Practice Session 2
A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? 1 Use a consistent approach to care and encourage participation. 2 Prepare equipment while doing the procedure and explain the treatment to the client. 3 Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. 4 Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done.
Correct Ans: 1 Client participation provides for a sense of control, and a consistent approach provides a routine with no surprises; these approaches may limit pain and promote adherence to the regimen. Preparation of the equipment and explanation of the procedure should be performed before the procedure; when performed during the procedure, it wastes time, which can prolong pain and increase anxiety. Water temperature of 105° F (40.6° C) is too hot; the rinse water should be room temperature. Changing staff disrupts the client's routine and sense of trust.
A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. Which action should the nurse take? 1 Notify the healthcare provider 2 Increase the intravenous (IV) flow rate 3 Raise the head of the bed 4 Place the client in the Trendelenburg position
Correct Ans: 1 The healthcare provider must evaluate the cause of the hypotension. Increasing the IV flow rate is a dependent function that requires a healthcare provider's prescription. Raising the head of the bed will further decrease blood flow to the brain. The Trendelenburg position is contraindicated because it will increase pressure in the carotid arteries.
What is the priority nursing care in the immediate postoperative period for a toddler with a newly applied hip spica cast? 1 Offering oral fluids 2 Checking the toddler's peripheral circulation 3 Encouraging independent incentive spirometer use 4 Teaching how to use the overhead trapeze
Correct Ans: 2 Priority nursing care for any cast application includes checking the color and temperature of the area surrounding the cast to ensure that the cast is not too tight. A tight cast compresses arteries and veins, thereby impairing circulation. Offering oral fluids is not the priority nursing care. The child has probably had a general anesthetic; if so, fluids will be offered later to avoid vomiting and aspiration. A toddler is not likely able to use an incentive spirometer independently. If a trapeze is to be used, this teaching should have been done before surgery or should be delayed until the child's condition has stabilized and the cast is dry.
A community health nurse makes a home visit to a disabled 13-year-old client who has a 6-month-old infant sister. The infant lies quietly in her crib and rarely smiles or vocalizes; it appears that the infant barely has her basic needs met. What is the nurse's most appropriate intervention? 1 Advise the parent that the infant will be retarded if not stimulated. 2 Ask the disabled client to spend more time playing with the sister. 3 Encourage purchasing toys that are appropriate for the infant's age level. 4 Determine whether there is anyone who can help with chores and the infant's care.
Correct Ans: 4 Recruiting someone to help with chores and infant care will allow the parent time to rest and will provide the infant with care and attention. Making the parent feel guilty is not therapeutic and will increase anxiety. The disabled sibling requires attention, and this responsibility may cause jealousy, rivalry, and resentment. Toys need not be employed for sensory stimulation; household objects and quality human contact can serve as well.
When a client with cancer reaches an incurable last stage, the nurse explains the situation to the client and calls the client's family members to provide support. Which need of the client does the nurse prioritize here? 1 Safety need 2 Belonging need 3 Self-esteem need 4 Self-actualization need
Correct Ans: 2 The client at an incurable stage of cancer might need the support of loved ones for emotional support. Therefore the belonging need is fulfilled through this action. Safety needs may not be the top priority of the client at this stage. Self-esteem needs may be fulfilled through recognition and personal growth. Self-actualization needs may not be a priority for the client.
A nurse notes that a client with dementia refuses to eat. Instead of informing the primary healthcare provider, the nurse threatens to force-feed the client, and proceeds to apply restraints in order to do so. What legal charges may be brought up against the nurse? Select all that apply. 1 Libel 2 Assault 3 Malpractice 4 Invasion of privacy 5 False imprisonment
Correct Ans: 2, 3, 5 In the given situation, the nurse threatens to force-feed the client, which is an example of assault. If the nurse fails to inform the primary healthcare provider regarding the problem faced when feeding the client, the nurse may be charged with malpractice for this action. Applying restraints to a client without the orders of the primary healthcare provider is considered false imprisonment.
What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa? 1 Set limits. 2 Maintain control. 3 Demonstrate sympathy. 4 Focus on a healthy diet.
Correct Ans: 1 The client's security is increased by the setting of limits; guidelines remove responsibility for behavior from the client and increase compliance with the regimen. Simply maintaining control is not therapeutic and increases the power struggle. The client needs structure, not sympathy. Emphasis on dietary intake increases the power struggle between the client and the staff.
A nurse is teaching dietary management to the parents of a toddler who is undergoing chelation therapy to treat lead poisoning. What will be included in the discussion of the dietary plan? 1 Maintaining a low-salt diet 2 Ensuring adequate fluid intake 3 Avoiding refined sugar and flour 4 Offering high-calorie, low-protein foods
Correct Ans: 2 Adequate hydration is needed because the lead complexes released during chelation therapy are excreted by the kidneys. There is no basis for restricting salt in the diet of a child with lead poisoning. There is no basis for restricting intake of refined sugar and flour except for improving the nutrition of every child, not just those with lead poisoning. There is no reason to increase caloric intake unless the child is underweight; it is unnecessary to restrict protein.
