NURSING 105: FUNDAMENTALS FINAL LIPPINCOTT CONCEPTS

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers." Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

When assessing a client, which statement indicates that the client is experiencing the anger stage of death and dying?

"I am a good person. Why did this happen to me?"

A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.

"It may take longer for an older adult to heal." "Consider having a home health aide to assist with bathing and personal care." "Older adults with lots of sun exposure may experience delayed healing." The nurse will teach that wound healing is delayed in older adult clients, especially those with long-term sun exposure. Normal aging changes include decreased (not increased) appetite. A home health aide can assist with caregiving to reduce stress from the client. Depression after surgery can affect wound healing, but this is not a normal finding.

The nurse is providing home care for a patient who traditionally drinks herbal tea to treat an illness. How should the nurse respond to a request for the herbal tea?

"Let me check with the doctor to make sure it is okay to drink the tea with your medicines."

The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The client asks why it is so important to do this. What is the nurse's best response? "Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke." "Because it is required by your insurance." "Your BP measurements at home are more accurate than the ones we do in the health care setting." "You must do this because the doctor ordered it."

"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."

A client with a sports injury undergoes a diagnostic arthroscopy of the left knee. What comment by the client following the procedure will the nurse address first?

"My toes are numb."

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.

"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation." Pressure injuries usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation. Pressure injuries can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure injury can appear in less than 2 hours of time, depending on the factors present. Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.

A nursing instructor lecturing about death and grief realizes a need for further instruction when a student states what?

"The grieving process is the same for children and adults."

A client tells the nurse that she will be researching an alternative method of treatment for her disease. What is the most appropriate response by the nurse?

"You are within your right to search for other methods of treatment. Just be sure to inform your physician what treatments you are using."

A healthy patient eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this patient's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

Which individual will take longer to sense thirst?

70-year-old When adults older than 65 years of age were compared with younger adults, the plasma osmolarity at which the older group experienced thirst was increased, indicating an increased risk for development of a water deficit.

To provide culturally sensitive care, the nurse should consider which when developing psychiatric interventions?

A client's background, beliefs, and concerns

The nurse is caring for a client with a pressure ulcer. When documenting findings from the assessment, which statement indicates the client has a stage 4 pressure ulcer? Select all that apply.

A strong, foul odor is present Necrotic tissue is present in the wound Temperature is 102.2 F/ 38.9 C Stage IV pressure ulcers are life-threatening. The tissue is deeply ulcerated, exposing muscle and bone. Slough and necrotic tissue may be evident. The dead or infected tissue may produce a foul odor. If an infection is present, it easily spreads throughout the body, causing sepsis (a potentially fatal systemic infection). The nurse is likely to assess a fever in a client with a stage 4 pressure ulcer due to the presence of infection. With a stage 1 pressure ulcer, skin remains intact but redness is present. A stage III pressure ulcer has a shallow skin crater that extends to the subcutaneous tissue. It may be accompanied by serous drainage (leaking plasma), undermining, slough, or purulent drainage (white or greenish fluid) caused by a wound infection. The area is relatively painless despite the severity of the ulcer.

In which ways can anticipatory grief be helpful for the client and family?

Acceptance of impending death

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve? Vagus Olfactory Facial Acoustic

Acoustic

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

An infant's skin and mucous membranes are easily injured and at risk for infection. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients?

An infant's skin and mucous membranes are injured easily and are subject to infection. In children younger than 2 years, the skin is thinner and weaker than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to, and infection of, the skin and mucous membranes. A child's skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages. The maturation of epidermal cells is prolonged, leading to thin, easily-damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply.

Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. The nurse would administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The medication would be in the client's system at the time of the dressing change. The nurse would change the dressing midway between meals so that pain and discomfort would be at a minimum at the time of the meal. A protective paste or ointment would protect the surrounding skin from the drainage of the wound. There is no need to apply another layer of protective ointment or paste on top of the previous layer when changing dressings. The nurse would not apply an absorbent dressing material as the first layer of the dressing. The nurse wants to wick the drainage from the wound. The nurse would not apply a nonabsorbent material over the first layer of absorbent material. Again, the nurse wants to wick the drainage from the wound.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

As a stage I pressure injury Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.

