B Level 3
Depressed nasal bridge The nurse should expect an infant who has Down syndrome to have a small nose, with a depressed nasal bridge.
A nurse is assessing an infant who has Down syndrome. Which of the following manifestations should the nurse expect? -Enlarged pupils -Long, thin fingers -Depressed nasal bridge -Concave abdomen
Ceftriaxone The nurse should plan to administer ceftriaxone intramuscularly to a client who has gonorrhea. Ceftriaxone is an antibiotic that kills the bacterium Neisseria gonorrhoeae, which causes gonorrhea infection.
A nurse is caring for a client who is at 13 weeks of gestation and has a positive gonorrhea culture. Which of the following medications should the nurse plan to administer? -Imiquimod -Acyclovir -Ceftriaxone -Metronidazole
"Rest your elbows on a table when doing an activity." The nurse should instruct the client to rest his elbows on a table during activities to prevent fatigue. Furthermore, the nurse should instruct the client to raise the height of the table to prevent back strain.
A nurse is teaching about managing fatigue with a client who has end-stage COPD. Which of the following statements should the nurse include in the teaching? -"Eat dry foods to minimize coughing." -"Rest your elbows on a table when -doing an activity." -"Walk daily for a total of 60 minutes followed with a rest period." -"Raise the head of your bed to 15 degrees when sleeping."
Sunken eyes The nurse should identify that sunken eyes is a manifestation of dehydration and can indicate elder neglect or abuse. Other manifestations can include malnutrition, contractures, and excessive body odor.
A community health nurse is assessing an older adult client. The nurse should identify that which of the following findings is a manifestation of elder neglect? -Peripheral edema -Difficulty sleeping -Sunken eyes -Decreased bowel sounds
Applying warm compresses Applying warm compresses is a form of tactile, or touch, distraction that can reduce pain by stimulation of the skin. The nurse should instruct the client's partner to test the temperature of the compresses before applying them to the client's skin.
A hospice nurse is caring for a client who has end-stage cancer. The client's partner asked about ways to help reduce the client's pain. Which of the following palliative actions should the nurse recommend for tactile distraction? -Singing to the client -Teaching the client to meditate -Applying warm compresses -Offering crossword puzzles
Apply a scopolamine transdermal patch for increased oral or respiratory secretions. The nurse should apply a scopolamine transdermal patch or administer atropine to decrease oral or respiratory secretions that can cause the loud, wet respirations referred to as a "death rattle."
A hospice nurse is providing palliative care for a client who is near death and not responding to verbal stimuli. Which of the following actions should the nurse take? -Administer morphine sulfate PO every 4 hr as needed for pain. -Apply a scopolamine transdermal patch for increased oral or respiratory secretions. -Use restraints if the client is experiencing restlessness. -Place a heating pad on the client's feet to warm cool extremities.
Client reports pain in the upper thigh. The nurse should expect a client who has Ewing sarcoma to report localized pain. Other manifestations include a palpable mass. swelling, and fever.
A nurse assessing an adolescent client who has Ewing sarcoma. Which of the following manifestations should the nurse expect? -Client reports pain in the upper thigh. -Client reports increased urination. -Client reports swelling of the fingers. -Client reports blood in the stool.
Identify the client's current coping strategies. The first action the nurse should take using the nursing process is to assess the client. Understanding the client's current coping strategies can help the nurse provide additional recommendations and strategies to help the client cope better in the future.
A nurse at a crisis center is meeting with a client who reports that his adolescent daughter has been increasingly defiant since his divorce 2 years ago. The client states, "I'm so stressed that I can't take this anymore." Which of the following actions should the nurse take first? -Refer the client and his daughter for family therapy. -Recommend that the client attend a support group for guardians of adolescents. -Identify the client's current coping strategies. -Teach the client stress-reduction techniques.
The client asks others for money to compensate for gambling losses. One of the diagnostic criteria for gambling disorder is a reliance on others to provide money to help with negative financial situations that are a direct result of gambling losses. According to the American Psychiatric Association, a diagnosis of gambling disorder requires that the client's behavior meets four of the defined criteria over the period of the past 12 months.
A nurse in a mental health clinic is assessing a client who states, "I don't think my gambling is as big of a problem as my friends think it is." Which of the following findings should the nurse identify as meeting the diagnostic criteria of gambling disorder? -The client makes no attempts to stop gambling. -The client gambles when feeling happy or enthusiastic. -The client gambles the same amount of money each week. -The client asks others for money to compensate for gambling losses.
Assist the client to identify their stage in the grief process. The nurse should explain to the client the stages of grief and help them identify their progression in the process. Knowing their feelings are an expected part of the grieving process, and that they can move forward through the process, can offer the client a sense of hope for the future.
A nurse in a mental health clinic is planning care for a client who has post-traumatic stress disorder (PTSD). Which of the following strategies should the nurse include? -Assist the client to identify their stage in the grief process. -Encourage the client to avoid discussing their trauma. -Offer the client alone time when flashbacks occur. -Provide the client with a rotating staffing assignment.
Tremors A client who has a history of alcohol use disorder with low physical dependence can manifest mild tremors within 12 to 72 hr of the last drink. If the physical dependence is high, the tremors can be intense.
A nurse in a mental health facility is assessing a client who has a history of alcohol use disorder. The client states their last drink was 24 hr ago. For which of the following manifestations of alcohol withdrawal should the nurse monitor? -Hypotension -Somnolence -Tremors -Bradycardia
Avoid using food as a reward for good behavior. The nurse should instruct guardians to use other means than food to reward good behavior. Verbal recognition and token gifts will promote better nutritional habits than unhealthy treats. Limit television viewing to 2 hr or less each day.
A nurse in a pediatric clinic is planning an education program for guardians of school-age children about preventing obesity. Which of the following information should the nurse include? -Do not allow snacking between meals. -Encourage a minimum of 720 mL (24 oz) of juice daily. -Avoid using food as a reward for good behavior. -Recommend educational television viewing for 3 hr per day.
Sodium 128 mEq/L The nurse should identify that this sodium level is below the expected reference range of 136 to 145 mEq/L and places the client at risk for lithium toxicity. The nurse should report this finding to the provider.
A nurse in a provider's office is reviewing the laboratory report of a client who takes lithium for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? -WBC count 7,000 mm3 -BUN 15 mg/dL -Potassium 4.2 mEq/L -Sodium 128 mEq/L
Agitation The nurse should identify that cocaine is a CNS stimulant. Manifestations of acute cocaine toxicity can include agitation, dizziness, hyperthermia, hypertension, pupil dilation, and tremor. Severe toxicity can cause convulsions and myocardial infarction.
A nurse in an emergency department is assessing a newly admitted client. The nurse should identify that which of the following findings is a manifestation of acute cocaine toxicity? -Hypotension -Pinpoint pupils -Agitation -Hypothermia
"You are safe here." When using Maslow's hierarchy of needs, the nurse should determine that the priority statement to make is to reassure the client of their safety. Clients who have experienced sexual assault often fear further injury and possibly death and need reassurance that they are safe. In Maslow's hierarchy, safety needs take precedence over love and belonging needs, self-esteem needs, and self-actualization needs.