When assisting an older adult (ages 65 to 75 years) in successfully completing Erikson's task of this stage, the nurse should help the client with what task? 1 Investing creative energies in promoting social welfare 2 Redefining a role in society that offers something of value 3 Look to recapturing those opportunities that were not experienced 4 Feeling a sense of satisfaction when reflecting on past achievements
I put 2 Ans: 4 Feeling a sense of satisfaction when reflecting on past achievements encourages the client to accept what life is or was and helps prevent feelings of despair. Although older adults may invest creative energies in promoting social welfare, it is not the task associated with Erikson's theory concerning older adults. According to Erikson's developmental theory, redefining a role in society is the task of young adults. Looking to recapture those opportunities that were not experienced is a desire that must come from the client.
A laboring client who is positive for group B Streptococcus (GBS) is given an initial dose of 2 g of ampicillin at 9 AM. According to established guidelines for intrapartum management of this client, what should the next dose be? 1 2 g given at 10 AM 2 1 g given at 11 AM 3 2 g given at noon 4 1 g given at 1 PM
Correct Ans: 4 The established guidelines for intrapartum antibiotic prophylaxis for a client infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4 hours.
When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, what should the nurse caution the client to avoid? 1 Applying a hot water bottle to the abdomen 2 Using a heating pad to warm the extremities 3 Drinking a warm cup of tea when feeling chilly 4 Turning the room thermostat above 72° F (23.3° C)
I put 1 Ans: 2 The client's extremities are less sensitive to thermal stress because of peripheral vascular problems, and burns may occur. Applying heat to the abdomen causes reflex dilation of the arteries in the extremities and increases blood flow without untoward effects. Raising the internal temperature by drinking warm fluid prevents vascular constriction and warms the extremities. Increasing heat of the external environment is an effort to prevent cold, chilling, and further constriction of peripheral vasculature.
A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? 1 Seek the help of an official interpreter. 2 Seek the help of the primary healthcare provider to assist the client. 3 Seek help from the client's family friend who speaks the client's language. 4 Seek help from the client's caregiver who speaks the same language as the client.
Correct Ans: 1 The nurse should seek the help of an official interpreter to explain the terms of consent to the client. The nurse should not ask for the primary healthcare provider's assistance because he or she might not know the language. The nurse should not seek help from the client's family friend who speaks the language because he or she is not authorized to interpret health information. The nurse should not seek help from the client's caregiver who speaks the same language because he or she should not interpret health information.
A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy? 1 Fetal growth 2 Fluid retention 3 Metabolic alterations 4 Increased blood volume
I put 4 Ans: 1 Weight gain during pregnancy averages 25 to 35 lb (11.3 to 15.9 kg). Of this amount, the fetus accounts for 7 to 8 lb (3.2 to 3.6 kg), or approximately 30%. Fluid retention accounts for 20% to 25% of weight gain. Metabolic alterations do not cause weight gain. Increased blood volume accounts for 12% to 16% of weight gain.
A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention but the client refuses. Which instruction will the nurse provide to the person? 1 "Go see a primary healthcare provider if blisters appear." 2 "Go see a primary healthcare provider if urinary output decreases." 3 "Go see a primary healthcare provider if edema and redness occur." 4 "Go see a primary healthcare provider if white patches develops."
I put 4 Ans: 2 Decreasing urinary output indicates hypovolemia that results from a fluid shift from the vascular space to the burned area. Blisters, edema and redness, and white patches are expected with deep partial-thickness burns.
One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic? 1 "You're frightened. Come with me to your room, and we can talk about it." 2 "Come with me to your room. I'll lock the door and no one will get in to harm you." 3 "Nobody here wants to harm you, and you know that. I'll come with you to your room." 4 "Thank you for trusting me. Maybe you can trust me when I tell you that no one will kill you here."
Correct Ans: 1 Acknowledging that the client is frightened and offering a chance to talk acknowledges the client's feelings and provides assurance that the staff member will be present. Locking the client in a room will only increase the fear and worsen the delusion. The client does not know that no one wants to cause the client harm; otherwise, the delusion would not be present. The client is not ready to accept that no one wants to kill the client and really believes that danger is imminent.
A client who is taking clozapine calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What will the nurse instruct the client to do? 1 Stay in bed, drink fluids, take a dose of aspirin, and ask the primary healthcare provider to reduce the dosage of clozapine. 2 Discontinue the medication immediately and see the primary healthcare provider as soon as an appointment becomes available. 3 Continue the medication, drink fluids, take aspirin, and see the primary healthcare provider in a few days if the symptoms do not improve. 4 Discontinue the medication and, if the primary healthcare provider is unavailable today, go to the emergency department for evaluation.
Correct Ans: 4 Symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and can cause death. Remaining in bed, drinking fluids, taking aspirin, and asking the primary healthcare provider to decrease the dose of clozapine is unsafe, because agranulocytosis may be developing, and this life-threatening side effect requires immediate treatment. Also, prescribing medications is outside the legal role of the nurse. Only a certified nurse practitioner or other licensed healthcare provider can prescribe medications. Although discontinuing the medication is acceptable advice, delaying a primary healthcare provider's evaluation is unsafe. Continuing the medication, drinking fluids, taking aspirin, and seeing the primary healthcare provider in a few days if the condition does not improve is unsafe, because agranulocytosis may be developing.