The nurse is performing a neurological assessment. What will this assessment include? Inspect the foot for edema. Observe for capillary refill of the great toe. Palpate the dorsalis pedis pulse. Ask the client to plantar flex the toes.

Ask the client to plantar flex the toes.

The nurse assesses an 8-month-old infant for a possible head injury after a fall of about 3 feet. The child is awake, alert, and crying. Vital signs are within normal limits. What action should the nurse take next? Obtain immediate intravenous access. Apply 100% supplemental oxygen. Interview the parents about the fall. Assess the infant's pupillary responses.

Assess the infant's pupillary responses.

What food would the nurse provide for a client who has hypokalemia?

Bananas Hypokalemia is a below normal potassium level. Bananas are high in potassium. Adding bananas to the diet can help increase the serum potassium level. Canned vegetables, cheese, and bread do not have a high potassium content.

What food would the nurse provide for a patient who has hypokalemia?

Bananas Hypokalemia is a below normal potassium level. Bananas are high in potassium. Adding bananas to the diet can help increase the serum potassium level. Canned vegetables, cheese, and bread do not have a high potassium content.

Which stages of grieving, according to Kubler-Ross (1969), occurs when the person asks God or fate for more time to delay the inevitable loss?

Bargaining

An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis?

Bone fracture Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

Potassium is needed for neural, muscle, and

Cardiac function Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for?

Cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac arrhythmias.

You are instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?

Cheese

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse?

Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment.

Which is not considered a skin appendage?

Connective tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

An older man has been sick for three weeks but will not seek medical help even though he is able to get to the doctor's office. The client does not know what his insurance will cover. The client has many medical bills from treatments not covered and does not want to be faced with more. Why is this client waiting to obtain medical treatment?

Cost

Upon responding to the patient's call bell, the nurse discovers the patient's wound has dehisced. Initial nursing management includes calling the physician and which of the following?

Covering the wound area with sterile towels moistened with sterile 0.9% saline If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The patient should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the patient alone.

The nurse is assessing a client who was diagnosed with metastatic prostate cancer. The nurse notes that the client is exhibiting signs of loss, grief and intense sadness. Based upon this assessment data, the nurse will document that the client is in what stage of death and dying?

Depression

Changes that are found during the mental status examination of a client diagnosed with delirium include what?

Difficulty focusing

A nurse is working with a teenage boy who was recently diagnosed with asthma. During the current session, the nurse has taught the boy how to administer his bronchodilator by metered-dose inhaler. How should the nurse best evaluate the teaching-learning process? Assess the boy's respiratory health at the next scheduled visit. Ask the boy specific questions about his medication. Ask the boy whether he now understands how to use his inhaler. Directly observe the boy using his inhaler to give himself a dose.

Directly observe the boy using his inhaler to give himself a dose.

Which is a term used to describe grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially?

Disenfranchised grief Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. Anticipatory grieving is when people facing imminent loss begin to grapple with the very real possibility of the loss or death in the near future. Bereavement refers to the process by which a person experiences the grief. Mourning is the outward expression of grief.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage. After completing a dressing change and retuning the client to a comfortable position, it is important to document color, odor, amount, and the type of wound drainage. Early documentation helps to assure the most accurate information can be recorded. Determining the extent of wound undermining and measuring length, width, and depth of the wound should be performed during the dressing change, while the wound is still exposed. The healthy tissue surrounding the wound should never be massaged because it could cause further breakdown of healthy tissue.

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. When charting the findings, draw an irregular-shaped wound, as in this question, and provide a description including its length and width. A sterile applicator moistened with saline should be used to measure the depth of a wound and to determine the presence of tunneling. A dry applicator could damage the wound by sticking to it. The nurse would use the imaginary face of a clock when describing where on the wound the locations of tunneling exist. The nurse would assess the color of the wound, and presence of drainage, pain or discomfort, and any complications, and include these in the charting.

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?

ECF Deficient Fluid Volume The most appropriate nursing diagnosis is ECF deficient fluid volume deficit because the client has the defining characteristics of the diagnosis. Impaired skin integrity is associated with edema and diarrhea. Risk for injury can occur if electrolyte or fluid imbalances cause postural hypotension, loss of consciousness, or impaired cognition. Water excess is characterized by symptoms like weight gain, headache, and delirium.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse caring for the client knows that the client needs restoration of which of the following?