A nurse in an emergency department is counseling a client who experienced sexual violence. After addressing the client's physical needs, which of the following statements is the priority for the nurse to make? -"I'm thankful you survived." -"You are not to blame." -"You are safe here." -"I'm sorry this happened to you."
Initiate IV access for the client. The nurse should initiate large-bore IV access for a client who has placenta previa and is bleeding. The nurse should also obtain blood specimens for testing and plan to administer a blood transfusion if the client's bleeding continues.
A nurse is admitting a client who is at 36 weeks of gestation and has placenta previa. The client is experiencing moderate vaginal bleeding. Which of the following actions should the nurse take? -Administer betamethasone to the client. -Assess the dilation of the client's cervix. -Perform a contraction stress test on the client. -Initiate IV access for the client.
Keep the client's head to one side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to one side and position a pillow under her shoulder. The client is at risk for aspiration during a seizure, so the nurse's priority is to keep her airway patent.
A nurse is admitting a client who is at 36 weeks of gestation and is experiencing eclampsia. Which of the following actions is the nurse's priority? -Keep the client's head to one side. -Pad the side rails. -Call for assistance. -Administer oxygen at 10 L/min via nonrebreather mask.
Avoid palpation of the abdomen. The greatest risk to the toddler is spread of cancer cells due to tumor rupture; therefore, the nurse should avoid palpating the abdomen to prevent tumor rupture Wilms' tumor manifestations: fever, hemorrhage, anorexia, weight loss
A nurse is admitting a toddler who has Wilms' tumor. Which of the following actions is the nurse's priority? -Avoid palpation of the abdomen. -Conduct a nutritional assessment. -Check the toddler's temperature. -Monitor the toddler's hemoglobin level.
Reluctance to make eye contact Deficits in social development, communication, and behavior are manifestations of ASD. Children who have ASD often display a lack of interest in social interaction and demonstrate delays in language skills, play, and motor function.
A nurse is assessing a 2-year-old toddler at a well-child visit. For which of the following findings should the nurse refer the toddler for an evaluation for autism spectrum disorder (ASD)? -Reluctance to make eye contact -Plays alongside but not with other children -Speaks using only two- to three-word phrases -Displays temper tantrums
"Is your child receiving the physical therapy we recommended?" The nurse should ensure that the child is enrolled in an early stimulation program which provides physical therapy regularly to develop motor skills. Children who have Down syndrome commonly experience muscle weakness. Early stimulation programs provide physical therapy to support muscular development and assist the child to achieve milestones such as standing and walking, as well as using words and phrases when talking.
A nurse is assessing a 2-year-old toddler who has Down syndrome during a well-child visit. The parent reports concerns regarding his child's delayed developmental achievement. Which of the following responses should the nurse make? -"Maybe you should have your child evaluated by a neurologist soon." -"Is your child receiving the physical therapy we recommended?" -"You should avoid outside excursions to crowded places with your child." -"Is your child seeing a dietitian to assist with feeding problems?"
Vomiting The nurse should identify that vomiting is a manifestation of increased intracranial pressure. Other manifestations include decreased level of consciousness, slurred speech, change in pupil size, cheyne-stokes respirations, hypertension, and widened pulse pressure.
A nurse is assessing a client following a stroke. The nurse should identify that which of the following findings is a manifestation of increased intracranial pressure? -Sudden onset of eye pain -Kussmaul respirations -Vomiting -Hypotension
Euphoria The nurse should identify that euphoria is a manifestation of a right hemisphere stroke. Other manifestations include impaired visual-spatial perception and left-sided neglect.
A nurse is assessing a client who had a stroke. The nurse should identify that which of the following findings is a manifestation of a right hemisphere stroke? -Anxiety -Low tolerance for frustration -Right visual field deficits -Euphoria
Bradykinesia The nurse should identify that bradykinesia is an expected finding for a client who has Parkinson's disease. Other manifestations include mask-like features, soft volume of speech, and pill-rolling movements.
A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? -Bradykinesia -Nuchal rigidity -Myalgia -Light sensitivity
Breast pain The nurse should expect a client who has a benign tumor from fibrocystic breast condition to have breast pain and tenderness as well as lumps, usually in the upper outer quadrant of the breast. ECTASIA breast disorder s/s: enlarged axillary nodes, nipple discharge INTRADUCTAL PAPILLOMA breast disorder s/s: mass in the duct, nipple discharge
A nurse is assessing a client who has a benign tumor resulting from fibrocystic breast condition. Which of the following findings should the nurse expect? -Breast pain -Mass in the duct -Nipple discharge -Enlarged axillary nodes
Diffuse rash The nurse should identify that a diffuse rash, which can include blistering and peeling of the skin, is a manifestation of GVHD due to progressive tissue damage. Other manifestations can include inflammation of the mucosa of the eyes, diarrhea, and abdominal pain.
A nurse is assessing a client who has acute leukemia and has received an allogeneic bone marrow transplant. The nurse should identify that which of the following findings is a manifestation of graft versus host disease (GVHD)? -Diffuse rash -Swollen calf -Constipation -Dry cough
Fasciculations of the face The nurse should identify that the client can have fasciculations or twitching of the face as an early manifestation of ALS. Other manifestations: twitching of the tongue, tongue atrophy, nasal tone of voice (early), dysarthria (late), weakness muscle atrophy of the arms (early), weakness muscle atrophy of the legs (late).
A nurse is assessing a client who has amyotrophic lateral sclerosis (ALS). Which of the following findings should the nurse identify as an early manifestation of this illness? -Swelling of the tongue -Hoarse tone of voice -Fasciculations of the face -Weakness and muscle atrophy of the legs
Impulsiveness The nurse should expect a client who has borderline personality disorder to exhibit impulsive behaviors, such as self-harm. Clients who have borderline personality disorder often experience frequent suicidal ideation and substance use disorders.
A nurse is assessing a client who has borderline personality disorder. Which of the following characteristics should the nurse expect? -Arrogance -Attention-seeking behavior -Impulsiveness -Suspicion
Hypersensitivity to criticism The nurse should identify that hypersensitivity to criticism is a manifestation of low self-esteem. Other manifestations of low self-esteem include guilt, shame, expression of helplessness, lack of eye contact, or a pessimistic outlook on life. Other manifestations include lack of energy, verbal reports of not feeling well rested, and difficulty concentrating.
A nurse is assessing a client who has depression. Which of the following manifestations should indicate to the nurse that the client is experiencing low self-esteem? -Expresses lack of meaning in life -Hypersensitivity to criticism -Impaired problem-solving ability -Difficulty falling asleep
Digital Clubbing The nurse should identify digital clubbing when assessing a client who has COPD. Digital clubbing is evidence of decreased arterial oxygen levels, which occurs over time and is evident as a late manifestation of COPD.
