Prep U Mastery Questions

Which is a potential complication of a low pressure in the endotracheal tube cuff?

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

On examination of an African newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which of the following actions of the nurse is appropriate?

Consider the finding as normal in Africans. The nurse should consider the pigmented area as normal in Africans. These are called Mongolian spots, which are clusters of melanocytes. Asking the mother about complications in pregnancy, informing the physician about the condition, and putting a dressing over the pigmented area are inappropriate responses, because Mongolian spots are normal in Africans.

The emergency department (ED) nurse should assess which client first?

a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain When the nurse is presented a choice between who to see first, safety and seriousness of the condition are considerations. The individual from the motorcycle accident is stating pain that could indicate internal injuries, a serious complication. This individual would be assessed by the nurse first. Through delegation and prioritization of the remaining clients, the others will have their needs met by the registered nurse and members of the health care team. The nurse identifies physiological jaundice in the 3-day old neonate. Diagnostic lab work will be completed and parental teaching on increasing feedings. A simple dressing on the bleeding laceration could be placed by a licensed practical/vocational nurse or nursing assistant until seen by the healthcare provider. The fractured arm will be examined and x-rayed confirming the fracture.

A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on their left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will

allow proper visualization of the large intestine.

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

below the client's cheekbones To palpate the maxillary sinuses, the nurse would place hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with petroleum gauze. If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?

current medications St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.

A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?

"Eat small amounts of bland, soft foods frequently." Because the client with megaloblastic anemia often reports mouth and tongue soreness, the nurse should instruct the client to eat small amounts of bland, soft foods frequently. The other answer choices do not factor in the client's mouth soreness or need for nutrition.

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?

"I need to inform you that your behavior is within the definition of assault." The nurse's response is threatening and could legally be interpreted as assault. The manager must intervene in the best interest of the client and take the opportunity to educate the nurse regarding the comments and potential actions. The other options do not represent appropriate interventions for the scenario described.

The nurse is collecting data on a client with a urinary tract infection (UTI). Which statements should the nurse expect the client to make? Select all that apply.

"I need to urinate frequently." "It burns when I urinate." "I need to urinate urgently."

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholycystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate?

"I will ask the surgeon to come speak to you about the procedure." It is the surgeon's responsibility to explain the procedure to the client and to answer questions so the client can provide an informed consent. The nurse can reinforce the information after the consent is obtained and clarify the information, but the surgeon must explain the procedure initially.

Which signs and symptoms accompany a diagnosis of pericarditis?

fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

A school-age child loses their appetite secondary to side effects of chemotherapy. What will the nurse teach the parents about nutritional choices for the child?

"Let your child eat any foods that appeal to them right now." The nurse should instruct the parents to let the child eat any food because any form of intake is better than none. Having large family meals may not stimulate the child's appetite. Withholding fluids will not stimulate the appetite. Rewarding the child for eating sends the message that when the child is unable to tolerate intake, they are doing something wrong. Loss of appetite is beyond the child's control.

Which client has the highest risk of ovarian cancer?

45-year-old woman who has never been pregnant The incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken hormonal contraceptives, have had multiple births, or have had a first child at a young age.

A community nurse is working with the family of an infant and teaching the parents about preventative health practices. Which of the following is a priority for the nurse to include in the teaching?

introducing screening tests Introducing screening tests is an important part of preventative health because the tests identify the presence of a health condition before symptoms are evident.

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again." The client demonstrates understanding of rheumatoid arthritis when expressing that it's an unpredictable disease characterized by periods of exacerbation and remission. There's no cure for rheumatoid arthritis, but symptoms can be managed. Surgery may be indicated in some cases.

A patient has had a traumatic amputation of the left leg above the knee following an industrial accident. What type of disability does this patient have?