Electrolytes The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have non-electrolytes, colloid solution, or interstitial fluid restored. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

A nurse is teaching a class to new parents on how to prevent the spread of infection in their children. What is the best suggestion the nurse could offer to these parents?

Encourage frequent hand hygiene.

The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?

Examine the legs for color, capillary refill time, and tissue integrity. The nurse examines the extremities and assesses skin color, temperature, capillary refill time, and tissue integrity and not for skin lesions for clients with thrombosis. Examining the client's mental and emotional status or examining for pain around the shoulder and neck region will not assist the nurse in evaluating a client with thrombosis.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. The best response by the nurse is to explain the possible complications of leaving cold therapy in place for too long, including cell death and tissue necrosis. This response not only answers the client's question but teaches at the same time the rationale and reason for limiting the cold therapy. Leaving the therapy on for 10 more minutes places the client at increased risk of tissue injury. Assisting the client out of bed ignores the client's request. Using the health care provider's prescription as the reason displays lack of understanding by the nurse and does not aid the client in understanding the rationale for the time limit.

A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding? Curling downward of the toes Withdrawing the foot from touch Dorsiflexion of the newborn's toes Fanning of the infant's toes

Fanning of the infant's toes

Who is considered to be the founder of professional nursing?

Florence Nightingale Florence Nightingale is considered to be the founder of professional nursing. She elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. Although the other choices are women who were important to the development of nursing, none of them is considered the founder. Dorothea Dix was an American activist on behalf of the indigent mentally ill who, through a vigorous program of lobbying state legislatures and the United States Congress, created the first generation of American mental asylums. During the Civil War, she served as a Superintendent of Army Nurses. Lillian Wald founded the Henry Street Settlement in New York City and was an early advocate to have nurses in public schools. Clara Barton was a pioneering nurse who founded the American Red Cross.

The nurse's morning assessment of a patient who has a history of heart failure reveals the presence of 2+ pitting edema in the patient's ankles and feet bilaterally. What is this assessment finding suggestive of?

Fluid volume excess Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis and hyponatremia are not directly associated with the development of peripheral edema.

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool?

Glasgow Coma Scale

The health care provider recommends that parents have their daughter vaccinated with HPV vaccine. What is this vaccine for? Help prevent cervical cancer Help prevent leukemia Help prevent breast cancer Help prevent lung cancer

Help prevent cervical cancer

The nurse is caring for a patient who has had an appendectomy. What is the best position for the nurse to maintain the patient in after the surgery?

High Fowler's After surgery, the nurse places the patient in a high Fowler's position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound?

Hydrocolloid dressing Hydrocolloid dressings are used for wounds that are shallow to moderate depth with minimal drainage. Saline-moistened dressing is often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings are recommended for chronic wounds.

A child is at risk for infection related to a respiratory disorder. What would the nurse educate the family on to prevent infection?

Hygiene, handwashing

The nurse is administering immunizations to a group of teens in a county health clinic. The nurse correctly identifies this action as: supportive nursing care. treatment of disease. restorative care. illness prevention.

Illness Prevention

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

Implement a 2-hour repositioning schedule The nurse must regularly turn and reposition the client who is immobile to prevent ischemia and consequent skin breakdown. Other skin integrity interventions include monitoring skin for changes, monitor client's continence status and prevent or minimize exposure to urine and feces, evaluate need for positioning devices and specialty mattresses, nutritional status assessment, and individualize skin care plan. Range-of-motion exercises are good to combat problems related to immobility. Frequent orientation is helpful for clients with dementia. Massage may promote circulation, but it is less important than turning the client on a scheduled basis, and massaging areas over bony prominences could harm the skin's integrity.

In teaching about using antibiotic medications, what is it critical to include to help stop the development of resistant strains of microorganisms?

In teaching about using antibiotic medications, what is it critical to include to help stop the development of resistant strains of microorganisms?

Which of the following individuals with diarrhea for 3 days are more likely to suffer from fluid and electrolyte imbalance?

Infant The very young child and older adults are at greatest risk for fluid or electrolyte imbalances.

