorders. Which statement, if made by the student, requires follow-up? Select all that apply. A. "Pyelonephritis causes a client to have massive amounts of proteinuria." B. "Acute kidney injury may be caused by nephrotoxic medications." C. "Bacterial cystitis is diagnosed using a 24-hour urine collection." D. "Polycystic kidney disease may cause hematuria after a cyst rupture." E. "Diabetic nephropathy is prevented by increasing the hemoglobin A1C."

A. "Pyelonephritis causes a client to have massive amounts of proteinuria." C. "Bacterial cystitis is diagnosed using a 24-hour urine collection." E. "Diabetic nephropathy is prevented by increasing the hemoglobin A1C." These statements are not accurate and do require further teaching from the nurse. Acute pyelonephritis is a consequence of untreated cystitis. This produces symptoms similar to cystitis in addition to manifestations of flank pain, fever, and dehydration. Massive amounts of proteinuria are a classic manifestation associated with nephrotic syndrome. A 24-hour urine collection is not necessary to diagnose bacterial cystitis. A simple single specimen, urine analysis (UA), would be evaluated to determine if the client has cystitis. Diabetic nephropathy can be prevented by tight glycemic control reflected in the hemoglobin A1C. The higher the A1C equates to more complications such as diabetic nephropathy.

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include? A. "You will need to lay flat immediately after this procedure." B. "A heating pad will be applied to the affected area for pain relief." C. "Before you eat, your gag reflex will need to return." D. "You can resume your regular activities and diet right after the procedure."

A. "You will need to lay flat immediately after this procedure." A percutaneous kidney biopsy will be required to lay supine immediately following the procedure to achieve and maintain hemostasis. A back roll may be used to provide additional support.

The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for compartment syndrome is the client who has which of the following? A. A left tibial fracture that was recently placed in a cast B. Swelling in the ankles and is wearing compression stockings C. Chronic osteomyelitis of the right femur D. Skin traction following a left hip fracture

A. A left tibial fracture that was recently placed in a cast A client who recently had a fracture and cast is at high risk of compartment syndrome. The recent fracture causes swelling, which can be enclosed by the cast. Orthopedic fractures are a significant risk factor for compartment syndrome.

The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision? A. Adjust the physician's order based on the client's pain level B. Ensure naloxone is always available C. Check the client's blood pressure before administering morphine sulfate D. Provide a high-fiber diet

A. Adjust the physician's order based on the client's pain level Pain medication orders may be titrated based on the client's pain level. However, the nurse cannot adjust the physician's order based on the client's pain level. If the nurse wants to adjust the dosage, the nurse will need the physician to adjust the prescription. This needs to be revised because it is inappropriate, as the nurse cannot unilaterally adjust a physician's order.

The nurse is caring for a client with acute pulmonary edema. The nurse plans to take which actions? Select all that apply. A. Administer prescribed furosemide B. Elevate the head-of-the-bed to 60 degrees C. Obtain a STAT chest computed tomography (CT) scan D. Notify the Rapid Response Team (RRT) E. Provide oxygen via nasal cannula F. Administer prescribed morphine

A. Administer prescribed furosemide D. Notify the Rapid Response Team (RRT) F. Administer prescribed morphine Acute pulmonary edema is a medical emergency and requires the nurse to act immediately. The nurse should administer the prescribed treatments of morphine and furosemide. Morphine will curb the client's anxiety and decrease the amount of fluid returning to the heart (preload). Furosemide will be administered to deplete the excessive fluid volume. Further, the nurse must stay with the client, call for help, and notify the rapid response team.

The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply. A. As needed (PRN) medications that were administered B. Normal assessment findings for the shift C. Normal laboratory results D. Scheduled medications that were administered E. Abnormal vital signs

A. As needed (PRN) medications that were administered E. Abnormal vital signs Medications administered as needed should be included in the nursing handoff and abnormal vital signs. Nursing handoffs should accurately and quickly review the client's condition during the past shift. As needed, medications are administered for a change in the client's condition, and abnormal vital signs will require follow-up.

The nurse observes a client clutching her abdomen and complaining of cramping, which is accompanied by sharp pain. Which of the following types of pain is the client experiencing? A. Cutaneous or superficial somatic B. Visceral C. Deep somatic D. Radiating

A. Cutaneous or superficial somatic Cutaneous or superficial somatic pain originates from the skin or underlying tissues. It is often described as sharp, localized, and easily pinpointed. The client's behavior of clutching the abdomen and describing the pain as sharp aligns with the characteristics of cutaneous or superficial somatic pain. This type of pain is often well-defined and easily identifiable by the client, matching the description provided. Physical pain is either nociceptive or neuropathic. These two types of pain differ in the way they affect the client as well as in how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to stimuli that are potentially damaging, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur as a result of trauma, surgery, or inflammation. Two types of nociceptive pain are visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue).

The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply. A. Decreased pain B. Increased urinary output C. Decreased blood pressure D. Decreased temperature E. Increased muscle coordination

A. Decreased pain D. Decreased temperature Ketorolac is a medication used to treat pain and pyrexia. A client exhibiting a decrease in pain and having a decrease in temperature would be a therapeutic response.

You are assigned to take care of a client who just underwent a cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client? Select all that apply. A. Deep inspiration. B. Supine position with the head end of the bed elevated. C. Change position every 2 hours. D. Encourage the patient to cough at least 10 times/hr. E. Encourage use of incentive spirometry

A. Deep inspiration. B. Supine position with the head end of the bed elevated. C. Change position every 2 hours. D. Encourage the patient to cough at least 10 times/hr. E. Encourage use of incentive spirometry Atelectasis is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/impaired oxygenation. Post-operatively, the client may not be able to take deep breaths due to pain from the movement of abdominal muscles. This impaired expansion of the alveoli leads to the accumulation of secretions/mucus plug, decreased surfactant, as well as the obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis. Such interventions include: Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry (Choice E). An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli. Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm. Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs. Encouraging the client to

The nurse is caring for a pregnant client who has an order to be on partial bed rest with bathroom privileges. The nurse understands that the side effects of this order can include: Select all that apply. A. Deep vein thrombosis B. Fetal demise C. Alterations in mood D. Undesirable weight gain E. Decreased bone density

A. Deep vein thrombosis C. Alterations in mood D. Undesirable weight gain E. Decreased bone density Prolonged bed rest can result in deep vein thrombosis (Choice A), alterations in mood due to stress and anxiety (Choice C), and undesirable weight gain (Choice D) due to inactivity. Although bed rest is not ordered often, the nurse must understand that compression stockings and ankle exercises might be requested to prevent DVT. The client should have an opportunity to talk about their feelings related to the bedrest. The nurse should consult the nutritionist to work with the client and obstetrician to ensure a healthy diet that takes into account the decreased activity. Prolonged bed rest can lead to decreased bone density(Choice E), which can increase the risk of osteoporosis.

The emergency department nurse is caring for an older adult with altered mental status Nurses' Notes 83-year-old female was brought in by her family for 'not acting right.' Over the past two days, the family reports that she has not eaten as much, become forgetful, and experienced urinary incontinence described as 'foul-smelling.' She is currently managed with insulin for her type II diabetes mellitus, and the family reports high blood glucose levels despite her not eating. The family reports that her blood glucose was 155 mg/dL, obtained before arrival. The family reports that her baseline is alert and fully oriented. The family states the symptoms started abruptly. The client is alert and only oriented to person and place. She has a degree of speech latency and perseveration. She repeats phrases such as 'It is burning, it burns!'. The client's skin appears dry, flaky, and warm—sunken eye appearance. Skin ten

A. Dehydration The clinical manifestations of a sunken eye appearance, dry skin, and skin tenting all indicate dehydration. The dehydration is also a causative factor of the client's likely bacterial cystitis. The client's glucose is elevated but not concerning because it is not hyperglycemia, representing more of a concern. The client's irregular pulse and limited mobility are all chronic problems and do not explain the clinical findings of dehydration.

A. Dehydration C. Cystitis D. Delirium The client is most likely experiencing dehydration, evidenced by skin tenting, sunken eye appearance, and dry skin. Cystitis is also a likely problem because of the client's altered mentation, sudden urinary incontinence, and complaints of burning. Delirium is a final problem that is associated with cystitis. This problem is evidenced by the client's abrupt onset of confusion and speech alterations. Dementia has an insidious onset - not abrupt. Diabetic ketoacidosis is not a problem because the client is not hyperglycemic (clinical hyperglycemia is a blood glucose of 250 mg/dL or greater). Finally, atrial fibrillation with rapid ventricular response is excluded because the pulse rate is normal.

