Comprehensive exam

A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? Asking the child to use a numeric rating scale of 0 to 100 Asking the child to describe the intensity of the pain Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain Asking the child to point to the face on a spectrum ranging from smiling to very sad, that best describes the pain Correct

A client of preschool age has the cognitive ability to recognize happy and sad faces and to correlate them with the level of pain they are experiencing. It may be too complicated for some preschoolers to come up with words to describe varying intensities of pain. Many preschool children are not yet able to count to 100 or to understand the value of numbers in relation to other numbers. A child of preschool age is too young to control a PCA pump.

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, what does the nurse prepare to do? Assist in intubating the client and beginning mechanical ventilation Correct Increase the amount of humidified oxygen Continue administering humidified oxygen Continue monitoring the client

A client who sustains smoke inhalation is immediately treated with 100% humidified oxygen, delivered by way of face mask. However, an arterial oxygenation (PaO2) of less than 60 mm Hg is an indication for intubation and mechanical ventilation. Normal arterial oxygenation is 80-100 mm Hg. Also, endotracheal intubation with mechanical ventilation is needed if the client exhibits respiratory stridor, crowing, or dyspnea, all of which indicate airway obstruction.

A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? Highly critical of self and others Projecting blame, possibly becoming hostile Correct Self-sacrificing and submissive Inflexible and rigid

A client with paranoid personality disorder projects blame, is suspicious of others, and may become hostile or violent. The client also experiences cognitive or perceptual distortions. A client who is inflexible and rigid and is highly critical of self and others is showing signs/symptoms of obsessive-compulsive disorder. Being self-sacrificing and submissive is a characteristic of a client with dependent personality disorder.

A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? Hemoglobin level 12-18 White blood cell count 5000-10000 Correct Sodium level 135-145 Blood urea nitrogen (BUN) level 10-20

A low white blood cell count puts the client at risk for infection. All of the other values are within normal limits.

A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? reverse trendelenburg trendelenburg supine semi fowlers

A nasogastric tube is inserted through the nose and into the stomach for the purpose of gastric decompression or feeding the client. The client is placed in the Fowler position before insertion of the tube to promote comfort and easy insertion. A flat position may be used for clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted with the foot of the bed down and may be used to promote gastric emptying or prevent esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the head of the bed down and may be used for postural drainage or to facilitate venous return in clients with poor peripheral perfusion.

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which finding does the nurse expect to note? Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present The bruise becomes an open sore that looks like an abrasion or blister. Full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epibole (rolled wound edges) are often present A red, blue, or purplish area first appears like a bruise on the skin

A stage I ulcer is characterized by intact skin that is red and does not blanch under external pressure. A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage III ulcer is characterized by full-thickness skin loss, and the subcutaneous tissue may be damaged or necrotic. The damage extends down to but not through the underlying tissues. A deep crater-like appearance or eschar is present. A stage IV ulcer is characterized by full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Sinus tracts may develop.

A client arrives at the clinic for their first prenatal assessment. The client tells the nurse that the first day of their last menstrual period (LMP) was September 25. Using Nägele's rule, what item of client information is needed for the nurse to accurately determine the estimated date of delivery (EDD)? Client has regular 28-day menstrual cycle Correct Client has never had an abortion Client's menstrual periods never last longer than 3 days Client was 14 years old when menses first started

Accurate use of Nägele's rule is used to calculate the EDD. It requires that the client have a regular 28-day menstrual cycle and knowing the date of the first day of the client's last menstrual period (LMP).

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the primary health care provider? Dark urine Correct Urinary frequency Decreased appetite Nausea

Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency, and decreased appetite are side effects of the medication.

A client who has undergone abdominal hysterectomy asks the nurse when they will be able to resume sexual intercourse. What does the nurse tell the client about when sexual intercourse can be resumed? In about 6 weeks, when the vaginal vault is satisfactorily healed Correct At any time after the surgery When pelvic sensation and response to stimuli return When menstruation resumes

After abdominal hysterectomy, the client is instructed to avoid sexual intercourse until the vaginal vault is satisfactorily healed. This takes about 6 weeks. A client who has undergone this procedure must adjust to changes in the nature of pelvic sensations and stimuli during sexual intercourse; however, this is not related to when sexual intercourse may be resumed. The client will not have menstrual periods after abdominal hysterectomy.

The nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, what would the nurse do? Check the client's vital signs Ask the client to gargle with a warm saline solution Assess the client for the presence of bowel sounds Check for the presence of a gag reflex Correct

After an EGD, the nurse places the highest priority on assessing the client for the return of the gag reflex. In preparation for EGD, the client's throat is usually sprayed with an anesthetic to dampen the gag reflex and permit the introduction of the endoscope used to visualize the gastrointestinal structures. No food or oral fluids are given to the client until the gag reflex is fully intact. Vital signs are checked frequently, but this action is not associated with giving the client oral fluids. The client may be asked to use throat lozenges or a saline gargle to relieve a sore throat after the test, but neither action is related to giving the client oral fluids; additionally, neither action would be taken until the gag reflex had been detected again. Bowel sounds are not affected by this test.

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. What does the nurse tell the client is the reason amniocentesis is often performed during the third trimester? To discover genetic characteristics To establish an accurate age for the fetus To assess the degree of fetal lung maturity Correct To know the sex of the fetus

Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal condition when the client has Rh isoimmunization. A common purpose of amniocentesis in the second trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex and age of the fetus are not determined with the use of amniocentesis.

The nurse is caring for a client who just returned to the surgical unit after having a suprapubic prostatectomy. What type of medication does the nurse expect to be ordered? Benzodiazepines Phenothiazines Antispasmodics Correct Antidyskinetics

Antispasmodics are prescribed for bladder spasms related to a suprapubic prostatectomy. This surgery involves removal of the prostate gland by an abdominal incision with a bladder incision. Phenothiazines are a class of antipsychotic medications. Antidyskinetics have an anticholinergic action and are used to treat Parkinson's disease and some of the acute movement disorders that may be caused by antipsychotic agents. Benzodiazepines are central nervous system (CNS) depressants and can cause sedation and psychomotor slowing. They can also intensify depression caused by other drugs. Benzodiazepines have some potential for abuse and would be used with caution in clients known to abuse alcohol or other psychoactive medications.