Acquired disability Disabilities can be categorized as developmental disabilities, acquired disabilities, and age-associated disabilities. Developmental disabilities are those that occur any time from birth to 22 years of age and result in impairment of physical or mental health, cognition, speech, language, or self-care. Examples of developmental disabilities are spina bifida, cerebral palsy, Down syndrome, and muscular dystrophy. Acquired disabilities may occur as a result of an acute and sudden injury (e.g., traumatic brain injury, spinal cord injury, traumatic amputation), acute nontraumatic disorders (e.g., stroke, myocardial infarction), or progression of a chronic disorder (e.g., arthritis, multiple sclerosis, chronic obstructive pulmonary disease, blindness due to diabetic retinopathy). A chronic disability is one that has a long disease course and is likely incurable. An impairment is a loss or abnormality of psychological physiologic, or anatomic structure or function at the organ level.

The nurse is caring for a client with peripheral arterial occlusive disease (PAD). What nursing intervention is most appropriate to reduce platelet aggregation and promote circulation?

Administer clopidogrel. Pharmacologic therapy for clients with PAD and claudication include pentoxifylline and cilostazal because these medications increase erythrocyte flexibility and decrease blood fibrinogen concentrations. Aspirin and clopidogrel are antiplatelet agents that prevent the formulation of emboli by reducing platelet aggregation. Statins are used to improve endothelial function. Therefore, clopidogrel should be administered because it is an antiplatelet agent that prevents the formulation of emboli by reducing platelet aggregation.

The instructor provides corrective information to the nursing student when the student refers to the client as the

COPDer in 216 "People-first" language means referring to the person first. Examples include patient who is disabled, man with an MI, and woman who has diabetes. Using "COPDer in 216" conveys that the illness or disability is of greater importance than the person

The nurse is discussing nutritional needs for a postmenopausal patient. What dietary increase should the nurse recommend to the patient?

Calcium Postmenopausal women should be encouraged to observe recommended calcium and vitamin D intake, including calcium supplements, if indicated, to slow the process of osteoporosis. Iron and vitamin K need not be increased unless there are signs of deficiency. Salt should be eaten in moderation, not increased, to prevent hypertension.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine level A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care?

An increased need for insulin and blood glucose monitoring Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications. Culture and sensitivity testing of purulent nasal drainage to show the causative bacterial organisms is rarely done with sinus infection, and tympanic membranes are never cultured by the nurse. Although a practitioner can illuminate the sinuses, it is not routine and is not necessary for diagnosis. Warm compresses can be applied for clients with sinusitis for comfort, however, hot compresses are not applied. Cold compresses are applied after sinus surgery, not in the case of acute infection.

A client at 30 weeks gestation experiences a rupture of membranes with mild contractions 8 minutes apart. Which nursing interventions are included on the plan of care to improve newborn outcomes? Select all that apply.

Arrange a neonatologist to be available for the birth. Administer a dose of betamethasone per healthcare provider's order. Maintain the client on the fetal monitor throughout the labor process. The nurse caring for a client at 30 weeks gestation who has a rupture of membranes realizes that preparation is needed for a premature delivery. To improve newborn outcomes, the nurse must be aware of the status of the fetus via a fetal monitor, administer betamethasone (it is best to have at least two doses 12 hours apart) to increase the surfactant level and fetal lung maturity, and have resuscitation equipment available, if needed. It is best have a neonatologist present as well to assess the neonate and plan medical care. The mother typically is permitted to have ice chips at most in case emergency surgery is needed. The mother is not placed in a supine position as there is the potential of compressing the vena cava causing maternal hypotension and reduced blood flow to the fetus. Oxytocin is naturally produced by the posterior pituitary with Pitocin being the synthetic version. It is used to stimulate contractions. Stimulating contractions is not indicated at this time.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler. The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of

fresh fruits. Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.

For an 8-month-old infant, which toy promotes cognitive development?

Jack-in-the-box According to Piaget's theory of cognitive development, an 8-month-old child will look for an object once it disappears from sight to develop the cognitive skill of object permanence. Therefore, a jack-in-the-box would promote cognitive development. Activity quilts are appropriate for younger infants, allowing for a familiar area to play. A climbing gym is appropriate for toddlers, but dangerous at this age. Anything strung across a crib, such as a play gym, is a safety hazard — especially to a child who may use it to pull up to a standing position.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?