A nurse is assessing a client who has end-stage COPD. Which of the following images should the nurse identify as a late manifestation of this terminal illness? -Digital Clubbing -Tophi (rare sodium urate crystal deposits) -Swan Neck Deformity -Flexion/Contracture of joints
Decreased visual acuity The nurse should expect to find a decrease in visual acuity in a client who has MS. Other manifestations involving the eyes include diplopia, changes in peripheral vision, and nystagmus.
A nurse is assessing a client who has multiple sclerosis (MS). Which of the following manifestations should the nurse expect? -Fasciculations of the face -Decreased visual acuity -Shuffling gait -Muscle rigidity
Hypervigilance The nurse should identify that hypervigilance, or an exaggerated startle response, is a common manifestation of PTSD. Other SE: Difficulty concentrating, Flashbacks
A nurse is assessing a client who has post-traumatic stress disorder (PTSD) after a workplace explosion 3 months ago. Which of the following findings should the nurse expect? -Hypervigilance -Delusions -Somnolence -Amnesia
Magical thinking is correct. The nurse should identify that magical thinking, or the belief that one's thoughts affect others, is a positive symptom of schizophrenia. Clang association is correct. The nurse should identify that clang association, or choosing words based on their sounds, is a positive symptom of schizophrenia. Auditory hallucinations is correct. The nurse should identify that experiencing auditory hallucinations, or hearing voices or sounds that do not exist, is a positive symptom of schizophrenia.
A nurse is assessing a client who has schizophrenia. Which of the following manifestations should the nurse identify as positive symptoms of schizophrenia? (Select all that apply.) -Magical thinking -Clang association -Auditory hallucinations -Flat affect -Emotional ambivalence
The client rationalizes the partner's battering behavior. The nurse should identify rationalization as a characteristic of the tension-building phase of battering, which is the first phase of the cycle of violence. The client purposefully provoking the batterer is characteristic of the acute-battering phase, which is the second phase of the cycle of violence. Evidence of severe battering injuries is characteristic of the acute-battering phase, which is the second phase of the cycle of violence. Belief that their partner can control the behavior is characteristic of the honeymoon phase, which is the third phase of the cycle of violence.
A nurse is assessing a client who is a survivor of intimate partner violence. Which of the following findings indicates that the client is in the tension-building phase of battering? -The client rationalizes the partner's battering behavior. -The client purposefully provokes anger from the batterer. -The client shows evidence of severe battering injuries. -The client believes that their partner can control the battering behavior.
Facial swelling Swelling of the fingers, face, and the sacral area is a manifestation of hypertensive conditions such as preeclampsia. The nurse should report facial swelling to the provider.
A nurse is assessing a client who is at 24 weeks of gestation during a monthly antepartum visit. Which of the following manifestations is a potential prenatal complication and should be reported to the provider? -Facial swelling -Leukorrhea -Periodic numbness of the fingers -Pyrosis
Uterine hypertonicity The nurse should identify that uterine hypertonicity is a manifestation of placental abruption. Other manifestations include abdominal pain, vaginal bleeding, and a boardlike abdomen. Other findings: Hypotension & Oliguria secondary to hypovolemia
A nurse is assessing a client who is at 35 weeks of gestation and is experiencing a placental abruption. Which of the following findings should the nurse expect? -Fundal height 34 cm -Polyuria -Hypertension -Uterine hypertonicity
Rhinorrhea The nurse should expect a client who is experiencing opioid withdrawal to exhibit rhinorrhea, yawning, tearing, and hyperthermia.
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? -Rhinorrhea -Pinpoint pupils -Bradypnea -Increased appetite
Difficulty reading The nurse should identify that having a new onset of difficulty reading is a manifestation associated with a left hemispheric stroke. The nurse should also further assess for manifestations such as deficits to the right visual field, inability to discriminate letters and words, aphasia, and memory deficits.
A nurse is assessing a newly admitted client following a stroke. Which of the following findings should indicate to the nurse the client has experienced a left hemispheric stroke? -Constant smiling -Poor judgment -Loss of hearing -Difficulty reading
Experiences delusions of persecution A client who has major depressive disorder can demonstrate delusions of persecution or somatic delusions regarding physical health problems.
A nurse is assessing a newly admitted client who has major depressive disorder. Which of the following manifestations should the nurse expect in this client? -Experiences delusions of persecution -Exhibits manipulative behavior -Concentrates excessively on work -Obtains attention using physical appearance
Position the client's head in a midline position. The nurse should position the client's head in a midline position to increase cerebral perfusion. The nurse should avoid flexing the client's neck, because this can decrease cerebral venous drainage and decrease cerebral perfusion. Brain ischemia can be minimized by positioning the client's head at less than 25° elevation. The nurse should place the client in a supine position to increase cerebral perfusion. The nurse should avoid flexing the client's hips, because this can increase intrathoracic pressure and cause decreased cerebral venous drainage and decreased cerebral perfusion .The nurse should avoid suctioning and should not encourage the client to cough, because these actions increase intracranial pressure and reduce cerebral perfusion.
A nurse is caring for a client following a stroke. Which of the following actions should the nurse take to increase the client's cerebral perfusion? -Elevate the head of the client's bed to 90°. -Position the client's head in a midline position. -Place the client in the Sims' position. -Encourage the client to cough deeply.
"You can be tested for the presence of apolipoprotein, an indication of an increased risk of developing AD." The nurse should inform the daughter that genetic testing can be done prior to the occurrence of any manifestations of AD. The test notes the presence of the apolipoprotein E-4 gene, which can indicate an increased risk of developing AD.
A nurse is caring for a client who has Alzheimer's disease (AD). The client's daughter asks the nurse if she will have AD as well. Which of the following responses should the nurse make regarding the genetic predisposition of this disease? -"You can be tested for the presence of apolipoprotein, an indication of an increased risk of developing AD." -"Having a family history of AD is not a known risk factor for developing the disease." -"Individuals who develop AD generally have a history of frequent bacterial infections." -"AD is more common in men, so your brothers have a higher risk of developing the disease than you do."
Determine whether the client plans to harm herself. The greatest risk to this client is self-injury or injury to the newborn from suicidal or homicidal thoughts or delusions; therefore, the priority assessment is to ask the client if she has any of these thoughts. Manifestations of postpartum depression include fatigue, restlessness, insomnia, episodes of crying, emotional lability, and thoughts of harming oneself or the newborn.
A nurse is caring for a client who has a newborn and exhibits manifestations of postpartum depression. Which of the following assessments is the nurse's priority? -Observe the client interacting with the newborn. -Determine whether the client plans to harm herself. -Ask the client if she has been sleeping less than usual. -Identify the client's available support systems.
Give the client short, firm directions when communicating. A client who is experiencing mania has difficulty focusing on long, involved communications or understanding reasons for commands from nursing staff. The nurse should give short, firm directions to allow the client to understand and assure the client that the nurse is in control, which gives a feeling of security.
