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Unit 2 Review

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****Which actions will the nurse take when caring for a client with possible lung cancer who has just had a thoracentesis? Select all that apply. One, some, or all responses may be correct. 1. Listen to breath sounds. 2. Encourage deep breaths. 3. Send pleural fluid to the laboratory. 4. Ensure that a chest x-ray is performed. 5. Place the client on bed rest for the next 4 hours.

1. Listen to breath sounds. 2. Encourage deep breaths. 3. Send pleural fluid to the laboratory. 4. Ensure that a chest x-ray is performed. Breath sounds should be verified in all lung fields after thoracentesis to rule out lung collapse. The client is encouraged to perform deep breaths to help expand the lungs. Pleural fluid will be sent to the laboratory to look for malignant cells. A chest x-ray should be obtained after the procedure to check for pneumothorax. There is no need for the client to remain on bed rest after the procedure.

****Which care plan would the nurse implement for a 1-month-old infant with hydrocephalus scheduled to have surgery for the insertion of a ventriculoperitoneal shunt? 1. Maintaining a satisfactory comfort level to limit crying 2. Applying bandages to the infant's head to protect it from injury 3. Establishing a fixed feeding schedule to ensure appropriate hydration 4. Providing play objects to maintain age-appropriate stimulation for the child

1. Maintaining a satisfactory comfort level to limit crying Preventing crying will avoid sudden increases in intracranial pressure. Applying head bandages is inappropriate and unnecessary. Young infants, especially those with hydrocephalus, tolerate a demand schedule better, and it may diminish the possibility of vomiting. Providing toys is inappropriate for a 1-month-old infant.

Which clinical findings would the nurse anticipate when assessing a child with newly diagnosed acute lymphoblastic leukemia? Select all that apply. One, some, or all responses may be correct. 1. Pallor 2. Fatigue 3. Jaundice 4. Multiple bruises 5. Generalized edema

1. Pallor 2. Fatigue 4. Multiple bruises Pallor is the result of anemia associated with leukemia. Fatigue is the result of anemia associated with leukemia. Multiple bruises are the result of thrombocytopenia associated with leukemia. Jaundice usually indicates liver damage or excessive hemolysis and is not an early sign of leukemia. Edema is not a manifestation of the disease because the pathophysiology does not involve the transport of fluids.

The health care team is caring for a client who has undergone surgery for lung cancer. The client needs respiratory therapy. Which task can be safely delegated to a respiratory therapist paired with a registered nurse (RN)? 1. Placing a Foley catheter 2. Assessing the respirations 3. Placing an intravenous (IV) catheter 4. Administering patient-controlled analgesia

2. Assessing the respirations Respiratory therapy is needed in clients who undergo surgery for lung cancer. Assessing respiration can be safely delegated to the respiratory therapist. Placing a Foley catheter, an IV catheter, or administering patient-controlled analgesia is within the scope of an RN's practice.

A client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. During this phase, which clinical indicators would the nurse assess? Select all that apply. One, some, or all responses may be correct. 1. Skin rash 2. Dehydration 3. Hypovolemia 4. Hyperkalemia 5. Metabolic acidosis

2. Dehydration 3. Hypovolemia In the diuretic phase, excretion of fluids retained during the oliguric phase occurs and may reach 3 to 5 L daily; unless fluid replacement occurs, dehydration and hypovolemia is a potential. Skin rash is not associated with the diuretic phase. Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. Metabolic acidosis occurs in the oliguric, not diuretic, phase.

Which nursing intervention would the nurse provide an infant exhibiting signs of increased intracranial pressure (ICP)? 1. Initiating clear fluid diet 2. Elevating the infant's head higher than the hips 3. Checking the infant's reflexes every 15 minutes 4. Stimulating the infant frequently while assessing the level of consciousness

2. Elevating the infant's head higher than the hips Elevation of the head helps decrease ICP by promoting venous return by way of gravity. There is no indication for restricting the infant's diet to clear fluids. Frequent checks of reflexes may be disturbing to the infant and impair the ability to rest. Frequent stimulation may further irritate an already traumatized central nervous system.

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. Which should promote psychological adjustment and early function immediately after surgery? 1. Allow the client to change the first dressing. 2. Help the client adjust to the temporary prosthesis. 3. Assign the client to a room with another adolescent. 4. Have the client meet with a member of a cancer survivor organization.

2. Help the client adjust to the temporary prosthesis. A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.

****What information from a client's history would the nurse identify as risk factors for the development of colon cancer? Select all that apply. One, some, or all responses may be correct. 1. Hemorrhoids 2. Increased age 3. High-fiber diet 4. Ulcerative colitis 5. Low hemoglobin level

2. Increased age 4. Ulcerative colitis A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies.

****Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? 1. Nausea 2. Lethargy 3. Sunset eyes 4. Hyperthermia

2. Lethargy Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases.

****The registered nurse (RN) is delegating tasks to the health care team. Which team member is most suitable for achieving an effective outcome in the care of a client who has been bedridden for long periods with seizures? 1. Health care provider 2. Licensed practical nurse 3. Newly hired registered nurse 4. Unlicensed assistive personnel

2. Licensed practical nurse The licensed practical nurse (LPN) is the most suitable in terms of achieving an effective outcome in the care of a client who is bedridden for long periods with seizures. The LPN can identify changes in the client and can report to the RN immediately. The health care provider does not provide care to the clients, but rather diagnoses and suggests the treatment for the health conditions of the clients. A newly hired RN may be involved in other critical cases. Unlicensed assistive personnel (UAP) may not be appropriate for caring for this client because changes in the client's condition would be reported in a timely manner and the UAP may not have enough knowledge to identify important changes.

Which intervention would the nurse perform first to manage the condition of a client with autonomic dysreflexia? 1. Cover the client with blanket. 2. Place the client in a sitting position. 3. Assess the client's urinary retention. 4. Administer alpha blockers to the client

2. Place the client in a sitting position. A client with autonomic dysreflexia should be first placed in the sitting position to increase blood flow to the lower body and stabilize blood pressure. Clients with hypothermia should be covered with a blanket. A client's urinary retention can be assessed once the condition is stabilized. After performing all the assessments, the client should be provided medications such as alpha blockers.

Which information would the nurse include in response to a client's questioning a protein-restricted dietary change required for his or her acute kidney injury? 1. "A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses." 2. "Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis." 3. "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." 4. "Currently, your body is unable to synthesize amino acids, so the nitrogen for amino acid synthesis must come from the dietary protein."

3. "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys." The amount of protein permitted in the diet depends on the extent of kidney function; excess protein causes an increase in urea concentration, excess metabolic waste, and added stress on the kidneys. The restricted protein diet prevents overburdening the client's kidneys at this time. When experiencing acute kidney injury, the kidneys are unable to eliminate the waste products of a high-protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.

The diagnostic reports of a client who underwent a hypophysectomy indicate an intracranial pressure (ICP) of 20 mm Hg. Which action made by the client is responsible for the reported ICP? 1. Drinking lots of water 2. Eating high-fiber foods 3. Bending over at the waist 4. Bending knees when lowering body

3. Bending over at the waist Clients without a pituitary gland (hypophysectomy) should avoid bending at the waist because this position increases intracranial pressures. Drinking lots of water and eating high-fiber foods reduce the risk of constipation, so this should not cause increased intracranial pressure. The client should bend the knees to lower the body, which reduces the risk of increased intracranial pressures.