You are performing a thorough assessment of a client to determine all responses to stress. Which of the following are examples of cognitive responses to stress? Select all that apply. A. Difficulty concentrating B. Poor judgment C. Depression D. Forgetfulness E. Lethargy F. Aggressiveness

A. Difficulty concentrating B. Poor judgment D. Forgetfulness These are examples of cognitive responses to stress. Psychological responses are both emotional and cognitive. They include feelings, thoughts, and behaviors. Emotional responses usually involve anxiety, fear, anger, and depression; whereas, cognitive responses affect thought processes.

A. Disorientation E. Urinary incontinence The nurse is concerned about the acute problems: the client's abrupt onset of disorientation and urinary incontinence. This suggests infection for older adults because older adults with cystitis often experience delirium. The rest of the problems the client has are chronic. The client's glucose is elevated but is not clinical hyperglycemia (hyperglycemia is a blood glucose of 250 mg/dL or greater). The client's irregular pulse coincides with the history of atrial fibrillation, which is rate controlled according to the client's vital signs.

The nurse explains the quad screen test to her prenatal client in the second trimester. Which of the following conditions can be detected by the quad screen test? Select all that apply. A. Down syndrome B. Tay-Sachs disease C. Spina bifida D. Cystic fibrosis E. Abdominal wall defects

A. Down syndrome C. Spina bifida E. Abdominal wall defects The quad screen, or quadruple marker test, is done in the second trimester of pregnancy and includes measuring levels of AFP, HCG, estriol, and inhibin A. The clinician uses this test to evaluate the chance of carrying a baby with genetic abnormalities such as Down syndrome (choice A), trisomy 18, and spina bifida (choice C). Gastroschisis or omphalocele are birth defects that affect the abdominal wall (choice E). A quad screen test can also diagnose these abdominal conditions if an ultrasound during the first trimester was not performed or is inconclusive. As DNA screening improves, that diagnostic method might be used instead of the quad screen.

The nurse is admitting a client who has cryptococcosis pneumonia. Which of the following actions would be appropriate for the nurse to take? A. Ensure a hand sanitizing station is near the client's room. B. Wear a surgical mask when working within three feet of the client. C. Keep the door to the client's room always closed. D. Place the client in a private room with monitored negative airflow.

A. Ensure a hand sanitizing station is near the client's room. Cryptococcosis pneumonia is a fungal infection not transmitted from human to human. Rather, this infection is opportunistic for individuals who are significantly immunocompromised. Standard precautions are necessary, which involve appropriate hand hygiene.

The nurse is performing a physical assessment on a child admitted with erythema infectiosum (Fifth disease). Which of the following would be an expected finding? Select all that apply. A. Erythema on face B. Headache C. Nuchal rigidity D. Hepatosplenomegaly E. Photophobia

A. Erythema on face B. Headache Erythema infectiosum (Fifth disease) characteristically causes a child to develop erythema on the face (slapped face appearance). It also causes the appearance of maculopapular red spots distributed on the upper and lower extremities. Finally, the client will have mild flu-like symptoms such as a fever, headache, and malaise.

The nurse is assessing a client with pheochromocytoma. Which of the following would be an expected finding? Select all that apply. A. Hyperglycemia B. Hypertension C. Ataxia D. Oliguria E. Headache

A. Hyperglycemia B. Hypertension E. Headache Manifestations of pheochromocytoma include hyperglycemia, hypertension, and headache. Other features associated with this condition include weight loss, anxiety, and palpitations.

The nurse reviews the pathophysiology of burns with students. It would be correct to state which hormone alterations occur during a major burn. Select all that apply. A. Increased secretion of epinephrine B. Increased secretion of antidiuretic hormone (ADH) C. Increased secretion of aldosterone D. Decreased levels of glucose E. Increased secretion of norepinephrine

A. Increased secretion of epinephrine B. Increased secretion of antidiuretic hormone (ADH) C. Increased secretion of aldosterone E. Increased secretion of norepinephrine Increased epinephrine levels are secreted during a major burn to reduce bleeding and fluid loss. Antidiuretic hormone is released in high levels to reduce bleeding and fluid loss. Aldosterone, released by the adrenal cortex, is released at high levels to reduce fluid loss. Aldosterone causes sodium retention (which in turn causes water retention) and potassium elimination. The adrenal glands release norepinephrine in response to a major burn, which causes vasoconstriction, thereby increasing fluid and blood volume.

The nurse is assessing a 9-month-old infant in the clinic. Which of the following findings requires follow up? Select all that apply. A. Infant sitting up with mom's support B. Infant is rolling over from front to back. C. Infant holds a cube and closes fingers around it. D. Infant cannot bring toys to their mouth. E. Infant's weight has just doubled since birth. F. Infant cries when handed to the nurse.

A. Infant sitting up with mom's support D. Infant cannot bring toys to their mouth. E. Infant's weight has just doubled since birth. This finding requires follow-up. At 7 months old, the infant should be able to sit up without any support. This milestone is a gross motor skill that should be achieved around 6 to 8 months. So at 9 months old, if the infant still requires help from mom to sit up, this needs to be further evaluated. This finding requires follow-up. At 4 months of age, the infants should have developed the fine motor skill of bringing objects to their mouths. This is an important way that infants explore the world around them, and it is not normal for a 9-month-old infant to not be able to bring toys up to their mouth. The nurse should follow up on this finding, as it is abnormal. This finding requires follow-up. By 5-6 months, the infant should weigh approximately double their weight at birth. If the infant's weight has only doubled by 9 months, it would require further evaluation.

The nurse in the medical-surgical unit is caring for a 23-year-old female client. History And Physical Client was admitted directly from the physician's office, where she reported fever, chills, headache, dyspnea, and overall malaise for the past three days. She reports pleuritic chest pain that is worse when she coughs. The onset of symptoms was three days ago and has worsened. Her fever has become so bad that she says at night she can never stay dry because of the intensity of the night sweats. She has a negative medical history but does have a remote history of using IV drugs. However, she reports she recently restarted because her anxiety has intensified, and she does not know "how to cope." She said her roommate had influenza three weeks ago and usually gets the influenza vaccine but decided against it this year because she had a lapse in health insurance. She smokes cigarettes daily and denies drinking alcoho

A. Infective Endocarditis. The client is at risk for infective endocarditis (IE). The client's history of intravenous drug use is a significant risk factor for IE. The manifestations also support this finding of IE (fever, cardiac murmur, night sweats, and petechiae). While the client did not receive their influenza vaccine, their manifestations do not suggest influenza because petechiae and murmur are not found in influenza. Pulmonary tuberculosis is excluded because cardiac murmur and petechiae are unrelated to TB.

The nurse is caring for a client experiencing a tonic-clonic seizure. Which of the following medications should the nurse be prepared to administer? A. Lorazepam B. Phenytoin C. Carbamazepine D. Benztropine

A. Lorazepam Lorazepam is a benzodiazepine that acts as an anticonvulsant. It is often used as a first-line medication to abort prolonged or status epilepticus seizures, including tonic-clonic seizures. Lorazepam has a rapid onset of action and can be administered intravenously or intramuscularly in emergency situations to quickly terminate the seizure.

The home health nurse is assessing a client with suspected carbon monoxide poisoning. The nurse should take which priority action? A. Move the client outdoors B. Notify the primary healthcare provider (PHCP) C. Auscultate the client's lung sounds D. Assess the client's pulse oximetry

A. Move the client outdoors Carbon monoxide poisoning is a serious emergency that is often fatal if not promptly treated. This medical emergency requires the client to be immediately relocated away from the carbon monoxide. Moving the client outside is effective because of the fresh air. Once this has been completed, the nurse should notify the PHCP or call emergency medical services (EMS) for further treatment. Another priority treatment is providing the client with 100% high-flow oxygen regardless of their pulse oximetry, lung sounds, or arterial blood gas results.