A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take? -Encourage the client to make choices about self-care activities. -Provide the client with low-fiber foods to prevent diarrhea. -Give the client short, firm directions when communicating. -Keep the client busy during the day to promote nighttime sleeping.
Orthostatic hypotension The nurse should identify that a client who has gastroenteritis can exhibit orthostatic hypotension caused by dehydration from fluid loss and electrolyte imbalance.
A nurse is caring for a client who has gastroenteritis and reports diarrhea and vomiting for 3 days. Which of the following findings should the nurse recognize as a manifestation of this inflammatory bowel disease? -Hiccups -Rebound tenderness of abdomen -Orthostatic hypotension -Shoulder pain
Use large calendars that are easy for the client to read. The nurse should provide large calendars and clocks that are easy for the client to read. This assists in orienting the client.
A nurse is caring for a client who has moderate dementia and is experiencing frequent episodes of confusion. Which of the following actions should the nurse take? -Use large calendars that are easy for the client to read. -Keep the client's room completely dark at night. -Provide thorough explanations when speaking with the client. -Speak loudly when communicating with the client.
"I understand that you believe the government is here, but I don't see any evidence of this." The nurse should convey belief in what the client is experiencing, but should express reasonable doubt to reinforce reality.
A nurse is caring for a client who has schizophrenia and states, "The government has spies here monitoring me in my room." Which of the following responses should the nurse give? -"The government is not monitoring your room." -"What would you like me to do about the government being here?" -I understand that you believe the government is here, but I don't see any evidence of this." -"Let's go see if the government is monitoring your room."
Massage the client's fundus. The nurse should identify that the greatest risk to the client is uterine atony leading to postpartum hemorrhage. The initial treatment of uterine atony is fundal massage, which enhances uterine muscle contraction, decreasing bleeding. Therefore, fundal massage is the nurse's priority action.
A nurse is caring for a client who is 4 hr postpartum and is experiencing excessive vaginal bleeding. Which of the following actions is the nurse's priority? -Administer oxytocin IV. -Massage the client's fundus. -Assist the client to the bathroom to void. -Apply oxygen via nonrebreather face ma
Nifedipine The nurse should expect the provider to prescribe nifedipine, which is a calcium channel blocker. Nifedipine relaxes vascular smooth muscle, which decreases blood pressure.
A nurse is caring for a client who is at 33 weeks of gestation and has a new diagnosis of preeclampsia. Which of the following medications should the nurse expect the provider to prescribe? -Nifedipine -Terbutaline -Methylergonovine -Misoprostol
Methylergonovine The nurse should plan to administer methylergonovine to a client who is experiencing a postpartum hemorrhage. Methylergonovine causes contraction of the uterine muscle, which decreases bleeding. Mag. Sulfate - prevent seizures (preeclampsia) Terbutaline - relaxation of uterus (preterm labor) Betamethasone - stimulate fetal lung maturity (preterm labor)
A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer? -Methylergonovine -Magnesium sulfate -Terbutaline -Betamethasone
Monitor the temperature of the client's toes. The nurse should monitor peripheral capillary refill, pulse oximetry, pulses, and skin temperature every hour, to assess perfusion of the client's extremities. Elevate the head of client's bed to 30° or less to increase perfusion to the client's lower extremities. Extend the client's knees to promote perfusion to the client's lower extremities.
A nurse is caring for a client who is experiencing a sickle cell crisis. Which of the following actions should the nurse take? -Flex the client's knees. -Initiate fluid restrictions for the client. -Elevate the head of the client's bed to 90°. -Monitor the temperature of the client's toes.
Clomiphene The nurse should expect the provider to prescribe clomiphene for a client who is experiencing infertility. Clomiphene stimulates the growth and release of eggs in the ovaries, increasing the chance for conception. Methylergonovine - contraction of uterine muscle Misoprostol - ripening of cervix Labetalol - BB for GHTN
A nurse is caring for a client who is experiencing infertility. Which of the following medications should the nurse expect the provider to prescribe? -Methylergonovine -Clomiphene -Misoprostol -Labetalol
Reposition the client. The nurse should reposition the client to relieve compression of the umbilical cord.
A nurse is caring for a client who is receiving IV oxytocin for induction of labor. The fetal heart rate tracing reveals multiple variable decelerations. Which of the following actions should the nurse take? -Reposition the client. -Administer methylergonovine IM. -Administer oxygen at 2 L/min via nasal cannula. -Prepare the client for a biophysical profile.
Apnea Newborns who are premature can experience a delay of spontaneous breathing for 20 or more seconds. This is called apnea of prematurity and can be due to CNS immaturity or obstruction of the upper airways. This occurs in more than half of newborns delivered at less than 32 weeks of gestation. Necrotizing enterocolitis Newborns who are premature have an increased risk of developing necrotizing enterocolitis due to intestinal ischemia, immature immune systems, and the type of formula feeding. Hypoglycemia Fetal glycogen stores develop primarily in the last trimester. The lack of glycogen stores and the difficulty of regulating temperature increase the risk of hypoglycemia in preterm newborns. Newborns who are premature are more prone to heat loss due to decreased fat stores and a limited ability to maintain a flexed position. Newborns who are premature are at risk for anemia and polycythemia, rather than thrombocytopenia.Necrotizing enterocolitis is correct. Newborns who are premature have an increased risk of developing necrotizing enterocolitis due to intestinal ischemia, immature immune systems, and the type of formula feeding.
A nurse is caring for an infant born at 31 weeks of gestation. For which of the following complications should the nurse anticipate and monitor the newborn? (Select all that apply.) -Hyperthermia -Apnea -Thrombocytopenia -Necrotizing enterocolitis -Hypoglycemia
Offer the infant small, frequent feedings. During times of heart failure, the decreased cardiac output lowers tolerance to activity. The infant might have difficulty meeting caloric needs due to fatigue. Small, frequent feedings can enable overall increased caloric intake.
A nurse is caring for an infant who has a patent ductus arteriosus and heart failure. Which of the following interventions should the nurse perform? -Weigh the infant every other day on the same scale. -Offer the infant small, frequent feedings. -Position the infant supine or side-lying. -Assess the infant's radial pulse every 2 hr.
"I say 'stop' out loud whenever I have a compulsion to wash my hands." The nurse should identify that this statement indicates that the therapy is effective. Thought stopping is a behavioral modification technique for interrupting obsessive or negative thoughts.
A nurse is counseling a client who has been undergoing treatment for obsessive-compulsive disorder (OCD). Which of the following statements should the nurse identify as an indication that the client's therapy has been effective? -"I am reducing time with my friends until I overcome my disorder." -"I am beginning to allow myself more time to complete my rituals." -"I threw away my schedule of activities to try to become more spontaneous." -"I say 'stop' out loud whenever I have a compulsion to wash my hands."
Develop a safety plan. The greatest risk to this client is injury from further violence; therefore, the priority instruction for the nurse to include is to develop a safety plan. The client will require a specific destination, a means of transportation, and a bag of essential items.