A client who has experienced a subarachnoid hemorrhage would be maintained in which position? 1. Supine 2. On the unaffected side 3. In bed with the head of the bed elevated 4. With sandbags on either side of the head

3. In bed with the head of the bed elevated With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure (ICP), which will intensify the ischemic manifestations of hemorrhage. The supine position will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases ICP. Lying on the unaffected side will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases ICP. Vomiting can occur with increased ICP, and placing sandbags to immobilize the head can result in aspiration.

A client is admitted to the hospital in the oliguric phase of acute kidney injury. The client's urine output for the past 12 hours was 200 mL. The nurse notes a prescription for 900 mL of oral fluids over the next 24 hours. Which interpretation of the amount of prescribed fluid would the nurse make? 1. It equals the expected urinary output for the next 24 hours. 2. It will prevent the development of pneumonia and a high fever. 3. It will compensate for both insensible and expected output over the next 24 hours. 4. It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

3. It will compensate for both insensible and expected output over the next 24 hours. Insensible losses are 500 mL to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.

The nurse estimates that a client admitted in the oliguric phase of acute kidney injury had a urinary output of 200 mL over the past 12 hours. The client's plan of care indicates a fluid restriction of 900 mL of free water per 24 hours. Which statement explains the amount of prescribed fluid? 1. The fluid equals the expected urinary output for the next 24 hours. 2. The fluid prevents the development of pneumonia and a high fever. 3. The fluid compensates for insensible fluid loss and the expected urinary output. 4. The fluid reduces hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

3. The fluid compensates for insensible fluid loss and the expected urinary output. Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.

Which arterial blood gas report is indicative of diabetic ketoacidosis? 1. Pco2: 49, HCO3: 32, pH: 7.50 2. Pco2: 26, HCO3: 20, pH: 7.52 3. Pco2: 54, HCO3: 28, pH: 7.30 4. Pco2: 28, HCO3: 18, pH: 7.28

4. Pco2: 28, HCO3: 18, pH: 7.28 Decreased pH and bicarbonate values reflect metabolic acidosis; a decreased Pco2 value indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased Pco2 value indicates compensatory hypoventilation. Increased pH and decreased Pco2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased Pco2 values reflect hypoventilation and respiratory acidosis.

The nurse is notified that the latest potassium level for a client who has acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action would the nurse take? 1. Alert the cardiac arrest team. 2. Call the laboratory to repeat the test. 3. Notify the primary health care provider. 4. Obtain an antiarrhythmic medication.

3. Notify the primary health care provider. The primary health care provider must treat this hyperkalemia to prevent cardiac dysrhythmias. The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. Obtaining an antiarrhythmic is premature, there is no evidence of dysrhythmia.

Which laboratory value supports the presence of diabetic ketoacidosis in a client with type 1 diabetes? 1. Decreased serum glucose levels 2. Decreased serum calcium levels 3. Increased blood urea nitrogen levels 4. Increased serum bicarbonate levels

3. Increased blood urea nitrogen levels With diabetic ketoacidosis, blood urea nitrogen level generally is increased because of dehydration. With diabetic ketoacidosis, the serum glucose levels are generally greater than 300 mg/dL (16.7 mmol/L). The calcium level is unrelated to diabetic ketoacidosis. Serum bicarbonate levels are less than 15 mEq/L (15 mmol/L).

The nurse is reviewing the electronic health record of a client admitted with syndrome of inappropriate antidiuretic hormone (SIADH). Which medication order would the nurse question? 1. Furosemide (Lasix) 2. Tolvaptan (Aquaretic) 3. Intravenous (IV) 0.9% sodium chloride 4. Demeclocycline (Declomycin)

3. Intravenous (IV) 0.9% sodium chloride IV 0.9% sodium chloride should be administered cautiously in clients with SIADH, as it can further potentiate fluid volume overload. Instead, a 3% sodium chloride is hypertonic and can be used to treat severe hyponatremia related to SIADH. Diuretics such as furosemide (Lasix) can be used to treat heart failure if the sodium level is normal. Tolvaptan (Aquaretic) and demeclocycline (Declomycin) are both medications used to treat SIADH.

Which nursing intervention is appropriate when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Providing oxygen 2. Encouraging carbohydrates 3. Administering fluid replacement 4. Teaching facts about dietary principles

3. Administering fluid replacement As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.

Which clinical finding would the nurse recognize as a sign that an infant's intracranial pressure has increased? 1. Hypoactive reflexes 2. Increased pulse rate 3. Decreased blood pressure 4. Tension of the anterior fontanel

4. Tension of the anterior fontanel The anterior fontanel will be widened and tense because of the increased volume of cerebrospinal fluid. The pulse rate will be decreased with increased intracranial pressure. The reflexes will be hyperactive with increased intracranial pressure. The blood pressure will be higher with increased intracranial pressure.

Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? 1. Ensuring patent airway 2. Administering intravenous (IV) fluids 3. Monitoring level of consciousness 4. Protecting the client from injury during seizures

1. Ensuring patent airway Ensuring a patent airway is the priority of the nurse because a client may lose consciousness during a seizure. IV fluids should be administered when the condition of the client is stable. Level of consciousness should be monitored during ongoing treatment. Continuous muscle contractions are observed in a client with tonic-clonic seizures, which may cause injury. The client should be protected from injury during seizures.

Which clinical manifestation would the nurse expect in a 3-year-old child newly diagnosed with a Wilms tumor? 1. Periorbital edema 2. Projectile vomiting 3. Abdominal swelling 4. Low-grade temperature

3. Abdominal swelling Wilms tumor is a nephroblastoma that is first observed as a firm, painless intra-abdominal mass located on one side of the abdomen. Periorbital edema is a sign of glomerulonephritis, not Wilms tumor. Projectile vomiting is indicative of central nervous system problems or a gastrointestinal obstruction, not Wilms tumor. A low-grade fever is a nonspecific sign of many illnesses, not necessarily Wilms tumor.

A health care provider prescribes dexamethasone for a client with head trauma. The nurse recognizes that it reduces swelling in the brain by which process? 1. Acts as a hyperosmotic diuretic 2. Increases resistance to infection 3. Reduces the inflammatory response of tissues 4. Decreases the formation of cerebrospinal fluid

3. Reduces the inflammatory response of tissues Corticosteroids act to decrease inflammation, which decreases edema. Dexamethasone is an anti-inflammatory agent, not a diuretic. Resistance to infection is decreased, not increased, with a corticosteroid. The client's problem is not with increased cerebrospinal fluid.

A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? 1. Acidosis 2. Calcium depletion 3. Potassium retention 4. Sodium chloride depletion

2. Calcium depletion In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.

Which complication is of most concern when the nurse is caring for a client with chronic lymphocytic leukemia (CLL)? 1. Bleeding 2. Fatigue 3. Infection 4. Cachexia

3. Infection In CLL, defects in humoral and cellular immunity increase the risk for infection, which can be life threatening. The other complications are also of concern but are not as dangerous as infection. Bleeding is possible because of thrombocytopenia associated with CLL, but the platelet count must drop to around 10,000 mm3 (10 × 109/L) before spontaneous bleeding occurs. Fatigue caused by CLL related anemia is also common, but not life threatening. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.