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply. A. Nausea and vomiting B. Constipation C. Pruritus D. Urinary retention E. Nystagmus

A. Nausea and vomiting B. Constipation C. Pruritus D. Urinary retention Fentanyl is an opioid analgesic used to manage acute and chronic pain. Common effects associated with this drug include nausea and vomiting, constipation, pruritus, and urinary retention.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing ovarian cancer? Select all that apply. A. Nulliparity B. Advancing age C. Family history D. Herpes simplex virus (HSV) E. Early menarche

A. Nulliparity B. Advancing age C. Family history E. Early menarche Risk factors for ovarian cancer include nulliparity, advancing age, family history, and early menarche.

The emergency department (ED) nurse cares for a client with a suspected cerebrovascular accident (CVA). Which actions should the nurse take? Select all that apply. A. Perform a Glasgow coma scale (GCS) B. Assess the client's capillary blood glucose (CBG) C. Prepare the client for an immediate computed tomography (CT) scan of the brain D. Insert a nasogastric tube (NGT) E. Determine the onset of the symptoms or the last known well (LKW)

A. Perform a Glasgow coma scale (GCS) B. Assess the client's capillary blood glucose (CBG) C. Prepare the client for an immediate computed tomography (CT) scan of the brain E. Determine the onset of the symptoms or the last known well (LKW) Early interventions for a client suspected of having a CVA is performing a focused neurological assessment, including a GCS (choice A). An NIH stroke scale is also performed. A capillary blood glucose is also performed to rule out hypoglycemia, as hypoglycemia manifestations (drowsiness, slurred speech) may mimic stroke manifestations (choice B). There are two types of stroke - ischemic or hemorrhagic. The management differs based on the type of stroke. An ischemic stroke may be treated with thrombolytic therapy, whereas thrombolytics are contraindicated in a hemorrhagic stroke. An immediate head CT scan, without contrast, is initially performed to exclude a hemorrhagic stroke (choice C). Later diagnostic testing includes a CT angiogram and magnetic resonance imaging (MRI). It is important to discern when the client's symptoms started (choice E). The last known well time (LKW) refers to the date and time at which the client was last known to be without the signs and symptoms of the present stroke. This information is critical for determining the client's eligibility for thrombolytic therapy (tPA) in an acute ischemic CVA. If tPA is prescribed, it must be within 4.5 hours following the onset of symptoms.

The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. A. Presbycusis B. Ototoxic substance C. Foreign body D. Exposure to loud noise E. Edema

A. Presbycusis B. Ototoxic substance D. Exposure to loud noise These are all risk factors for sensorineural hearing loss. Presbycusis is progressive and irreversible hearing loss that is often associated with aging. Ototoxic substances (gentamycin, vancomycin) may also induce sensorineural hearing loss. Exposure to loud noise is a pointed risk factor because this causes damage to the hair cells of the cochlea.

The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up? A. Pulse 112/minute B. Nausea and vomiting C. Respiratory rate 21/minute D. Blood glucose 299 mg/dL

A. Pulse 112/minute A complication associated with DKA is hypovolemic shock. The client having tachycardia is demonstrating early signs of this type of shock. The treatment modalities of DKA include fluid repletion and insulin administration. Considering the client's tachycardia, the nurse should initially administer the prescribed isotonic fluids to treat the significant fluid volume deficit.

Which of the following are components of the definition of critical thinking? Select all that apply. A. Reasoned thinking B. Openness to alternatives C. Adherence to established guidelines D. Ability to reflect E. Loyalty to traditional approaches F. Desire to seek the truth

A. Reasoned thinking B. Openness to alternatives D. Ability to reflect F. Desire to seek the truth Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth. There are many definitions of critical thinking. It is a complex concept and people think about it in different ways. Any situation that requires critical thinking is likely to have more than one "right" answer. You do not need critical thinking to add 2 + 2 and come up with the solution. However, you do need critical thinking to problem-solve essential decisions. A crucial aspect of critical thinking is the process of identifying and checking your assumption. This is also a necessary part of the research process. Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth.

The nurse is performing a home visit for the parents of an infant. Which action by the parents while giving the infant a sponge bath requires follow-up by the nurse? A. Removes all of the infant's clothing for the bath B. Uses a mild soap for the bath C. Provides the bath in a warm room D. Washes and dries one part of the baby's body at a time

A. Removes all of the infant's clothing for the bath This action requires follow-up because it is incorrect. Only the area that is being washed should be uncovered to prevent the infant from getting cold during a sponge bath. Removing all the clothing articles would expose the infant, lowering their temperature.

The nurse is assisting a client to pick out food options appropriate for Dumping Syndrome. Which food items would be appropriate to select? Select all that apply. A. Rice cereal B. Pastries C. Chicken breast D. Cola E. Scrambled eggs

A. Rice cereal C. Chicken breast E. Scrambled eggs Dumping syndrome is characterized by rapid peristalsis, especially with foods that are simple carbohydrates (refined sugars). Rice cereal, chicken breast, and scrambled eggs reflect foods that are not simple carbohydrates. Foods recommended for clients with dumping syndrome include complex carbohydrates, high protein, and high fiber.

The nurse is conducting a community health course. Which of the following would be an example of secondary prevention? A. Sexually transmitted disease (STD) partner notification B. Human immunodeficiency virus (HIV) PrEP pre-exposure prophylaxis C. Reviewing safe food-handling practices in the home. D. Cardiac rehabilitation following a heart attack

A. Sexually transmitted disease (STD) partner notification Secondary prevention involves both screening and early intervention. Specifically, secondary prevention aims to stop the progress of the disease (or disorder) by early detection and treatment, thus reducing prevalence and chronicity. Notifying sexual partners about a confirmed sexually transmitted infection is a form of secondary prevention as it is an early intervention to prevent the spread.

The nurse is assessing an infant who is 9 months old. Which of the following would be an expected age-related finding? Select all that apply. A. Sitting without support B. Rolling over C. Standing without support D. Taking their first steps E. Walks unsupported

A. Sitting without support B. Rolling over Sitting without support is a gross motor skill that should be developed by 8 to 9 months. Indeed, a 9-month-old infant should already be able to sit up without support. If they have not yet met this milestone by 9 months of age, follow-up is warranted to evaluate the infant further. They may miss other milestones and need help, such as physical therapy. Rolling over is a milestone that should be developed in a 9-month-old infant. Rolling completely over should be accomplished by the time the infant is six months old. If they have not met this milestone by nine months of age, follow-up is warranted to evaluate the infant further. They may miss other milestones and need help, such as physical therapy.

When caring for an Amish patient, what does the nurse know to be true? Select all that apply. A. They use traditional and alternative health care. B. Funerals are conducted in the home. C. The authority of women and men are equal. D. Many choose to live without health insurance. E. Health is believed to be a gift from God.

A. They use traditional and alternative health care. B. Funerals are conducted in the home. D. Many choose to live without health insurance. E. Health is believed to be a gift from God. Amish live a life that is generally strictly separate from society. While women are highly respected and valued, men hold the authority in the home. Traditional and alternative health care is appreciated, although many live without insurance. Health is believed to be a gift from God.

A. Urine analysis B. Insertion of peripheral vascular access C. Fall precautions E. Complete metabolic panel (CMP) A urine analysis is necessary to determine if the client is experiencing cystitis. Rehydrating the client is also essential, so inserting a peripheral vascular access device would be appropriate. The risk of falls and injury cannot be ignored because the client is delirious. Thus, fall precautions should be instituted. Finally, a CMP would be necessary to determine if the client has any electrolyte imbalances which may coexist with dehydration. Serum ketones are not necessary because the client is not hyperglycemic. The client has no manifestations of meningitis, and an LP would be unnecessary. IV furosemide would be contraindicated because the client is already dehydrated, and this medication would make it worse. An EEG would be indicated for any unexplained seizure activity or to exclude certain neurological disorders such as epilepsy. The client's altered mental status is related to delirium linked to cystitis.

The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)? A. WBC 19,000 mm3 [5,000-10,000 mm3] B. Hemoglobin 9 g/dL [Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)] C. Calcium 8.6 mg/dL [9.0-10.5 mg/dL] D. Serum pH 7.33 [7.35-7.45]

A. WBC 19,000 mm3 [5,000-10,000 mm3] Leucocytosis (predominantly neutrophilic) suggests infection in a client on peritoneal dialysis. The most significant complication with peritoneal dialysis is peritonitis. During peritoneal dialysis, the peritoneum is used as the dialyzing membrane, and the dialysate is infused through a catheter tunneled into the peritoneum. Maintaining a sterile technique is essential during peritoneal dialysis. Infection of the peritoneum (peritonitis) may occur due to contamination by touch during exchanges (by pathogenic skin bacteria) or due to an exit-site catheter infection. Peritonitis symptoms include fever, abdominal rigidity, purulent effluent, and nausea/vomiting. Cloudy outflow (into the drainage bag) is one of the earliest signs of peritonitis associated with peritoneal dialysis.