A nurse is counseling a client who has experienced intimate partner violence. Which of the following instructions is the priority for the nurse to include in the teaching? -Develop a safety plan. -Arrange for legal counseling. -Open a separate bank account. -Attend a support group.
"Non-Hodgkin's lymphoma progresses erratically through the lymphatic system." The nurse should instruct the staff that NHL spreads erratically through the lymphatic system to other lymph nodes and organ systems. HL spreads systematically from one group of lymph nodes to the next group of nodes. NHL manifest painless, swollen lymph nodes often found in the cervical, axillary, inguinal, and femoral areas.
A nurse is educating a group of staff nurses about the difference between non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL). The nurse should include which of the following statements in the teaching? -"Non-Hodgkin's lymphoma involves painful lymph nodes." -"Hodgkin's lymphoma is the result of a previous bacterial infection." -"Non-Hodgkin's lymphoma progresses erratically through the lymphatic system." -"Hodgkin's lymphoma rarely responds to treatment."
"I work well in groups of two or three people." The nurse should identify this statement as indicating an improvement in the adolescent's social interaction.
A nurse is evaluating the plan of care for an adolescent who has attention deficit hyperactive disorder (ADHD). Which of the following statements made by the adolescent should indicate to the nurse an improvement in the adolescent's social interaction? -"I establish goals for completing tasks." -"I work well in groups of two or three people." -"I can list four good things about myself." -"I am able to pay better attention in class."
Recent move across the country to look for work Loss of employment as well as isolation from one's usual social networks, family, and friends can increase a client's risk for suicide.
A nurse is obtaining a history from a client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for suicide? -Family history of obsessive compulsive disorder -Attends weekly religious services -Schedules monthly appointments with a health care provider -Recent move across the country to look for work
An irregularly shaped, colored papule A melanoma is an irregularly shaped, colored papule with various colors such as blue, white, and red. These are malignant and can occur anywhere on the body, particularly where birthmarks or moles are evident.
A nurse is performing a skin assessment for a client who has a history of melanoma. Which of the following findings should the nurse expect? -A nodular lesion with ulceration -An irregularly shaped, colored papule -A pearly papule with a waxy border -A dry, scaly macule
Foul-smelling bulky stool A manifestation of chronic pancreatitis is steatorrhea, which is described as foul-smelling, fatty stools that are bulky in volume. This finding worsens as pancreatitis becomes more advanced and the production of lipase further decreases. Other SE: severe continuouse abdominal pain, unintentional weight loss.
A nurse is performing an admission assessment on a client with chronic pancreatitis. Which of the following findings should the nurse expect? -Report of recent weight gain -Chest pain that radiates down the left armm -Foul-smelling bulky stool -Blood glucose level of 65 mg/dL
Recommend joining a self-help group. A self-help group, such as Gambler's Anonymous, is an effective treatment for gambling disorder.
A nurse is planning care for a client who has a gambling disorder. Which of the following interventions should the nurse include in the plan? -Recommend joining a self-help group. -Administer antipsychotic medications. -Begin disulfiram therapy. -Initiate aversion therapy.
Naltrexone The nurse should expect the provider to prescribe naltrexone for a client who is experiencing withdrawal from alcohol. This medication can also be used for the treatment of opioid use disorder. Bupropion - nictone withdrawl Buprenorphine - opiod withdrawl Methadone - opiod use disorder & requires detoxification
A nurse is planning care for a client who has alcohol use disorder. Which of the following medications should the nurse expect the provider to prescribe? -Bupropion -Naltrexone -Buprenorphine -Methadone
Observe the client for 60 min after meals. The nurse should observe the client while eating and for at least 60 min after meals and snacks. This will prevent the client from purging after eating. Encourage conversation that does not focus on food to decrease the client's anxiety during meals. The nurse should not allow the client to exercise until the target weight is reached.
A nurse is planning care for a client who is being admitted for treatment of anorexia nervosa. Which of the following actions should the nurse include in the plan? -Emphasize nutritional value of foods during meals. -Limit the client's exercise to no more than 30 min per day. -Observe the client for 60 min after meals. -Weigh the client every other day.
Position the newborn side-lying or prone while in the nursery. The use of the prone position will promote optimal air exchange in a premature newborn who has impaired pulmonary function. The side-lying position is appropriate after a feeding or if the infant has exessive secretions. The premature newborn should be cleansed with only plain water.
A nurse is planning care for a newborn who was born at 33 weeks of gestation and is 2 days old. Which of the following interventions should the nurse include? -Bathe the newborn daily with an alkaline-based soap. -Dim the lights in the nursery for 2 hr during each 24-hr period. -Position the newborn side-lying or prone while in the nursery. -Refrain from skin-to-skin contact until the newborn weighs 2.72 kg (6 lb).
Instruct the client to avoid coughing. The nurse should instruct the client to avoid coughing because this increases intra-abdominal pressure and places the client at risk for bowel perforation.
A nurse is planning care to decrease the risk of bowel perforation for a client who is in the acute phase of diverticulitis. Which of the following interventions should the nurse include in the plan? -Avoid use of opioid analgesics. -Administer an enema to rest the bowel. -Provide the client with a high-fiber diet. -Instruct the client to avoid coughing.
Herpes zoster (Shingles) vaccine It is recommended that individuals aged 65 or older receive one dose of this vaccine. Pneumococcal vaccine Clients should have received one or two pneumococcal immunizations between the ages of 19 to 64 and then receive one more dose of the vaccine at age 65 or older. Influenza vaccine It is recommended that all individuals over the age of 50, clients who have a chronic illness, clients living in an institution setting, and all clients who work in a health care setting should receive an annual influenza vaccine. The vaccine changes yearly due to predicted changes in the viral strain of the seasonal flu.
A nurse is planning to administer recommended immunizations to a 65-year-old client. Which of the following immunizations should the nurse plan to administer? (Select all that apply.) -Influenza vaccine -Human papillomavirus (HPV) vaccine -Herpes zoster (Shingles) vaccine -Pneumococcal vaccine -Inactivated polio virus (IPV) vaccine
Use the injector pen regardless of severity of manifestations. The nurse should instruct the client to administer the medication whenever manifestations of an allergic reaction occur and to promptly call 911. Immediate intervention reduces the risk of injury to the client.
A nurse is preparing discharge instructions for a client who experienced an anaphylactic reaction to seafood. Which of the following instructions should the nurse plan to include regarding the client's new prescription for an epinephrine injector pen? -Quickly remove clothing from the area of the planned injection site. -Carry the injector pen in a dark metal container. -Expect the medication to appear cloudy. -Use the injector pen regardless of severity of manifestations.
Administer phenytoin at a rate no greater than 50 mg/min. The nurse should administer phenytoin intermittent IV bolus at a rate of no greater than 50 mg/min to prevent the client from developing hypotension and bradycardia. The nurse should mix the phenytoin with no more than 50 mL of 0.9% sodium chloride. The nurse should monitor for hypotension and bradycardia when infusing phenytoin intermittent IV bolus and plan to decrease the rate of the infusion if these cardiac conditions occur.
A nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is having a tonic-clonic seizure caused by epilepsy. Which of the following factors should the nurse consider when administering IV phenytoin? -Mix the phenytoin with 5% dextrose in water. -Discard phenytoin if precipitate occurs when refrigerated. -Administer phenytoin at a rate no greater than 50 mg/min. -Monitor for hypertension while infusing the phenytoin.
"You should eat at least every 2 hours." The nurse should instruct the client to avoid an empty stomach. Instruct the client to eat frequent meals, at least every 2 to 3 hr. Consume foods at cold temperatures because they might be better tolerated than foods at warm temperatures.
A nurse is providing dietary management to a client who is at 10 weeks of gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make? -"You should eat foods at warm temperatures." -"You should eat protein before sweets." -"You should avoid dairy products." -"You should eat at least every 2 hours."
"Clean the penis with warm water until it is healed." The nurse should instruct the guardian to gently clean the penis with plain warm water to remove urine and feces, decrease pain, and reduce the risk for infection. The guardian should not use soap to clean the penis until the circumcision site is healed, usually in 5 to 6 days.
A nurse is providing discharge teaching for the guardian of a newborn who was recently circumcised. Which of the following statements should the nurse make? -"Clean the penis with warm water until it is healed." -"Expect the site to be swollen for several days." -"Fasten the diaper tightly over the penis." -"Remove any yellow film from the site with a soft washcloth."
"If contractions recur, drink two or three glasses of water." Dehydration can lead to uterine contractions due to stimulation of the anterior pituitary gland, which secretes antidiuretic hormone and oxytocin. If the client notices contractions, they should first drink 480 to 720 mL (16 to 24 oz) of fluids to ensure hydration. If contractions persist beyond 1 hr, the client should notify the provider.
A nurse is providing discharge teaching to a client who is at 32 weeks of gestation and had an episode of preterm labor. Which of the following should the nurse include in the instructions? -"Increased watery vaginal discharge will occur as pregnancy progresses." -"If contractions recur, drink two or three glasses of water." -"Maintain complete bed rest for the remainder of the pregnancy." -"There is no need to report painless contractions to the provider."
"I need to make arrangements so that I am not by myself at home." The client should have close supervision and continuous access to transportation. If bleeding resumes, massive hemorrhage and hypovolemic shock can occur quickly.
A nurse is providing discharge teaching to a client who is at 34 weeks of gestation and has placenta previa. Which of the following statements by the client indicates an understanding of the instructions? -"If my bleeding saturates more than one pad per hour, I should return to the hospital." -"I can only do light yard work such as raking leaves." -"I should expect some spotting after I have sexual intercourse." -"I need to make arrangements so that I am not by myself at home."
"Give a second injection if the first fails to entirely reverse your child's reaction." The nurse should instruct the parent to administer a second dose, using a second auto-injector, if the first dose does not completely reverse the child's allergic reaction. The effects of the medication will begin to fade in 20 min. Therefore, hospitalization for a few hours is recommended. The nurse should instruct the parent that the auto-injector should be taken with the child to the hospital.
A nurse is providing discharge teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include in the teaching? -"Administer the medication subcutaneously into your child's abdomen." -"Monitor your child for increased urination as the most frequent adverse effect of the medication." -"Place your child's unused extra syringes in the refrigerator for storage." -"Give a second injection if the first fails to entirely reverse your child's reaction."
"Drink at least 1.5 liters of fluid per day while taking this medication." The nurse should instruct the client to drink 1.5 to 3 L of fluids per day while taking lithium. Dehydration can lead to lithium toxicity.
A nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. Which of the following statements should the nurse make? -"Take this medication on an empty stomach." -"Restrict your intake of salt while taking this medication." -"Drink at least 1.5 liters of fluid per day while taking this medication." -"Expect a weight loss of 10 to 20 pounds with this medication."
Use a side-lying position when resting in bed or on the couch. The nurse should instruct the client that the side-lying position increases blood flow to the uterus and placenta. This position optimizes the delivery of nutrients and oxygen to the fetus. Supine positioning can result in hypotension, which diminishes blood flow to the uterus and placenta.
A nurse is providing teaching to a client who has preeclampsia without severe features. Which of the following instructions should the nurse include? -Monitor temperature twice each day. -Restrict fluid intake to four 245-mL (8-oz) glasses a day. -Maintain a dark, quiet environment as much as possible. -Use a side-lying position when resting in bed or on the couch.
Amylase 300 units/L The nurse should identify that a client who has acute pancreatitis can have an elevated amylase level. The expected reference range for amylase is 30 to 220 units/L. An amylase value rises within 12 to 24 hr of the onset of pancreatitis.
A nurse is reviewing the laboratory findings of a client who has acute pancreatitis. Which of the following findings should the nurse expect? -Calcium 10.2 mg/dL -Amylase 300 units/L -WBC count 7,000/mm3 -Blood glucose 100 mg/dL
Increased specific gravity The nurse should expect the laboratory report of a child who has acute poststreptococcal glomerulonephritis to show an increase in the child's specific gravity level. This test measures the concentration of particles in the urine. Therefore, this result indicates the child's urine is concentrated.
A nurse is reviewing the laboratory report of a school-age child who has acute poststreptococcal glomerulonephritis. Which of the following laboratory values should the nurse expect? -Increased specific gravity -Decreased creatinine -Decreased BUN -Positive urine culture
Serum uric acid 11 mg/dL The nurse should identify that a serum uric acid of 11 mg/dL is above the expected reference range of 2.7 to 7.3 mg/dL. The nurse should expect a client who has HELLP syndrome to have an elevated serum uric acid level due to decreased renal perfusion.
A nurse is reviewing the laboratory results for a client who has HELLP syndrome. Which of the following laboratory results should the nurse expect? -Hct 37% -BUN 15 mg/dL -Platelet count 150,000/mm3 -Serum uric acid 11 mg/dL
Takes a combination oral contraceptive A client who takes combination oral contraceptives is at risk for a stroke caused by a thromboembolism. Thromboembolism is an adverse effect of the estrogen found in oral contraceptives.
A nurse is reviewing the medical history of a client. The nurse should identify that which of the following findings indicates the client is at risk for a stroke? -History of hypopituitarism -Takes a combination oral contraceptive -Drinks 150 mL (5 oz) of wine each day -Avoids saturated fats in cooking
Labor induced with oxytocin The nurse should identify that a labor induced with oxytocin or a prolonged labor are risk factors for postpartum hemorrhage. Other risk factors include high parity, uterine inversion, and placenta previa. Other risk factors: Polyhydramnios, fetal macrosomia, and vacuum-assisted birth, high parity, placenta accreta, chorioamnionitis, placenta previa, uterine inversion.