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In the report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and the client's spouse are worried about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? Fluid volume overload Fluid volume loss Premature grief Anxiety Correct

Anxiety is the priority client concern identified by the nurse. Anxiety is vague uneasiness or discomfort that warns of trouble and enables an individual to approach and deal with the threat. Fluid volume loss indicates a hypovolemic state, whereas fluid volume overload indicates a hypervolemic state. Premature grief is a state in which an individual grieves before an actual loss. There is no information in the question to indicate that fluid volume loss, fluid volume overload, or premature grief are factors for concern.

A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? "You aren't talking today. Cat got your tongue?" "You need to get yourself cleaned up. You have company coming today." "What are your feelings right now?" Correct "Why don't you feel like washing up?"

Asking, "What are your feelings right now?" encourages the client to identify their emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a non therapeutic communication technique. "You aren't talking today. Cat got your tongue?" is a non-therapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and non-therapeutic.

A nurse working the evening shift is helping clients get ready for sleep. A client diagnosed with mania is hyperactive and pacing the hallway. What is the most appropriate action the nurse can take? Tell the client that it is time for sleep and that they needs to go to their room Stay with the client and observe their behavior Take the client to the bathroom and provide them with a warm bath Correct Tell the client that other clients are trying to sleep and that they is being disruptive

At bedtime, the nurse would take the client to the bathroom and provide warm baths, soothing music, and medication when indicated. For the client with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize manic behavior. The nurse would encourage frequent rest periods during the day and keep the client in areas of low stimulation. The client would not consume products containing caffeine. Staying with the client and observing their behavior, telling the client that it is time to go to sleep and to go to their room, and telling the client that other clients are trying to sleep and that they are being disruptive do not address the client's needs and are not measures that will help the client relax and sleep.

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available? Protamine sulfate Vitamin K Calcium gluconate Correct Potassium chloride

Calcium gluconate needs to be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium level becomes too high. Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures (eclampsia). It also causes central nervous system depression, however, so toxicity is a concern. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency.

A client undergoing therapy with carbidopa/levodopa calls the nurse at the clinic and reports that their urine has become darker since starting the medication. What would the nurse tell the client? That they need to drink more fluids That this is an occasional side effect of the medication Correct That this may be a sign/symptom of developing toxicity of the medication To call the primary health care provider (PHCP)

Carbidopa/levodopa, an antiparkinsonism agent, may cause darkening of the urine or sweat. The client would be reassured that this is a harmless side effect of the medication and that the medication's use would be continued. Although fluid intake is important, telling the client that they need to drink more fluid is incorrect and unnecessary. Telling the client that the darkening of the urine may signal developing medication toxicity is incorrect and might alarm the client unnecessarily. There is no need for the client to call the PHCP.

A school nurse observing a child diagnosed with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the most appropriate action by the nurse? Asking that the child not attend the physical education class until the neck pain has subsided Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control Administering acetaminophen to the child to relieve the pain Contacting the child's primary health care provider (PHCP) to report the findings Correct

Children with Down syndrome who participate in sports that may involve stress on the neck need to be evaluated radiologically for atlantoaxial instability. Signs/symptoms of the disorder include neck pain, weakness, and torticollis. Affected children are at risk for spinal cord compression. Signs/symptoms of spinal cord compression include persistent neck pain, loss of established motor skills and bladder or bowel control, and changes in sensation. If any of these signs/symptoms are noted, it must be reported immediately to the PHCP. Administering acetaminophen to relieve the pain and not allowing the child to attend physical education class until the pain has subsided are inappropriate actions that will delay necessary interventions. Teaching the child to use peripads to prevent embarrassment resulting from loss of bladder control may be appropriate in certain scenarios, but in this situation the child is exhibiting signs/symptoms of spinal cord compression, requiring immediate intervention.

Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements (repetitive and rapid, jerky, involuntary movements that appear well-coordinated). Of which common side effect does the nurse warn the client? Urinary frequency Headache Photophobia Drowsiness Correct

Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication.

A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client? Nausea Electrocardiographic changes Hearing loss Correct Bloody urine

Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin causes cardiotoxicity.

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? The client reports a history of sexual abuse by their parent. Correct The client reports a satisfying intimate relationship with their spouse. The client reports irregular menses during relations with their spouse. The client reports that they and their spouse have never been able to conceive children.

Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality would be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment.

A client in the mental health unit says to the nurse, "Everything is contaminated." The client scrubs their hands if forced to touch any object. While planning care, what does the nurse remember about compulsive behavior? Is a response by the client to voices saying that everything is contaminated and that they must engage in this behavior Is an attempt on the client's part to punish self Is an attempt on the client's part to seek the attention of others Temporarily eases anxiety in the client Correct

Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. The other options identify interpretations of the client's obsessive behavior.

A client arrives in the emergency department and tells the nurse that they are experiencing tingling in both hands and are unable to move their fingers. The client states that they have been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier their partner said they wanted a separation and that they would have to support themselves financially. What problem does the nurse conclude that this client is exhibiting signs/symptoms compatible with? Conversion disorder Correct Severe anxiety Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder

Conversion disorder is characterized by the presence of one or more signs/symptoms suggesting a neurological problem that cannot be attributed to a medical disorder.

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? Inability to cope Decreased fluid volume Correct Decreased nutrition Inability to tolerate activity

Decreased fluid volume is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific signs/symptoms at the time. Sickle cell disease is a genetic disorder that is manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant client and the fetus, including interruption of blood flow to the respiratory system and placenta.

Disulfiram is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication. What does the nurse tell the client? A.That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol. Correct B. That driving is prohibited while the client is taking the medication. C. To take the medication immediately if the desire to drink alcohol occurs D. That the effect of the medication ends as soon as the client stops taking the medication

Disulfiram is an alcohol abuse deterrent prescribed to motivated clients who have shown the ability to stay sober. Driving is not prohibited; however, the client is instructed to use caution when driving and performing other tasks that require alertness. The medication is taken daily (not just when the client has a desire to drink alcohol), and the effects of the medication last 5 days to 2 weeks after the last dose is taken. The medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol. Otherwise, an alcohol-disulfiram reaction will occur, with effects consisting of facial flushing, sweating, a throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting. This reaction may last 30 to 120 minutes.