Which is considered a disadvantage when the primary nursing model is used to implement client care? 1 Increase in cost 2 Loss of autonomy 3 Lack of holistic care 4 Decrease in client rapport
I put 2 Ans: 1 One disadvantage when using the primary nursing model to implement client care is an increase in overall cost. The primary nursing model enhances autonomy and increases holistic care and rapport between the nurse and the client.
A mother indicates to the nurse in the pediatric clinic that she is concerned that her 20-month-old child's bedtime thumb-sucking will cause the teeth to protrude. How should the nurse respond? 1 "You should seek counseling; the thumb-sucking could indicate an emotional problem." 2 "Children need to satisfy their sucking needs until about 2 years of age before they stop on their own." 3 "If you switch your child to a pacifier within the next 2 months, you can prevent protrusion of the teeth." 4 "There is no reason to be concerned about the teeth protruding unless your child keeps sucking the thumb after the permanent teeth have come in."
I put 2 Ans: 4 Lips and teeth closed around the finger create suction and can move permanent teeth forward, causing malocclusion. Thumb-sucking is not considered to be related to emotional problems during the toddler years. Developmentally, children's sucking needs diminish at about 1 year of age when they are able to drink from a cup and ingest a variety of solid foods; however, thumb-sucking often persists as a means of gratification, especially at bedtime. Using a pacifier to replace thumb-sucking has the same result on the permanent teeth that thumb-sucking does. In addition, a toddler with a well-established thumb-sucking habit will refuse a pacifier as a substitute.
A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply. 1 Drink a glass of wine. 2 Engage in vigorous exercise before bedtime. 3 Eat foods containing lysine. 4 Follow the same bedtime ritual each night. 5 Perform deep-breathing exercises.
I put 3, 4, 5 Ans: 4, 5 A bedtime ritual provides a familiar routine that promotes comfort and the self-fulfilling prophesy of sleep. Relaxation exercises slow body processes and reduce tension, both of which facilitate rest and promote sleep. People who drink alcohol may fall asleep more quickly but have depressed levels of rapid eye movement, less stage 4 sleep, and interruptions between sleep stages (sleep fragmentation). Physical exercise before bedtime has a stimulating rather than a relaxing effect. Lysine, an amino acid, maintains nitrogen equilibrium and promotes growth and development, but it does not influence sleep.
An 8-year-old boy who has been undergoing chemotherapy will soon return to school after a prolonged absence. What should the school nurse do to help prepare the class for his return to school? 1 Encourage the students to think about how they feel toward their classmate. 2 Explain to the students why it is important to tolerate those who are different. 3 Ask the students not to make fun of their classmate because he has lost weight and has no hair. 4 Initiate a general discussion with the students about cancer, its treatments, and the side effects of chemotherapy.
Correct Ans: 4 According to Piaget's cognitive development theory, school-aged children use concrete operational thinking; a general discussion in concrete terms will be understood and transferred to the actual situation. Having the students address their feelings or discuss tolerance requires conceptual thinking that is just beginning to develop during the school-aged years; 8-year-olds are not ready for these thought processes. These children are capable of understanding a concrete explanation; asking them not to mock the classmate belittles them.
A nurse employed in an outpatient radiology department is reviewing safety precautions with staff members. What explanation does the nurse provide to explain the reason radium is stored in lead containers? 1 Lead functions as a barrier. 2 Radium is a heavy substance. 3 Heat is produced as radium disintegrates. 4 Lead prevents disintegration of the radium.
Correct Ans: 1 Radium atoms are unstable and spontaneously disintegrate. This disintegration produces potentially harmful radiation; lead is a barrier to radiation. Radium is not heavy, but is unstable. Radiation, not heat, is produced during spontaneous disintegration of radium atoms. Disintegration of radium occurs in lead containers.
What foods should a nurse order for a 30-month-old toddler on a regular diet? 1 Hamburger with bun and grapes 2 Chicken fingers and French fries 3 Hot dog with bun and potato chips 4 Macaroni and cheese and Cheerios
Correct Ans: 4 Macaroni and cheese and Cheerios are foods that a toddler enjoys and can handle; in addition, they are nutritious. Grapes are dangerous because both the skins and the shape pose a choking hazard to toddlers. Chicken fingers and French fries each have a high fat content and, if eaten regularly, can cause obesity. The skin and shape of a hot dog may cause choking, and potato chips are not nutritious.
A child is born to a mother whose hepatitis B status is negative. While assessing the newborn, the nurse finds that the birth weight is 1.8 kg. Which action by the nurse is appropriate in this situation? 1 Administer HepB vaccine to the newborn 1 month after birth. 2 Administer monovalent HepB vaccine to the newborn during discharge. 3 Administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. 4 Administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.
I put 4 Ans: 1 The immune response to the HepB vaccine is not optimum in newborns who weigh less than 2 kg. Because the mother's hepatitis B status is negative, the first dose of HepB vaccine should be administered 1 month after birth. There is no need to administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth, because the mother's hepatitis B status is negative. Monovalent HepB vaccine is administered during discharge to newborns whose birth weight is more than 2 kg. If the infant were born to a hepatitis B-positive mother, HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) would be administered within 12 hours of birth.