The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply. A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. B. Obtains orthostatic blood pressure by having the client stand first. C. Places the cane on the unaffected side of a client who had a stroke. D. Provides a hot foot soak for a client with diabetes mellitus. E. Obtains a urine culture from an indwelling urinary catheter.

A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. B. Obtains orthostatic blood pressure by having the client stand first. D. Provides a hot foot soak for a client with diabetes mellitus. E. Obtains a urine culture from an indwelling urinary catheter. When supervising a UAP, the nurse should intervene if the UAP is flexing and extending the client's elbow, as that is not an active range of motion. The UAP doing the exercise for the client would be considered a passive range of motion. The UAP starting the orthostatic vital signs with the client standing is inappropriate. When obtaining orthostatic blood pressure, the correct sequence is supine, sitting, and standing. During the orthostatic vitals, the observer looks for a drop in blood pressure when the client stands up from a lying or sitting position. Neuropathy is a common manifestation in diabetic clients. Loss of sensation in the feet resulting from diabetic neuropathy may impair the client's ability to remove the feet despite the heat damage. A client with diabetes mellitus should not have feet soaked in hot water, which could impair their skin integrity and cause ulceration. Finally, UAPs may not perform any tasks involving sterility. When obtaining a urine culture from an indwelling urinary catheter, the distal tubing needs to be clamped, and a sterile syringe will then need to be used to aspirate urine from the cleaned port. Any task involving sterility cannot be delegated to the UAP. A UAP may assist with clean catch urine specimen collection, but not urine from an indwelling urinary catheter intended for culture.

A nurse is reviewing prescriptions for assigned clients. Which prescriptions require follow-up with the primary healthcare provider? A client with Select all that apply. A. congestive heart failure prescribed diltiazem. B. hypertension prescribed clonidine. C. diabetes insipidus prescribed hydrocortisone. D. pulmonary emboli prescribed clopidogrel. E. atrial fibrillation prescribed amiodarone. F. bacterial cystitis prescribed valacyclovir.

A. congestive heart failure prescribed diltiazem. C. diabetes insipidus prescribed hydrocortisone. D. pulmonary emboli prescribed clopidogrel. F. bacterial cystitis prescribed valacyclovir. These prescriptions are inappropriate and require follow-up with the PHCP. Diltiazem is a calcium channel blocker. The client with congestive heart failure should not be prescribed calcium channel blockers because of their negative inotropic effects, which worsen heart failure (choice A). Hydrocortisone would be indicated to treat adrenal insufficiency, not diabetes insipidus. Diabetes insipidus is characterized by increased urinary output due to inadequate or ineffective anti-diuretic hormone (ADH, vasopressin). Desmopressin, which is similar to ADH, would be used for diabetes insipidus (choice C). Clopidogrel is an antiplatelet medication used to prevent ischemic stroke or myocardial infarction, not pulmonary embolism. A client with a pulmonary embolism requires anticoagulants (warfarin, direct factor Xa inhibitors) or thrombolytics (choice D). Antibiotics such as ceftriaxone are indicated for bacterial cystitis, not antivirals such as valacyclovir (choice F).

The nurse is caring for a client experiencing digitalis toxicity. The nurse anticipates a prescription for which medication? A. digoxin immune fab B. milrinone C. amrinone D. flecainide

A. digoxin immune fab The antidote for digoxin toxicity is the administration of digoxin immune fab, which binds to digoxin, preventing it from reaching the tissues. Its onset of action is rapid, occurring in less than 1 minute after the IV infusion begins. Cardiac glycosides can cause potentially dangerous adverse effects at high doses and in specific individuals. The margin of safety between a beneficial and toxic dose is narrow; therefore, therapy should be closely monitored. Serum digoxin levels above 2.2 ng/mL are considered toxic, and initial side effects include GI-related symptoms such as appetite loss, vomiting, and diarrhea. Headache, drowsiness, confusion, and blurred vision may also occur.

A. echocardiogram B. vegetation or abscess To confirm the diagnosis of IE, the physician will order echocardiography. This echocardiography can be the standard transthoracic or transesophageal. IE would be confirmed with the presence of vegetation or abscess. Exercise electrocardiogram (ECG) testing is used to detect myocardial ischemia. This type of testing attempts to identify coronary artery disease and whether further intervention with percutaneous coronary intervention (PCI) is necessary. In this testing, the physician will be evaluating the ST segment at specific intervals of the testing. This test is not used in diagnosing IE. Chest radiograph (x-ray) would not assist in the identification or confirmation of IE. This test would likely exclude a mediastinal shift or pulmonary disease. A complete blood count (CBC) would be done for an individual with IE. It will likely show leukocytosis. However, this is a supporting factor of IE. This is not a confirmatory diagnostic test because many pathologies increase the white count.

The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with A. hemophilia reporting knee and ankle stiffness with dizziness. B. chronic obstructive pulmonary disease (COPD) reporting a productive cough. C. chronic pericarditis reporting intermittent chest pain during inspiration. D. pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses.

A. hemophilia reporting knee and ankle stiffness with dizziness. This client is the priority because strong evidence of internal bleeding is evident. Clients with hemophilia often bleed at the joints (ankles and knees) because they absorb the most impact. This client's situation is quite serious because they report dizziness, which is also collateral support for internal bleeding. This client should be prioritized.

The nurse is caring for a client receiving prescribed atomoxetine for attention deficit hyperactivity disorder (ADHD). Which clinical data should the nurse monitor while the client receives this medication? A. liver function tests B. complete blood count C. urine analysis D. fasting blood glucose

A. liver function tests Atomoxetine is a non-stimulant treatment option for ADHD. This medication may adversely cause hepatic injury, and the nurse should monitor the client's liver function tests as they receive this medication. Atomoxetine is an attractive option for ADHD as it may not cause the nervousness, weight loss, and tics associated with stimulants.

The intensive care unit (ICU) nurse has completed an assessment of a client Nurses Notes' Emergency Department Nurses' Notes 0632: 77-year-old male arrived via ambulance from a long-term care facility with manifestations of infection. The client was found extremely lethargic and hot to touch. The client had a temperature of 102°F (39°). The client has a medical history of hyperlipidemia, advanced Alzheimer's disease, hypertension, diabetes mellitus (type two), and osteoarthritis. 0710: Assessment completed: Vital signs: T 103°F (39.4°C), P 109, RR 25, BP 113/85 (MAP 94 mm Hg), pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The client's breathing appears slightly labored; tachypnea, rhonchi, and wheezing are noted in the bilateral lung bases. Skin hot to the touch and extremely dry and flaky. Peripheral pulses 2+ and regular. Sinus tachycardia on cardiac monitor. Capillary refill is 3 seconds

A. prothrombin time (PT) B. international normalized ratio (INR) C. activated partial thromboplastin time (aPTT) D. arterial blood gas (ABG) A. regular insulin via intravenous push B. dopamine via continuous infusion C. ampule of sodium bicarbonate via intravenous infusion A. fall precautions D. insertion of an indwelling urinary catheter Laboratory All clotting laboratory tests are necessary for this client as the bruising on the client's torso petechiae suggests the client is developing DIC. DIC is a major complication of gram-negative sepsis. If the client has DIC, all of these values will be high. The client needs to have their ABG repeated after the sodium bicarbonate infusion to determine if the client is no longer in metabolic acidosis. Medications The client is hyperkalemia secondary to severe metabolic acidosis. The abnormal rhythm on the monitor supports this finding. Regular insulin will drive potassium back into the cell. The nurse must also watch the client's CBG because this may cause the client to develop hypoglycemia. Dopamine, a vasopressor, is necessary for this client as they did not respond favorably to the fluid challenge. The client's MAP is trending downward, and with the lactic acid still high, the client needs to increase their perfusion. The client is grossly acidotic, and to correct this metabolic acidosis, the nurse should request a prescription for sodium bicarbonate. The client does not need glargine insulin. Glargine insulin has no peak and lasts for 24 hours. Its onset is about two hours, which will not remedy the high potassium. This order is inappropriate as regular insulin is necessary for glucose management and the treatment of hyperkalemia. Miscellaneous Fall precautions are necessary because of the client's advanced Alzheimer's disease. The client is in shock, and an indwelling u

After offering one of your newly admitted clients a partial bed bath, the client states, "I took a bath at home three days ago. I do not need a bath for another three or four days." How should you, the nurse, respond to this client? A. "Would it be okay with you if I teach you about the benefits and need for daily bathing?" B. "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" C. "A once-a-week bath is not good. You must bathe at least every other day to protect against infection." D. "I am sorry, but we have rules here. All clients must be bathed at least every other day. Let's start the bath."