Cyclobenzaprine is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client? Abdominal pain Drowsiness Correct Diarrhea Increased salivation

Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. Cyclobenzaprine is a centrally acting skeletal muscle relaxant used in the management of muscle spasm accompanying a variety of conditions. Rare side effects include fatigue, tiredness, blurred vision, headache, nervousness, confusion, nausea, constipation, dyspepsia, and an unpleasant taste in the mouth.

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. Low-grade fever Correct Weight loss Fatigue Correct Anemia Joint deformities

Early manifestations of RA include fatigue, low-grade fever, weakness, anorexia, and paresthesias. Rheumatoid arthritis is a chronic, progressive, systemic and inflammatory autoimmune disease process that affects the synovial joints, resulting in their destruction. Anemia, weight loss, and joint deformities are some of the late manifestations.

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. The nurse is assisting the primary health care provider with the procedure. What characteristics of the fluid removed during thoracentesis would the nurse expect to note? Clear, with a foul odor Thick and opaque Correct White and odorless Clear and yellow

Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect descriptions of the fluid that occurs in this disorder.

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? Checking the client's blood pressure Correct Checking the client's peripheral pulses Checking the client's intake-and-output record for the last 24 hours Checking the most recent potassium level

Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore, the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.

Ergotamine is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the client to report to the primary health care provider (PHCP) if they experience them while taking the medication? Fatigue and lethargy Numbness and tingling of the fingers or toes Correct Dizziness and fatigue Cough

Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce ergotamine poisoning (ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain in the limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these signs/symptoms to the PHCP if they occur. Cough, fatigue, lethargy, and dizziness are side effects and not adverse effects of the medication.

Ferrous sulfate is prescribed for a client. What does the nurse tell the client is best to take the medication with? Milk Tomato juice Correct Water Any meal

Ferrous sulfate is an iron product. Absorption of iron is best promoted when the supplement is taken with orange juice or tomato juice, another food source of vitamin C or ascorbic acid. Calcium and phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid.

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. What one food item high in calcium does the nurse tell the client to eat? Sardines Correct Corn Peaches Cocoa

Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Corn, cocoa, and peaches do not contain appreciable amounts of calcium.

A nurse is providing information about home care to a client with acute gout. Which measures does the nurse tell the client to take? Select all that apply. Performing range-of-motion exercise to the affected joint three times a day Applying heat packs to the affected joint Resting and immobilizing the affected area Correct Drinking 2 to 3 L of fluid each day Correct Consuming foods high in purines

Gout is a systemic disease in which urate crystals are deposited in the joints and other tissues, resulting in inflammation. In acute gout, rest and immobilization are recommended until the acute attack and inflammation have subsided. Local application of cold may help relieve the pain. The application of heat is avoided because it may worsen the inflammatory process. Dietary instructions include reducing or eliminating alcohol intake and avoiding excessive intake of foods containing purines (e.g., sweetbreads, yeast, heart, herring, herring roe, sardines). The client is encouraged to drink 2 to 3 L of fluid per day to help eliminate uric acid and to prevent the formation of renal calculi.

A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. Avoid contact with all individuals other than immediate family members Drink copious amounts of fluid and void frequently Correct Avoid contact with any individual who has signs/symptoms of a cold Correct Eat foods that are low in fat and protein Obtain pneumococcal and influenza vaccines

Hemorrhagic cystitis is an adverse effect of this medication. The client is encouraged to drink copious amounts of fluid at least 24 hours before, during, and after chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. The client is also encouraged to void frequently to prevent cystitis. The client is not to receive immunizations without the primary health care provider's approval, because they could diminish the body's resistance, putting the client at increased risk for infection. It is not necessary for the client to avoid contact with all individuals other than immediate family members. The client needs to avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. Encouraging adequate dietary intake is appropriate, but a low-protein or low-fat diet is not necessary.

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the primary health care provider (PHCP), which does the nurse specify as the first action in the event of shock? Inserting an intravenous (IV) line Obtaining informed consent for a cesarean delivery Incorrect Placing the client in a lateral position with the bed flat Correct Checking the client's urine output

If the client exhibits signs/symptoms of hypovolemic shock, the client would first be placed in a lateral position, with the head of the bed flat to increase cardiac return. It is necessary for the nurse to take this initial action to minimize the effects of hypovolemic shock and promote tissue oxygenation and thus increase circulation and oxygenation of the placenta and other vital organs. The nurse would also contact the PHCP and monitor fetal status closely. After positioning the client, the nurse would insert IV lines in accordance with the PHCP's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this is not the first action.

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? Administration of oxytocin Insertion of an indwelling catheter Replacement of the uterus through the vagina into a normal position Correct Hysterectomy

If uterine inversion is suspected, the immediate intervention by the nurse is to prepare the client for replacement of the uterus through the vagina. If this is not possible or effective, laparotomy with replacement is performed. Hysterectomy may be required. Intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia is usually needed to relax the uterus enough to replace it. Once the uterus has been replaced and the placenta removed, oxytocin is given to induce uterine contraction and control blood loss. To help prevent trapping of the inverted fundus in the cervix, oxytocin is not given until the uterus has been repositioned. An indwelling catheter is often inserted to aid monitoring of fluid balance and keep the bladder empty so that the uterus can contract fully, but this is not the immediate action taken by the nurse.

The blood serum level of imipramine is determined in a client who is being treated for depression. The laboratory test indicates a concentration of 250 ng/mL (reference range 225-300 ng/mL). On the basis of this result, what would the nurse do? Document the laboratory result in the client's record Correct Have another blood sample drawn and ask the laboratory to recheck the imipramine level Hold the next dose of imipramine Contact the primary health care provider (PHCP)

Imipramine is a tricyclic antidepressant that is often used to treat depression. The therapeutic blood serum level is between 225 and 300 ng/mL, so the nurse would simply document the laboratory result in the client's record. Asking the laboratory to recheck the level and withholding the next dose of the imipramine and contacting the PHCP are unnecessary.

A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which finding elicited during the assessment indicates that the condition has not yet been resolved? _____ Nursing Progress Notes Hyperreflexia is present. (correct) Urinary protein is not detectable. Urine output is 45 mL/hr. Blood pressure is 128/78 mm Hg.

