The Nursing Process
autonomic dysreflexia
Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above).
Nursing interventions for autonomic dysreflexia
Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above). If you suspect this condition, call the practitioner and perform these actions: Help the patient sit up. Loosen any constrictive clothing or devices. Check urinary output; if the patient doesn't have a urinary catheter in place, perform an intermittent catheterization. If a catheter is in place, check for kinks; if the catheter appears blocked, gently irrigate it with 10 to 15 mL of normal saline solution. If the patient's systolic blood pressure is less than 150 mm Hg, check for bowel impaction. Perform digital disimpaction of the rectum, as ordered, to remove stool, if present. If the patient's blood pressure remains over 150 mm Hg, administer an antihypertensive agent, such as immediate-release nifedipine or nitroglycerin ointment. If the situation doesn't resolve, check for additional causes, such as a pressure injury or infection.
To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? P wave PR interval QRS complex T wave
Correct response: P wave Explanation: The P wave depicts atrial depolarization or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.
What is the symptothermal method of contraception?
Is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning.
A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse? A. "Because you are underage, we will need your parent's consent to treat you." B. "We can treat you without your parents' consent, but they have the right to review your medical record." C. "We can see you without your parents' consent but have to report any positive results to the public health department." D. "We can see you, treat any infections, and will not share your results with anyone."
Correct response: C."We can see you without your parents' consent but have to report any positive results to the public health department." Explanation: While some areas may specify a minimum age for treatment (usually 12 to 14 years), generally adolescents have the right to seek treatment for sexually transmitted infections without their parents' permission. These medical records are not shared with parents without the client's permission. However, adolescents must be made aware that certain infections, including gonorrhea, must be reported by law to public health agencies. Partner notification will also take place, but methods vary.
Thirty people are injured in a train derailment. Which client should be transported to the hospital first? -a 20-year-old who is unresponsive and has a high injury to his spinal cord -an 80-year-old who has a compound fracture of the arm -a 10-year-old with a laceration on his leg -a 25-year-old with a sucking chest wound
Correct response: a 25-year-old with a sucking chest wound Explanation: During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.
A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest? charting by exception medication administration records problem, intervention, and evaluation note focus data, action, and response note
Correct response: charting by exception Explanation: The nurse should suggest the use of charting by exception, which is an abbreviated form of documentation. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a focus can be a problem area, but does not need to be. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The medication administration record documents only medication administration.
The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make? "Why are you trying to access that information on the client?" "You should contact the information technology department to let them know." "You are not authorized to view all of the details on the client." "I can pull up the data for you under my log-in information."
Correct response: "You are not authorized to view all of the details on the client." Explanation: To protect confidentiality, it is important to control the type of information that personnel in various departments can retrieve. Unlicensed nursing assistants can retrieve information from the medical records, but they cannot view information from the social worker. The reason the assistant wants to view that information is irrelevant. The information technology department does not need to be notified, because there is not a problem with the nursing assistant's log-in information. The nurse should not pull up the data for the assistant, because it is information that the assistant is not authorized to have.
A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next? Have the client sign the consent form. Call the surgeon. Change the consent form. Review the client's history.
Correct response: Call the surgeon. Explanation: Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form.
A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which information would the nurse include in the teaching plan? This method has a 50% failure rate during the first year of use. Couples must abstain from coitus for 5 days after the menses. Cervical mucus is carefully monitored for changes. The male partner uses condoms for significant effectiveness.
Correct response: Cervical mucus is carefully monitored for changes. Explanation: The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning.
A health care provider (HCP) prescribes a lengthy X-ray examination for a client with osteoarthritis with severe pain. Which action by the nurse would demonstrate client advocacy? A. Contact the X-ray technician to see if the lengthy session can be divided into shorter sessions. B. Contact the HCP to determine if an alternative examination could be scheduled. C. Request a prescription for acetaminophen prior to the examination. D. Request padding and careful positioning for the hard X-ray table.
Correct response: Contact the X-ray technician to see if the lengthy session can be divided into shorter sessions. Explanation: Shorter sessions will allow the client to rest between the sessions. Changing the HCP's prescription to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent; thus, it would not help this client avoid the adverse effects of a lengthy X-ray examination. Although the X-ray table is hard, it is not possible to provide padding and obtain the needed diagnostic X-rays.