Which of the following solutions is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

A nurse is assessing a client's fluid balance status. The nurse understands that which organ plays the major role in regulating fluid balance?

Kidneys Although the skin, gastrointestinal tract, and lungs play a role in fluid balance, the kidneys are the major organs regulating fluid balance, conserving or excreting water and electrolytes as necessary to maintain homeostasis.

A nurse is researching information about the different cultures of the population served by the facility. Which aspects of culture would be important for the nurse to keep in mind when learning about them? Select all that apply. Culture is something a child is born with. Culture includes explicit beliefs and attitudes. Characteristics apply more to an individual than a group. Language is a means for communicating culture. Culture facilitates self-worth and self-esteem.

Language is a means for communicating culture. Culture facilitates self-worth and self-esteem.

What is the ultimate goal of expanding nursing knowledge through nursing research?

Learn improved ways to promote and maintain health

The nurse walks into the client's room and finds a shaman "fluffing the aura" of the client. What is the best action of the nurse?

Leave the room and provide privacy to the client.

A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the:

Left lower quadrant

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure. Local capillary pressure must be higher than external pressure for adequate skin perfusion.

A nursing instructor is discussing characteristics of chronic illness with a class. The instructor asks the students to name one characteristic. Which of the following answers is correct? Chronic illness affects the client only. Chronic conditions only involve one phase of a person's life. One chronic disease never develops into another chronic condition. Managing chronic conditions must be a collaborative process.

Managing chronic conditions must be a collaborative process. Managing chronic conditions must be a collaborative process. Chronic illness does affect the entire family to the extent that family life can be dramatically altered. One chronic disease can lead to the development of other chronic conditions. Chronic conditions usually involve many different phases over the course of a person's lifetime.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert?

Muscle weakness, fatigue, and dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

When teaching a patient about foods that affect fluid balance, the nurse would advise the patient to decrease:

Na+ Sodium (Na+) is the most abundant electrolyte in the extracellular fluid (ECF). Na+ regulates extracellular fluid volume; Na+ loss or gain is accompanied by a loss or gain of water. Potassium (K+) is the major intracellular electrolyte. Calcium (Ca++) is a major component of bones and teeth. Magnesium (Mg++) is the most abundant intracellular cation after potassium.

The nurse working in the ED is evaluating a client for signs and symptoms of appendicitis. Which of the client's signs/symptoms should the nurse report to the physician?

Nausea

A nurse monitoring a patient's IV infusion auscultates the patient's lung sounds and finds crackles in the bases in lungs that were previously clear. What would be the appropriate intervention in this situation?

Notify primary care provider immediately for possible fluid overload. If the patient's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify primary care provider immediately. The patient may be exhibiting signs of fluid overload. Be prepared to tell the healthcare provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the patient.

The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply.

Nutritional status Mental status Skin moisture Sensory perception he client has blood clots that could potentially travel to the lungs (thromboembolism), so the client needs to be on strict bed rest until treated for the condition and determined safe to ambulate. Stages of pressure injuries are used after there is a break in the skin's integrity, and the nurse is examining the client for potential risks for developing a pressure injury in this case. Nutritional status is important to assess to determine if skin has adequate nutrients to replace damaged or dead cells daily. In older adults, the first clue of an infection—fluid and electrolyte imbalance—is often a change in the mental status, and all these factors can influence the client not adequately moving in bed and increase pressure on the bony prominences. Skin moisture needs to be assessed because excessively dry or moist skin will break down easier than skin with a normal amount of moisture. Sensory perception is important to assess because if the client cannot feel light touch or painful stimuli, the client may not recognize lying in one position too long, which leads to increased pressure on tissues and damage to the skin.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?

Orientation

When measuring the size, depth, and wound tunneling of a client's stage IV pressure injury, what action should the nurse perform first?

Perform hand hygiene.

When measuring the size, depth, and wound tunneling of a patient's stage IV pressure ulcer, what action should the nurse perform first?

Perform hand hygiene. Hand hygiene should precede any wound assessment or wound treatment.

Post appendectomy, a nurse should assess the patient for abdominal rigidity and tenderness, fever, loss of bowel sounds, and tachycardia, all clinical signs of: peritonitis A pelvic abscess. An abscess under the diaphragm. An ileus.