In a client with preeclampsia, deep tendon reflexes may be very brisk (hyperreflexia) and clonus (series of involuntary, rhythmic, muscular contractions and relaxations) may be present, suggesting cerebral irritability resulting from decreased brain circulation and edema. Decreased urinary output (less than 30 mL/hr) indicates poor perfusion of the kidneys and may precede acute kidney injury. Negative findings of the urinary protein assay, urine output of 45 mL/hr, and a blood pressure of 128/78 mm Hg are all signs that preeclampsia is resolving.

A client diagnosed with type 1 diabetes mellitus has just been told that they are 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs. What comment by the client suggests an understanding of the information? "I know I will have to increase my insulin during this time period." "My insulin needs should decrease during the first trimester." Correct "I will have to double up on the insulin dose during this time span." "Needs for insulin will not change during the first 3 months of pregnancy."

Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect.

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. A heart rate of 88 beats/min A respiratory rate of 18 breaths/min Flat neck veins Correct Moist oral mucous membranes Skin tenting Correct Weak peripheral pulses Correct

Isotonic dehydration decreases circulating blood volume (hypovolemia), leading to inadequate tissue perfusion. The nurse would expect to note tachycardia, tachypnea, and dry oral mucous membranes. The oral mucous membranes may be covered with a thick, sticky, pastelike coating and may exhibit fissures. The client may also experience weight loss, lethargy or headache, sunken eyes, poor skin turgor (e.g., tenting), flat neck and peripheral veins, and low blood pressure. Peripheral pulses are weak, difficult to find, and easily obstructed with light pressure.

A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. What does the nurse tell the client to do? Always perform the exercises while lying down Tighten the pelvic muscles for as long as 5 minutes, three or four times a day Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Correct Expect an improvement in the control of urine in about 1 week

Kegel exercises strengthen the muscles of the pelvic floor. To perform the exercises, the client is taught to tighten the pelvic muscles to a slow count of 10, then relax to a slow count of 10. The client is also instructed to do this exercise 15 times while lying down, sitting up, and standing (a total of 45 repetitions). The client is told that an improvement in the control of urine will be noticed after several weeks of the exercises; some individuals report that improvement takes as long as 3 months.

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin. Which finding, indicating an adverse reaction to the medication, does the nurse monitor the client? Flatulence Dizziness Drowsiness Fever Correct

Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication.

A nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. "Diarrhea and muscle weakness are to be expected, and if these occur, I don't need to be concerned." Correct "I need to avoid salt in my diet." Correct "It's fine to take any over-the-counter medication with lithium." Correct "I need to drink 2 to 3 quarts (1.9 to 2.8 liters) of liquid every day." "I need to come back to the clinic to have my lithium blood level checked."

Lithium carbonate is a mood stabilizer used to treat manic-depressive illness. Equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Therefore, the client would maintain a normal salt intake and drink 2 to 3 quarts (1.9 to 2.8 liters) of fluid each day. Many over-the-counter medications contain sodium and would therefore affect the lithium concentration, possibly pushing it out of the therapeutic range. For this reason, over-the-counter medications must be avoided. The blood level of lithium needs to be tested every 3 or 4 days during the initial phase of therapy and every 1 to 2 months during maintenance therapy. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs/symptoms of toxicity; if any of these problems occur, the primary health care provider must be notified.

Lorazepam 1 mg by intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed. Over what period of time would the nurse administer this medication? 10 seconds 30 minutes 15 seconds 3 minutes Correct

Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period.

A nurse is caring for a client with open-angle glaucoma. The nurse knows what agents are used to treat this condition? Mydriatic agents Anticholinergic agents Myotic agents Correct Cycloplegic agents

Miotic agents are used to treat glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Besides mydriatic agents, cycloplegic and anticholinergic agents are contraindicated in clients with glaucoma.Test-Taking Strategy: Focus on the subject, glaucoma. Remember that mydriatic, cycloplegic, and anticholinergic agents dilate the pupil and that these medications are contraindicated in glaucoma.

A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that what is acceptable to use? Processed foods as desired Herbs and spices Correct Salt substitutes Salt with cooking only

Most clients with CKD retain sodium. The client with CKD is instructed not to add salt at the table or during food preparation. Herbs and spices may be used as an alternative to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit potassium intake. The client is also instructed to avoid salt substitutes, many of which are composed of potassium chloride, if oliguria is present. Processed foods are discouraged because they are high in sodium.

A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? Alternating the use of a cuffed tube with a cuffless tube on a daily basis Frequent suctioning Maintaining cuff pressure Correct Maintaining mechanical ventilation settings

Necrosis of the tracheal wall caused by pressure of the cuff of an endotracheal tube can lead to the development of an opening between the posterior trachea and esophagus, a complication known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the primary health care provider.

A client with myasthenia gravis is taking neostigmine bromide. What does the nurse note that indicates the client is gaining a therapeutic effect from the medication? Decreased blood pressure Increased heart rate Improved swallowing function Correct Bradycardia

Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myasthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs/symptoms of an adverse reaction to the medication.

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Correct "I need to fast for 8 hours before the test." "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating." "The test will take about 30 minutes."

No special preparation is necessary before a GI series, except that NPO (nothing by mouth) status must be maintained for 8 hours before the test. An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

A client admitted to the mental health unit tells the nurse that they cannot leave the house without checking to be sure that they have shut off the coffee maker and unplugged the toaster. The client states that they even leave the house, get into the car, and then have to go back into the house to check these appliances again and that these behaviors are interfering with their work and social commitments. Which anxiety disorder does the nurse associate with this client's symptoms? Agoraphobia Avoidant personality disorder Dependent personality disorder Obsessive-compulsive disorder Correct

Obsessive-compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing anxiety; or by a combination of such thoughts (obsessions) and behaviors (compulsions). The client is inflexible and rigid, and is highly critical of self and others. The characteristics of dependent personality disorder include neediness and self-sacrificing and submissive behaviors. The client with avoidant personality disorder is extremely shy, feels inadequate, and is sensitive to rejection. Agoraphobia is the fear of open spaces.