B. "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" In response to the client's statement stating they took a bath at home three days ago and, therefore, do not require an additional bath for another three to four days, the nurse would respond with, "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" This response acknowledges that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. The nurse should explore the client's perspective regarding hygiene care by asking about personal care products desired and preferences such as frequency, time of day, and amount of assistance needed. Additionally, a once-weekly bath is acceptable as long as the client remains clean, without bodily odors, and is still hygienic.

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? Select all that apply. A. "This procedure will require you to receive general anesthesia." B. "You will need to report any shortness of breath following the procedure." C. "You will need to empty your bladder before this procedure." D. "After the procedure, a follow-up chest x-ray will be done." E. "You will need to be on a clear liquid diet one day before the procedure."

B. "You will need to report any shortness of breath following the procedure." D. "After the procedure, a follow-up chest x-ray will be done." These two statements should be included in patient education about thoracentesis. A thoracentesis is a procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure (choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following thoracentesis (studies report post-thoracentesis pneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath and reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as a tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of these signs or symptoms occur. A chest x-ray (choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax, even if the patient did not show any of the above signs or symptoms. Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to 24 hours. It has been reported that <1% of most studies are associated with high mortality. The pathophysiologic mechanism of REPE is unknown. Clinical features vary from coughing and chest tightness to acute respiratory failure. Treatment is usually supportive and includes continuous non-invasive positive pressure ventilation or mechanical ventilation in severe cases; some patients also require vasopressors, steroids, and diuretics.

You are caring for an 8-month-old infant with a tracheostomy. Upon assessment, you visualize secretions within the tracheostomy that require suctioning. In preparation to suction the infant's tracheostomy, which of the following settings would be the most appropriate suction setting? A. 120 mmHg B. 90 mmHg C. 60 mmHg D. 40 mmHg

B. 90 mmHg 90 mmHg would be the most appropriate suction setting for an 8-month-old infant based on the choices provided. For infants and children up to 24 months, tracheostomies should be suctioned using 80-100 mmHg.

The nurse is caring for a client that has been declared brain dead, and the hospital is preparing for organ donation. Which of the following actions would be most appropriate for the nurse to take in caring for the potential donor? A. Notify the family about the organ procurement organization's discussion with them regarding organ donation. B. Coordinate with the healthcare provider to ensure appropriate lab values are monitored for the potential donor. C. Provide comfort measures and support to the client's family during the discussion about organ donation with the organ procurement organization. D. Transfer the client to the operating room immediately for organ procurement.

B. Coordinate with the healthcare provider to ensure appropriate lab values are monitored for the potential donor. When caring for a potential organ donor, it is crucial to monitor appropriate lab values to assess organ function and suitability for donation. Lab values such as electrolytes, renal function tests, liver function tests, coagulation studies, and arterial blood gases may be monitored to evaluate the donor's organ function and overall health status. Coordinating with the healthcare provider(s) ensures that the necessary lab tests are ordered and monitored appropriately to assess the donor's suitability for organ donation.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. A. Troponin B. Creatinine C. Thyroid-stimulating hormone D. Sodium E. Potassium

B. Creatinine C. Thyroid-stimulating hormone D. Sodium Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity).

The nurse is caring for a client with peritoneal dialysis. The client reports an outflow of only one-half of the dialysate solution that was dwelled. The nurse should instruct the client to do which of the following? A. Apply heat to the abdomen. B. Encourage the client to have a bowel movement. C. Strip the dialysis catheter. D. Instill more dialysate solution.

B. Encourage the client to have a bowel movement. Outflow failure is suspected when the peritoneal dialysate drainage volume is less than the inflow volume. Constipation often suppresses dialysate outflow. Constipation is a common problem in peritoneal dialysis, and it occurs due to the consumption of prescribed phosphate binders as well as due to decreased intestinal motility from chronic kidney disease itself.

The nurse is preparing to administer a prescribed infusion of oxytocin to a client with labor dystocia. During the infusion, the nurse plans to monitor which of the following? Select all that apply. A. Deep tendon reflexes (DTR) B. Fetal heart rate (FHR) patterns C. Uterine activity (UA) D. Blood pressure (BP) E. Urine specific gravity (USG)

B. Fetal heart rate (FHR) patterns C. Uterine activity (UA) D. Blood pressure (BP) FHR patterns, UA, and BP are three monitoring parameters essential to monitor an infusion of oxytocin. Oxytocin may cause nonreassuring FHR patterns such as tachycardia, bradycardia, decreased variability, and pathologic (late, variable, or prolonged) decelerations. Oxytocin may cause excessive uterine activity (UA) (tachysystole, hypertonus, inadequate relaxation time). Rapid infusion of oxytocin may cause maternal hypotension. BP monitoring is recommended.

The nurse in the Labor and Delivery department of the local hospital is caring for a newborn born at term. Before discharge from the hospital, the nurse should ensure that the newborn has received: A. Hep A (hepatitis A) vaccine B. Hep B (hepatitis B) vaccine C. RV (Rotavirus) vaccine D. DTaP (diphtheria, tetanus, and pertussis) vaccine

B. Hep B (hepatitis B) vaccine The Hepatitis B vaccine is given in three doses; the first dose is administered at the time of birth, the second dose at two months, and the third dose at six months of age. The Centers for Disease Control and Prevention (CDC) makes recommendations for vaccines and reviews special situations in vaccinations.

The nurse is caring for a client in the third trimester of pregnancy. Which of the following assessment findings would be expected? Select All That Apply. A. Persistent abdominal pain B. Increased fetal movement C. Swollen ankles and feet D. Weight loss E. Decreased frequency of urination

B. Increased fetal movement C. Swollen ankles and feet Increased fetal movement is a normal finding in the third trimester of pregnancy. As the fetus grows, their movements become more noticeable and frequent. Sometimes the movements differ as there is less room to move about, but the movement does not decrease. Swelling of feet, also known as edema, is expected in the third trimester due to increased fluid retention. Should the swelling occur in the face and hands, coupled with high blood pressure, one should suspect preeclampsia and a follow-up will be required. However, swelling of feet and ankles is a common finding in the third trimester.

The emergency department (ED) nurse is caring for a client with liver cirrhosis Nurses' Note 57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact. Vital Signs Oral Temperature 101 o F (38.3o C) Heart rate 94/minute Respirations 24/minute Blood pressure 104/68 mm Hg Oxygen saturation 95% on room air Medical History Hepatitis C Liver cirrhosis Substance use disorder Hyperlipidemia Which assessment findings require follow-up? Select all that apply. A. Jaundice B. Labored breathing C. Hypoactive bowel sounds D. Resp

B. Labored breathing D. Respiratory rate E. Oral temperature The client's labored breathing, tachypnea, and oral temperature are of serious concern. A complication of liver cirrhosis is spontaneous bacterial peritonitis (SBP) which occurs when the ascitic fluid is infected. The infection comes from bacteria that have migrated from the bowel that has entered the lymphatic system. The risk for this potentially fatal infection is increased when an excessive amount of ascitic fluid is evident. The client's temperature being elevated is highly suggestive of this infection. Finally, the client's labored breathing and tachypnea may be a result of the ascites, or it could be related to the potential SBP the client may be experiencing. Either way, these findings require follow-up. The client's jaundice and yellowing of the eyes is an expected finding because of the cirrhosis, and it does not require follow-up. Hypoactive bowel sounds are unremarkable and do not require follow-up.