A nurse is reviewing the medical record for a client who is in active labor. Which of the following findings should the nurse identify as a risk factor for postpartum hemorrhage? -Gestational diabetes mellitus -Inadequate pregnancy weight gain -Oligohydramnios -Labor induced with oxytocin
Migraine with aura The nurse should identify that migraine with neurologic symptoms is a contraindication to the use of oral contraceptives because this increases a client's risk for stroke.
A nurse is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to an oral contraceptive? -History of gestational diabetes mellitus -Migraine with aura -History of asthma -Renal lithiasis
Sodium bicarbonate Sodium bicarbonate is an antacid used to treat GI upset. This medication alkalizes the client's urine, which increases the accumulation of memantine, leading to toxicity. The nurse should instruct the client to avoid taking sodium bicarbonate while also taking memantine.
A nurse is reviewing the medication record of a client who was recently diagnosed with Alzheimer's disease and has a new prescription for memantine. The nurse should instruct the client that which of the following medications can interact adversely with memantine? -Sodium bicarbonate -Ibuprofen -Diphenhydramine -Omeprazole
BUN 18 mg/dL The nurse should identify that the client has a BUN level within the expected reference range of 10 to 20 mg/dL, which indicates a therapeutic response to treatment. Clients who have anorexia nervosa with recurrent purging behavior often have increased BUN levels due to dehydration from excessive vomiting or diuretic use.
A nurse is reviewing the recent laboratory reports for a client who has anorexia nervosa with recurrent purging behavior. Which of the following laboratory values indicates a therapeutic response to the treatment plan? -Hematocrit 55% -BUN 18 mg/dL -Potassium 3.3 mEq/L -Sodium 133 mEq/L
Restrict fluid intake based on previous day's urine output. The nurse should instruct the client to restrict fluid intake to 500 to 600 mL above the 24 hr urine output measurement to prevent fluid volume overload, increased blood pressure, and edema.
A nurse is teaching a client about acute glomerulonephritis. Which of the following information should the nurse include? -Expect urine to remain clear or straw-colored. -Restrict fluid intake based on previous day's urine output. -Include foods high in sodium in the diet. -Measure weight twice per week.
"Avoid sexual activity until antibiotic therapy is complete." The nurse should instruct the client to avoid sexual activity until antibiotic therapy is completed by the client and her partner and manifestations of PID have resolved. The nurse should instruct the client to restrict ambulation and to recline in a semi-Fowler's position.
A nurse is teaching a client who has a new diagnosis of pelvic inflammatory disease (PID) and is starting oral antibiotic therapy. Which of the following information should the nurse include in the teaching? -"Avoid sexual activity until antibiotic therapy is complete." -"Check your temperature once per week." -"Apply cold packs to your abdomen." -"Ambulate for 30 minutes, three times per day."
Monitor for dizziness while on this medication. The nurse should instruct the client that sildenafil can cause hypotension and to monitor for and report dizziness to the provider. Take sildenafil no more than once per day to reduce the risk for adverse effects, such as priapism, hearing loss, and myocardial infarction. SE: insomnia Sildenafil is effective 30 min to 4 hr before sexual activity.
A nurse is teaching a client who has a new prescription for sildenafil to treat erectile dysfunction. Which of the following information should the nurse include in the teaching? -Use this medication no more than twice per day. -Expect this medication to cause drowsiness. -Take this medication 6 hr before sexual activity. -Monitor for dizziness while on this medication.
Biofeedback provides audio and visual signals to induce a physiological change. Biofeedback is a technique that uses audio and visual signals that allow clients to reduce muscle tension by gaining control over autonomic physiological functions.
A nurse is teaching a client who has chronic pain about biofeedback. Which of the following information should the nurse include about this complementary therapy? -Biofeedback provides audio and visual signals to induce a physiological change. -Biofeedback involves manipulating soft tissue to increase circulation. -Biofeedback uses a variety of body movements to strengthen muscles. -Biofeedback uses digital pressure to reduce pain and improve function.
Yellow sclera Hepatotoxcity is a potentially life-threatening adverse effect of valproic acid. The nurse should instruct the client to report yellow sclera or yellowing of the mucous membranes, abdominal pain, hypothermia, indigestion, anorexia, and loss of appetite to the provider immediately.
A nurse is teaching a client who has epilepsy and a prescription for valproic acid. The nurse should instruct the client to report which of the following as an adverse effect of the medication? -Yellow sclera -Elevated temperature -Bleeding gums -Respiratory depression
Targeted therapy The nurse should instruct the client about targeted therapy. The medication vemurafenib is an oral medication administered for the treatment of melanoma that can target specific molecules and interfere with cell division and the growth and progression of the disease.
A nurse is teaching a client who has melanoma about nonsurgical treatment options. The nurse should include which of the following options in the teaching? -Brachytherapy -Topical chemotherapy -Targeted therapy -Radiation therap
"Avoid going outside when temperatures are extreme." The nurse should instruct the client to avoid both extreme hot and cold temperatures to prevent increased stress on the body and sickling of the red blood cells. Instruct the client to drink at least 3 to 4 L (100 to 135 oz) of fluid daily because dehydration leads to increased sickling of red blood cells.
A nurse is teaching a client who has sickle cell anemia about preventing sickle cell crisis. Which of the following information should the nurse include? -"Avoid going outside when temperatures are extreme." -"Limit your intake of fluids to 2.5 liters daily." -"Engage in strenuous physical exercise several times a week." -"Contact your provider if you have a fever that lasts more than 3 days."
Gestational hypertension usually resolves during the first postpartum week. Gestational hypertension usually resolves during the first postpartum week, although for some clients, it can persist for up to 12 weeks after delivery. Gestational hypertension is a blood pressure greater than or equal to 140/90 mm Hg after 20 weeks of gestation after previously having blood pressure readings within the expected reference range.
A nurse is teaching a client who is at 22 weeks of gestation and has gestational hypertension. Which of the following information should the nurse include in the teaching? -Gestational hypertension usually begins around 12 weeks of gestation. -Clients who have gestational hypertension generally have protein in their urine. -Gestational hypertension usually resolves during the first postpartum week. -Clients who have gestational hypertension generally develop headaches.
"You might develop menopausal symptoms after this procedure." The nurse should instruct the client that they might develop manifestations of menopause after this procedure, such as hot flashes, night sweats, and vaginal dryness, because the ovaries, which produce sex steroid hormones, will be removed. The nurse should instruct the client to avoid sexual intercourse for 4 to 6 weeks following the procedure to reduce the risk of bleeding.
A nurse is teaching a client who is preoperative for an abdominal hysterectomy with a bilateral salpingo-oophorectomy. Which of the following statements should the nurse make? -"You might develop menopausal symptoms after this procedure." -"You no longer need to use condoms after this procedure." -"You might continue to have your period each month after this procedure." -"You should avoid sexual intercourse for 2 weeks after this procedure."
"This implant can be deflated by pushing a button in my scrotum." The nurse should instruct the client that a penile implant causes tumescence through the use of saline that fills a prosthesis in the penis. The prosthesis is deflated by pushing a button located above the reservoir in the scrotum.