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet? Select all that apply. High alcohol intake Correct Smoking Correct Family history of the disorder Correct A high-calcium diet Participation in physical activities that promote flexibility and muscle strength

Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Risk factors include being 65 to 75 years older, family history of the disorder, history of fracture after age 50, low body weight and slender build, chronically low calcium intake, a history of smoking, high alcohol intake, and lack of physical exercise or prolonged immobility.

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client? Complaints of abdominal pain Painful vaginal bleeding Soft, relaxed, nontender uterus Correct Sustained tetanic contractions

Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.

A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of their life says to the nurse, "Why would I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? Disturbed body image Anxiety Powerlessness Correct Ineffective coping

Powerlessness is present when a client believes that they have no control over the situation or that their actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives their own body image.

A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the primary health care provider (PHCP)? White lochia on postpartum day 11 Bloody lochia on postpartum day 2 Pink lochia on postpartum day 4 Reddish lochia on postpartum day 8 Correct

Reddish lochia on postpartum day 8 is an abnormal finding and would be reported to the PHCP. Lochia is the post delivery vaginal discharge from the uterus consisting of blood from the vessels of the placental site and debris from the deciduas. Rubra is the bright-red lochial discharge that appears from delivery day to day 3. Serosa is the brownish-pink lochial discharge that appears on days 4 to 10. Alba is the white lochial discharge that appears on days 10 to 14.

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? Nulliparity Early menarche Hormone-replacement therapy Multiple sexual partners Correct

Risk factors for cervical cancer include multiple sexual partners, a history of human papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical cancer.

A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of signs/symptoms of hypoglycemia. Which answers by the client, on being asked to list the signs/symptoms, tells the nurse that the client understands the information? Select all that apply. Hunger Correct Increased urine output Blurred vision Correct Increased thirst Weakness Correct

Signs/symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations. The manifestations of hyperglycemia include polydipsia, polyuria, and polyphagia.

Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing primary health care provider before administering the medication? The client has a history of cataracts. The client is allergic to acetylsalicylic acid (aspirin). The client has a history of hypothyroidism. The client takes a prescribed antihypertensive. Correct

Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication.

A client is taking gentamicin sulfate for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? "Are you having any difficulty hearing?" Correct "When was your last bowel movement?" "Are you having any difficulty breathing?" "When was your last menstrual period?"

Serious adverse reactions to aminoglycosides include ototoxicity and nephrotoxicity. Gentamicin sulfate is an aminoglycoside. It inhibits bacterial protein synthesis and has a bactericidal effect. The nurse must assess the client for changes in hearing, balance, and urine output. The remaining assessment questions are not associated with the adverse effects of this medication.

The client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" What does the nurse tell the client? They need not be worrying about their hair at this point Their hair may fall out but will regrow after the chemotherapy is discontinued Correct Their hair will definitely fall out Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss

Some chemotherapeutic agents cause hair loss, and the client would be informed of this possibility. The client would also be reassured that chemotherapy-related hair loss is temporary and that the hair will regrow after the chemotherapy is discontinued, perhaps in a different shade, color, or texture. Telling the client that the hair will definitely fall out is incorrect and telling them that they need not be worrying about their hair at this point ignores the client's concern. Hair dyes, permanents, and vigorous hair-brushing are avoided to minimize thinning.

A nurse provides instruction to a pregnant client about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. Whole grains Correct Legumes Correct Milk products Spinach Correct Potatoes Bananas

Some foods high in folic acid are glandular meats, yeast, dark-green leafy vegetables, legumes, and whole grains. Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant client would have at least four servings of folic acid-rich foods per day. Bananas provide potassium. Potatoes provide vitamin B6, and milk products are a source of calcium.

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. Weight gain Abdominal pain Correct Vasculitis Correct Increased energy Fever Correct

Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon (discoloration of fingers and/or toes after exposure to changes in temperature), pleural effusions, joint inflammation, and myositis.

A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse knows what elements are related to the basic crutch stance? Select all that apply. Hips and knees are extended Correct Improves client's balance Correct Provides narrow base of support Body alignment includes erect head and neck and straight vertebrae Correct Axillae bear half of client's weight Tripod position assumed before crutch walking Correct

The basic crutch stance is the tripod position, which the client assumes before crutch walking. It is formed when the crutches are placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. This position improves the client's balance by providing a wider, not narrower, base of support. The body alignment of the client in the tripod position includes an erect head and neck, straight vertebrae, and extended hips and knees. The axillae would not bear any weight.

The parent of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that their child is a member of the school soccer team and expresses concern about their child's participation in sports. What does the nurse tell the parent after providing information to the parent about diet, exercise, insulin, and blood glucose control? That the child needs to eat a carbohydrate snack about a half-hour before each soccer game Correct To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL (13.3 mmol/L) or higher and ketones are present. That it is best not to encourage the child to participate in sports activities To always administer less insulin on the days of soccer games

The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity would be postponed until the blood glucose has been controlled. Moderate to high ketone values need to be reported to the primary health care provider. There is no reason for the child to avoid participating in sports.

Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the primary health care provider immediately if experiencing what sign/symptom? Neck stiffness or soreness Correct Feelings of depression Restlessness Dry mouth

The client is taught to immediately contact the primary health care provider if the client experiences any occipital headache radiating frontally and neck stiffness or soreness, which could be the first sign of a hypertensive crisis. Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. Dry mouth and restlessness are common side effects of the medication.

A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching? "I need to rest a lot during the day and get enough sleep at night." "I can't drink alcohol." "I have to avoid having sex until the test for antibodies comes back negative." "I need to eat three meals a day with foods high in protein, fat, and carbs." Correct

The client needs further teaching if the client states, "I need to eat three meals a day with foods high in protein, fat, and carbs." The client with viral hepatitis would consume a high-carbohydrate, low-fat diet, not a diet high in fat. The client would avoid hepatotoxic substances such as alcohol. Sexual intercourse is avoided until antibody testing results are negative. The client with hepatitis is easily fatigued and may require several weeks to reach his or her former activity level. It is important for the client to get adequate rest both during the day and at night so that the liver may heal.

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? "I need to limit my intake of fluids while I'm taking this medication." "I need to stop the medication and call my doctor if I have severe diarrhea." Correct "I can expect skin redness and a rash when I take this medication." "I may get a burning feeling in my throat, but it's normal and will go away."

