Select All That Apply Comprehensive

A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply. A. Being honest, nonjudgmental, and empathetic B. Assessing the immediate posttraumatic reaction C. Encouraging the client to keep a journal focused on the trauma D. Asking the client about the use of alcohol and drugs before and since the event E. Promoting discussion of the reasons the client was responsible for the traumatic event F. Discouraging the use of support groups until the client is able to use effective coping techniques

Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event Rationale: An honest, nonjudgmental, and empathetic attitude helps the nurse build a trusting relationship with the client. The nurse would assess the immediate posttraumatic reaction and later coping. Numbing and denial are common reactions after a traumatic event, and knowing the range of the client's behavior can help the nurse assess the impact and meaning of the trauma. Writing about the trauma in a journal can lessen the intensity of the client's emotions and his or her preoccupation with the event over time.The nurse would ask the client about the use of alcohol and drugs before and since the event. It is important for the nurse to obtain this information, because attempts to self-medicate to reduce anxiety and induce sleep are common after a traumatic event. The client needs to understand that he or she is not responsible for the event, but the nurse should emphasize that the client is responsible for learning to cope. This strategy will assist the client in easing feelings of powerlessness. The nurse would encourage attendance at support groups so that the client can share experiences, feel understood, and begin to heal.

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

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

A nurse provides information to a client diagnosed with peripheral vascular disease about ways to limit the disease's progression. Which measures does the nurse tell the client to take? Select all that apply. A. Crossing the legs at the ankles only B. Engaging in exercise such as walking on a daily basis C. Washing the feet daily with a mild soap and drying them well D. Inspecting the feet at least once a week for injuries, especially abrasions E. Using a heating pad on the legs to help keep the blood vessels dilated

Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Rationale: Long-term management of peripheral vascular disease consists of measures that increase peripheral circulation. The client is instructed to avoid crossing the legs at any level because it promotes vasoconstriction. The client is instructed to exercise regularly and is encouraged to walk for 20 minutes each day. Keeping the extremities warm is important; however, heating pads and hot water bottles should not be placed on the extremity. Sensitivity may be diminished in the affected extremity, increasing the risk for burns. Also, direct application of heat increases the oxygen and nutritional requirements of the tissue even further. The client is instructed to wash the feet daily with a mild soap, to dry the feet well, and to inspect the feet daily for injuries or abrasions.

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply. A. Use a straw to drink. B. Avoid sexual activity while the vest is in place. C. Apply powder under the vest to prevent irritation. D. Use caution when leaning forward or backward. E. Wear snug clothing to prevent the device from shifting. F. Do not drive, because full range of vision is impaired with the device.

Use a straw to drink. Use caution when leaning forward or backward. Do not drive, because full range of vision is impaired with the device. Rationale: A halo fixation (stabilization) device is used to prevent the head and neck from moving after a neck injury. Straws are used to drink, and meat and other foods are cut into small pieces to facilitate swallowing. The halo fixation device is not removed. Sexual activity does not have to be avoided; the client is instructed to use a position of comfort. Powders and lotions are used sparingly or not at all to prevent buildup of moisture and subsequent skin breakdown. The weight of the halo device alters balance; therefore the client should use caution when leaning forward or backward. The client is instructed to wear loose clothing with a large neck. The client is not to drive, because full range of vision is impaired with the device. The halo fixation device should not shift; if it does, the health care provider must be notified. The client is taught to sleep with the head supported with a small pillow to prevent unnecessary pressure and discomfort.

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

"I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." Rationale: Lithium carbonate is a mood stabilizer used to treat manic-depressive illness. Equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Therefore the client should maintain a normal salt intake and drink 2 to 3 quarts (1.9 to 2.8 litres) of fluid each day. Many over-the-counter medications contain sodium and would therefore affect the lithium concentration, possibly pushing it out of the therapeutic range. For this reason, over-the-counter medications must be avoided. The blood level of lithium should be tested every 3 or 4 days during the initial phase of therapy and every 1 to 2 months during maintenance therapy. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs of toxicity; if any of these problems occur, the health care provider must be notified.