Confusion Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

The student nurse is precepting on a surgical unit and is caring for a client of the Jehovah's Witness faith reporting abdominal pain and dark stools. Which student nursing actions would be appropriate? Select all that apply.

Explain to the client that dark stools may be caused by bleeding higher in the gastrointestinal tract. Educates the client on actions and side effects of prescribed proton pump inhibitors to prevent recurrence of stomach irritation. Orders the client a lunch tray of chicken noodle soup, crackers, vanilla pudding, and ginger ale to be delivered after the xray. Explaining to the client that dark stools may be caused by bleeding higher in the gastrointestinal tract and educating the client on prescribed medications and proper diet would be expected behaviors of the nursing student. Ordering a diet free of greasy, spicy food, alcohol or caffeine would also be appropriate for a client with peptic ulcer disease or bleeding ulcers. Medical information should not be provided to anyone without the express consent of the client. Jehovah's Witness clients rarely accept blood products so consent would need to be obtained first.

According to Maslow's hierarchy of human needs, which of the following is the highest level of need?

Self-actualization Maslow's hierarchy of need shows how a person moves from fulfilling basic needs to a higher level of priority. The ultimate goal is integrated human functioning and health. Self-actualization is the highest level need. Safety and security, physiological needs, and a sense of belonging are below the level of self-actualization.

The nurse is admitting a client after a recent fall who reports tenderness and bruising to the right hip. List the nursing actions in the appropriate order, utilizing the nursing process. All options must be used.

Identify the primary problem after assessing the client. Selects the appropriate nursing diagnosis of high risk for falls. Discusses with the client the need to call for assistance to get out of bed. Sets up a bed alarm and provides skid proof slippers to the client. Educates the client on ways to prevent falls and how to use the call bell. Re-evaluates that the client is remembering to call for assistance before using the bathroom.

A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first? Initiate oxygen therapy. Administer a heparin bolus and begin an infusion at 500 units/hour. Administer analgesics as ordered. Perform nasopharyngeal suctioning.

Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide. Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Topical products, such as those containing zinc oxide, may need to be applied in cases of rash or excoriation.

The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?

Liver function studies The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.

The nurse needs to administer intravenous immunoglobulin to a client who has DiGeorge syndrome. What interventions should the nurse perform before administering the medication? Select all that apply.

Obtain baseline vital signs on the client. Premedicate the client with acetaminophen and diphenhydramine. Document a height and weight on the client. Obtaining baseline vital signs allows for comparison of vital signs during and after the immunoglobulin infusion. Premedication with acetaminophen and diphenhydramine is given to prevent a transfusion reaction. Get a height and weight to verify accurate dosing. Checking the brain natriuretic peptide level is done when a client has heart failure. The blood glucose level is measured with a client diagnosed with diabetes mellitus.

A primigravida client arrives at the labor and birth unit at 39 weeks gestation. Once completing the initial assessment, the nurse documents the note above. Which nursing action is anticipated per the healthcare provider?

Provide instructions to remain within 10 minutes of the birthing center and to ambulate. The nurse identifies the client as being in early labor by symptoms of back pain, varying contractions, moderate pain, and cervical dilation of 4 cm. The nurse identifies the normal progress of labor thus far and conveys to the healthcare provider. Until the healthcare provider admits the client, it is appropriate to have the client discharged; however, remain close to the birthing center with instruction to ambulate. Typically, the client is instructed to return to the birthing center/hospital when contractions are 4 to 5 minutes apart. Ambulation may progress the labor process. The client does not need to turn on her left side as there is no sign of fetal compromise. The client is considered a full-term pregnancy. There is no indication of a need for a cesarean section.

A nurse is obtaining health history from a young adult woman. Which of the following would alert the nurse to a possible problem?