The client understands the information by stating, "I need to stop the medication and call my doctor if I have severe diarrhea." The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose. Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client needs to maintain a high fluid intake (eight to ten 8-oz [235 mL] glasses of fluid per day) while taking the medication.

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions? Cheeseburger Correct Coffee Broccoli Chocolate milk

The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness.

A client diagnosed with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? Weighing the client daily so that the client may determine whether the nutritional plan is working Completing the dietary menu for the client to ensure that adequate nutrition is provided Providing food and fluid as the client requests Offering high-calorie and high-protein foods and fluids frequently throughout the day Correct

The client would be offered high-calorie and high-protein foods and fluids frequently throughout the day. Small, frequent snacks are more easily tolerated than large plates of food when the client is anorexic. The client would be offered choices of foods and fluids they like, because the client is more likely to consume foods they have selected. The client would be weighed weekly, not daily. Weight gain may not be noted daily, which may cause the client to view the interventions to improve nutritional status as useless.

A home care nurse visits a client who delivered a healthy newborn 4 days ago and assesses how the client is doing breast/chest feeding the infant. What does the nurse ask the client to do to permit assessment of whether the infant is receiving an adequate amount of milk? Count the number of times that the infant swallows during a feeding Weigh the infant every day and check for a daily weight gain of 2 oz (60 ml) Count wet diapers to be sure that the infant is having at least six to 10 each day Correct Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant

The client would be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally, an infant would have at least 6 to 10 wet diapers (after the first 2 days of life) and at least 4 stools each day. The client may also assess the swallowing and nutritive suckling of the infant, but this would not provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The parent is not usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0.5 to 1 oz) each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the parent's bottle-feeding technique.

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? Fever Diarrhea Tongue protrusion Correct Hypertension

The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face. Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia.

A client diagnosed with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which response by the nurse is therapeutic? "Why don't you really want to attend?" "Perhaps you could attend and talk to the other clients and see what they're drawing and painting." Correct "OK, let's have you attend music therapy. You can sing there. How does that sound?" "This is what your primary health care provider has prescribed for you as part of the treatment plan."

The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your primary health care provider has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern.

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Increased platelet count Decreased fibrin-degradation products Shortened prothrombin time Positive result on d-dimer study Correct

The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC. DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased.

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the most appropriate action on the part of the nurse? Place small pieces of tape over the rough edges of the cast Correct Use a nail file to smooth the rough edges Bivalve the cast Ask the primary health care provider (PHCP) to reapply the cast

The most appropriate action by the nurse is to petal (place small pieces of tape over) the rough edges of the cast to minimize the irritation. Bivalving is performed if the limb swells and the cast becomes too tight. Using a nail file to smooth the rough edges could cause pieces of the cast to fall into the cast, possibly resulting in the disruption of skin integrity. It is not necessary to contact the PHCP, and there is no reason to reapply the cast.

A client experiencing delusions says to the nurse, I am the only one who can save the world from all of the terrorists. What is the most appropriate response by the nurse? "Tell me your plan for saving the world." "I don't think anyone can save the world from the terrorists by themself." Correct "You must be powerful. Do you really believe that you can do this by yourself?" "Why do you think that you can accomplish this by yourself?"

The most appropriate response by the nurse is "I don't think anyone can save the world from the terrorists by themself." The nurse would not go along with or reinforce the client's delusion. The nurse would respond to the client by presenting reality. "Tell me your plan for saving the world," "Why do you think that you can accomplish this by yourself?" and "You must be powerful. Do you really believe you can do this by yourself?" all reinforce the delusion and encourage further conversation about it.

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the most appropriate response by the nurse? "HIV is rarely an issue in rape victims." "Let's talk about the information that you need to determine your risk of contracting HIV." Correct "Every rape victim is concerned about HIV." "You're more likely to get pregnant than to contract HIV."

The most appropriate response by the nurse is the one that encourages the client to talk about their condition. HIV is a concern of rape victims. Such concern would always be addressed, and the victim would be given the information needed to evaluate the risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once the results of a pregnancy test have been obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that avoid the client's concern.

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. What does the nurse determine is the priority in the 24 hours after surgery? Monitoring the client for signs of returning peristalsis Instructing the client in dietary changes to prevent constipation Encouraging the client to talk about the effects of the surgery on their sexuality Encouraging the client to deep-breathe, cough, and use an incentive spirometer Correct

The nurse determines that the priority in the 24 hours after surgery is to encourage the client to deep-breathe, cough, and use an incentive spirometer. Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs/symptoms of returning peristalsis, instructing the client in dietary habits to prevent constipation, and encouraging them to talk about the effects of the surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer.

A laxative has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication. What does the nurse tell the client to do? Increase fluid intake Correct Contact the primary health care provider if the urine turns yellow-brown Consume low-fiber foods Consume foods that are low in potassium

The nurse encourages the client to increase fluid intake, to consume a high-fiber diet, and to exercise. Hypokalemia may result from use of a laxative, so the nurse encourages the client to consume foods high in potassium. The client's urine may turn pink-red, red-violet, red-brown, or yellow-brown, but the client is told that this is a temporary, harmless effect.

A nurse on the evening shift checks a primary health care provider's (PHCP) prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the PHCP's answering service and is told that the PHCP is off for the night and will be available in the morning. What would the nurse do next? Ask the answering service to contact the on-call PHCP Correct Call the nursing supervisor Administer the medication but consult the PHCP when they becomes available Withhold the medication until the PHCP can be reached in the morning

The nurse has a duty to protect the client from harm. A nurse who believes that a PHCP's prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore, the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor.

A client says to the nurse, "My doctor just left and told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" How does the nurse interpret the client's reaction? Acceptance Anger Fear Correct Denial

The nurse interprets the client's reaction as fear. Fear is a response to a threat that is consciously recognized as a danger. In this situation, the client's reaction is one of fear, and the client verbalizes the object of fear (dying). There is no evidence of denial, acceptance, or anger in the client's statement.

The night nurse is caring for a client who just had a craniotomy. The nurse is monitoring the client's Jackson-Pratt drain that is being maintained on suction. The nurse notes that a total of 200 mL of red drainage has drained from the Jackson-Pratt (J-P) tube in the last 8 hours. What action would the nurse take? Continue to monitor the amount and color of the drainage. Discontinue the Jackson-Pratt drain from suction. Notify the primary health care provider (PHCP) immediately of the amount of drainage. Correct Document the amount in the client's record.