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

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

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which recommendations does the nurse include on the poster? Select all that apply. A. Seek medical advice if you find a skin lesion. B. Use sunscreen with a low sun protection factor (SPF). C. Avoid sun exposure before 10 a.m. and after 4 p.m. D. Wear a hat, opaque clothing, and sunglasses when out in the sun E. Examine the body every 6 months for possibly cancerous or precancerous lesions.

Seek medical advice if you find a skin lesion. Wear a hat, opaque clothing, and sunglasses when out in the sun.

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

Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short Rationale: A cerebral aneurysm is a thin-walled outpouching or dilation of an artery of the brain. When an aneurysm ruptures, bleeding into the subarachnoid space usually ensues. Aneurysm precautions are implemented to maintain a stable perfusion pressure and help prevent rupture. The client is placed in a quiet private room without a telephone. The room is kept slightly darkened, and bright lighting is avoided. Stool softeners are administered to help keep the client from straining during defecation. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and significant others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. Isometric exercises and use of the Valsalva maneuver are avoided because both increase intrathoracic and intraabdominal pressure. Bed rest with the head of the bed elevated 30 degrees may be prescribed. Some health care providers permit bathroom privileges for selected clients. If the client is allowed out of bed, the nurse stresses the importance of not bending over.

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which characteristic of the disorder does the nurse expect the client to exhibit? Select all that apply. A. Nausea B. Eye pain C. Vomiting D. Headache E. Diminished central vision F. Increased light perception

Nausea Eye pain Vomiting Headache Rationale: In acute closed-angle glaucoma, the onset of symptoms is acute and the client complains of sudden excruciating pain around the eyes that radiates over the sensory distribution of the fifth cranial nerve. Headache or brow ache, nausea, vomiting, and abdominal discomfort may also occur. Other symptoms of glaucoma include seeing colored halos around lights, sudden blurred vision with decreased light perception, and loss of peripheral vision.

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

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

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply. A. Weight loss B. Facial edema C. Metabolic acidosis D. Projectile vomiting E. Distended upper abdomen

Weight loss Projectile vomiting Distended upper abdomen Rationale: HPS occurs when the circular muscle of the pylorus becomes thickened, causing constriction of the pylorus and obstruction of the gastric outlet. Clinical manifestations include projectile vomiting, a hungry infant who eagerly accepts a second feeding after the vomiting episode, weight loss, signs of dehydration, and a distended upper abdomen. A readily palpable olive-shaped mass in the epigastrium just to the right of the umbilicus is noted, and gastric peristaltic waves, moving from left to right across the epigastrium, are visible. Laboratory findings include metabolic alkalosis, a result of the vomiting that occurs in this disorder. Facial edema and metabolic acidosis do not occur in this disorder.

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

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

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

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

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply. A. Maintaining the client in a high Fowler's position B. Checking the client's vital signs every hour until stable C. Ensuring that direct pressure is applied to the external hemorrhage site D. Ensuring a patent airway and supplying oxygen to the client as prescribed E. Inserting an intravenous (IV) catheter and administering fluids as prescribed F. Ensuring that the call bell is in place for the client's use when the nurse is out of the room

Ensuring that direct pressure is applied to the external hemorrhage site Ensuring a patent airway and supplying oxygen to the client as prescribed Inserting an intravenous (IV) catheter and administering fluids as prescribed Rationale: When caring for a client in hypovolemic shock, the nurse must first ensure a patent airway and supply oxygen to the client. The nurse would insert an IV catheter if one is not already present and administer fluids as prescribed. The nurse would elevate the client's feet, keeping his or her head flat or elevated to a 30-degree angle. Direct pressure is applied to the site of external bleeding. The nurse would take the client's vital signs every 5 minutes until they were stable. The nurse would not leave the client alone.