Peritonitis Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. Peritonitis is typically a life-threatening emergency that requires prompt surgical intervention, and typically involves postoperative critical care monitoring due to the risk of sepsis, organ failure, and subsequent infections.

A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects the total being. Which would best be considered a holistic approach to health? Physical, emotional, and spiritual well-being Healthy work environment Emotional and sexual contact Financial success and post-secondary education

Physical, emotional, and spiritual well-being

The delivery of culturally competent nursing care requires the incorporation of which concept?

Planning and implementing care that is sensitive to the needs of clients from diverse cultures.

Upon assessment of a patient's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Proliferation phase The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about 4 to 6 days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound and a scar forms.

Which of the following are functions of the skin? Select all that apply.

Protection Temperature regulation Sensation Immunological The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination.

A nurse is caring for a young client with acute renal failure who is dying. What care should the nurse take when helping dying clients to cope?

Provide opportunities for client to express his or her feelings freely.

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?

Rebound pain

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy to

Replace fluid and electrolytes The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost due to the NPO order and the loss of fluid and electrolytes due to the nasogastric suctioning.

A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires

Replacement of fluids for those lost from vomiting and diarrhea The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? Left upper quadrant Left lower quadrant Right lower quadrant Right upper quadrant

Right lower quadrant

The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis?

Rovsing sign When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the right lower quadrant, this is referred to as a positive Rovsing sign and suggests acute appendicitis. Referred pain indicates pain in another area but is not necessarily manipulated by the examiner. Rebound pain is indicated when the pain of palpation is worse when the pressure is off of the site. The cremasteric reflex is a superficial reflex that is present in male clients.

Which must the nurse consider a priority in the assessment of mental status?

Safety The most important priority in conducting a mental health assessment interview is determination of the client's safety toward self, toward others, and from others.

A young client died following a cardiac arrest. The nurse caring for the client and the family notes that some members of the family refuse to accept that the client has died.What stage of grief is the family experiencing?

Shock and disbelief

When developing a preventative plan of care for a patient at risk for developing chronic obstructive pulmonary disease (COPD), which of the following should be incorporated? Cholesterol management Smoking cessation Weight reduction Cancer prevention

Smoking cessation

The primary extracellular electrolytes are

Sodium, chloride, and bicarbonate

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

While performing a bedbath, you noted an area of tissue injury on the patient's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound?

Stage II pressure ulcer Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

A hospice nurse is providing emotional care and support for a family who lost a child. The nurse will provide care on the basis of what knowledge?

Stages of grief reactions may overlap and are individualized

While working on the unit, a nurse overhears another nurse colleague talking with several staff members about a client who is of Asian descent. During the conversation, the nurse says, "Asians are always so intelligent." The observing nurse interprets this statement as what?

Stereotyping

A nurse is providing end-of-life care to a client at a health care facility. The client is anticipating death. The nurse understands that the client is in the acceptance stage of dying. What indicates that the client is in the acceptance stage of dying?

The client has settled all financial matters for surviving family members.

A 74-year-old is being seen in the mental health clinic. The client has never fully regained the level of activity the client had prior to the death of the client's spouse. The client continues to have symptoms of depression and has not been able to work or volunteer. In addition, the client complains of "anxiety attacks" that occur nearly every night. What type of grief reaction is this client exhibiting?

The client is experiencing complicated grieving reaction. The client needs to have a comprehensive mental health assessment.

A nurse has performed disease prevention teaching with a female client who has genital herpes. Which client behavior indicates that the teaching has been successful? The client keeps the affected area moist. The client washes her hands before and after touching lesions. The client keeps her fingernails long. The client wears tight-fitting jeans.

The client washes her hands before and after touching lesions.

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. This would be a correct way to document a normally healing wound. A wound that does not feel hot upon palpation would be another example of correctly documenting a wound that has no complications. A wound that is warm to touch is not an abnormal finding. A wound that forms exudate due to the inflammatory response would be correct documentation of a normal finding.

A nurse is caring for a client from another country. How might the client's culture impact his or her readiness to learn when the nurse attempts teaching? Select all that apply. The severity of disease or injury impacts learning. The client's present lifestyle impacts learning. The information in which the client learns is impacted. The manner in which the client learns is impacted. The client's previous life experience impacts learning.