The nurse must immediately notify the PHCP of this excessive amount of drainage. The PHCP must also be immediately notified of any saturated head dressings. The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL per shift. Discontinuing the suction from the J-P drain is not an option and is not done. Also, just documenting the amount in the client's record is not correct even though the nurse would document that the primary health care provider was notified of the total drain amount. Just continuing to monitor the amount of drainage is also not an option.

A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which action would the nurse take next? Removing some weight from the traction Notifying the primary health care provider (PHCP) Correct Providing pin care Medicating the client

The nurse realigns the client and, if this is ineffective in relieving the pain, would next notify the PHCP. A client in traction who complains of severe pain may require realignment or may have traction weights that are too heavy. Severe leg pain, once traction has been established, indicates a problem. Provision of pin care is not related to the problem as described. The client would be medicated after an attempt has been made to determine and treat the cause; the cause of the severe pain would be investigated first. The nurse would never remove the weights from the traction without a specific prescription to do so.

A nurse is monitoring a pregnant client in labor and notes this finding on the fetal-monitor tracing (see figure). Which action would the nurse take as a result of this observation? (accelerations) Reposition the client Take the client's vital signs Document the finding Correct Notify the primary health care provider

The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal movement. This nurse would document the finding. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the client, notifying the primary health care provider, and taking the client's vital signs are all unnecessary actions.

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. What does the nurse tell the client about this blood test? Is a measure of the client's hematocrit level Helps predict the risk for the development of chronic complications of diabetes mellitus Correct Is a measure of the client's hemoglobin level Provides a determination of short-term glycemic control in the client with diabetes mellitus

The nurse tells the client that the blood test is used to assess long-term glycemic control, as well as to predict the risk for the development of chronic complications. Glycosylated hemoglobin is the best indicator of the average blood glucose level. Because glucose attaches itself to the hemoglobin molecule, measurement of glycosylated hemoglobin indicates the average blood glucose level during the previous 120 days, the lifespan of the red blood cell.

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. What action would the nurse take? Administer the antihypertensive with a small sip of water Correct Administer the medication by way of the intravenous (IV) route Hold the antihypertensive and resume its administration on the day after the ECT Withhold the antihypertensive and administer it at bedtime

The nurse would administer the antihypertensive with a small sip of water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which would be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer medication by way of a route that has not been prescribed.

A nurse has assisted a primary health care provider in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving total parenteral nutrition (TPN). After insertion of the catheter what does the nurse immediately do? Hang the prescribed bag of TPN and start the infusion at the prescribed rate. Check the client's blood glucose level to serve as a baseline measurement. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency. Call the radiography department to obtain a chest x-ray Correct

The nurse would immediately make arrangements to have a chest x-ray done. One major complication associated with central venous catheter placement is pneumothorax, which may result from accidental puncture of the lung. After the catheter has been placed but before it is used for infusions, its placement must be checked with an x-ray. Hanging the prescribed bag of TPN and starting the infusion at the prescribed rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because they could result in the infusion of solution into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority.

A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity. What does the nurse immediately do? Encourage the client to take short, deep breaths Stop the oxytocin infusion Correct Increase the rate of the oxytocin infusion and call the primary health care provider Check the vagina for crowning

The nurse would immediately stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen with the use of a snug face mask at 8 to 10 L/min. If uterine hypertonicity or a nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would also notify the primary health care provider. Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. It is used to induce or augment labor at or near term. The nurse monitors uterine activity for the establishment of an effective labor pattern and for complications associated with the use of the medication. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion are not the immediate actions.

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, what would the nurse do? Encourage the client to breastfeed/chest feed the newborn Recheck the temperature in 4 hours Correct Notify the primary health care provider Institute strict bed rest for the client and notify the primary health care provider

The nurse would recheck the temperature in 4 hours. A temperature of 100.4° F (38° C) is common during the 24 hours after childbirth and may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for more than 24 hours or exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. There is no reason to restrict the client to strict bedrest or to notify the primary health care provider. Although the client would be encouraged to breastfeed/chestfeed the newborn, this action is unrelated to the client's temperature.

A hospitalized client demonstrating mania enters the unit community room and says to a client who is wearing a blue shirt, "People in blue are fun to do! People in blue are fun to do!" What is the most appropriate response by the nurse? "Why are you saying that?" "Stop saying that. It's not true!" "You wouldn't like someone saying that to you. Would you?" "Don't say that. If you can't control yourself, we'll help you." Correct

The nurse would respond using a firm, calm approach, providing the client with clear expectations. The appropriate response is the only one that involves a firm, calm approach and offers the client help if they need it. The other three statements challenge the client.

A nurse caring for a client in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? ( Inadequate pacemaker activity of the fetal heart Pressure on the fetal head during a contraction Umbilical cord compression Uteroplacental insufficiency during a contraction Correct

The observation that the nurse noted in this tracing is late decelerations. Late decelerations constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly associated with a contraction. Early decelerations result from pressure on the fetal head during a contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability refers to the difference between successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly.

An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which finding does the nurse expect to note? Ability to wrinkle the forehead on request A symmetrical smile Tightening of all facial muscles Complaints of inability to close the eye on the affected side Correct

The onset of Bell's palsy is acute. Maximal paralysis occurs within 5 days in almost all clients. Pain behind the ear or on the face may precede paralysis by a few hours or days. The disorder is characterized by a drawing sensation and paralysis, not tightening, of all facial muscles on the affected side. The client cannot close the eye, wrinkle the forehead, smile, whistle, or grimace. The face appears mask-like and sags. Taste is usually impaired to some degree, but this symptom seldom persists beyond the second week of paralysis. Loss of peripheral vision is not associated with Bell's palsy.

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action would be the nurse's priority? Document the findings Contact the primary health care provider (PHCP) Correct Check the fluid for protein Continue to monitor the client and the FHR

The priority action is for the nurse to contact the PHCP. The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid would be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the PHCP. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of post term gestation or placental insufficiency. Checking the fluid for protein is not associated with the data in the question. The nurse would continue to monitor the client and the FHR and would document the findings.