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

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

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

Hunger Weakness Blurred vision Rationale: The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia. Symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations. Test-Taking Strategy: Focus on the subject, symptoms of hypoglycemia. Recalling the "three P's" — polyuria, polydipsia, and polyphagia — associated with diabetes mellitus and hyperglycemia will direct you to the correct options. Also, think about the pathophysiology of hypoglycemia to help answer correctly. Review the symptoms of hypoglycemia and hyperglycemia if you had difficulty with this question.

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. A. Always sneeze with the mouth closed. B. Occlude one nostril when blowing the nose. C. Keep the volume of headphones at the lowest setting. D. Avoid environmental conditions involving rapid changes in air pressure. E. Clean the external ear and canal daily in the shower or while washing the hair. F. Be cautious when using cotton-tipped applicators to clean the external ear canal.

Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair. Rationale: The client is instructed to wash the external ear and canal daily in the shower or while washing his or her hair. The client should never use a small object such as a cotton-tipped applicator to clean the external ear canal. The client is instructed to blow the nose gently and is told not to occlude a nostril when blowing the nose. The client should also wear sound protection around loud or continuous noises, avoid activities with a high risk for ear trauma, keep the volume of headphones at the lowest setting, and avoid environmental conditions involving rapid changes in air pressure.

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet? Select all that apply. A. Smoking B. high-calcium diet C. High alcohol intake D. White or Asian ethnicity E. Participation in physical activities that promote flexibility and muscle strength

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

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

Spinach Legumes Whole grains Rationale: Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four servings of folic acid-rich foods per day. Some foods high in folic acid are glandular meats, yeast, dark-green leafy vegetables, legumes, and whole grains. Bananas provide potassium. Potatoes provide vitamin B6, and milk products are a source of calcium.Test-Taking Strategy: Knowledge regarding foods high in folic acid will direct you to the correct options. Use of the process of elimination and think about the components of each of the foods in the options to answer correctly. Review the food sources of folic acid if you had difficulty with this question.

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

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

A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin 0.25 mg in the treatment of heart failure (HF). Which instructions should the nurse include on the list? Select all that apply. A. Take your pulse before taking each dose. B. Avoid eating foods that contain potassium. C. Take the digoxin at the same time each day. D. Take the digoxin with a chewable antacid to prevent nausea. E. If you forget to take your daily dose, double the dose on the next day. F. Notify the health care provider if you experience loss of appetite, muscle weakness, or visual disturbances.

Take your pulse before taking each dose. Take the digoxin at the same time each day. Notify the health care provider if you experience loss of appetite, muscle weakness, or visual disturbances. Rationale: Digoxin is a cardiac glycoside that increases the force of myocardial contraction. It is used to treat HF and to control the ventricular rate in clients with atrial fibrillation. The client is instructed to take the medication at the same time each day and to check the pulse rate before taking the medication. If the pulse rate is slower than 60 beats/min or faster than 100 beats/min, the health care provider is notified. The medication is not taken with an antacid, because the antacid will affect absorption of the medication. If the client forgets to take a dose, it needs to be taken as soon as remembered. The dose is never doubled. Loss of appetite, muscle weakness, and visual disturbances are signs of digoxin toxicity, and the health care provider is notified if any of them occurs. Hypokalemia predisposes a client to digoxin toxicity. A client is not instructed to avoid foods that contain potassium unless specifically instructed to do so by the health care provider.

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. A. Drooling B. Wheezing C. Hiccuping D. Short periods of apnea E. Excessive oral secretions F. Bowel sounds over the chest

Drooling Excessive oral secretions Rationale: EA and TEF, the most life-threatening anomalies of the esophagus, often occur together, although they may occur singly. EA is a congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thereby failing to form a continuous passageway to the stomach. TEF is an abnormal connection between the esophagus and trachea. EA with or without TEF results in excessive oral secretions, drooling, and feeding intolerance. When fed, the infant may swallow but will then cough and gag and return the fluid through the nose and mouth. Bowel sounds over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccuping and spitting up after a meal are clinical manifestations of gastroesophageal reflux. Coughing, wheezing, and short periods of apnea are clinical manifestations of hiatal hernia.