Reports of dyspareunia Dyspareunia, or pain with intercourse, is an abnormal finding associated with numerous potential problems. Onset of menarche is usually between 12 to 14 years but could be as early as age 10 or 11 years. The menstrual cycle typically averages 28 days but it can vary from 21 to 42 days. A mucus-like vaginal discharge is normal.

A patient in the ICU starts complaining of being "short of breath." An arterial blood gas (ABG) is drawn. The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis The pH <7.40, PaCO2 >40, and the HCO3 is normal, therefore it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. Option B is incorrect, the HCO3 = 24, which is within the normal range so it is not metabolic alkalosis. Option C is incorrect, the pH = 7.21, so it is an acidosis not alkalosis. Option D is incorrect, the pH = 7.21 so it is an acidosis, but the HCO3 = 24, which is within the normal range so it is not a metabolic acidosis.

A 14-year-old adolescent tells the nurse about being in love with a 22-year-old neighbor and that they've had sex on several occasions. The client doesn't want the parents to know because the client is in love and is afraid the parents will be angry. What is the nurse's best course of action?

Tell the adolescent that the law requires the nurse to report the sexual contact because of the age difference. Although what a client says is considered privileged communication, there are exceptions when there's a risk of danger to the client or to another person. In this case, the adolescent is having sex with an adult, which is considered statutory rape even if the sex is consensual. The nurse must report this information to the proper authorities. It's inappropriate to tell the adolescent that the nurse will speak only with the physician because the law requires the nurse to report this situation to the authorities. Although consulting with the charge nurse might be useful, doing so doesn't relieve the nurse of the duty to report the situation.

A home care lactation nurse has asked a client to keep a record of her intake, including calories, and output for 1 day. After reviewing the flow sheet that the client used to document the results, the nurse would make which assessments?

The client consumed an inadequate amount of fluids and calories for breast-feeding. In general, new mothers who are breast-feeding should consume 2 to 3 L of fluids and 2,300 to 2,700 calories daily. Consuming less than 1,500 to 1,800 calories per day may put the mother's milk supply at risk.

A newly admitted long-term care client refuses to attend afternoon group activities or social events offered by the facility. According to Maslow's theories on human needs, what is the reason the client refuses to participate in activities?

The client likes to go to have a nap in afternoon and go to bed early in the evening. According to Maslow, the client would need to be sure that basic physiologic and safety and security needs were being met before becoming interested in meeting love and belonging (social) needs. The client needs to have physical needs met like food, sleep, and bowel elimination before requiring increased self-esteem through social activities.

A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?

The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight. During any client-transferring task, if the lift is more than 35 lb (16 kg) of a client's weight, consider the client to be fully dependent and use assistive devices for the transfer. The nurse would encourage the client to help with the transfer if the client is able and can safely assist. Pain medication would not be indicated after the transfer unless a pain assessment indicated this action. The nurse would not grab and hold the client by the arms. This action could cause injury to the client.

The termination stage of the Transtheoretical Model of Change occurs when:

The person has the ability to resist relapse back to unhealthy behavior. The termination stage of the Transtheoretical Model of Change occurs when a person has the ability to resist relapse back to unhealthy behavior. Operationalizing a plan of action, constructing a plan to change behavior, and not thinking about making a change are not parts of the termination stage.

A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores?

There is a strong correlation between iron stores and hemoglobin levels. A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls.

The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child's allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents?

identifying ways to reduce the child's exposure to the allergens The primary goal of therapeutic management for the parents of a child diagnosed with allergies includes reducing the child's exposure to the allergens. This intervention will inevitably reduce the presenting clinical manifestations and corresponding discomfort.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane) Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate?

adduction and flexion of the extremities with gently rounded shoulders The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

A 10-year-old boy is at a clinic for followup after being diagnosed with rheumatic fever (RF) several months ago. The child's symptoms have resolved, but antibiotics will continue for several years. The nurse teaches the parents to seek medical attention for recurrence of rheumatic fever if what signs or symptoms develop? Select all that apply.

arthritis in a single joint loss of coordination temperature ≥100.4F (≥ 38C) Once a chlild has been diagnosed with RF, diagnosis of a recurrence can be made even if presentation is mild. While polyarthritis and a high-grade fever are required as part of diagnosing an initial case of RF, monoarthritis and low-grade fever are sufficient for a recurrence. Loss of coordination is a sign of chorea, a major neurological manifestation of RF. The rash associated with RF is called erythema marginatum and consists of non-itchy, slightly raised pink rings rather than papules. Neither nausea and vomiting nor a runny nose with excessive tearing are associated with a recurrence of RF.