Which client activities warrant the highest priority for education about health promotion to prevent head and neck cancer? Select all that apply. One, some, or all responses may be correct. 1. Chews tobacco 2. Multiple sex partners 3. Uses condoms when having sex 4. History of alcohol abuse for 5 years 5. Brushes with a soft-bristle toothbrush

1. Chews tobacco 2. Multiple sex partners 4. History of alcohol abuse for 5 years Tobacco, alcohol, and human papilloma virus (HPV) are the major causes of neck cancer. The nurse would counsel the client who chews tobacco and educate regarding the importance of oral hygiene. The nurse would advise the client to stop chewing tobacco to reduce the risk of head and neck cancer. The nurse would educate the client with multiple sex partners about protecting against HPV, which is a risk factor for cancer. The nurse would place a high priority on health promotion in a client with a history of alcohol abuse for 5 years because it is 1 of the major risk factors for head and neck cancer. The client should use condoms when having sex with potentially infectious partners to prevent HPV infections that can lead to head and neck cancer. A client should maintain proper oral hygiene by brushing her or his teeth regularly with a soft-bristle brush and flossing.

***When assessing a client with diabetes insipidus, which signs would the nurse anticipate finding? Select all that apply. One, some, or all responses may be correct. 1. Excessive thirst 2. Increased blood glucose 3. Dry mucous membranes 4. Increased blood pressure 5. Decreased serum osmolarity

1. Excessive thirst 3. Dry mucous membranes 6. Decreased urine specific gravity As excessive fluid is lost through urination, dehydration triggers the thirst response. As excessive fluid is lost through urination, dehydration occurs, resulting in dry mucous membranes and poor skin turgor. Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005). Diabetes insipidus is not a disorder of glucose metabolism; blood glucose levels are not affected. Diabetes mellitus affects glucose metabolism. Loss of fluid may decrease the blood pressure because fluid is lost from the intravascular compartment. As fluid is lost from the intravascular compartment, serum osmolarity increases, not decreases.

****Which clinical manifestations does the nurse expect the client to report when admitted for surgical resection of a rectosigmoid colon cancer? Select all that apply. One, some, or all responses may be correct. 1. Feeling tired 2. Rectal bleeding 3. Inability to digest fat 4. Change in the shape of stools 5. Feeling of abdominal bloating 6. Stools float and are clay-colored

1. Feeling tired 2. Rectal bleeding 4. Change in the shape of stools 5. Feeling of abdominal bloating Anemia may manifest as fatigue, feeling tired, and/or generalized weakness. Anemia is common with rectosigmoid colon cancer from the loss of blood rectally. Passage of red blood (hematochezia) is 1 of the cardinal signs of rectosigmoid colon cancer; ulceration of the tumor and straining to pass stool precipitate this clinical finding. A cancerous mass can grow into the lumen of the sigmoid colon, altering the shape of stool; stools may be ribbonlike or pencil thin. Tumors in the rectosigmoid colon cause partial and eventually complete obstruction of the intestinal lumen. Because there is less fluid in the stool of the descending and sigmoid colon, a formed mass develops; thus, the client strains to pass stools, and gas pains (causing a feeling of abdominal bloating), cramping, and incomplete evacuation commonly occur. An inability to digest fat is not specific to rectosigmoid colon cancer; therefore, stools will not float and will contain bile, which colors the stool brown.

Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)? 1. Hypertension and bradycardia 2. Flaccid paralysis and numbness 3. Absence of sweating and pyrexia 4. Escalating tachycardia and shock

1. Hypertension and bradycardia Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs rather than tachycardia.

Which laboratory value supports the presence of diabetic ketoacidosis? 1. Increased serum lipids 2. Decreased hematocrit level 3. Increased serum calcium levels 4. Decreased blood urea nitrogen level

1. Increased serum lipids With diabetic ketoacidosis, serum lipid levels are high because of the increased breakdown of fat. Serum lipid levels can go so high that the serum appears opalescent and creamy. With diabetic ketoacidosis the hematocrit level generally is increased because of dehydration. The calcium level is unrelated to diabetic ketoacidosis. With diabetic ketoacidosis the blood urea nitrogen level generally is increased because of dehydration.

Which nursing action is a priority for a client with a spinal cord injury who has developed sudden autonomic dysreflexia? 1. Place in a sitting position. 2. Give nifedipine as prescribed. 3. Examine for symptoms of pressure injuries. 4. Monitor blood pressure (BP) every 10 to 15 minutes.

1. Place in a sitting position. Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high BP. The first step in this situation is to assist the client into a sitting position because it naturally reduces BP. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure injuries after stabilizing the client. The nurse would monitor client's BP every 10 to 15 minutes after stabilizing the client.

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? 1. Preoxygenate the client before suctioning. 2. Employ gentle suctioning as the catheter is being inserted. 3. Loosen the client's secretions before suctioning by instilling saline. 4. Ensure that the cuff of the tracheostomy is inflated during suctioning.

1. Preoxygenate the client before suctioning. Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a saline solution may be instilled into a tracheostomy, this practice is not recommended.

The nurse is developing a plan of care for a client who underwent extensive oral surgery for head and neck cancer. Which interventions would the nurse include in the plan to prevent infection? Select all that apply. One, some, or all responses may be correct. 1. Protect incision site. 2. Elevate head of the bed. 3. Remove thick secretions. 4. Offer small frequent feedings. 5.Provide oral care at least every 4 hours.

1. Protect incision site. 3. Remove thick secretions. 5.Provide oral care at least every 4 hours. The nurse must take care to protect the incision site, remove thick secretions, and provide oral care at least every 4 hours to prevent infection. Elevating the head of the bed prevents aspiration. When the client can initiate oral intake, small, frequent feedings prevent aspiration.

****Which interventions would the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or all responses may be correct. 1. Provide frequent oral care. 2. Institute fall risk precautions. 3. Restrict fluids to 2 L per day. 4. Place the client in high-Fowler position. 5. Monitor for and report neurological changes.

1. Provide frequent oral care. 2. Institute fall risk precautions. 5. Monitor for and report neurological changes. The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. Increased water reabsorption results in decreased urinary output, increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting fluids, frequent oral care is provided to increase client comfort. Fall risk precautions are instituted to protect the client from injury that might occur as a result of neurological changes associated with declining serum sodium. The nurse monitors for and reports changes in neurological status resulting from cerebral edema and hyponatremia. Immediate treatment goals are to restore normal fluid balance and normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no more than 500 mL for the client with severe hyponatremia. Treatment of SIADH includes placing the bed flat or elevating the head of the bed no more than 10 degrees. This position promotes venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that antidiuretic hormone release should be decreased.

A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask the nurse, "How much longer will my child need to take the medication?" Which answer will the nurse provide? 1. "Medications are continued for 3 years after the last seizure." 2. "This is usually attempted after 2 years, but medications must be gradually decreased." 3. "Children are usually able to stop seizure medication after puberty." 4. "Seizure disorders are lifelong problems that require ongoing medications."

2. "This is usually attempted after 2 years, but medications must be gradually decreased." A predesigned protocol is used to wean a child off anticonvulsants gradually because abrupt removal of the drug can result in a seizure. Anticonvulsants are discontinued gradually after a child is seizure free for 2, not 3, years and has an EEG within expected limits. Anticonvulsants cannot be stopped abruptly at the 2-year follow-up visit, but the discontinuation process may be started. The statement that seizure disorders are lifelong problems that require ongoing medications may or may not be true; this is determined on an individual basis.