The nurse is caring for a client immediately following an abdominal paracentesis Procedure Note 1845 - Emergency ultrasound-guided abdominal paracentesis was performed because the client presented with labored respirations, dyspnea, abdominal cramping, and overall discomfort. Informed consent was obtained, and the client agreed to the procedure. Prior to the procedure, the client emptied their bladder. The site was cleaned and numbed with 1% lidocaine, and using an aseptic technique and an ultrasound; a 14-gauge catheter was inserted to remove 10 mL of clear ascitic fluid. Subsequently, the fluid was drained via tubing. 6 liters of fluid were removed. The client tolerated the procedure well and reported immediate relief in the dyspnea and abdominal cramping following the procedure. Immediately following this procedure, the nurse should monitor the client's A. culture and sensitivity results B. blood pressure C. urin

B. blood pressure B. hypotension A. albumin. The client had six liters of fluid drained from their peritoneal cavity. This is a significant volume (any volume > 5 liters is considered a large abdominal paracentesis). The rapid fluid removal could cause a fluid shift; therefore, the nurse should be prepared to monitor the client for post-procedure hypotension. This hypotension can be treated by infusing prescribed albumin, a colloid. This colloid will restore intravascular fluid volume, which shifted during the procedure. Infection is a concern associated with the procedure. However, it would not be an immediate post-procedure complication. The client emptied their bladder before this procedure, significantly decreasing the likelihood of bladder trauma.

The nurse in the emergency department (ED) is caring for a 64-year-old male client. Nurses' Notes 1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, "My head really hurts and I'm dizzy." Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full rang

B. pupil assessment E. Glasgow coma scale G. home medications

The nurse is performing a pain assessment on a client receiving mechanical ventilation via an oral endotracheal tube (ETT). Which of the following assessment findings would support the finding that the client is experiencing pain? Select all that apply. A. tenacious sputum after suctioning the client B. resistance with passive movements C. ventilator asynchrony D. constricted pupils E. dry, flaky skin

B. resistance with passive movements C. ventilator asynchrony Resistance with passive movements, muscle tension, and restlessness are nonverbal indications of a client experiencing pain while receiving mechanical ventilation. If ventilator asynchrony occurs, the client may be biting on the tube or experiencing tachypnea as a result of pain. If the client is biting on the tube, this would trigger the high-pressure alarm. These are all indicators that the client is experiencing pain while being mechanically ventilated.

The nurse is caring for a client prescribed propylthiouracil (PTU). To monitor the effectiveness of this medication, the nurse anticipates the primary healthcare provider will order a A. serum calcium level. B. thyroid panel. C. fasting blood glucose. D. white blood cell (WBC) count.

B. thyroid panel. PTU is an antithyroid medication used in the treatment of hyperthyroidism. This medication is also emergently indicated if a client should develop a thyroid storm. To determine the effectiveness of the medication, the physician will monitor the client's thyroid panel for efficacy.

Which nursing intervention would be a priority for a patient receiving 3% saline maintenance fluids? A. Monitor serum HCO3- B. Monitor urine sodium C. Assess blood pressure D. Collect 24-hour urine output

C. Assess blood pressure 3% saline is a hypertonic solution, so the nurse should monitor for signs/symptoms of fluid volume overload and pulmonary edema (increased blood pressure, crackles in lungs, shortness of breath). This type of fluid increases extracellular osmolality and volume. High osmotic pressure causes water to shift from inside cells into the extracellular fluid. Hypertonic solutions are used to treat hypovolemia and hyponatremia.

The nurse is caring for a neonate with a decreased cardiac output. If noted in this client, which of the following is not a sign of decreased cardiac output? A. Oliguria B. Difficulty breastfeeding C. Bradycardia D. Hypotension

C. Bradycardia Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses.

During a 12-hour shift on a medical-surgical unit, nurses are assigned a specific task applicable to all clients within the unit. On this shift, one nurse is assigned to perform wound care and dressing changes for those clients requiring these services, one nurse is assigned to dispense medications to all clients, and one nurse is assigned to monitor the vital signs and assist with all other nursing care. Which nursing delivery system does this example exemplify? A. Individual nursing B. Team nursing C. Functional nursing D. Primary nursing

C. Functional nursing Functional nursing involves assigning each nurse a specific task to perform for the shift. More specifically, a functional nursing delivery system ("functional nursing"), also known as task nursing, focuses on the distribution of work based on the performance of tasks and procedures, where the target of the action is not the client but rather the task. This is a task-focused method of nursing.

The nurse is developing a plan of care for a child with severe acute glomerulonephritis (AGN). Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Restrict the activity to strict bed rest. B. Offer snacks rich in potassium. C. Obtain daily weights. D. Monitor the client's blood pressure closely. E. Obtain a prescription for sodium chloride (normal saline) fluid boluses.

C. Obtain daily weights. D. Monitor the client's blood pressure closely. Obtaining and monitoring the child's daily weight is key in determining the child's fluid status. The weights should be obtained in the morning, after the first void, using the same scale while the child wears the same clothing. Monitoring the child's blood pressure is key in preventing the client from developing hypertensive encephalopathy. This is a significant complication associated with AGN and features the client having hypertension, headache, dizziness, vomiting, and abdominal discomfort.

The nurse plans care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personnel protective equipment (PPE)? A. Boot (shoe) covers B. Face shield C. Surgical mask D. Gown

C. Surgical mask Haemophilus influenzae, type b Meningi requires droplet precautions. Droplet precautions require the nurse to don a surgical mask upon entry to the client's room. Cohorting with droplet precautions is permitted as long as the other individual has the same pathogen. Clients who require transport or want to ambulate outside their room should don a surgical mask.

The nurse in the psychiatric emergency department (ED) is caring for a 33-year-old male client Nurses' Note 1400: Client was brought to the psychiatric ED by his parents for acting 'bizarre.' Apparently, the client was visiting his parents and was disheveled, not oriented, and stated 'something is out to get me.' The client has a medical history of schizophrenia, and it is unknown if the client has been adherent to his prescribed antipsychotic. Vital signs: T 97° F (36° C), P 87, RR 19, BP 154/86, pulse oximetry reading 98% on room air. On assessment, the client is alert and completely disoriented, repeating, 'something is out to get me' the client does not identify what is out to get him when asked. The client cooperative with some questions but became hostile later towards the end of the assessment. Speech latency was noted with normal volume. The client denies suicidal ideations. Intense eye contact was noted

C. dystonia B. obtain a prescription for diphenhydramine D. notify the physician C. vital signs D. mental status

C. peripheral pulses D. pulse E. blood pressure F. cardiac rhythm G. lactic acid level The nurse is concerned about the client's peripheral pulses as being 1+, which indicates decreased peripheral perfusion. The nurse is concerned about the client's pulse, which has steadily increased. The client has tachycardia, a concerning sign of shock. The nurse is concerned that the client's blood pressure has steadily declined. The blood pressure is 90/60 mm Hg which is clinical hypotension. This is especially concerning because the client already had the fluid bolus. The nurse is concerned about the client's cardiac rhythm because of the peaked T-wave elevation—a clinical manifestation of hyperkalemia. The worsening metabolic acidosis likely is causing hyperkalemia. The lactic acid level is still elevated. A favorable outcome would be if the lactic acid level would decrease after the fluid bolus. Considering it has not, this is an ominous sign of hypoxemia to organs. The client's temperature has decreased and is not a clinical fever. A clinical fever is 100.4° F (38° C). While the temperature is not optimal, it is not a fever. The client's disorientation is not of concern considering the client has advanced Alzheimer's disease.

The nurse is teaching a group of older adults about effective sleep. Which of the following statements, if made by the client, would require further teaching? A. "Nicotine replacement gum may make insomnia worse." B. "I should try to limit my daily naps to no more than thirty minutes." C. "Reading before bed may help me fall asleep." D. "Drinking a cup of hot green tea before bed is okay."

D. "Drinking a cup of hot green tea before bed is okay." Hot green tea contains caffeine which will worsen insomnia. The client should be instructed to avoid this product immediately before bedtime as caffeinated products (sodas, etc.) will increase the client's arousal.

The nurse has taught a client scheduled for a vasectomy. Which of the following statements by the client would indicate a correct understanding of the teaching? A. "This surgery is easily reversible." B. "This procedure could increase my risk for prostate cancer." C. "I won't be able to have this surgery because I have erectile dysfunction." D. "I will need to use another type of birth control until my sperm count is zero."