A nurse is teaching a client who is scheduled for the placement of a penile implant for the treatment of erectile dysfunction. Which of the following statements by the client indicates an understanding of the teaching? -"This implant has a suction device that will draw blood into my penis." -"This implant can be deflated by pushing a button in my scrotum." -"This implant uses a rubber ring to help maintain my erection." -This implant will protect me from sexually transmitted infections."
Briefly leave the room when the client becomes agitated. The nurse should instruct the family member to briefly leave the room when the client becomes agitated. The family member should return in a short period of time to promote a sense of safety. If the client is still agitated, the family member should leave the room again and repeat the process until the client displays positive behavior.
A nurse is teaching a family member of a client who has Alzheimer's disease about minimizing behavioral problems at home. Which of the following information should the nurse include in the teaching? -Use a loud, firm tone of voice when redirecting the client. -Explain to the client the reason for not acting out. -Briefly leave the room when the client becomes agitated. -Plan outings for cognitive stimulation where there are crowds of people.
Have a tuberculin skin test prior to administration of adalimumab. The nurse should teach the client to have a tuberculin (TB) skin test before the first dose of adalimumab is administered, because if the client has tuberculosis a flare-up could occur. Adalimumab is administered every other week for a client who has rheumatoid arthritis. Clients can take the medication weekly if they are not also taking methotrexate.
A nurse is teaching about adalimumab with a client who has rheumatoid arthritis. Which of the following information should the nurse include in the teaching? -Plan to self-administer adalimumab once a month. -Have a tuberculin skin test prior to administration of adalimumab. -Administer adalimumab deep into the thigh muscle. -Roll the vial of adalimumab to mix the particulate matter.
Use pictures and gestures when giving instructions. The family should use pictures and gestures to help the client understand instructions, which will minimize confusion and agitation.
A nurse is teaching about approaches to care with the family of a client who has a new diagnosis of dementia with confusion. Which of the following information should the nurse include in the teaching? -Place abstract pictures on the walls rather than family pictures. -Allow the client to make choices about clothes to wear. -Turn the client's television on in the evening before bedtime. -Use pictures and gestures when giving instructions.
"Take medications at the same time each day." The nurse should instruct the client to take medications on schedule, or at the same time, each day to maintain therapeutic medication levels. The nurse should instruct the client to plan high-calorie meals which are high in protein to maintain adequate caloric intake.
A nurse is teaching about disease management with a client who has Parkinson's disease. Which of the following statements should the nurse include in the teaching? -"Schedule appointments early in the morning." -"Take medications at the same time each day." -"Plan low-calorie meals which are high in fiber." -"Lean forward and watch your feet when walking."
Increase the temperature of the room prior to bathing the newborn. The nurse should instruct the parent to increase the room temperature to 26° to 27° C (79° to 81° F) to prevent hypothermia. The parent should keep the newborn wrapped and only expose the part of the body that is being bathed. The nurse should instruct the parent to set the water heater temperature to no more than 49° C (120° F) to prevent burns.
A nurse is teaching about home safety with a parent of a newborn. Which of the following information should the nurse include? -Set the temperature of the water heater to 54.4° C (130° F). -Cover the newborn with a light blanket while sleeping. -Place a heater next to the newborn's crib during the winter months. -Increase the temperature of the room prior to bathing the newborn.
Vary the amount of medication taken based on the amount of food consumed. The nurse should instruct the client to take half the medication dosage prescribed for meals whenever having a snack. The total daily dose of medication should equal the amount needed for three meals and two to three snacks per day.
A nurse is teaching about pancreatic enzyme replacement therapy with a client who has chronic pancreatitis and is starting to take pancrelipase capsules. Which of the following information should the nurse include when teaching about pancrelipase? -Administer the enzyme capsules after each meal. -Vary the amount of medication taken based on the amount of food consumed. -Sprinkle the medication capsule contents on a protein-rich food. -Take the medication capsules with calcium carbonate antacids when needed.
"Wear gloves when applying anesthetic ointments." The nurse should instruct the client to wear gloves when applying anesthetic ointments to avoid spreading the infection to other areas of the body. The nurse should instruct the client to take a sitz bath three to four times a day to help minimize the discomfort during an outbreak.
A nurse is teaching about self-management of sexually transmitted infections with a client who has genital herpes. Which of the following instructions should the nurse include in the teaching? -"Begin topical antiviral medication during an outbreak." -"Wear gloves when applying anesthetic ointments." -"Use natural membrane condoms during sexual activity." -"Take a sitz bath once daily."
"You may experience flu-like illness for 7 days after the procedure." The nurse should instruct the client to expect flu-like illness for up to 7 days after the procedure, which is called embolectomy syndrome. The client should slowly resume usual activities within a week as the symptoms subside.
A nurse is teaching about uterine artery embolization with a client who has uterine fibroids. Which of the following information should the nurse include in the teaching? -"You do not need sedation during the procedure." -"The internal fibroids are excised and removed." -"You may experience flu-like illness for 7 days after the procedure." -"Cramping can last 4 weeks after the procedure."
"Discourage your child from taking naps during the daytime." The nurse should instruct the guardian to discourage daytime napping because this can make nighttime sleep more difficult in children who have JIA. Also, daytime inactivity can increase joint stiffness and pain, resulting in poor nighttime sleep. The guardian should suggest a quiet activity, such as reading or playing a video game for 30 to 60 min, rather than a nap.
A nurse is teaching the guardian of a child who has juvenile idiopathic arthritis (JIA) about pain management. Which of the following statements should the nurse make? -"Discourage your child from taking naps during the daytime." -"Place cold packs on affected joints three times per day to reduce swelling." -"Decrease your child's daily intake of high-fiber foods." -"Limit your child's physical activities to decrease inflammation."
Discontinue suctioning when the newborn's cry sounds clear. The nurse should instruct the parent to discontinue suctioning when the newborn's cry sounds clear. If the newborn has an obstruction that is not cleared with the bulb suctioning, the nurse should notify the provider.
A nurse is teaching the parents of a newborn about using a bulb syringe to clear the newborn's nose and mouth of excess secretions. Which of the following instructions should the nurse include? -Insert the tip of the syringe into the center of the newborn's mouth. -Suction each of the nares, and then suction the mouth. -Insert the syringe tip, and then compress the bulb. -Discontinue suctioning when the newborn's cry sounds clear.
Children who are victims of bullying behavior have an increased risk of suicidal ideation. The nurse should inform the parents of children who are victims of bullying behavior that this places them at an increased risk for depression and they are more likely to attempt suicide.
A school nurse is planning an educational program for parents about bullying. Which of the following information should the nurse include? -Children who are victims of bullying behavior have an increased risk of suicidal ideation. -Victims of bullying behavior in elementary school will have increased self-esteem as adults. -There is no evidence that a favorable relationship with parents can prevent bullying behavior. -Children who bully others have conduct disorder and should be evaluated by a psychiatrist immediately.