When a client who has seemed cheerful after a diagnosis of lung cancer and pneumonectomy becomes withdrawn after being discharged home, which action by the home health nurse will be best? 1. Suggest that an antidepressant may be helpful. 2. Ask the client to describe the current emotional state. 3. Reassure the client that depression is a normal reaction. 4. Ask the health care provider to make a mental health referral.

2. Ask the client to describe the current emotional state. Further assessment of the client is needed before developing a treatment plan. Antidepressant use may be needed, but is not commonly used for grieving and loss after a cancer diagnosis. Although depression is common after a cancer diagnosis, it is not very helpful for the client to know this and further assessment is needed before the nurse knows whether depression is the cause of the client's withdrawal. A mental health referral can be very helpful for some clients with a new cancer diagnosis, but more assessment is needed to determine whether a referral is needed or acceptable to the client.

After a child undergoes craniotomy for the removal of a brain tumor, the nurse identifies an area of serosanguineous drainage about the size of a quarter on the child's dressing. Which would be the immediate response by the nurse? 1. Notifying the neurosurgeon 2. Circling the area with nonabsorbable ink 3. Reinforcing the dressing with gauze pads 4. Removing the dressing to check the sutures

2. Circling the area with nonabsorbable ink Progression of the discoloration beyond the markings shows that the drainage is increasing. Circling the area with nonabsorbable ink allows the nurse to monitor the progression of the drainage. It is not necessary to notify the neurosurgeon; it is not an emergency. Some drainage is expected. Reinforcing the dressing prevents the nurse from monitoring the progression of the drainage. Only the neurosurgeon should remove the dressing during the immediate postoperative period.

??During the oliguric phase of acute kidney injury, for which abnormal finding would the nurse monitor in the client? 1. Hypothermia 2. Hyperphosphatemia 3. Hypocalcemia 4. Hypernatremia

2. Hyperphosphatemia The kidneys retain potassium during the oliguric phase of acute kidney injury; an elevated potassium level is one of the main indicators for placing a client on hemodialysis when he or she is experiencing acute kidney injury. Hypothermia does not occur with acute kidney injury. Serum levels of phosphorus decrease during the oliguric phase of kidney failure. The retained fluids create a hemodilution effect and hyponatremia occurs, not hypernatremia.

****Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy? 1. The client will take anticonvulsant medications for life. 2. Individuals taking phenytoin must floss their teeth regularly. 3. A diagnosis of epilepsy prevents individuals from ever obtaining a driver's license. 4. Loss of consciousness during a seizure requires emergency evaluation.

2. Individuals taking phenytoin must floss their teeth regularly. Gingival hyperplasia is a common side effect of phenytoin. Clients may decrease or delay development of gingival hyperplasia by regular brushing and flossing of their teeth. Although lifelong treatment with antiseizure medication often is required, some people are able to wean from antiseizure medication after they have been seizure free for a period of several years (generally 3 to 5) and have a normal electroencephalogram and neurological examination. Driving laws for people with epilepsy vary from state to state. For example, some states require a seizure-free period of several months and some states require a seizure-free period of up to a year before reinstating or issuing a driver's license. The person who has experienced a single seizure may not need to go to the hospital, unless the event is a first-time seizure, the seizure is prolonged, or the seizure results in bodily harm.

****When a client with acute myelocytic leukemia who is receiving chemotherapy develops tumor lysis syndrome, the nurse will anticipate a need to implement which collaborative action? 1. Offer analgesics frequently. 2. Infuse large amounts of fluids. 3. Administer antibiotic therapy. 4. Give anticoagulant medication.

2. Infuse large amounts of fluids. Tumor lysis syndrome occurs when chemotherapy destroys large numbers of abnormal cells quickly, leading to high levels of potassium and uric acid and the risk for hyperkalemia and acute kidney injury. Hydration prevents and manages tumor lysis syndrome by dilution, lowering potassium and uric acid levels, increasing potassium excretion, and preventing kidney stones. More frequent analgesia is will not treat tumor lysis syndrome. Antibiotics are used to treat infection and sepsis associated with leukemia, but are not a treatment for tumor lysis syndrome. Anticoagulant medications are not used to treat tumor lysis syndrome.

Which intervention would the nurse perform first for a client with a spinal cord injury who is experiencing autonomic dysreflexia? 1. Assess for the cause. 2. Place the client in sitting position. 3. Check the client for fecal impaction. 4. Give an alpha blocker prophylactically.

2. Place the client in sitting position. Clients experiencing autonomic dysreflexia would immediately be placed in a sitting position because the condition may cause involuntary nervous system reaction and dangerous spikes in blood pressure. The next step is to assess for the cause for autonomic dysreflexia. Fecal impaction and other colorectal complications are routinely assessed in the client. Alpha blockers can be given to treat recurrent autonomic dysreflexia.

****When a newly admitted client tells the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked," which response by the nurse is best? 1. "What type of cancer did your father have?" 2. "You are feeling guilty about your smoking." 3. "You have been thinking about your diagnosis." 4. "How many years have you smoked cigarettes?"

3. "You have been thinking about your diagnosis." The correct response acknowledges the client's statements, encourages further expression of feelings, and provides an opportunity for further discussion. The statement indicating that the client feels guilty about smoking focuses on only one of the client's statements and discourages communication about the other client concerns. Although the nurse will obtain information about smoking history during the admission assessment, asking about how many years the client has smoked discourages further communication about the client's concerns. Asking about the client's father indicates that the nurse is not open to discussion of the client's concerns and cuts off communication.

The nurse provides discharge teaching to a client related to management of the client's new colostomy. The client states, "I hope that I can manage all of this at home; it's a lot to remember." Which is an appropriate nursing response? 1. "I'm sure you will be able to do it." 2. "Maybe a family member can do it for you." 3. "You seem to be nervous about going home." 4. "Perhaps you can stay in the hospital another day."

3. "You seem to be nervous about going home." Reflection of feelings conveys acceptance and encourages further communication. The response "I'm sure you will be able to do it" is false reassurance that does not help reduce anxiety. The response "Maybe a family member can do it for you" provides false reassurance and promotes dependence. The response "Perhaps you can stay in the hospital another day" is unrealistic and does not address the client's concern in a way that supports the ventilation of feelings.

The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do? 1. Ask the client to take several deep breaths. 2. Instruct the client to cough before suctioning. 3. Administer 100% oxygen to the client. 4. Change the suctioning equipment to ensure sterility

3. Administer 100% oxygen to the client. Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to take deep breaths or cough or have the strength to do either, which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not be changed.

****The nurse is caring for a client hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which action performed by the nurse may result in a positive outcome of the treatment? 1. Obtaining the client's weight weekly 2. Elevating the head of the bed to 20 degrees 3. Changing the position of the client frequently 4. Restricting the client's total fluid intake to 500 mL/day

3. Changing the position of the client frequently Changing the position of the client frequently helps in maintaining skin integrity and joint mobility. The head of the bed should not be elevated more than 10 degrees to enhance venous return to the heart. The client's weight should be obtained daily to help assess fluid retention. In acute care settings, the client's fluid intake should be no more than 800 to 1000 mL/day. Fluid intake is restricted to 500 mL/day in severe hyponatremia cases.