When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do? A. Place a dry dressing in the wound. B. Use an aqueous solution of aluminum acetate (Burow's solution) to wet the dressing. C. Pack the wet dressing tightly into the wound. D. Cover the wet packing with a dry sterile dressing.
Correct response: Cover the wet packing with a dry sterile dressing. Explanation: A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the dressing should be moist, not dry, when applied. As the moist dressing dries, the wound will be debrided of necrotic tissue and exudate. Normal saline is most commonly used to moisten the sponge; Burow's solution will irritate the wound. The sponge should not be packed into the wound tightly because the circulation to the site could be impaired. The moist sponge should be placed so that all surfaces of the wound are in contact with the dressing. Then the sponge is covered and protected by a dry sterile dressing to prevent contamination from the external environment.
A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? A. Make sure the UAP has practiced sterile technique on at least one other occasion. B. Reassign the UAP to a client requiring basic tasks that the UAP has mastered. C. Supervise the UAP during the treatments involving sterile technique. D. Provide the UAP with a list of resources to guide the implementation of care.
Correct response: Reassign the UAP to a client requiring basic tasks that the UAP has mastered. Explanation: The nurse is accountable for the delegation of tasks to UAPs. The nurse delegates tasks to UAPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UAPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UAP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UAP has the knowledge and skill to provide the care or carry out the task.
A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take? State that the physician will be a witness. Arrange for another colleague to sign as a witness. Note that the nurse caring for the client cannot be a witness. Inform the physician about the living will.
Correct response: Note that the nurse caring for the client cannot be a witness. Explanation: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the healthcare facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action.
A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client? The client's intake and output are balanced. The client performs oral hygiene every 4 hours. The client verbalized the importance of increasing fluid intake. The client's skin remains dry and intact throughout the hospital stay.
Correct response: The client's intake and output are balanced. Explanation: During the planning step of the nursing process, the nurse identifies expected client outcomes, establishes priorities, and develops the care plan. This outcome provides measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements do not resolve the problem of fluid volume deficiency.
The nurse recognizes that discharge planning begins upon admission and the initial step in discharge planning is... -collecting and organizing data about the client. -establishing goals with client. -teaching the client self-care activities to be conducted in the home setting. providing home healthcare referrals.
Correct response: collecting and organizing data about the client. Explanation: The initial step in discharge planning is collecting and organizing data about the client because this provides information on the client's healthcare needs. Establishing goals, client teaching, and providing home healthcare referrals are steps that will follow the collection and organization of data.
When performing an assessment, the nurse identifies these signs and symptoms in the client: decreased muscle strength, limited range of motion, and reluctance to move. Based on these symptoms, the nurse should perform which interventions? Select all that apply. wearing a gown and gloves when in room encouraging client turning and repositioning every 2 hours having call bell within easy reach having four-sided rails up when client is in bed initiating hospital fall risk protocols
Correct response: encouraging client turning and repositioning every 2 hours having call bell within easy reach initiating hospital fall risk protocols Explanation: The client with discoordination, decreased muscle strength, limited range of motion, and reluctance to move is at risk for falls and also for pressure ulcers. The nurse should encourage/assist the client in turning and repositioning every 2 hours and ensure that the call bell is within easy reach. The hospital's fall risk protocols should be initiated at this time. Having four-sided rails up is considered a restraint and is not indicated at this time. Gowning and gloving when in the room is appropriate for clients needing isolation precautions—these are not indicated at this time.
A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? pain depression sexual dysfunction self-consciousness
Correct response: pain Explanation: The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness.
The nurse should instruct the client with a platelet count of less than 150,000/?L (150 × 109/L) to avoid which activity? walking for more than 10 minutes straining to have a bowel movement visiting with young children sitting in semi-Fowler's position
Correct response: straining to have a bowel movement Explanation: When the platelet count is less than 150,000/?L (150 × 109/L), prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp surfaces should be padded. Clients can visit with their families but should avoid any scratches, bumps, or scrapes. Clients can sit in a semi-Fowler's position but should change positions to promote circulation and check for petechiae.