The nurse decides to teach deep-breathing exercises to a client recovering from a surgery. Which professional responsibility does the nurse display? 1 Advisory 2 Advocacy 3 Autonomy 4 Caregiving
I put 4 Ans: 3 The nurse practices autonomy by initiating independent nursing interventions without medical orders. Autonomy is an essential element of professional responsibility. The nurse explains concepts and facts related to health, but does not advise the client. The nurse acts as a client's advocate by speaking for the client and protecting the client's health care rights. As a caregiver, the nurse helps the client to improve physical, emotional, spiritual, and social well-being.
A client is found to have pelvic inflammatory disease, and the primary healthcare provider prescribes 2 g of intravenous cefotetan twice a day. The instructions on the vial of cefotetan say to reconstitute 20 mL of diluent to yield 1 g/10.5 mL. How much solution (mL) should the nurse add to the 100-mL bag of 0.9% sodium chloride? Record your answer using a whole number. ___ mL
21 mL
What is the most appropriate approach for the school nurse to take regarding children who are to be given medications while in school? 1 Assuring the children that their privacy will be respected 2 Teaching each class about taking medications in the school setting 3 Encouraging the children to tell their friends that they are taking a medication 4 Asking teachers to answer questions when other students ask about medications given in school
Correct Ans: 1 Children's and adults' confidentiality is protected by privacy laws. Although health classes may address medication as part of its curriculum, the information should be taught on a general, not a personal, level. Children and their teachers should not be encouraged to divulge private information.
Which action by the nurse while administering human growth hormone ensures effective therapy? 1 Administration at nighttime 2 Administration via oral route 3 Administration along with meals 4 Administration by metered spray
Correct Ans: 1 Human growth hormone therapy shows best results when the hormone is administered at nighttime because the body naturally produces growth hormone at night. Therefore the normal body rhythm is being mimicked to ensure effective therapy. Subcutaneous injections of growth hormone yield effective results. Hyperpituitarism is treated by the administration of bromocriptine, which should be taken along with food to reduce side effects. Desmopressin acetate is administered either orally or intranasally with a metered spray to treat diabetes insipidus.
Following a motor vehicle accident, a client at 37-weeks' gestation is triaged in the emergency room and quickly admitted to the birthing unit. Vital signs upon arrival to the emergency room: BP 110/72 mm Hg, HR 98 beats/min. The client begins complaining of sudden, sharp abdominal pain. The admitting nurse repeated vital signs: BP 90/60 mm Hg, HR 108 beats/min. What is the priority nursing intervention at this time? 1 Applying an electronic fetal monitor 2 Preparing for a possible cesarean birth 3 Drawing blood for a type and crossmatch 4 Assessing the amount of vaginal bleeding
Correct Ans: 1 The client's clinical manifestations suggest abruptio placentae and her vital signs indicate that shock may be occurring. Quickly determining fetal viability so that appropriate treatment may be instituted immediately is the priority. Other interventions may be done simultaneously depending on the urgency. Assessing for vaginal bleeding, drawing blood in anticipation for an emergent cesarean section are critical next steps.
A nursing instructor is teaching a group of nursing students about sentinel events. What is appropriate to include in the education? 1 A sentinel event causes moderate harm to the client. 2 A sentinel event is undesirable and largely avoidable. 3 A sentinel event's impact is mitigated by interventions. 4 A sentinel event is very common in hospital settings.
Correct Ans: 2 A sentinel event causes severe, undesirable, and avoidable harm or even death to the client. It causes severe harm to the client, whereas an adverse event causes moderate to severe harm to the client. The impact of near-miss events can be mitigated by various interventions. Sentinel events are not common in hospitals; they should be ideally rare.
A nurse caring for a client tries to prioritize nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client would the nurse pay attention to last? 1 "I feel that I have failed to be a worthy child of my parents." 2 "My aim is to be a famous writer, and I will do anything to achieve my dream." 3 "I do not like to speak to the people in my neighborhood as they are all snobs." 4 "My house is being reconstructed, and chunks of the ceiling are quite often falling off."
Correct Ans: 2 According to the Maslow's hierarchy of needs, higher level needs should be addressed after fulfilling all the basic level needs of the client. The client displays the need for self-actualization by conveying to the nurse that he/she intends to do anything in order to become a writer. Self-actualization is the highest level of need, therefore, it should be addressed last. Since the client feels worthless, he/she shows a lack of self-esteem. Self-esteem needs should be addressed before self-actualization needs. The client in the given situation shows a lack of social interaction. Love and belonging needs should be met before addressing higher level needs such as self-esteem need and self-actualization need. In the given situation, the client lacks physical safety as he/she may be hurt by the chunks of the ceiling falling off. Therefore, the need for safety and security should be addressed by the nurse first before turning to the other needs.
What should a nurse teach the client to do to avoid lipodystrophy when self-administering insulin therapy? 1 Exercise regularly. 2 Rotate injection sites. 3 Use the Z-track technique. 4 Avoid massaging the injection site.
Correct Ans: 2 Fibrous scar tissue can result from the trauma of repeated injections at the same site. Exercise is unrelated to lipodystrophy, but it reduces blood glucose, which decreases insulin requirements. Insulin is given subcutaneously; the Z-track technique is used with some intramuscular injections. Gentle pressure over the injection site after insulin administration promotes absorption.
A nurse is caring for a female client during the manic phase of bipolar disorder. What should the nurse do to help the client with personal hygiene? 1 Suggest that she wear hospital clothing. 2 Guide her to dress appropriately in her own clothing. 3 Allow her to apply makeup in whatever manner she chooses. 4 Keep makeup away from her because she will apply it too freely.