****A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. One, some, or all responses may be correct. 1. Fever 2. Diarrhea 3. Melena 4. Hematuria 5. Ecchymosis

3. Melena 4. Hematuria 5. Ecchymosis Thrombocytopenia is a condition characterized by abnormally low levels of thrombocytes, also known as platelets, in the blood. This reduction in platelet activity impairs blood clotting, so any assessment finding associated with potentially abnormal bleeding would alert the nurse to the possibility of thrombocytopenia. This includes melena (digested blood in feces), hematuria (bleeding within the renal system), and ecchymosis (bleeding into skeletal soft tissue). Fever and diarrhea are common side effects of chemotherapy but are not findings specifically attributed to thrombocytopenia.

An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. Which nursing intervention would the nurse implement for the infant during the initial postoperative period? 1. Change the dressing when soiled. 2. Offer the infant fluids to increase fluid intake. 3. Place the infant flat with the head on the unaffected side. 4. Encourage the parents to hold their infant to help prevent crying

3. Place the infant flat with the head on the unaffected side. A flat position helps prevent complications associated with too-rapid reduction of intracranial fluid. Lying on the unaffected side prevents pressure on the shunt valve. The dressing is not changed by the nurse; if there is drainage, the nurse should mark the area, reinforce the dressing, and notify the health care provider. Fluids are initially restricted to prevent fluid overload. Moving the infant will unintentionally raise the head; initially the infant is positioned flat, and the head should not be elevated at this time.

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rational? 1. Deep tendon reflexes have been lost. 2. There is partial transection of the cord. 3. There is damage above the sixth thoracic vertebra. 4. Flaccid paralysis of the lower extremities has occurred.

3. There is damage above the sixth thoracic vertebra. The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

****The parents of a 4-year-old child with newly diagnosed acute lymphoblastic leukemia express confusion over the care plan. Which response would the nurse provide? 1. "There are support groups for parents with children who have leukemia." 2. "The new treatment protocols have been shown to have excellent results." 3. "Let me get you the telephone number of the Leukemia Society, where you can get some advice." 4. "Maybe you could talk with your health care provider about getting a second opinion from a specialist in leukemia."

4. "Maybe you could talk with your health care provider about getting a second opinion from a specialist in leukemia." Referring the parent back to the health care provider with a suggestion that addresses the need for more information is an appropriate initial intervention. The health care provider can coordinate the referral to the appropriate specialists (e.g., oncologist, hematologist), where they may get information on any new treatment protocols and results. Although it is true that there are support groups for parents of children with leukemia, this suggestion minimizes the parent's concern. Although the parents may eventually be referred to such a group, this statement does not address the parent's need for information. The Leukemia Society may disseminate information, and the parents may be referred there eventually, but it does not give advice on a personal level.

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? 1. "Is your job demanding or stressful most of the time?" 2. "Do you participate in any strenuous sports activities on a regular basis?" 3. "Does anyone in your family have a history of central nervous system (CNS) problems?" 4. "Were you aware of anything different or unusual just before your seizure began?"

4. "Were you aware of anything different or unusual just before your seizure began?" Identification of a sensation that occurs before each seizure (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. Although the response "Is your job demanding or stressful most of the time?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Do you participate in any strenuous sports activities on a regular basis?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Does anyone in your family have a history of CNS problems?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply.

Which clinical findings support the diagnosis of diabetic ketoacidosis (DKA)? 1. Nervousness and tachycardia 2. Erythema toxicum rash and pruritus 3. Diaphoresis and altered mental state 4. Deep respirations and fruity odor to the breath

4. Deep respirations and fruity odor to the breath Deep respirations and a fruity odor to the breath are classic signs of DKA, because of the respiratory system's attempt to compensate by blowing off excess carbon dioxide, a component of carbonic acid. Nervousness and tachycardia are indicative of an insulin reaction (diabetic hypoglycemia). When the blood glucose level decreases, the sympathetic nervous system is stimulated, resulting in an increase in epinephrine and norepinephrine; this causes clinical findings such as nervousness, tachycardia, palpitations, sweating, tremors, and hunger. Erythema toxicum rash and pruritus are unrelated to diabetes; they indicate a hypersensitivity reaction. Although an altered mental state is associated with both hypoglycemia and DKA, diaphoresis is associated only with hypoglycemia. Diaphoresis occurs when the blood glucose level decreases and stimulates an increase in epinephrine and norepinephrine.

****An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication would the nurse instruct the parents to report if it occurs at home? 1. Visibility of the sclerae above the irises 2. Violent involuntary muscle contractions 3. Excessive fluid accumulation in the abdomen 4. Fever accompanied by decreased responsiveness

4. Fever accompanied by decreased responsiveness Fever accompanied by decreased responsiveness is associated with infection. This is the greatest postoperative hazard for children with shunts for hydrocephalus. Eyes with sclerae visible above the irises occur with progressively increasing intracranial pressure, usually before shunt insertion. Violent involuntary muscle contractions may occur as the result of an infected shunt; however, it is not the most common sign of an infectious process. The peritoneum absorbs cerebrospinal fluid adequately; ascites (excessive fluid accumulation in the abdomen) is not a problem.

****While assessing the airway patency of a client after a bomb blast, which intervention is most appropriate when the nurse suspects the client has severe brain injury and gives the client a score of 7 using the Glasgow Coma Scale (GCS)? 1. Performing the jaw-thrust maneuver 2. Maintaining vascular access using a large-bore catheter 3. Observing for chest wall trauma or other physical abnormalities 4. Preparing for endotracheal intubation and mechanical ventilation

4. Preparing for endotracheal intubation and mechanical ventilation The most appropriate intervention for a client with a GCS score of 7 is preparing for endotracheal intubation and mechanical ventilation. The jaw-thrust maneuver is performed in a client if there is any risk of spinal injury. The use of large-bore catheters to maintain vascular access is done to perform resuscitation in traumatic conditions. Observing for chest wall trauma or other physical abnormalities may not be the appropriate intervention for a client with brain injury.

Which position would the nurse select for an infant with hydrocephalus? 1. On either side and supine 2. Supine and Trendelenburg 3. Prone, with the legs elevated about 30 degrees 4. Supine, with the head elevated about 45 degrees

4. Supine, with the head elevated about 45 degrees The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant should be positioned on the back or side to allow routine changes in head position; prone positioning is unsafe for infants and increases the risk of sudden infant death syndrome.

During the oliguric phase of acute kidney injury, for which abnormal finding would the nurse monitor in the client? 1. Hypothermia 2. Hyperphosphatemia 3. Hypocalcemia 4. Hypernatremia

****A client receiving cisplatin therapy developed tumor lysis syndrome (TLS). Which medication would the nurse anticipate administering to this client for treatment of the TLS? 1. Mesna 2. Flavoxate 3. Allopurinol 4. Aprepitant

3. Allopurinol Allopurinol should be administered to this client to promote purine excretion. Cisplatin is a nephrotoxic agent that is used in clients with cancer. TLS is the precipitation of metabolites (purine and potassium) of cell breakdown. Mesna and flavoxate are used to treat hemorrhagic cystitis in clients on chemotherapy; mesna is a protectant whereas flavoxate manages symptoms. Aprepitant is used to prevent nausea and vomiting in a client on the day of chemotherapy.