The nurse is assessing a 39-year-old client during her 32-week prenatal checkup. The client has attended regular prenatal checkups throughout the pregnancy. Which assessment data is a priority for the nurse to complete?

blood pressure Older pregnant women are more likely to develop gestational hypertension, so the priority assessment for this client is blood pressure. Gestational hypertension is characterized by hypertension (BP > 140/90 mmHg) without proteinuria after 20 weeks gestation. It occurs in women known to be normotensive prior to pregnancy. It resolves by 12 weeks postpartum. If the hypertension becomes too severe, preeclampsia will develop. The nurse would examine the urine for protein, not ketones. The mother could have developed iron deficiency anemia, but this is not the priority over assessing the blood pressure. Routine STI screening would have been done at an earlier prenatal checkup and will be repeated at the 37-week checkup.

The nurse is developing a client's care plan. What activity best exemplifies the assessment phase of the nursing process?

determines the client has a pulse rate of 88 bpm The assessment phase of the nursing process includes a health history and physical examination. The pulse rate is obtained during a physical assessment. The remaining options are not data obtained during the assessment phase, but steps in the implementation phase of the nursing process.

A nurse is caring for a 34-month-old who is hospitalized for a lengthy illness. Which behaviors would the nurse identify as examples of expected developmental regression for the child's age group? Select all that apply.

enuresis one to two word expressions encopresis Enuresis (uncontrolled voiding) and encopresis (uncontrolled stooling) are often seen in toddlers who were previously toilet trained and return to diapers during hospitalization. Language regression with one to two word expressions ("baby talk") is often observed during hospitalization. Altered gait and loss of fine motor skills are not typical regressive behaviors; when seen in a child, they may indicate musculoskeletal or neurological problems.

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

identity According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position?

left lateral The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

A client in the emergency department reports that they have been vomiting excessively for the past 2 days. The client's arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

metabolic alkalosis A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should

notify the physician that the client doesn't understand the procedure. Informed consent requires that four essential elements be satisfied: competence, adequate disclosure, sufficient comprehension, and client voluntariness. The client must be mentally competent to give consent. The client must receive adequate information on which to base an informed decision. This information includes the nature of the procedure, expected benefits and positive outcomes of the procedure, potential risks or negative outcomes of the procedure, potential risks if the client chooses not to have the procedure, and available alternative therapies and their risk and benefits. The client must sufficiently comprehend this information and must be free to decide without coercion. The physician or the person who will perform the procedure is responsible for securing informed consent. A nurse witnesses the client's signing of the consent form and validates the client's identity, mental status, and voluntary signature.

A client asks the nurse what PSA is. The nurse should reply that it stands for

prostate-specific antigen, which is used to screen for prostate cancer.

A young child with a history of bronchial asthma is brought to the emergency department for the second time in a month with symptoms of audible expiratory wheezing and intercostal retractions. The parents voice frustration about repeated hospital visits. What information is most important for the nurse to address with the parents?

providing a variety of resources to help the parents quit smoking Smoking is a main allergen that can initiate the inflammatory response in children with bronchial asthma. Few children with bronchial asthma will remain asymptomatic for the remainder of their lives. As many as one in two children who had childhood asthma and who are asymptomatic at 18 years of age are likely to have recurrent, symptomatic disease by age 26 years. Asthma usually persists as a low-grade, subclinical condition. Asthmatic episodes may be life threatening in all age groups.