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. Keeping the room slightly darkened Correct Monitoring the client for changes in alertness or mental status Correct Restricting visits to close family members and significant others and keeping visits short Correct Encouraging isometric exercises if bed rest is prescribed Placing the client in a room with a quiet roommate

The room is kept slightly darkened, and bright lighting is avoided. The client is placed in a quiet private room without a telephone. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and significant others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. Aneurysm precautions are implemented to maintain a stable perfusion pressure and help prevent rupture. Stool softeners are administered to help keep the client from straining during defecation. Isometric exercises and use of the Valsalva maneuver are avoided because both increase intrathoracic and intra abdominal pressure. Bed rest with the head of the bed elevated 30 degrees may be prescribed. If the client is allowed out of bed, the nurse stresses the importance of not bending over.

The nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, what would the nurse do? Document the findings Correct Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes Ask the client to walk for 5 minutes, then recheck the reflexes Contact the primary health care provider (PHCP)

The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present, hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes would be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes (3+ to 4+) suggest preeclampsia and must be reported to the PHCP. It is not necessary to contact the PHCP, because the finding is normal. Likewise, rechecking the client's reflexes after ambulation and performing active and passive ROM exercises incorrect and unnecessary actions.

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, what does the nurse tell the client this technique involves? Providing a high degree of exposure of the client to the stimulus that the client finds undesirable Having the client perform a healthy coping behavior Having the client perform a ritualistic or compulsive behavior Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Correct

The technique of systematic desensitization involves gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening with the goal of defusing the phobia. Having the client perform a healthy coping behavior is the description of modeling. Performing ritualistic or compulsive behaviors is a behavior characteristic of clients with obsessive-compulsive disorder. Having the client perform a ritualistic or compulsive behavior may not be therapeutic; additionally, it is not associated with systematic desensitization. Providing a high degree of exposure to a stimulus that the client finds undesirable is the technique known as flooding.

A client who recently underwent coronary artery bypass graft surgery comes to the primary health care provider's office for a follow-up visit. On assessment, the client tells the nurse that they are feeling depressed. Which response by the nurse is therapeutic? "It will take time, but I promise you, you will get over this depression." "Every client who has this surgery feels the same way for about a month." "Tell me more about what you're feeling." Correct "That's a normal response after this type of surgery."

The therapeutic response by the nurse is, "Tell me more about what you're feeling." When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will take time, but I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client's feelings.

A maternity nurse providing an education session to a group of expectant clients describes the purpose of the placenta. Which statement by one of the clients attending the session indicates a need for further discussion of the purpose of the placenta? "Many of my antibodies are passed through the placenta." "Glucose, vitamins, and electrolytes pass through the placenta." "It provides an exchange of oxygen and carbon dioxide between me and my baby." "The placenta maintains the body temperature of my baby." Correct

There is a need for further discussion if the client states that the placenta maintains the body temperature of the baby. Many of the immunoglobulin G (IgG) class of antibodies are passed from client to fetus through the placenta. Glucose, fatty acids, vitamins, and electrolytes pass readily across the placenta; glucose is the major source of energy for fetal growth and metabolic activities. The placenta provides an exchange of nutrients and waste products between the client and fetus. Oxygen and carbon dioxide pass through the placental membrane by way of simple diffusion. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus.

A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? "It's important to rotate injection sites." "I need to check the expiration date on the insulin before I use it." "I need to store the insulin in a cool, dry place." "I need to keep any unopened bottles of insulin in the freezer." Correct

There is a need for further instruction if the client states, "I need to keep any unopened bottles of insulin in the freezer." Insulin is stored in a cool, dry place. It would not be placed in the freezer or exposed to excess heat or agitation. Injection sites would be rotated to ensure adequate insulin absorption and to prevent complications of insulin administration. Once a bottle of insulin has been opened, it is dated and discarded as recommended. The client would check the expiration date on the insulin vial before using it.

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate. Which foods does the nurse tell the client to avoid while they are taking this medication? Select all that apply. Roasted fresh potatoes Beer Correct Pickled herring Correct Apples Baked haddock Yogurt Correct

Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) used to treat depression. The client must follow a tyramine-restricted diet while taking the medication to help prevent hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided include meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausages (e.g., salami, pepperoni, bologna). In addition, figs, bananas, aged cheeses, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged, pickled, fermented, or smoked foods must be avoided. Many over-the-counter medications contain tyramine and must be avoided as well.

A nurse provides home care instructions to a client with a diagnosis of preeclampsia without severe features. What does the nurse tell the client? Urinary protein must be measured and the PHCP would be notified if the results indicate a trace amount of protein Urine output must be measured and the primary health care provider (PHCP) would be notified if output is less than 500 mL in a 24-hour period Correct Sodium intake is restricted Fluid intake must be limited to 1 quart (1 liters) each day

Urine output of less than 500 mL/24 hr would prompt the client to notify the PHCP. Preeclampsia without severe features is characterized by a diastolic blood pressure that does not exceed 100 mm Hg, proteinuria that is no more than 500 mg/day (trace to 1+), and signs/symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet would provide ample protein and calories, and fluid and sodium would not be limited. The disease is characterized as preeclampsia with severe features when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours).

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs/symptoms of hypovolemic shock does the nurse closely monitor the client? Select all that apply. Tachycardia Correct Diminished peripheral pulses Correct Decreased respiratory rate Cool, clammy skin Urine output of less than 30 mL/hr

When hypovolemic shock develops, the body attempts to compensate for decreased blood volume and to maintain oxygenation of essential organs by increasing the rate and effort of the heart and lungs by shunting blood from less essential organs, such as the skin and extremities, to more essential ones, such as the brain and kidneys. This compensatory mechanism results in the early signs/symptoms of hypovolemic shock, which include tachycardia, diminished peripheral pulses, normal or slightly decreased blood pressure, increased respiratory rate, and cool, pale skin and mucous membranes. The compensatory mechanism fails if hypovolemic shock progresses and there is insufficient blood to perfuse the brain, heart, and kidneys. Later signs/symptoms of hypovolemic shock include decreasing blood pressure, pallor, cold and clammy skin, and urine output of less than 30 mL/hr.