Correct Ans: 2 Having clients who are experiencing the manic phase of bipolar disorder wear personal clothing helps keep them more in touch with reality. The client may need direction to dress appropriately. Suggesting that she wear hospital clothing does not help the client learn new ways to cope with problem situations. Allowing her to apply makeup in whatever manner she chooses may set up the client as a target of ridicule by other clients. The client may use makeup but with supervision.
What is the priority nursing action in the care of a young child with severe diarrhea? 1 Measuring daily urine output 2 Maintaining fluid and electrolyte balance 3 Replacing the lost calories with high-fiber foods 4 Promoting perianal skin integrity by bathing often
Correct Ans: 2 Maintaining fluid and electrolyte balance is the priority intervention to reduce risk of harm to the client. Measuring daily urine output is important as a means of checking kidney function, but maintaining overall fluid and electrolyte balance is the priority. If a child is severely dehydrated, urine output needs to be checked more often than daily. Nutrition is not a priority above fluid and electrolyte balance at this time. Although important, skin integrity is not the priority.
Which recommendation should the nurse make to the parents of a preschool-age client who is experiencing frequent nightmares? Select all that apply. 1 Bring the child to the parental bed. 2 Allow the child time to settle back into sleep. 3 Reassure the child by rubbing his or her back. 4 Repeat a nighttime routine, such as reading a story. 5 Place a television in the child's room as a distraction.
Correct Ans: 2, 3, 4 Recommendations to the parents of a preschool-age client who is experiencing nightmares include allowing the child time to settle back into sleep, reassuring the child by rubbing his or her back, and repeating a nighttime routine, such as reading a story. It is not recommended for the parent to bring the child to the parental bed as the child may continue to awaken at night to continue this practice. It is also not recommended to place a television in the child's room as a form of distraction for the nightmare.
What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply. 1 Focus on achieving the highest level of health and absence of disease 2 Encourage regular physical activity and the use of stress-management strategies 3 Encourage the client to accept help for carrying out activities of daily living (ADLs) 4 Consider the client's social environment and strengthen social support to promote health 5 Assess the client for fear of falling and provide support by making environmental changes
Correct Ans: 2, 4, 5 The nurse should encourage the client to include physical activity regularly and to use stress-management strategies to promote a healthy lifestyle. The nurse should consider the client's social environment and strengthen social support to promote health. Because a fear of falling is a significant risk related to older adults, the nurse should assess the client for fear and provide support by making environmental changes. The nurse should not focus on the absence of a disease, but on achieving the highest level of health in the presence of disease. The nurse should encourage older adults to perform activities of daily living on their own to promote health.
A primary healthcare provider prescribes an antidepressant for a hospitalized client who has been severely depressed. Eight days later the nurse notes that the client is neatly dressed and well groomed. The client smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the client's statement? 1 Complimenting the client's appearance 2 Starting preparations for the client's discharge 3 Arranging for constant supervision of the client 4 Adding privileges to the client's plan of care as a reward
Correct Ans: 3 A change in behavior that seems positive may actually indicate that the client has worked out a plan for suicide; the potential for suicide increases when physical energy returns. Increased supervision is needed. Complimenting the client's appearance may increase the client's feelings of inadequacy, because it implies that the client did not look good before. It is inappropriate to consider discharge simply because of a change in behavior. Many factors should be considered in the decision to discharge a client. The addition of privileges is not indicated at this time.
A nurse caring for a client from another country asks about the client's healthcare traditions. Which Quality and Safety Education for Nurses (QSEN) competency does the nurse comply with? 1 Safety 2 Informatics 3 Patient-centered care 4 Teamwork and collaboration
Correct Ans: 3 A nurse who provides compassionate and coordinated care to clients based on their preferences, values, and needs is providing patient-centered care. Asking about the healthcare traditions followed in the client's country is an example of patient-centered care. Safety involves minimizing the risk of harm to clients and primary healthcare providers. Informatics involves using information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. Teamwork and collaboration involves nursing and interprofessional teams working together effectively to achieve quality client care.
While interacting with parents of children ranging in ages from 6 to 12 years, the nurse suggests that the parents should avoid imposing too many expectations on their children. What is the rationale behind the nurse's suggestion? 1 To prevent role confusion in the children 2 To reduce the feelings of guilt in the children 3 To prevent inferiority complexes in the children 4 To improve the decision-making abilities of the children
Correct Ans: 3 Erikson's life span approach in the development of children is categorized into eight stages relating to childhood. In the stage of industry versus inferiority, development is attained by children between 6 and 12 years of age. Children at this stage act as workers and producers: they initiate and complete work aiming at real achievement. The child may feel inferior if parents impose many expectations on him or her. Identity versus role confusion is seen in children between 12 and 18 years of age and is the stage in which rapid and marked physical changes occur. Adolescents struggle to fit the roles they have played and those they expect to play. When the ability to solve these conflicts fails, it leads to role confusion. Initiative versus guilt is seen in children between 3 and 6 years old; children in this stage explore the physical world with all their senses and powers and may feel guilty when parents make them feel as though their behaviors are bad. Children in the age group of 1 to 3 years are in the stage of autonomy versus shame and doubt. Children in this stage increase their ability to develop, control their bodies and their environment, and use their mental powers for decision-making. However, avoiding imposing too many expectations does not prevent role confusion or guilt and does not improve the children's decision-making abilities.
Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first? 1 Auscultate the chest for diminished breath sounds. 2 Encourage coughing and deep breathing every hour. 3 Record the temperature reading and continue to monitor it. 4 Suspect an infection and notify the healthcare provider immediately.
Correct Ans: 3 Myocardial necrosis causes a rise in body temperature within the first 24 hours after a myocardial infarction. This increase in temperature gradually returns to the usual range for an adult after several days. A temperature of 100.2° F (37.9° C) is an expected response to myocardial necrosis, not a respiratory infection. Auscultating lung sounds and encouraging coughing and deep breathing are not necessary for the temperature elevation. A temperature of 100.2° F (37.9° C) is an expected response and is not an emergency requiring notification of the primary healthcare provider.
A 13-year-old girl is brought to the emergency department by her mother, who tells the nurse that she just found out that her daughter has been sexually abused by her grandfather for almost 2 years. What is the nurse's priority intervention? 1 Keeping the family unit intact 2 Validating the truth of the child's accusations 3 Providing a safe, nonjudgmental environment 4 Securing psychiatric treatment for the grandfather
Correct Ans: 3 Victims of sexual abuse need to feel safe and accepted when discussing their histories. The nurse's primary responsibility is toward the child, not the family. The story should initially be accepted as true. The nurse's primary responsibility is toward the child, not the grandfather.
The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response? 1 "It's such a short procedure that the pain won't last long." 2 "Your baby should have no memory of it, even if there is pain." 3 "A newborn's nerves are not mature enough for him to feel pain." 4 "The health care provider will tell you how your baby's pain will be controlled."
Correct Ans: 4 Each health care provider has a protocol for relieving the pain caused by circumcision, and the parent has the right to be informed before signing the consent form. Newborns do feel pain, although their nervous systems are not yet mature enough to localize it. The mother is concerned about her newborn's pain regardless of the duration of the procedure. Although the infant may have no memory of the pain, this statement does not address the mother's concern adequately.
A nurse is counseling a pregnant client with iron-deficiency anemia about when and how to take supplemental iron. What time of day is iron absorption most efficient? 1 Dinnertime 2 Bedtime 3 After lunch 4 Before breakfast
Correct Ans: 4 Iron should be taken before breakfast, on an empty stomach, to permit maximal absorption. Iron should not be taken with or after meals or at bedtime.
A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? 1 Mannitol 2 Dexamethasone 3 Chlorpromazine 4 Morphine
Correct Ans: 4 Morphine injection is contraindicated for an unconscious, neurologically impaired client because it depresses respirations. Mannitol, an osmotic diuretic, is used to reduce increased intracranial pressure. Dexamethasone, a corticosteroid antiinflammatory agent, is used to help reduce increased intracranial pressure. Chlorpromazine, an antipsychotic/neuroleptic/antiemetic, can be given safely to a neurologically impaired client for restlessness.
Which procedure is preferred to find out the composition of a thyroid nodule and ascertain the need for further surgical intervention in a client? 1 Mass spectrometry 2 Computed tomography scans 3 Glycosylated hemoglobin test 4 Needle biopsy
Correct Ans: 4 Needle biopsy is an ambulatory surgical procedure. A fine needle is used to aspirate the contents of thyroid nodules to study the composition and ascertain the need for further surgical interventions. Mass spectrometry is an assay in which several different hormone concentrations can be simultaneously analyzed. Computed tomography scans are useful for evaluation of ovaries, adrenal glands, and the pancreas. The average blood glucose level over 2 to 3 months is revealed by a glycosylated hemoglobin test.
A couple interested in delaying the start of a family discuss the various methods of family planning. Together they decide to use the basal body temperature method. The nurse explains that the fertile period surrounding ovulation lasts from when to when? 1 12 hours before to 24 hours after ovulation 2 72 hours before to 24 hours after ovulation 3 72 to 80 hours before to 72 hours after ovulation 4 24 to 48 hours before to 48 hours after ovulation
I put 1 Ans: 2 The ovum is fertilizable for 12 to 24 hours, and sperm remain motile for about 72 hours. Therefore the period of fertility is a total of 96 hours (72 hours before ovulation plus 24 hours after ovulation). The fertility period before ovulation is longer than 12 hours. Seventy-two to 80 hours before to 72 hours after ovulation is too long before and after ovulation. The period of fertility is longer than 48 hours before ovulation and shorter than 48 hours after ovulation.
A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action? 1 Setting limits on manipulative behavior 2 Encouraging participation in group therapy 3 Respecting the client's need for social isolation 4 Recognizing that seductive behavior is expected
I put 1 Ans: 3 These clients are withdrawn, aloof, and socially distant; allowing distance and providing support may foster the eventual development of a therapeutic alliance. Manipulative behavior is typical of clients with the diagnosis of antisocial personality disorder or borderline personality disorder. Group therapy will increase this client's anxiety; cognitive or behavioral therapy is more appropriate. Seductive behavior is associated with clients with the diagnosis of histrionic personality disorder.