The nurse is preparing a teaching plan for a 15-year-old adolescent who is 7 months pregnant. The nurse should reevaluate the teaching plan if which teaching strategy is included?

providing age-appropriate reading materials Because adolescents absorb less information through reading than through demonstration or discussion, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent. The other options engage more than one of the senses and therefore serve as effective teaching strategies.

What dietary recommendations should the nurse provide for a client with intermittent claudication to assist in the prevention of disease? Select all that apply.

reduce fat decrease cholesterol Intermittent claudication is a symptom of artherosclerosis. Association guidelines recommend a diet with decreased fat, decreased cholesterol, and unsaturated fats instead of saturated fats to prevent disease. Guidlelines do not recommend limiting the number of calories to 1500, nor do they specifically recommend refraining from processed foods.

When caring for a client with a newly diagnosed cardiac dysrhythmia, which laboratory values are the priority for the nurse to monitor? Select all that apply. blood urea nitrogen (BUN) of 20 mg/dL hematocrit of 40% sodium of 124 mEq/L potassium of 3.1 mEq/L hemoglobin of 14 g/dL calcium of 8.5 mEq/L prothrombin time of 12 seconds with INR of 1

sodium of 124 mEq/L potassium of 3.1 mEq/L calcium of 8.5 mEq/L Because abnormalities in electrolytes are likely to affect depolarization and repolarization of cardiac cells, it is most important for the nurse to monitor sodium, potassium, and calcium levels. The blood urea nitrogen is within normal range. Hemoglobin and hematocrit are not generally associated with cardiac dysrhythmias; the hemoglobin is within normal range. The prothrombin time and INR would be monitored closely on a client taking warfarin, not necessarily a client with cardiac dysrhythmia; the PT and INR are within normal range.

Which sign is an early indicator of heart failure in an infant with a congenital heart defect?

tachycardia The earliest sign of heart failure in infants is tachycardia (sleeping heart rate greater than 160 beats/minute) as a direct result of sympathetic stimulation. Tachypnea (respiratory rate greater than 60 breaths/minute in infants) occurs later in response to decreased lung compliance. Poor weight gain is a result of the increased energy demands to the heart and breathing efforts, not an early sign of heart failure itself. Pulmonary edema occurs as the left ventricle fails and blood volume and pressure increase in the left atrium, pulmonary veins, and lungs; it isn't an early sign of heart failure.

A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?

taking-in phase The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from childbirth. Taking-hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression may occur during this stage.

A client and her partner, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as:

the inability to conceive after 1 year of unprotected attempts. The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse. The inability to sustain a pregnancy doesn't factor into the definition of infertility. A low sperm count and decreased motility may contribute to infertility, but they don't determine infertility.

A client who is 10 weeks pregnant develops spotting; however, the cervix remains closed. What should the nurse should suspect?

threatened abortion Spotting in the first trimester may indicate that the pregnancy is in jeopardy. Bed rest and avoidance of physical and emotional stress are recommended. Abortion is usually inevitable if the bleeding is accompanied by pain with dilation and effacement of the cervix. An inevitable abortion is associated with cervical dilation. An ectopic pregnancy is in the fallopian tubes, and a false positive pregnancy could reflect a missed abortion.

Parents of a 6-year-old tell a healthcare provider that the child has been having periods of unawareness with short periods of staring. Based on this history, the child is probably having which type of seizure?

typical absence This child is probably having typical absence seizures. Typical absence seizures have an onset between ages 3 and 12. This type of seizure is exhibited by an abrupt loss of consciousness, amnesia, or unawareness characterized by staring and a 3-cycle/second spike and waveform on an EEG. The attack lasts from 10 to 30 seconds and may occur as frequently as 50 to 100 times a day. No postictal or confused state follows the attack. A complex partial seizure causes a brief impairment of consciousness. A myoclonic seizure occurs in older children and is exhibited by lightning jerks without loss of consciousness. An abrupt increase in muscle tone, loss of consciousness, and marked autonomic signs and symptoms characterize the tonic seizure.

A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?

weight loss, nervousness, and tachycardia