Which position would the nurse use for an infant after the insertion of a ventriculoperitoneal shunt for hydrocephalus? 1. Supine on the unaffected side 2. Side-lying on the affected side 3. Head elevated at 45 degrees on the affected side 4. Head elevated at 90 degrees on the unaffected side

1. Supine on the unaffected side Placing the infant supine will prevent complications from too-rapid reduction of intracranial fluid; placing the infant on the unaffected side will prevent pressure on the shunt valve. Placing the infant on the affected side will put pressure on the shunt valve, which may cause it to become obstructed, interfering with the outflow of cerebrospinal fluid. Raising the head of the bed will allow a too-rapid reduction in cerebrospinal fluid, which may cause the cerebral cortex to pull away from the dura, resulting in a subdural hematoma. Placing the infant on the affected side will put pressure on the shunt valve. Elevating the head to 90 degrees will permit too rapid a reduction in cerebrospinal fluid.

****Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct. 1. Type of employment 2. Presence of ear pain 3. History of tobacco use 4. Oral hygiene practices 5. Amount of alcohol intake

1. Type of employment 2. Presence of ear pain 3. History of tobacco use 4. Oral hygiene practices 5. Amount of alcohol intake There are several risk factors for head and neck cancers. The nurse would obtain information about the client's employment to determine possible chemical or environmental exposures that can increase the risk for head and neck cancers. The symptom of ear pain along with a nagging cough can indicate head or neck cancer. The use of tobacco and alcohol is a major risk factor for head and neck cancer. Poor oral hygiene is another risk factor the nurse can assess for.

Which clinical indicators would the nurse consider evidence of increasing intracranial pressure? Select all that apply. One, some, or all responses may be correct. 1. Vomiting 2. Irritability 3. Hypotension 4. Increased respirations 5. Decreased level of consciousness

1. Vomiting 2. Irritability 5. Decreased level of consciousness Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations

According to priority, in which order would the nurse perform care activities for a client with complete partial seizures? 1.Maintaining airway 2.Recording the time and duration of seizure 3.Assessing vital signs 4.Performing neurological checks

1.Maintaining airway 2.Recording the time and duration of seizure 3.Assessing vital signs 4.Performing neurological checks Maintaining the airway is the priority for a client with any type of seizure. Then the nurse would record the time and duration of the seizure to determine the severity of the condition. Then the nurse would assess the client's vital signs after completion of the seizure. Then the nurse would assess the client's neurological status.

****During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. One, some, or all responses may be correct. 1. These seizures are associated with amnesia. 2. These seizures increase the risk for injuries from a fall. 3. These seizures are most resistant to medication therapy. 4. These seizures are preceded by perception of an offensive smell. 5. These seizures cause one-sided movement of extremities in the client.

2. These seizures increase the risk for injuries from a fall. 3. These seizures are most resistant to medication therapy. Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to medication therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.

2. calcium depletion Rationale: In kidney failure, as the glomerular filtration rate decreases, phosphorus is retained. As hyperphosphatemia occurs, calcium is excreted. Calcium depletion hypocalcemia causes tetany, which causes twitching and tingling of the extremities, among other symptoms. Acidosis, potassium retention, and sodium chloride depletion are not characterized by twitching and tingling of the extremities.

****The nurse understands which antiepileptic medication would be used as the first-line treatment for absence seizures? 1. Phenytoin 2. Diazepam 3. Valproic acid 4. Acetazolamide

3. Valproic acid Valproic acid is used as the first-line treatment for absence seizures. Phenytoin is used to treat partial, secondary, and generalized tonic-clonic seizures. Diazepam is used to treat status epilepticus. Acetazolamide is used as an adjunct medication for the treatment of absence seizures.

Which factor may have precipitated ketoacidosis in a client with type 1 diabetes who has been adhering to a prescribed insulin regimen? 1. Increased exercise 2. Decreased food intake 3. Working the night shift 4. Upper respiratory infection

4. Upper respiratory infection Infection is a stress that increases adrenocortical secretion of glucocorticoids, which will increase the blood glucose level. Exercise requires glucose for muscle contraction, which decreases the blood glucose level. Decreased food intake will decrease the blood glucose level. Working the night shift will have no effect on the blood glucose level.

A client has surgery for the creation of a colostomy. Postoperatively, which color would the nurse expect a viable stoma to be? 1. Brick red 2. Pale pink 3. Light gray 4. Dark purple

1. Brick red Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

****A client with epilepsy is prescribed phenytoin for seizure control. Which instruction about phenytoin will the nurse provide during discharge teaching? 1. "Antiseizure medications will probably be continued for life." 2. Phenytoin prevents any further occurrence of seizures." 3. "This medication needs to be taken during periods of emotional stress." 4. "Your antiseizure medication usually can be stopped after a year's absence of seizures."

1. "Antiseizure medications will probably be continued for life." Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. Seizures may occur despite medication therapy; the dosage may need to be adjusted. A therapeutic blood level must be maintained through consistent administration of the medication irrespective of emotional stress. Absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiological condition.

The nurse is caring for a client who has a traumatic brain injury with increased intracranial pressure. Which health care provider prescription would the nurse question? 1. Continue anticonvulsants 2. Teach isometric exercises 3. Continue osmotic diuretics 4. Keep head of bed at 30 degrees

2. Teach isometric exercises The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.

****A client with colon cancer had surgery for resection of the tumor and creation of a colostomy. During the 6-week postoperative checkup, the nurse teaches the client about nutrition. Which response by the client indicates learning has taken place? 1. "I should follow a diet that is rich in protein." 2. "I should follow a diet that is low in sodium content." 3. "I should follow a diet that is as close to normal as possible." 4. "I should follow a diet that is higher in calories than before."

3. "I should follow a diet that is as close to normal as possible." Although foods that produce gas generally are avoided, the diet should be as close to normal as possible for optimal physiological and psychological adaptation. A high-protein diet is important until healing occurs, but this is at the 6-week checkup; a balanced diet generally meets nutritional needs for protein. There is no need to limit sodium. Absorption of nutrients is unaffected; there is no need to increase caloric intake.

Which assessment finding alerts the nurse to increasing intracranial pressure? 1. Hypervigilance 2. Constricted pupils 3. Increased heart rate 4. Widening pulse pressure

4. Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

****A client with a head injury has a computed tomography (CT) scan that shows a subdural hematoma. How would the nurse interpret this finding? 1. Blood within the brain tissue 2. Blood in the subarachnoid space 3. Blood between the dura and the skull 4. Blood between the dura mater and the arachnoid layer

4. Blood between the dura mater and the arachnoid layer A subdural hematoma refers to blood between the dura mater and the arachnoid layer of the meninges. Blood within the brain tissue is an intracerebral hematoma. Blood in the subarachnoid space is below the arachnoid and is called a subarachnoid hematoma. Epidural hematoma refers to blood between the dura and the skull.

A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching? 1. "I wanted another child, and now pregnancy is not an option for me." 2. "I must allow extra time for irrigating my colostomy when traveling." 3. "It is good to know that I can swim every day after my incision heals." 4. "I'm glad I won't have to have special clothing and I can wear what I have."

1. "I wanted another child, and now pregnancy is not an option for me." Pregnancy is possible; it should be determined whether the client is referring to physiological capability or emotional concern about sexual relationships. Extra time usually is necessary in an unfamiliar environment and should be calculated into traveling plans. Swimming is permitted; the water will not injure the stoma or intestine. There are no adaptations or restrictions on the types of clothing.

The nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations would the nurse expect? Select all that apply. One, some, or all responses may be correct. 1. Dry skin 2. Abdominal pain 3. Kussmaul respirations 4. Absence of ketones in the urine 5. Blood glucose level of less than 72 mg/dL (3.3 mmol/L)

1. Dry skin 2. Abdominal pain 3. Kussmaul respirations Dry skin is a sign of dehydration in response to polyuria associated with the osmotic effect of an elevated serum glucose level. Abdominal pain is associated with diabetic ketoacidosis. In the absence of insulin, glucose cannot enter the cell or be converted to glycogen, so it remains in the blood. Breakdown of fats as an energy source causes an accumulation of ketones, which results in acidosis. The lungs, in an attempt to compensate for lowered pH, will blow off CO2 (Kussmaul respirations). An absence of ketones in the urine indicates adequate production of glucose for energy. Insulin deficiency stimulates production of ketones as a by-product of fat oxidation for energy. Blood glucose level of less than 72 mg/dL (4 mmol/L) indicates hypoglycemia, not ketoacidosis.

Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)? 1. Place the head and neck in neutral alignment. 2. Obtain a prescription for 100 mg of pentobarbital IV. 3. Administer 1 g mannitol intravenously (IV) as prescribed. 4. Increase the ventilator's respiratory rate to 20 breaths/minute

1. Place the head and neck in neutral alignment. The nurse would first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the health care provider, who may prescribe mannitol. The nurse would notify the health care provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.

Which finding in a client who has syndrome of inappropriate antidiuretic hormone (SIADH) is an expected finding? 1. Preservation of salt 2. Retention of water 3. Decrease of vasopressin 4. Presence of pedal edema

2. Retention of water SIADH is manifested in the form of retention of free water. This is because of excessive secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia and dilution of serum sodium in SIADH. Decreased vasopressin is seen in diabetes insipidus. Generally, pedal (dependent) edema is not seen in SIADH despite the water retention.

****A client has increased intracranial pressure and is unconscious with a heart rate of 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

4. Morphine 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 anti-inflammatory 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.

A client has been receiving phenytoin for epilepsy and is newly prescribed haloperidol. The nurse would include which information when teaching the client about the interaction of these medications? 1. Masking of haloperidol's therapeutic effect 2. Interference with haloperidol's absorption 3. Enhancement of haloperidol's rate of metabolism 4. Potentiation of haloperidol's central nervous system depressant effect

4. Potentiation of haloperidol's central nervous system depressant effect Antiseizure medications and haloperidol exert a synergistic central nervous system depressant effect. The effect is potentiated, not masked. Anticonvulsants do not affect the absorption or metabolism of haloperidol.

Which clinical assessment would the nurse perform to evaluate the effectiveness of a shunt for an infant with hydrocephalus? 1. Palpating the anterior fontanel 2. Determining the frequency of voiding 3. Assessing the child for periorbital edema 4. Assessing the symmetry of the Moro reflex

1. Palpating the anterior fontanel A bulging fontanel is the most significant sign of increased intracranial pressure in an infant. Periorbital edema, the frequency of voiding, and the symmetry of the Moro reflex are not indicators of increased intracranial pressure.

Which sign would the nurse place at the bedside of a child admitted with a diagnosis of Wilms tumor? 1. Keep NPO (nothing by mouth). 2. No intravenous (IV) medications 3. Record intake and output. 4. Do not palpate the abdomen

4. Do not palpate the abdomen Palpation increases the risk of tumor rupture and is contraindicated. There are no data to indicate that surgery is scheduled; therefore, there is no reason to maintain NPO status. There is no contraindication to IV medication. Recording of intake and output may or may not be instituted; it is not specific to children with Wilms tumor.

****Which of these assessments leads the nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct. 1. Irritability 2. High-pitched cry 3. Depressed fontanels 4. Decreased urinary output 5. Ineffective feeding behavior

1. Irritability 2. High-pitched cry 5. Ineffective feeding behavior Pressure on the cerebral structures influences the central nervous system, resulting in irritability. A high-pitched cry is common in neonates with increased ICP. Ineffective feeding behavior is typical of neonates with increased ICP. The fontanels are bulging, not depressed, with increased ICP. Decreased urinary output is related to dehydration and kidney problems, not increased ICP.

Which unique response is associated with diabetic ketoacidosis (DKA) that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? 1. Fluid loss 2. Glycosuria 3. Kussmaul respirations 4. Increased blood glucose level

3. Kussmaul respirations Kussmaul respirations occur in diabetic ketoacidosis (DKA) as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.

Which education would the nurse provide about the occurrence of febrile seizures? 1. They may occur in minor illnesses. 2. The cause is usually readily identified. 3. They usually do not occur during the toddler years. 4. The frequency of occurrence is greater in females than males.

1. They may occur in minor illnesses. Febrile seizures are usually not associated with major neurological problems; they may occur during minor illnesses. Between 95% and 98% of these children do not experience epilepsy or other neurological problems. The cause of febrile seizures is still uncertain. Most febrile seizures occur after 6 months of age and before age 3 years, with the average age of onset between 18 and 22 months. Boys are affected about twice as frequently as girls.

****Which intervention would the nurse include in the care of a child with Wilms tumor? 1. Palpating for liver size 2. Monitoring blood pressure 3. Obtaining urine for a culture 4. Maintaining the prone position

2. Monitoring blood pressure Blood pressure monitoring is important because the tumor is of renal origin and the renin-angiotensin mechanism may be involved. Palpating the liver should be avoided; it puts pressure on the involved area, increasing the risk of rupture of the tumor and seeding of cancer cells. There are no data to indicate that the child has a urinary tract infection. Lying in the prone position puts pressure on the involved area, increasing the risk of rupture of the tumor and seeding of cancer cells.

A child with Wilms tumor is prescribed doxorubicin hydrochloride. Which common side effect unique to doxorubicin would the nurse expect to observe in the child? 1. Hair loss 2. Vomiting 3. Red urine 4. Stomatitis

3. Red urine Red urine is a common side effect of doxorubicin administration. The medication is not metabolized and is excreted in the urine. The genitourinary responses to vincristine are nocturia, oliguria, urine retention, and gonadal suppression. Hair loss, vomiting, and stomatitis occur with both medications.

Which laboratory results support the nurse's suspicion that a client diagnosed with type 1 diabetes is experiencing ketoacidosis? 1. Blood glucose of 40 mg/100 mL (2.2 mmol/L), blood pH of 7.37 2.Blood glucose of 130 mg/100 mL (7.2 mmol/L), blood pH of 7.35 3.Blood glucose of 650 mg/100 mL (36.1 mmol/L), blood pH of 7.42 4. Blood glucose of 300 mg/100 mL (16.7 mmol/L), blood pH of 7.20

4. Blood glucose of 300 mg/100 mL (16.7 mmol/L), blood pH of 7.20 The blood glucose level of 300 mg/100 mL (16.7 mmol/L) is greater than the expected range of individuals with type 1 diabetes, indicating hyperglycemia. The normal serum pH is 7.35 to 7.45; therefore, 7.20 indicates acidosis. The blood glucose level of 40 mg/100 mL (2.2 mmol/L) is less than the expected range for all individuals, indicating hypoglycemia; the serum pH of 7.37 is within the expected range for pH. The blood glucose level of 130 mg/100 mL (7.2 mmol/L) is within the expected range for individuals with type 1 diabetes, and the pH of 7.35 is within the expected range for pH. The blood glucose level of 650 mg/100 mL (36.1 mmol/L) indicates hyperglycemia, but the serum pH is within the expected range for pH.