A high school student reports to the school health nurse that the prescribed antidepressant is no longer needed and should be discontinued. What is the best response by the nurse? 1 Seeking further information 2 Emphasizing the importance of continuing the medication 3 Encouraging the student to discuss it with the healthcare provider 4 Recommending that the student stop the medication for several days to determine whether it is still needed
I put 2 Ans: 1 The nurse needs more information from the adolescent before proceeding. The student may eventually be encouraged to talk to the healthcare provider or be told how important it is to continue the medication, but neither is the priority intervention. Recommending that the client stop the medication for several days to determine whether it is still needed is beyond the legal scope of nursing practice; a prescription for a psychotropic medication should not be altered without prior notification of the healthcare provider.
A client who is 28 weeks into her second pregnancy is experiencing increased edema in the lower extremities. The nurse advises rest with the legs elevated and provides dietary instructions. What other advice should the nurse provide? 1 The preferred diet will include favorite foods. 2 A nutritionist should be involved in planning a diet. 3 The selected foods do not need to have a low salt content. 4 The client should consult the healthcare provider at the prenatal clinic.
I put 2 Ans: 3 Dependent edema is common during the last trimester; there is no need to lower the salt content of the client's diet. Teaching should be based on optimal nutrition, as well as the caloric content of the diet. Not all preferences can be included; the diet should include a normal sodium and high protein intake and sufficient calories. Immediate planning based on the nurse's knowledge of dietary needs is sufficient. Unless there is reason to believe that a need for medical intervention exists, the nurse may discuss care related to human responses.
A staff member is planning to start a new job but is worried about the impact it might have on future growth opportunities. The nurse leader is helping the staff member understand all the implications. Which ethical principle is the nurse manager as a leader following? 1 Justice 2 Veracity 3 Paternalism 4 Non-maleficence
I put 2 Ans: 3 Paternalism is assisting people to make decisions when they do not have sufficient data or expertise. Helping the staff member understand all effects of a possible career change and how the potential change could impact his or her future growth reflects the leader nurse following paternalism .Justice is the principle of treating all persons equally and fairly. By following veracity, the nurse manager tells the truth and demands that the truth be told completely. The principle of non-maleficence states that one should do no harm to others.
A client is admitted to the hospital with a history of increasingly bizarre behavior. The client says, "I'm wired to the TV, and it told me that my family is out to kill me." What is the best initial action by the admitting nurse? 1 Taking the client to the dayroom and introducing the other clients on the unit 2 Reassuring the client that the unit is safe and that the client will be protected from the family 3 Telling the client that the door is locked and that no one will be permitted to enter the unit to harm anyone 4 Introducing the client to the primary nurse who will be assigned to work on a one-on-one basis with the client
I put 2 Ans: 4 Introducing the client to the primary nurse who will be assigned to work on a one-on-one basis with the client is extremely important, because the client can be assisted back to reality by a nurse who is interested the client's feelings. It can also start to build the therapeutic relationship, which will be the foundation of trust. Taking the client to the dayroom and introducing the other clients on the unit should come later. Reassuring the client that the unit is safe and that the client will be protected from the family is false reassurance that the client will not believe. Telling the client that the door is locked and that no one will be permitted to enter the unit to harm anyone will have no effect because the client is under a strong delusion.
While communicating with a client, the nurse determines that the client has realized the harmful effects of alcohol consumption and plans to stop drinking within 6 months. To what stage of Transtheoretical Model of Change does the nurse correlate the client's behavior? 1 Action 2 Preparation 3 Maintenance 4 Contemplation
I put 2 Ans: 4 The Transtheoretical Model of Change model defines the changing patterns in an individual in five stages based on beliefs of readiness to change. They are precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the client recognizes the beneficial effects of the change and thinks about the change within 6 months. In the action stage, the client does not think; instead, he or she actively starts making changes. In the preparation stage, the client sets goals and intends to change in the next 60 days. In the maintenance stage, the client sustains the changed action for 6 months and follows preventive measures to prevent relapse.
A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? 1 Question the client about the confusion. 2 Change the method of oxygen delivery. 3 Percuss and vibrate the client's chest wall. 4 Discontinue or decrease the oxygen flow rate.
I put 2 Ans: 4 With emphysema, it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe. However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. A confused client cannot answer questions about the confusion. There are no indications that respiratory secretions have increased.
The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with hypocalcemia. Which statements provided by a student nurse indicate the need for further learning? Select all that apply. 1 "The client would show signs of twitching." 2 "The client would show signs of hyporeflexia." 3 "The client would show signs of paresthesias." 4 "The client would show signs of muscle cramping." 5 "The client would show signs of skeletal muscle weakness."
I put 2 & 5 Ans: 2, 3, & 5 The neuromuscular manifestation of alkalosis with hypocalcemia is hyperreflexia, not hyporeflexia. Paresthesias is a symptom of alkalosis, which is manifested in the central nervous system not the neuromuscular system. The manifestation of alkalosis is neuromuscular and can be observed through twitching, muscle cramping, and skeletal muscle weakness.
A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion? 1 Energy level is set at its maximum level. 2 Synchronizer switch is in the "on" position. 3 Skin electrodes are applied after the T wave. 4 Alarm system of the cardiac monitor is functioning simultaneously.