D. "I will need to use another type of birth control until my sperm count is zero." A second method of birth control is necessary until the sperm count is zero. A follow-up semen assessment to ensure no sperm is present is typically performed within eight to twelve weeks after this procedure. Until the client is informed that the count is zero, a birth control method should be utilized, as pregnancy may still be possible.

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective? A. "At around the time I would normally have my period, I should abstain from intercourse." B. "I should no longer have sex during the last trimester of pregnancy." C. "My sexual desire will remain the same for the entire pregnancy." D. "The best time to enjoy sex is in the second trimester."

D. "The best time to enjoy sex is in the second trimester." Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities.

The nurse is performing a follow-up visit on an adolescent recently prescribed guanfacine. Which of the following assessments indicates a therapeutic response to the medication? A. Euthymic mood B. Less social anxiety C. Improved academic performance D. No suicidal ideations

D. No suicidal ideations Guanfacine is an alpha2A-adrenergic receptor agonist and is approved to treat symptoms of attention deficit hyperactivity disorder (ADHD). The medication comes in an extended-release form to lessen the common side-effect of sedation. Guanfacine is efficacious for individuals with ADHD, especially if they possess motor hyperactivity and impaired concentration. The client reporting improving academic performance indicates that the client is receiving the therapeutic benefit of the medication, as individuals with ADHD usually have decreased work and scholastic performance.

The nurse is caring for a client who has been diagnosed with chronic pancreatitis secondary to alcohol abuse. Which of the following is the most appropriate tertiary prevention expected outcome for this client? A. Altered digestion is secondary to pancreatitis. B. Altered coping secondary to alcoholism. C. The client will be free of insomnia during hospitalization. D. The client will have the opportunity to participate in a 12-step recovery program

D. The client will have the opportunity to participate in a 12-step recovery program This option represents the most appropriate tertiary prevention outcome for a client with chronic pancreatitis secondary to alcohol abuse. Participating in a 12-step recovery program is essential for addressing the root cause (alcoholism) and preventing further complications related to pancreatitis. It focuses on long-term recovery and sobriety, which are crucial for the client's overall well-being. It's important to note that tertiary prevention includes rehabilitation, and a 12-step recovery program is a form of rehabilitation.

Nurses' Notes 1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, "My head really hurts and I'm dizzy." Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse

indicated not indicated indicated not indicated not indicated not indicated indicated

necessary not necessary not necessary necessary

The nurse is providing education for a diabetic client who is given a terbinafine prescription for onychomycosis. Which statements by the client demonstrate a good understanding regarding the treatment with terbinafine? Select all that apply. A. "Following a successful course of treatment, my chance of getting cured is 90%." B. "I will have to take terbinafine for 3 to 6 months." C. "I will need liver function tests before starting terbinafine." D. "I will take this on an empty stomach to help improve its absorption." E. "It may cause taste or vision changes, so I will report vision changes to my doctor." F. "Dark urine, pale stools, and persistent nausea may indicate a serious side effect."

B. "I will have to take terbinafine for 3 to 6 months." C. "I will need liver function tests before starting terbinafine." E. "It may cause taste or vision changes, so I will report vision changes to my doctor." F. "Dark urine, pale stools, and persistent nausea may indicate a serious side effect." Onychomycosis, also known as Tinea unguium, is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Dermatophytes cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). By inhibiting squalene epoxidase, terbinafine blocks the synthesis of ergosterol (Ergosterol is a crucial component of the fungal cell membranes). The nurse should be aware of the interactions and common side effects of terbinafine because it is one of the commonly prescribed antifungal drugs. Client education points include: Even after prolonged treatment, failure and recurrence rate is high (20 to 50% failure). The cure rate with terbinafine is close to 50% (Choice A is incorrect). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails (1 month). Educate the client regarding the prolonged duration of treatment and instruct them to be compliant (Choice B is correct). Educate the client regarding essential side effects and when to contact the healthcare provider. Common side effects include headache, gastrointestinal side effects (abdominal pain, nausea, dyspepsia, diarrhea), rash, and taste changes. To minimize gastrointestinal side effects, terbinafine should be taken with food. Taking it on an empty stomach may exacerbate gastrointestinal side effe

The nurse is caring for a toddler diagnosed with Reye syndrome. Upon assessment of the child's medical history, which condition should the nurse expect? A. cellulitis B. influenza C. meningitis D. mumps

B. influenza Upon assessment of the child's medical history, the nurse should anticipate a finding of a viral infection, specifically influenza (A or B) or varicella, within the preceding two-week period. This is because individuals with these viral infections may have a fever, and taking aspirin could trigger this complication.

The nurse performs a physical assessment on a newborn and observes fine, downy hair on the cheeks and forehead. The nurse analyzes this finding as A. milia. B. lanugo. C. vernix caseosa. D. mongolian spot.

B. lanugo. Lanugo is the soft, down hairs present on newborns' shoulders, back, and forehead. It is theorized that this assists in keeping the newborn warm.

The nurse is caring for a client with suspected bowel perforation. Which of the following would be contraindicated? A. Administering gastrografin for an upper GI x-ray. B. An exploratory laparotomy procedure. C. Administering milk of magnesia following an upper GI study. D. An abdominal CT scan.

C. Administering milk of magnesia following an upper GI study. The client should not be given milk of magnesia (MOM). MOM is a cathartic agent used to promote the excretion of barium sulfate following an upper GI study. Barium sulfate is a liquid suspension that makes intestines visible on the X-rays. Following the procedure, patients are instructed to take plenty of fluids and a mild laxative such as MOM to clear barium from the intestines. However, the client has bowel perforation, so barium sulfate would not be appropriate. Instead, a water-soluble contrast, such as gastrografin, would be used in patients with bowel perforation. Gastrografin has a laxative effect and may cause diarrhea, which would be exacerbated by giving this patient milk of magnesia.

The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who A. delivered a term newborn 2 days ago and reports sweating and increased urinary frequency. B. is 15 weeks pregnant and is being treated for hyperemesis gravidarum and reports increased nausea following a meal. C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain. D. is in the first stage of labor, and the most recent fetal heart rate pattern showed early decelerations.

C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain. This client requires immediate assessment because of the report of increased lower back pain, which is an ominous suggestion of abruptio placentae. The client already has placenta previa, and constant surveillance for abruptio placentae is the standard of care. Signs and symptoms of abruptio placentae include - uterine tenderness, uterine irritability, vaginal bleeding, abdominal or low back pain.

The nurse is caring for a client with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would reduce this client's aspiration risk? A. Flush tubing with 10 mL water after feeding is completed B. Assess the client's gag reflex prior to feeding C. Assess blood glucose every 6 hours D. Place the client in semi-Fowler's following the meal

D. Place the client in semi-Fowler's following the meal The nurse should assist this client in positioning in a semi-Fowlers position for 30 minutes to an hour following meals to prevent aspiration.

The nurse is providing discharge instructions to a client prescribed phenazopyridine. Which of the following instructions should the nurse include? A. Discontinue this medication if urinary discoloration occurs B. Take this medication on an empty stomach C. This medication may increase the amount of urine you produce D. Urine may have a reddish or orange coloration after taking this medication

D. Urine may have a reddish or orange coloration after taking this medication After taking this medication, the urine may become discolored. The nurse should provide teaching that this is an expected finding, and the client should be advised that this is a normal effect associated with the medication.

Fever: IE, pulmonary tuberculosis, influenza Cardiac Murmurs: IE Night Sweats: IE and pulmonary tuberculosis Petechiae: IE Nonproductive Cough: IE and influenza Fever, cardiac murmur, night sweats, petechiae, and nonproductive cough are associated with infective endocarditis (IE). Other manifestations associated with IE include anorexia, malaise, abdominal pain, and weight loss. Fever and night sweats are classic features of pulmonary tuberculosis. The cough with pulmonary tuberculosis is often productive and may contain blood (hemoptysis). Pulmonary TB does not cause cardiac murmurs. Fever and a nonproductive cough is a classic finding associated with influenza. Symptoms of influenza are often abrupt and include body aches, malaise, and headache.

The nurse is caring for a client with bleeding related to hemophilia. Which of the following assessment findings would be expected? Select all that apply. Joint pain Splenomegaly Decreased range of motion in joints Hematuria Epistaxis

Joint pain Decreased range of motion in joints Hematuria Epistaxis Hemophilia is a genetic disorder that causes a factor VIII deficiency. Factor VIII is produced by the liver and is necessary for the formation of thromboplastin in phase I of blood coagulation. Bleeding is commonly found in the joints (termed hemarthrosis), which causes joint stiffness, aches, and a decreased range of motion. Hematuria is also a clinical feature that may be evident (either grossly or by microscopy that would be shown on a urine analysis). Epistaxis is a feature as well if trauma to the nose occurs.

Not Appropriate Appropriate Not Appropriate Appropriate

The nurse is caring for a client who sustained a full-thickness burn to his anterior torso, back, and bilateral anterior arms. Using the rule of nine's, calculate the total body surface area (TBSA) burned. Fill in the blank. __%

This client sustained a 45% TBSA burn ➢ Anterior torso, 18% ➢ Entire back, 18% ➢ Bilateral anterior arms, 4.5% each x 2 = 9% 45%

1. B. traumatic brain injury 2. A. neurological assessment 3. C. anticoagulant use

The nurse should prioritize obtaining an order for a ____________ and ___________ to better determine the extent of the client's injuries. 1. A. radiograph (x-ray) of the head and neck B. electrocardiogram C. electroencephalogram D. computed tomography scan of the head 2. A. hematocrit B. platelet count C. internal normalized ratio D. activated partial thromboplastin time

1. D. computed tomography scan of the head 2. C. internal normalized ratio

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication? A. Diabetes insipidus B. Cushing's syndrome C. Hemophilia D. Inflammatory bowel disease

B. Cushing's syndrome Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence.

The nurse is caring for a client with diverticulosis who reports difficulty getting enough dietary fiber. The nurse should anticipate the primary healthcare care provider (PHCP) will prescribe A. psyllium. B. oil-retention enema. C. codeine. D. bisacodyl.

A. psyllium. For clients with difficulty consuming adequate fiber to manage their diverticulitis, a bulk-forming laxative, such as psyllium, is recommended. Adding bulk to stools is established by drawing water into the stool and making it easier to pass. Increasing the fecal mass and softening the stool causes less constipation. Less constipation will cause less pressure on the diverticula, decreasing the risk of diverticulitis. Bulk-forming laxatives may take two days to work and must be taken with adequate water intake for maximum efficacy.

The nurse is calculating intake for a client. The client received one 100 mL intravenous antibiotic One eight-ounce cup of ice chips One eight-ounce cup of coffee One eight-ounce cup of ice cream Three eight-ounce cups of water The nurse should calculate the client's total intake as how many mL? Fill in the blank.

1420 To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. The client received one 100 mL intravenous antibiotic → 100 mL total One cup of ice → 120 mL total When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts One cup of ice is 240 mL, and it would be divided by half to account for the melt = 120 mL One cup of coffee → 240 mL One cup of ice cream → 240 mL Three cups of water → 720 mL When added up, the total intake was 1420 mL

The nurse is performing a physical assessment on a child with suspected Kawasaki disease (KD). Which of the following assessment findings would support this diagnosis? Select all that apply. A. strawberry tongue B. fruity breath C. drooling D. fever E. bright red rash on the cheeks

A. strawberry tongue D. fever KD is an autoimmune disorder that occurs primarily in individuals younger than five. This condition may cause systemic vasculitis and cardiac abnormalities, including an aneurysm. The classic manifestations of KD include a high fever (unresponsive to antibiotics and antipyretics), red, cracked lips, strawberry tongue, and cervical lymphadenopathy.

The nurse is educating a diabetic client regarding foot care. Which of the following statements by the client indicates a correct understanding of the nurse's instructions? Select all that apply. A. "I need to check my feet daily for sores, blisters, dry skin, and cuts." B. "I need to wash my feet daily and keep them dry." C. "If I get sores or blisters on my feet, I should not pop them." D. "I need to apply cream to my heels and between my toes daily." E. "I should wear tight compression socks on both feet."

A. "I need to check my feet daily for sores, blisters, dry skin, and cuts." B. "I need to wash my feet daily and keep them dry." C. "If I get sores or blisters on my feet, I should not pop them." The client should be instructed to check their feet daily for any signs of blisters, sores, or dryness, which can cause cracking. The earlier the detection of an abnormality, the earlier an intervention can be employed, such as prescribed medicinal creams.

The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with A. human immunodeficiency virus (HIV). B. delirium tremens who is agitated. C. disseminated herpes zoster. D. an implantable port that is accessed.

C. disseminated herpes zoster. Disseminated herpes zoster requires airborne and contact precautions until lesions are dry and crusted. This client requires a private room because negative airflow is necessary, and thus, the door must be kept closed. The client should not be placed in a room with another client because of the high risk of disease transmission.

You work in a community clinic in a large city. There has been a recent outbreak of meningococcal meningitis at the local university and students who have been in contact with the sick students have been advised by public health officials to obtain prophylactic treatment. Which of the following would be helpful in preventing this disease? Select all that apply. A. Amoxicillin B. Ciprofloxacin C. Rifampin D. Meningococcal conjugate vaccine E. Vancomycin

Ciprofloxacin C. Rifampin D. Meningococcal conjugate vaccine Meningococcal meningitis is transmitted through respiratory droplets from infected individuals. After exposure, symptoms will usually appear within 3 to 4 days. The CDC does not recommend universal prophylaxis during an outbreak, but prophylactic treatment should be provided for individuals in close contact with the infected individuals. A single dose of ciprofloxacin or four doses of rifampin over two days can be useful in preventing the acquisition of the disease. Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for at-risk individuals in this group. College students often receive this vaccination before attending school.

Wilms tumor is a cancer most commonly in children under the age of 5. These tumor cells originate from which of the following? A. Lung cells B. Epithelial cells C. Adipose cells D. Renal cells

D. Renal cells Wilms tumor, also known as nephroblastoma, is a cancer of the kidneys. It's tumor cells originate from renal cells.

You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice an unlicensed assistive personnel (UAP) on the unit escorting this client to the telephone. After you speak to the client about the telephone privileges, the UAP tells you, "It is unfair for this client not to be able to use the telephone when other clients are free to do so." What should you determine about this UAP's comment? A. This comment demonstrates that the unlicensed assistive personnel (UAP) favors this client. B. This comment indicates that the unlicensed assistive personnel (UAP) is ensuring equal rights. C. This comment indicates that the unlicensed assistive personnel (UAP) is preventing discrimination. D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the ther

D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the therapeutic milieu. This comment indicates a learning need for this unlicensed assistive personnel (UAP) relating to the therapeutic milieu. A therapeutic milieu has consistent boundaries that are adhered to by all members of the healthcare team. Milieu therapy takes advantage of the naturally occurring events in the client's environment to utilize these events as learning opportunities for clients. A consistent routine and structure are maintained to provide clients with predictability and trust.

The emergency department (ED) nurse is caring for a client who arrives with altered mental status, slurred speech, pinpoint pupils, bradypnea, and hypotension. The nurse is concerned that this client is experiencing A. alcohol intoxication. B. alcohol withdrawal. C. cocaine intoxication. D. opioid intoxication

D. opioid intoxication The client is showing signs of opiate intoxication. Pinpoint pupils, slurred speech, inattention, lethargy, psychomotor retardation, and impaired memory, judgment, and social function characterize opiate intoxication. Changes to vitals include hypotension, decreased heart rate, reduced temperature, and bradypnea are expected.

The nurse has instructed a client newly diagnosed with the human immunodeficiency virus (HIV). Which of the following statements by the client would indicate effective understanding? This disease is caused by a retrovirus leading to A. encapsulation of CD4+ T-cells. B. inflammation of the CD4+ T-cells. C. abnormal proliferation of CD4+ T-cells. D. viral integration into the CD4+ T-cells.

D. viral integration into the CD4+ T-cells. HIV is a retrovirus because of its ability to insert itself into a cell's DNA via its viral RNA. This process causes the CD4/T-cell to be hijacked. HIV infection causes a virion to dock with a CD4/T-cell, which causes it to seize its nucleus. This hijacking alters the cell's DNA by inserting its viral RNA, which DNA then converts by an enzyme reverse transcriptase. This integrative process completes the process, making the CD4/T-cell able to create more HIV viral particles to infect other healthy CD4/T-cells.

The nurse is caring for a 71-year-old female in the emergency department (ED) Nurses' Note 1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation. 1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan. 1438: Computed tomography scan completed. Physician at bedside

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