Which responses would alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1. Flaccid paralysis and numbness 2. Absence of sweating and pyrexia 3. Escalating tachycardia and shock 4. Paroxysmal hypertension and bradycardia

4. Paroxysmal hypertension and bradycardia An exaggerated response of the autonomic nervous system causes paroxysmal hypertension and bradycardia. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Bradycardia occurs. These clinical findings occur as a result of exaggerated autonomic responses.

The nurse administers desmopressin acetate (DDAVP) to a client with diabetes insipidus. Which would the nurse monitor to evaluate the effectiveness of the medication? 1. Arterial blood pH 2. Intake and output 3. Fasting serum glucose 4. Pulse and respiratory rates

2. Intake and output DDAVP replaces antidiuretic hormone, facilitating the reabsorption of water and the consequent return of balanced fluid intake and urinary output. The mechanisms that regulate pH are not affected. DDAVP does not alter serum glucose levels; diabetes mellitus, not diabetes insipidus, results in hyperglycemia. Although the correction of tachycardia is consistent with the correction of dehydration, the client is not dehydrated if the fluid intake is adequate; respirations are unaffected.

How would the nurse describe the clonic phase of a tonic-clonic seizure? 1. Generalized rigidity 2. Loss of consciousness 3. Rhythmic body jerking 4. Tremors of upper extremities

3. Rhythmic body jerking The clonic phase of a tonic-clonic seizure is associated with the rapid rhythmic extension and relaxation of muscle groups throughout the body. Rigidity occurs during the tonic phase of a seizure. Loss of consciousness is not specific to the clonic phase; it occurs at the beginning of the tonic phase and continues into the clonic phase. The movements during the clonic episode are more marked than the movements of a tremor and occur throughout the body, not just in the extremities.

****A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. Which action would the nurse take? 1. Omit the 9:00 AM dose of the medication. 2. Give the same dosage of the medication rectally. 3. Administer the medication with 30 mL of water at 9:00 AM. 4. Ask the health care provider to prescribe an alternative.

4. Ask the health care provider to prescribe an alternative. To achieve the anticonvulsant effect, therapeutic blood levels must be maintained. If the client is not able to take the prescribed oral preparation, the health care provider should be questioned about alternative routes of administration. Omission will result in lowered blood levels, possibly to less than the necessary therapeutic level to prevent a seizure. The route of administration cannot be altered without health care provider approval. The client is being kept nothing by mouth.

Upon entering a client's room, the nurse sees the client exhibiting seizure activity. Which is the first action the nurse would take? 1. Assess the client's airway. 2. Place pads on the side rails. 3. Notify the client's health care provider. 4. Leave to obtain the crash cart.

1. Assess the client's airway. Ensuring an airway is the first action in an emergency response to any client. Placing pads on the side rails during the procedure is too late; protecting the airway and client are priority. The health care provider will be notified as soon as the nurse ensures the client's safety and that she or he has a patent airway. The nurse would not leave the client during a seizure.

Which nursing intervention is appropriate to include in the plan of care for a client with diabetic ketoacidosis (DKA)? 1. Intravenous administration of regular insulin 2. Administer insulin glargine subcutaneously at hour of sleep 3. Maintain nothing prescribed orally (NPO) status 4. Intravenous administration of 10% dextrose

1. Intravenous administration of regular insulin A client admitted with DKA will have a blood glucose value greater than 250 and blood ketones. Intravenous (IV) administration of regular insulin is needed to rid the body of ketones and regulate blood glucose. Administration of insulin glargine is not going to reverse the ketoacidosis. The client will be allowed fluids to maintain hydration. Administration of 10% dextrose IV will increase the client's blood glucose.

A client with a history of hemoptysis and cough for the past 6 months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. Which is the nurse's priority? 1. Contact the primary health care provider. 2. Document the amount of sputum. 3. Monitor vital signs every hour. 4. Increase the frequency of cough and deep-breathing exercises

1. Contact the primary health care provider. The observation may be indicative of bleeding, and the health care provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing to only monitor the client is unsafe. Documenting the amount of sputum is an action to be taken, but not until after contacting the primary health care provider. Vital signs should be monitored, but the priority is to take action to identify and treat bleeding. Increasing the coughing and deep-breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.

The nurse observes an orientee nurse caring for an unconscious client who has increasing intracranial pressure. Which of the orientee's interventions would the nurse question? 1. Lubricating the skin with moisturizing lotion 2. Suctioning the endotracheal tube every hour 3. Elevating the head of the bed 30 degrees 4. Instilling artificial tears every 2 hours

2. Suctioning the endotracheal tube every hour Although suctioning is done when needed to maintain an airway, it is not done routinely on a schedule because it increases intracranial pressure. The nurse would intervene to correct this behavior. All the rest are correct behaviors. Lubricating the skin keeps the skin from drying, which helps prevent skin breakdown. Elevating the head of the bed promotes venous return to the heart and is used to limit increased intracranial pressure. Instilling artificial tears every 2 hours is an appropriate intervention. The corneal reflex may be absent in the unconscious client; a dry cornea is prone to injury.

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention? 1. Maintains a sterile field 2. Applies suction during insertion of the catheter 3. Preoxygenates with 100% oxygen for 1 minute 4. Tests suction pressure at 100 mm Hg before inserting catheter

3. Preoxygenates with 100% oxygen for 1 minute Suction should be applied during withdrawal, not insertion, of the catheter. A sterile field is required for tracheal suctioning, but not oral suctioning. Preoxygenation will be completed for 30 seconds to 3 minutes. Pressure must be tested before suctioning and be within the range of 80 to 120 mm Hg.

A client with a newly formed colostomy, secondary to cancer of the rectum, received instructions regarding ostomy care and management. Which client statement indicates understanding of colostomy care? 1****. "I will call the clinic and report if I notice a loss of sensation to touch in the stoma tissue." 2. "I will call the clinic and report when mucus is passed from the stoma between irrigations." 3. "I will call the clinic and report expulsion of flatus while the irrigating fluid is running out." 4. "I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma."

4. "I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma." Difficulty inserting the irrigating tube into the stoma occurs with stenosis of the stoma; forcing insertion of the tube may cause injury. Loss of sensation to touch in the stomal tissue is expected; there is no need to call the clinic. Mucus exiting the stoma between irrigations is expected; there is no need to call the clinic. Expulsion of flatus while irrigating fluid is running out is expected; feces and flatus accompany fluid expulsion.

Which question made by the nurse will help determine diabetes insipidus in a client who reports frequent urination? 1. "Do you have history of cancer?" 2. "Are you on fluoroquinolone therapy?" 3. "Are you on lithium carbonate therapy?" 4. "Do you have a history of lymphoma?"

3. "Are you on lithium carbonate therapy?" Lithium carbonate is known to interfere with normal kidney response to antidiuretic hormone. Enquiring about lithium carbonate therapy can help assess for diabetes insipidus, which has a clinical manifestation of frequent urination. Inquiry about history of cancer helps in assessing syndrome of inappropriate antidiuretic hormone (SIADH) because some cancer therapy medications result in SIADH. Treatment with fluoroquinolone antibiotics also can result in SIADH. Hodgkin and non-Hodgkin lymphoma are causes of SIADH.

Which manifestations are exhibited with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? 1. Increased blood urea nitrogen (BUN) and hypotension 2. Hyperkalemia and poor skin turgor 3. Hyponatremia and decreased urine output 4. Polyuria and increased specific gravity of urine

3. Hyponatremia and decreased urine output Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

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