The manner in which the client learns is impacted. The information in which the client learns is impacted.

A client, age 85, is in advanced stages of pneumonia with a no-code order in the chart. Which nursing care action will help establish a trusting nurse-client relationship?

The nurse discusses the client's fears and doubts openly and serves as a nonjudgmental listener.

The nurse-client relationship is classified as which type of relationship?

Therapeutic

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first?

Verify the orders for type of solution and amount of infusion. The nurse should verify the order from the health care provider first. The order for intravenous therapy should include the type of solution, the volume, possible additives, and the duration of the infusion. After verifying the order, the nurse prepares the solution for administration, performs a venipuncture, and regulates the rate of administration.

A client with a history of pressure injuries is discussing nutrition with the nurse. The client correctly indicates plans to include which vitamin in the diet to promote wound healing? Select all that apply.

Vitamin B3 (niacin) Vitamin B6 (pyridoxine) Adequate intake of vitamins A, B6, C, K, niacin, and riboflavin is important to prevent abnormal skin changes.

Which of the following statements most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration. Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis and plasma proteins facilitate colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

An elderly client has presented to the clinic with a new diagnosis of osteoarthritis. The client's daughter is accompanying him and the nurse has explained why the incidence of chronic diseases tends to increase with age. What rationale for this phenomenon should the nurse describe? Chronic illnesses are diagnosed more often in older adults because they have more contact with the health care system. There is an increased morbidity of peers in this age group, and this leads to the older adult's desire to also assume the "sick role." Older adults often have less support and care from their family, resulting in illness. With age, biologic changes reduce the efficiency of body systems.

With age, biologic changes reduce the efficiency of body systems.

Which client should receive the pictured examination first?

a client with facial drooping and left-sided weakness

The nurse should explain to the client's family member that a comfort-measures-only order is being implemented to obtain which expected outcome?

a comfortable, dignified death for the client

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

A client has been diagnosed with a terminal illness and has made an appointment with an attorney to complete a will. How will the nurse document this stage of grief according the Kübler-Ross Model?

acceptance

A terminally ill client states, "I am ready to die." What stage of grief does the nurse suspect?

acceptance

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk?

an 86-year-old who is bedfast Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

A middle-age woman is mentally preparing for the death of her mother. What is the term for this mental preparation?

anticipatory grieving

The nurse is providing care to an older adult client. Which intervention(s) will the nurse perform to protect the client's skin? Select all that apply.

apply moisturizing lotion to feet and hands daily minimize the use of any tape on the skin wash the perineal area every day offer fluids every hour while the client is awake Nursing interventions to protect the older adult client's skin include applying moisturizing lotions to feet and hands. This is because the older client's skin becomes more dry as the person ages. The nurse protects the skin from injury by minimizing the use of tape on the skin. The older adult client's skin is more easily injured. The nurse washes the perineal area daily and as needed to clean the skin of urine and feces. Both are irritants to the skin and may cause damage. The nurse offers fluids to the client to ensure adequate hydration, which helps protect the skin. The nurse does not bathe the older client every day, since this will cause the skin to become more dry.

The nurse is caring for a client who is dying. She overhears the client saying, "God, if you will only let me live to see my daughter get married, I promise I will start going to church again." The nurse understands that the client is in which stage of grief according to Kübler-Ross?

bargaining

To adequately assist a client and family from a different culture with the death and dying process, the nurse should:

be aware of the client's cultural beliefs.

A father, mother, grandmother, and three school-aged children have immigrated to the United States from Thailand. Which member(s) of the family are likely to learn to speak English more rapidly?

children

A client with severe anemia is prescribed 2 units of packed red blood cells. The client refuses to sign the consent form for blood administration because to do so conflicts with the client's Jehovah's Witness faith. What did the nurse fail to assess prior to witnessing consent?

cultural beliefs

A client has been asked to undergo a series of diagnostic tests following a routine blood test that indicates leukemia. The client refuses to believe the diagnosis and feels that there has been an error in the reports. Which stage of grief is the client going through?

denial

The nurse is assessing a client recently diagnosed with terminal lung cancer who states, "This can't be happening to me. Maybe the doctor made a mistake." Which stage of death and dying is the client exhibiting?

denial

The hospice nurse is caring for a client with lung cancer. The client's daughter states, "My mom isn't happy with anything I do for her. She is constantly yelling at me." The nurse understands that the client is in which stage of grief according to Kübler-Ross?

depression

A nurse is providing care to a client and actively involves the client's family members in the care planning and implementation, dealing with the client and family as a unit. The nurse is engaging in:

family-centered care.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of:

fluid volume excess.