I put 3 Ans: 2 The precordial shock during cardioversion must not be delivered on the T wave, or ventricular fibrillation may ensue. By placing the synchronizer in the "on" position, the machine is preset so that it will not deliver the shock on the T wave. The energy level may be set from 50 to 100 Watts/second. Skin electrodes applied after the T wave and an alarm system of the cardiac monitor functioning simultaneously will not ensure that the shock is not delivered on the T wave.
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. What would be the best explanation by the nurse regarding the cause of this discoloration? 1 Inadequate arterial blood supply 2 Delayed healing of tissues after an injury 3 Increased production of melanin in the area 4 Leakage of red blood cells through the vascular wall
I put 3 Ans: 4 Increased venous pressure alters the permeability of the veins, allowing extravasation of red blood cells (RBCs); hemolysis of RBCs releases a pigment called hemosiderin, which causes a characteristic brownish discoloration (brawny appearance). The arterial circulation is not affected by the pathology of varicose veins. Although tissue healing may be delayed, the brownish discoloration is the result of the hemolysis of RBCs, not trauma. There is no increase in melanocyte activity in the skin surrounding varicose veins.
In which process of Swanson's theory is the nurse engaging when explaining neonatal care to a parent? 1 Enabling 2 Knowing 3 Doing for 4 Being with
I put 4 Ans: 1 According to Swanson's theory, the nurse is engaging in enabling when explaining the care of a neonate to a parent. Enabling includes informing/explaining/supporting/allowing, focusing, generating alternatives, validating, and giving feedback. The process of knowing includes avoiding assumptions, centering on the one being cared for, assessing thoroughly, seeking cues, and engaging the self or both. The process of doing for includes comforting, anticipating, performing skillfully, protecting, and preserving dignity. The process of being with includes being there, conveying ability, sharing feelings, and not burdening.
A nurse provides dietary instructions to a client with calcium oxalate kidney stones. Which instruction should the nurse give to the client? 1 "You should limit your sodium intake." 2 "You should limit your intake of gravies." 3 "You should limit your intake of red wines." 4 "You should limit your intake of organ meat."
I put 4 Ans: 1 High sodium intake in clients with calcium oxalate kidney stones will reduce kidney tubular reabsorption of calcium. Therefore the nurse should instruct the client to reduce his or her sodium intake. Clients with uric acid kidney stones should decrease their intake of gravies and red wines. Clients with struvite, uric acid, and cystine types of kidney stones should limit their intake of animal proteins such as organ meats.
A client with glaucoma is receiving a carbonic anhydrase inhibitor. Which statement made by the client will require the nurse to notify the primary healthcare provider? 1 "I have asthma." 2 "I use contact lenses." 3 "I am allergic to sulfonamides." 4 "I have been taking phenelzine medication for three months."
I put 4 Ans: 3 Carbonic anhydrase inhibitors are used for the treatment of glaucoma. These drugs are similar to sulfonamides, and if a client is allergic to the sulfonamides, they may have a chance of developing an allergy. Beta-adrenergic blockers such as betaxolol hydrochloride and carteolol are used for treating glaucoma. These drugs, when absorbed systemically, may lead to constriction of the pulmonary smooth muscles and narrow airway. Clients who wear contact lenses is not an issue with carbonic anhydrase inhibitors; however, if using adrenergic agonists clients should not use the eyedrops with the contact lenses in place and should wait 15 minutes after using the drug to put in the lenses. Clients taking antidepressants such as phenelzine should not be prescribed adrenergic agonists because it may lead to a hypertension crisis when taken together.
A nurse caring for a client prioritizes nursing actions based on Maslow's hierarchy of needs. Which statement made by the client meets the love and belonging need? 1 "I do not like the way I look, speak, or act." 2 "I dream of becoming the richest person in the world." 3 "I hardly speak to my children because they live in different countries." 4 "I want to go back home because I am afraid of the tests you are performing."
I put 4 Ans: 3 If a client says that he or she hardly speaks to his or her children because they live in different countries, this statement is an example of the love and belonging need according to Maslow's hierarchy of needs. If a client says that he or she does not like the way he or she looks, speaks, or acts, this statement is an example of low self-esteem. Here, the nurse needs to address the client's self-esteem needs. If a client says that he or she dreams of becoming the richest person in the world, this statement is an example of self-actualization needs. If a client says that he or she wants to go back home because he or she is afraid of the tests being performed, this statement is an example of safety and security needs.
During a recent tornado the emergency department mishandled several client situations. In which order should the manager perform actions to improve the quality of care in the future? 1. Chose an approach to meet the expected quality indicators 2. Assess client expectations for emergency room care 3. Determine outcomes and quality indicators for emergency room services 4. Collect data regarding the current status of emergency room services 5. Analyze data collected to determine achievement of expected quality indicators 6. Identify members of an interprofessional team to review client expectations
Wrong. Completely guessed Ans: 2, 6, 4, 3, 1, 5 The steps in the quality improvement process begin with assessing the needs most important to the consumer, or in this situation, client expectations for emergency room care. The second step is to assemble an interprofessional team to review client needs and expectations. The third step is to collect data regarding the current status of emergency room services. The fourth step is to determine measurable outcomes and quality indicators for the emergency room services. The fifth step is to choose an approach to meet the expected outcomes or quality indicators. And the final step is to collect data to determine if the implemented plan achieved the expected quality indicators.
