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UWORLD PN

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A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so that the client can ambulate safely with a cane 3. Instruct the UAP to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

4 SIGHTED GUIDE TECHNIQUE Nurse walks slightly ahead and to the side of the client. CLient hold the elbow of nurse's arm On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. (Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. (Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. (Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely. Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report bruises to the client's health care provider 4. Talk to the client's child about the injuries

2 The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso (trunk). In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. (Option 1) Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. (Option 3) Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client's status and situation. (Option 4) Talking to the client's child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client's status to determine needed interventions. Further assessment for indications of elder abuse is the priority. Educational objective: When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? 1. "i can see that you are very upset. Let's talk about what happened" 2. "Ill report the technician to the head of the radiology dept" 3. "The technician never should have said that to you" 4. "Your health care provider will discuss tx options with you"

1 Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations. (Option 2) This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor. (Option 3) This statement may be true, but it does not facilitate a dialogue about the client's feelings and fears. (Option 4) This response does not address the client's feelings or what happened during the mammogram. Educational objective: Therapeutic communication techniques such as acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs" 2."His heart has stopped and we are attempting to revive him" 3. "I do not know how he is doing but you need to come" 4. "I will have the health care provider talk to you once you arrive"

1 Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely. (Option 2) This is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely. (Option 3) This is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child. (Option 4) Although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis. Educational objective: The ethical principle of beneficence means doing good. It can involve not saying all known information immediately but delaying notification until appropriate support is in place.

The nurse is reinforcing proper insulin self-administration technique to a client of American Indian heritage. As the nurse describes the necessary steps in the injection process, the client avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue instructing the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the instruction by following the cient's movements 4. provide written instructions and a private place for the client to learn independently

1 Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles, including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If these clients avoid eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. (Option 2) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. (Option 3) In the American Indian culture, maintaining eye contact during a conversation is viewed as disrespectful. Attempting to force eye contact would likely make the client uncomfortable or upset. (Option 4) A client learning the process of insulin self-administration requires guidance and evaluation from the nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational objective: Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move their eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube? 1. Flush and aspirate the tube with warm water 2. Instill a digestive enzyme solution into the tube 3.Instill cola or cranberry juice into the tube 4.Use a small-barrel syringe to flush the tube

1 Enteral feeding tubes are more likely to become obstructed if the tube is not flushed frequently enough, medications are not adequately crushed or diluted before administration, a thick feeding formula is used, or a small-bore feeding tube is required. Interventions to unclog a feeding tube are more successful if they are initiated immediately. The nurse should first attempt to dislodge the clogged contents by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube (Option 1). (Option 2) If a feeding tube cannot be unclogged with warm water, the nurse may then attempt to use a digestive enzyme solution. These commercial declogging kits contain prefilled syringes of enzymatic solution that must be added to the tube and dwell in it for a period of time (usually 30 minutes to 1 hour) before flushing and aspiration are attempted. (Option 3) Instilling a carbonated beverage (eg, dark cola) or cranberry juice into a clogged feeding tube is not appropriate. The acidity of either liquid can worsen an obstruction, and the dark color may mask gastrointestinal bleeding. (Option 4) Flushing a feeding tube with a small-barrel syringe can create too much pressure and rupture the tube. Educational objective: When a feeding tube becomes clogged, the nurse should first attempt to unclog the tube by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube. A digestive enzyme solution may help if warm water flushing is not effective.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. ask the mother's permision to touch the child's hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is no reason for distress 4. Suggest postponing the examination until mother calms down

1 In Latin American culture, an illness called "mal de ojo" ("evil eye") is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward (Option 1). Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse. (Option 2) Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress. (Option 3) This response is nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness. (Option 4) Postponing the examination does not address the cause of the mother's distress. Educational objective: Many Latin Americans believe in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward. Copyright © UWorld. All rights reserved.

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this dx must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent this from happening" 3. "Well, we are all going to die sometime" 4. "You should concentrate on getting better rather than thinking about death"

1 The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?," the client is most likely not looking for a direct "yes" or "no" answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings. The nurse can facilitate a sense of trust, connection, and collaboration by the following: Providing empathy - acknowledging the distressing nature of the diagnosis Providing situations (eg, broad opening for discussion) in which the client can share thoughts and feelings in a safe environment Active listening - being very attentive to what the client is saying and trying to understand what the client is thinking and feeling Focusing - going beyond words and explanations to attain new awareness of a client's concerns Communicating effectively will assist the client in coping with difficult situations, reducing stress, and developing approaches for making necessary life changes (Option 2) This response attempts to give reassurance but does not address the client's thoughts and concerns. (Option 3) This is a very trite response and will close down any opportunity for further discussion. (Option 4) This response gives advice to the client and is non-therapeutic; it does not acknowledge the client's current concerns. Educational objective: Clients with devastating conditions or situations may have difficulty expressing their concerns, thoughts, and feelings. A nurse who is skilled in using effective communication techniques such as active listening, providing broad openings for discussion, and focusing can help clients cope with and reduce the stress of difficult situations.

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear 2. The client has a 30 degree bend at the elbow when walking 3. The crutches and injured foot are moved simultaneously in a 3-point gait 4. There is a 3 finger width space noted between the axilla and axillary pad

1 he proper fit and use of crutches are important in preventing injury. They include: Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational objective: Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues. Copyright © UWorld. All rights reserved.

The community health nurse is preparing to reinforce teaching to a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1.Cervical cancer 2. Hypertension 3. Ishemic stroke 4. Osteoporosis 5. Skin Melanoma

1,2,3 he incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3). (Option 4) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. (Option 5) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than in African Americans. Educational objective: African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer (melanoma).

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for health care workers of the same sex to provide care for client 2. Coordinate with the Registered Dietcian to provide halai meals 3. Reposition the immobile client to face the city of Mecca During Daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. upon death, provide the family with supplies for postmortem care

1,2,3,5 Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer (Option 3) - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible (Option 1). The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable (Option 2). During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day (Option 5). (Option 4) In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care. Educational objective: Important aspects of care for Muslim clients include accommodating the following client needs: Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply. 1. Administer docusate sodium orally every day 2. Assist in applying an abdominal binder 3. Implement caloric restriction to promote weight 4. Monitor blood glucose to maintain tight control 5. Reinforce teachings to hug a pillow while coughing

1,2,4,5 Dehiscence occurs when the edges of a surgical wound fail to approximate (ie, partial or total separation of the skin and tissue layers). Clients with conditions that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection) are at a higher risk. Mechanical stress on the wound (eg, straining to cough, vomit, or defecate) also increases the potential for dehiscence. Interventions to prevent dehiscence include: Administer stool softeners (docusate [Colace]) to prevent straining during defecation and alleviate constipation from postoperative immobility and opioid medications (Option 1). Administer antiemetics (ondansetron [Zofran]) as needed to prevent straining with vomiting. Apply an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing/moving (Option 2). Monitor blood sugar to maintain tight glycemic control (fasting glucose <140 mg/dL, random glucose <180 mg/dL) to help prevent infection and promote wound healing (Option 4). Splint the abdomen by holding a pillow or folded blanket against the wound for support when coughing/moving (Option 5). (Option 3) Nutritional therapy is critical to the normal wound healing process, which depends on adequate intake of calories and protein. Although this client should be educated about weight loss measures prior to discharge, caloric restriction is unnecessary at this time and could further delay wound healing. Educational objective: Interventions to prevent wound dehiscence include administering stool softeners and antiemetics, applying an abdominal binder, splinting the abdomen, and maintaining tight glycemic control.

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Leaving the television on for diversion at night 3. Opening the window blinds/shades in the morning 4. Scheduling interventions and activities during the day when possible 5. Turning off equipment alarms in the client's room at night

1,3,4 It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, allowing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the window shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. (Option 2) Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. (Option 5) Turning the alarms off in the client's room would pose a risk to safety as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. Educational objective: To prevent disorientation and delirium in the intensive care unit, it is important to provide care that maintains the client's normal circadian rhythm (dimming lights at night, allowing uninterrupted sleep when possible, scheduling interventions and activities during the day, frequent reorientation, and opening window shades in the morning).

The nurse is reinforcing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2. Discourage the client from using the internet to look up health information 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium 5. Speak slowly and loudly so the client can understand you

1,3,4 The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language. (Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view. (Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning. Educational objective: For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions. Copyright © UWorld. All rights reserved.

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. 1. Palliative care focuses on quality of life and can be provided at any time 2. Palliative care is only possible with a terminal dx of <6 months 3. Palliative care is provided by a multidiscplinary team 4. Palliative care is another term for hospice care 5. Palliative care provides relief from symptomx assoc with chronic illnesses

1,3,5 Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. (Option 2) Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer). (Option 4) The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment. Educational objective: Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families.

The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year old man with a head injury sustained during a college football game 2. 30-year old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year old man 2 weeks post myocardial infarction 4. 68-year old woman recently dx with pancreatic cancer 5. 74-year old man with portal hypertension related to alchol-induced cirrhosis 6. 82-year old woman 1 week post cataract surgery

1,3,5,6 The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure (Option 1). The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3). Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding (Option 5). The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6). (Option 2) The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver. (Option 4) The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver. Educational objective: The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis. Reduction of risk potential

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. 1. Epoetin alfa 2. Frozen plasma 3. Homologous packed red blood cells 4. normal saline 5. platelet transfusion

1,4 Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4). Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1). Educational objective: Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.

A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse? 1."How is your spouse's new job going" 2."Ive noticed that you seem frustrated lately" 3. "It's normal to be angry when you can't work anymore" 4. "We have a support group that can help you adjust to rehab"

2 A client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new role, and this stress can increase a client's vulnerability to ongoing health problems. This client has gone from being the main source of income to being unable to support the family and dependent on the spouse for financial stability. This causes a strain, and such a drastic role change can be particularly difficult for individuals who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not interviewed the client to determine the factors contributing to this change. The nurse should first communicate with the client in a therapeutic manner, using open-ended reflective statements and nonverbal communication to express acceptance and willingness to listen. (Option 1) This response ignores the client's feelings and closes off an opportunity to assess the client's emotional state regarding the role change brought on by illness and the spouse's new job. (Option 3) The nurse is assuming that the client is angry about the inability to work, but the client has not said this. Further communication is needed to understand the client's emotions and their source. (Option 4) The cause of the client's behavior change is not apparent at this point, so further communication is needed. It is premature to intervene by recommending a support group. Educational objective: Chronic illness can result in role changes that negatively influence a client's self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and listening to the client's feelings and perceptions on the issue.

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? 1. Client scheduled for dx who has had a peripheral IV in place for 84 hours 2. Client with a do-not-resuscitate prescription who has swelling at the IV site 3. Client with a saline lock who had a scheduled IV saline flush due 15 minute ago 4. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

2 During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. Interventions include: Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) Elevating the affected extremity to decrease swelling Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs. (Option 1) Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority. (Option 3) It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority. (Option 4) An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag. Educational objective: The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit? 1. High-fowler's position with affected side's arm resting on the bed 2. Semi-fowler's positin with the affected side's arm on several pillows 3. supine with the affected side's arm on several pillows 4. supine with the affected side's arm resting on the bed

2 Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy. (Option 1) Placing the client in a high-Fowler's position immediately after anesthesia might cause a decrease in blood pressure and subsequent dizziness. Resting the affected side's arm on the bed would place the arm in a dependent position, which would lead to swelling due to decrease in lymphatic and venous drainage. (Options 3 and 4) Raising the head of the bed slightly would promote ease of breathing. Resting the arm on several pillows would promote drainage and prevent lymphatic pooling. Educational objective: Immediately post mastectomy, the client is placed in a semi-Fowler's position to promote ease of breathing. The affected side's arm and hand should be elevated on several pillows to promote drainage and prevent lymphatic pooling.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1. Ask the HCP prescribe a difffereent calcium channel blocker 2. Consult with the pharmacist to see if an alternate form of the drug is available 3. Open the capsul and sprinkle the medication in a cup of applesauce 4. Warn the client about the dangers of uncontrolled hpertension

2 Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill. (Option 1) It is not necessary to ask the health care provider to prescribe a different medication unless the religious dietary laws cannot be relaxed or the client desires a kosher alternate form of diltiazem (Cardizem) that is unavailable. (Option 3) Extended-release capsules should be swallowed whole. Crushing or breaking the capsule may cause uncontrolled delivery of the medication and increase the risk of overdose or other serious adverse effects. (Option 4) Although it is important to perform client teaching, the nurse should first assess the reason for this client's nonadherence to the prescribed regimen. Additionally, the nurse should avoid using scare tactics in client teaching. Educational objective: Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill. Copyright © UWorld. All rights reserved.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report the bruises to the client's health care provider 4. Talk to the clent's child about the injuries

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply. 1. High fowler position in preparation for a paracentesis 2. Left side-lying position after percutaneous liver biopsy 3. Semi-fowler after cardiac catheterizeation via femoral entry 4. Sims during soap-suds enema administration 5. Supine position after a lumbar puncture

2,3 A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it (Option 1). Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid (Option 5). Sims position (left side-lying with right hip and knee flexed) is best for enema administration (Option 4). (Option 2) After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding. (Option 3) After cardiac catheterization via femoral entry, place clients flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma. Educational objective: Clients undergoing paracentesis should be upright. After liver biopsy, clients should be in a right side-lying position to prevent hemorrhage. After femoral cardiac catheterization, clients should remain flat. After lumbar puncture, clients should be flat in bed to minimize risk of headache.

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. 1. Check gastric residual every 12 hours 2. Keep head of the bed at >30 degrees 3. Maintain endotracheal cuff pressure 4. Monitor for abdominal distension every 4 hours 5. Use caution when adminstering sedatives

2,3,4,5 Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk in clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension and pain, bowel movements, and flatus (Option 4). Assess feeding tube placement at regular intervals. Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal, to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 2). Keep the endotracheal cuff inflated at appropriate pressure (about 25 cm H2O) for intubated clients as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 3). Suction any secretions that may have collected above the endotracheal tube before deflating the cuff, if deflation is necessary. Use caution when giving sedatives and frequently monitor for oversedation, which can slow gastric emptying and reduce gag reflex (Option 5). Avoid bolus tube feedings for clients at high risk for aspiration. (Option 1) Gastric residual should be checked at least every 4 hours with continuous feedings. Educational objective: Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for tube placement regularly and gastric intolerance (eg, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, and using sedation cautiously. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and the area above the tube suctioned appropriately.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPPA 5. Teach about one intervention at a time and in the order it will occur

2,3,5 Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2). The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3). Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure" (Option 5). (Option 1) The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond nodding as some people nod to indicate that they are listening or nod in agreement to "save face" even though they do not understand. It is better to use a tactic such as having the client repeat back information (which is then translated into English). (Option 4) Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights. Educational objective: When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding. Copyright © UWorld. All rights reserved.

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1. Ask a family member about the client's preferences for room arrangement 2. Offer the clent an elbow to hold, walk a half-step ahead for guidance 3. Say "goodbye" when leavning the room to help orient the client 4. Speak slowly and slightly louder so that client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray

2,3,5 The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: Offer the client an elbow for guidance while walking slightly ahead and describing the environment (Option 2). Announce room entry and exit to orient and avoid startling the client (Option 3). Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily (Option 5). Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety. (Option 1) Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement. (Option 4) The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and slightly louder would be useful for a client with a hearing deficit. Educational objective: When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPPA 5. Teach about one intervention at a time and in the order it will occur 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tube once a week, then clean with hydrogen perioxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

2.4.5 Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Avoid tub baths due to the risk of infection (Option 3). Do not apply powders or lotions on incisions as these trap bacteria at the incision site (Option 3). Report any redness, swelling, drainage increase, or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling (Option 5). Educational objective: The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions; to report any redness, swelling, or drainage increase; and to wear an elastic compression hose on the legs. Copyright © UWorld. All rights reserved.

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your HCP" 2. "If I were you, I would be more worried about whether the melanoma has spread" 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications" 4. "There is special make-up you can use to hide any facial scars left from the surgery

3 Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: The client is provided with factual information about facial surgery and the healing process. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. (Option 1) This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions. (Option 2) This is a non-therapeutic response; it gives advice to the client, suggests that the nurse "knows better," and minimizes the client's concerns. It also introduces a more serious issue about the diagnosis. (Option 4) This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client's concerns. Educational objective: Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important? 1. Allowing the client's husband to be with her during clinical examinations 2. Assigning the client to a private room 3. Ensuring that female health care workers are available to provide care to the client 4. Obtaining the services of a local Muslim imam

3 For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently. (Option 1) A husband will often request to be with his wife during an examination; efforts should be made to fulfill this request, but it is not the priority consideration. (Option 2) A private room may not be necessary. This client should be assigned to a room with another Muslim woman or a woman with similar practices regarding modesty. Otherwise, male visitors to the client's roommate could be problematic and cause distress. (Option 4) Consulting with a local Muslim imam or hospital chaplaincy staff may enhance culturally congruent care; however, this is not the most pressing consideration. Educational objective: In the care of female Muslim clients, modesty is highly valued and most body parts are covered. Female health care workers should be available to provide care and conduct examinations. If a male health care provider must be involved in care, female clinical staff should also be present whenever possible.

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? 1. "cancer is no longer a death sentence, you may live for many years" 2. "I will ask the chaplain to talk to you sometime today" 3. "People with cancer experience fear of dying, tell me about your concerns 4. "Tell me about your life and hopes for the future"

3 Many individuals diagnosed with cancer experience anxiety and fear related to death and desire to talk with someone about these feelings. To promote a therapeutic relationship, the nurse should initiate conversations by acknowledging clients' fears, use open-ended statements to invite them to talk about death, and actively listen as they verbalize their feelings. (Option 1) The nurse offers false reassurance by making this statement. Providing false reassurance is not part of a therapeutic relationship or an effective communication strategy. (Option 2) This statement does not acknowledge the client's concerns and blocks communication. The nurse should first assess the client's cultural and spiritual practices. If the client requests spiritual support, then the nurse may make a referral to the chaplain's office. (Option 4) By changing the subject, the nurse is attempting to redirect the conversation away from the client's desire to talk about death; this does not promote a therapeutic relationship. Educational objective: Fear of dying is a common concern for many clients with a terminal disease. The nurse should acknowledge these feelings and use open-ended statements and active listening to invite clients to talk about death.

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? 1. Give the client gentle reminders that the client has already eaten 2.Say that the client can have a snack in a couple of hours 3. Serve the client half of the meal initially and offer the other half later 4. Take a picure of the client having a meal and show it when the client becomes upset

3 Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. (Option 1) Reality orientation has been recommended in the past as a way to deal with confusion (eg, dementia, Alzheimer disease), but research has shown that it may cause anxiety and distress. Validation therapy is a newer and more therapeutic approach that validates and accepts the client's reality. (Option 2) Offering to provide a snack later does not address the client's stated need to eat now. