EAQ week 5

A client with cancer experiences severe nausea and vomiting from chemotherapy. The client wants to know if it is true that smoking marijuana will help. How will the nurse respond?

"There are some tetrahydrocanacinol (THC)-based medications that contain marijuana control chemotherapy-induced nausea and vomiting in some people."

Prednisone is being prescribed for a client with an exacerbation of colitis. What does the nurse teach the client before administering the first dose?

-Although the medication decreases intestinal inflammation, it will not cure the colitis. Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative.

After the nurse provides education about all-terrain vehicle (ATV) safety for a parent of a 11-year-old child, which statement made by the parent indicates an understanding of the information?

"I will make sure my child does not get on an ATV."

Which parental statement would the nurse recognize as indicating the need for further education about bicycle safety for a school-aged client?

"My child should be able to safely ride after being supervised for a couple weeks".

Which tort involves intentional touching without the client's consent? 1 Battery 2 Invasion of privacy 3 False imprisonment 4 Defamation of character

1 Battery is defined as intentional touching without the client's consent; this action may cause an injury or may be offensive to the client's personal dignity. Invasion of privacy is the announcement of a client's medical information to an unauthorized person. False imprisonment occurs when the nurse places the client in restraints without the approval of the primary healthcare provider. Defamation of character is the publication of false statements that result in damage to a person's reputation.

Which would be a normal blood pressure of a 12-year-old client? 1 95/65 mm Hg 2 105/65 mm Hg 3 110/65 mm Hg 4 119/75 mm Hg

110/65 mm Hg A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing?

How do toddlers learn self-protection? 1Through trial-and-error strategies 2By imitating playmates and siblings 3By obeying orders from mother and father 4By playing with age-appropriate toys and puzzles

1Through trial-and-error strategies

Which describes the role of the nurse in this situation when he or she informs the health care provider the client is requesting pain medication after surgery? 1. Educator 2. Manager 3. Advocate 4. Administrator

3. Advocate *The nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager used appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services with a health care agency.

Which muscle-strength rating would the nurse record for a client who can complete range of motion with some resistance?

4

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation

Absence of breath sounds on auscultation The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax[1][2]. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)?

All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed.

Which component is the ability to perform duties in a specific role? 1 Authority 2 Responsibility 3 Accountability 4 Legal authority

Authority Authority is the ability to perform duties in a specific role. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability determines whether a person's actions were appropriate and provides a detailed explanation of what occurred. Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual.

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container?

A plastic liquid detergent bottle with a screw-top lid

A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child? 1 Flexion of the hip 2 Extension of the hip 3 Adduction of the hip 4

Abduction of the hip

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect?

Demonstration of a personal bias.

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. Which should promote psychological adjustment and early function immediately after surgery?

Help the client adjust to the temporary prosthesis.

Which is the role of the nurse explaining the reason for the intravenous infusion and kit to the client? 1. Educator 2. Manager 3. Advocate 4. Caregiver

1. Educator * The nurse assumes the role of educator when explaining to the client that need for an intravenous infusion. The nurse as a manager oversees the budget of a specific nursing unit or agency and is also responsible for coordinating the activates of the staff providing nursing care. As an advocate, the nurse protects the human and legal rights of the client. The nurse empowers the client with information required to make important health care decisions. The nurse is a caregiver when helping the client maintain and regain health, manage disease symptoms, and achieve a maximum level of functioning.

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? 1. Elevate the head of the bed between 30 and 45 degrees 2. Decrease flow rate at night 3. Check for residual daily 4. Irrigate regularly with warm tap water

1. Elevate the head of the bed between 30 and 45 degrees * To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45 degrees. Elevating the head an higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not prevent aspiration.

Which team member acts as a liaison between the health care facility and the media?

Public information officer

Who is mainly responsible for analyzing the knowledge and work of newly hired unlicensed assistive personnel (UAP) before delegating a task?

Registered nurse The registered nurse must analyze any individual's knowledge before delegating a task. The charge nurse mainly functions as a liaison between team leaders and other healthcare providers. The associate nurse follows the care plan in the absence of a registered nurse. The nursing manager is responsible for more than one unit and has other managerial responsibilities.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? The client weighs 151 lbs (68.5 Kg). The client's pain is 7 on a scale of 1 to 10. The client's fasting blood sugar is 95 mg/dL. The client's blood pressure is 140/90 mm/Hg.

The client's pain is 7 on a scale of 1 to 10. Rationale Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data.

At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group?

The good boy-nice girl orientation This stage involves an individual who wants to win the approval and maintain the expectations of one's immediate group. During the society-maintaining orientation stage, an individual expands focus from a relationship with others to societal concerns. The instrumental relativist orientation stage involves a child who wants to follow his or her parent's rules. The universal ethical principle orientation stage defines "right" by the decision of conscience according to self-chosen ethical principles.

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? Visceral pain Somatic pain Referred pain Intractable pain Abdominal cavity.

Visceral pain Rationale Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity

An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

The nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. How would the nurse explain this choice to the parents?

It provides for equal but partial weight bearing on each limb.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what?

Loosen pulmonary secretions

A 55-year-old client reports cessation of menstrual periods. Which term best describes the client's condition?

Menopause

Which intervention relieves pruritus associated with varicella (chickenpox)?

Pat the lesions while applying the prescribed calamine lotion.

What is a percussion test?

Percussion is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?

Placing the prescribed as-needed warm, wet compress on the elbow Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated.

Which hormone is crucial in maintaining the implanted egg at its site? 1. Inhibin 2. Estrogen 3. Progesterone 4. Testosterone

Progesterone Progesterone is necessary to maintain an implanted egg. Inhibin regulates the release of follicle-stimulating hormone (FSH) and gonadotropin-releasing hormone (GnRH). Estrogen plays a vital role in the development and maintenance of secondary sexual characteristics. Testosterone is important for bone strength and development of muscle mass.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? a. bruit b. ectropion c. entropion d. borborygmi

a. bruit A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines

Which description provided by the parent of a preschool-age client would suggest to the nurse that the child is experiencing sleep terrors? a. sweating profusely b. calling out after a dream c. awakening during the second half of the night d. being aware that others are in the room after awakening

a. sweating profusely Profuse sweating is a characteristic that would cause the nurse to believe that the child is experiencing a sleep terror versus a bad dream. Calling out after the dream is over, awakening during the second half of the night, and being aware that others are with them after the dream is over are characteristics associated with a bad dream, not a sleep terror.

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?

assessment diagnosis planning implementation evaluation

In which settings should the nurse prepare to administer developmental assessments for pediatric clients? Select all that apply. home school hospital daycare center environments assisted living center

home school hospital daycare center environments Pediatric developmental assessments are performed in many settings, including the home, school, hospital, and daycare center environments. It is unlikely that a pediatric developmental assessment would be performed in an assisted living center.

Which is appropriate for the nurse to include in the education of the ethical principle of nonmaleficence to a group of nursing students? 1. Treat all clients equitably and fairly 2. Act in ways to prevent harm to clients 3. Tell the client the truth about their health 4. Help the clients make informed choices

2. Act in ways to prevent harm to clients * Nonmaleficence means to act in ways that prevent client harm or even the risk of harm. Telling the truth to clients about their health refers to veracity. Helping clients make informed choices promotes autonomy. Justice involves treating all clients equitably and fairly.

The nurse records the clients weight and body mass index (BMI) at a health range, but the client states, "I wish I were as thin as my coworkers." Which culturally bound condition is the client at risk for? 1. Neurasthenia 2. Anorexia nervosa 3. Shenjing shuairuo 4. Ataque de nervios

2. Anorexia nervosa * Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latin0-Caribbean culture-bound syndrome and is not associated with body image.

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this? 1 "I don't understand what you mean." 2 "I do understand; I was a teenager once too." 3 "It would be helpful to understand; let's talk." 4 "It's you who should try to understand others."

3 "It would be helpful to understand; let's talk" attempts to open the communication process. Reflecting the words, not the feelings, serves to entrench the communicant's position and does little to open the flow of communication. Saying "I was a teenager once too" shifts the focus away from the client. Telling the client to try to understand others is authoritative and closes the flow of communication.

A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent? 1 Golf 2 Bowling 3 Swimming 4 Badminton

3 Swimming The hyperextension required in swimming helps strengthen back muscles and necessitates deeper respirations, both of which are necessary before surgery and before wearing a brace or cast. The other options involve twisting the back muscles, which is not therapeutic for a child with this condition.

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the correct response by the nurse? 1. "You must keep up a strong appearance for him." 2. "I think he'd have difficulty dealing with that now." 3. "Don't you think he knows that without you telling him?" 4. "You should share your feelings with him while you can."

4. "You should share your feelings with him while you can." * It is difficult to work through loss; however, encouraging the sharing of feeling helps both parties feel better about having to let go. The response, "You must keep up a strong appearance for him" impedes the work of acceptance of one's finality and the use of the remaining time to the best advantage. There is not evidence to suggest that the client cannot cope with these emotions; the response, "I think he'd have difficulty dealing with that now" denies that this is a time for closeness and honestly. The response, "Don't you think he knows that without you telling him?" is demeaning, closes off communication, and does not foster the expression of feelings.

During a home visit, the nurse finds that a healthy elderly person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. What does the nurse infer from these findings? An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy upon suggestion or pressure created by other individuals.

An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy upon suggestion or pressure created by other individuals.

An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury? A. Sacrum B. Scapulae C. Ischial spine D. Greater trochanter

Answer: A. Sacrum Rationale: The sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.

What should the nurse encourage the parents of a child with plumbism (lead poisoning) to do? 1 Discourage the child's pica by providing nutritious snacks. 2 Move the family away from areas that are next to gas stations. 3 Assess the family's home environment for lead sources and have them removed. 4 Have the child take repeat x-rays of the wrist and forearm for signs of a lead line.

Assess the family's home environment for lead sources and have them removed

Which treatment is beneficial for a client with muscle spasm? 1 Thermotherapy 2 Muscle massage 3 Frequent position changes 4 Muscle-strengthening exercise regimen

Thermotherapy

For which purpose is a goniometer used?

To assess range of motion