A nurse has begun a new role in a clinic that focuses on genetics and genomics. In this role, the nurse will aim to help individuals and families understand how: genetic and environmental factors influence health and disease. genomic and physical factors influence longevity. physical factors influence genetics and wellness. genetic and psychological factors influence coping.

genetic and environmental factors influence health and disease.

Which of the following is an example of the body's defense against infection?

immune response

A client is attending a support session with a nurse after hearing about the sudden death of the client's best friend due to heart attack. The client asks, "I just don't understand how this could have happened? He exercised every day." This client is attempting to:

make sense of the loss.

A typical sign/symptom of appendicitis is:

nausea Nausea, with or without vomiting, is typically associated with appendicitis. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt upon the release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.

Which client has more extracellular fluid?

newborn Newborns have more extracellular fluid than intracellular fluid.

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?

nonblanchable redness A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. A stage II pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer. A stage III pressure injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. A stage IV pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often includes undermining and tunneling.

When providing end-of-life care for clients, what will the nurse most often need to prioritize?

pain control and emotional support

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen.

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention. Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing.

What is the most important goal of care for the dying client who is receiving comfort care?

providing a comfortable, dignified death

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for:

rupture of the appendix.

A nurse is caring for a client whose husband died over 4 years ago. The nurse suspects that the client has abnormal grief. Which assessment finding would support this?

talking about her husband as if he were still alive

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply.

the client who has a body mass index (BMI) of 34 the client who is emaciated from self-induced vomiting and food deprivation the client who has a temperature of 104°F (40°C) and is perspiring the client who is experiencing an allergic reaction and is scratching the skin The clients at risk for injury to the skin are the client with a BMI of 34, the emaciated client, the perspiring client, and the client who is scratching. The client with a BMI of 34 is obese, placing him at risk for skin irritation and injury. The emaciated client is also at risk for skin irritation and injury due to poor nutrition. The perspiring client has excessive moisture that predisposes the client to skin breakdown, particularly in skin folds. The client who is scratching may tear the skin. The ambulatory client will be mobile within a few hours of the endoscopic procedure.

The nurse is working with a group of clients. Which clients are at risk for a skin alteration? Select all that apply.

the client who is a roofer and spends a lot of time outdoors participating in sports the client who has experienced vomiting and diarrhea for several days with a loss of 12 lb (5.4 kg) in weight the client who has paralysis and is unable to move in bed, turned by the nurse every 2 hours the client with newly diagnosed diabetes who requires management education for the disease The clients at risk for skin alterations are the roofer, the one experiencing fluid disturbances, the client who is paralyzed, and the client who has diabetes. The client who is a roofer and spends a lot of time outdoors has prolonged exposure to the sun and is at risk for skin cancer. The client experiencing vomiting and diarrhea with weight loss is dehydrated. The skin loses elasticity and is prone to breakdown. The client who is paralyzed has reduced sensation and is at risk for pressure injuries due to immobility and friction caused by the lifting and turning by others. The client who has diabetes is at risk for problems related to the disease (nerve damage, poor perfusion) and must be taught how to properly care for himself. The client who had numbness that has resolved is the least at risk; sensation has returned for this client.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

thorough hand hygiene The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Proper intake of fluids and fiber as well as adequate sleep and rest are general guidelines to promote health. Taking medications especially antibiotics are important if an infection occurs.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

to apply sunscreen when exposed to ultraviolet rays. Sunscreen is necessary to protect against damage caused by ultraviolet rays.

A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should: wash and inspect the feet daily. walk barefoot at least once each day. use commercial preparations to remove corns. cut the toenails by rounding edges.

wash and inspect the feet daily. A client with diabetes mellitus should wash and inspect his feet daily and should wear nonconstrictive shoes. Corns should be treated by a podiatrist — not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot.

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?

white blood cells, debris, bacteria Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.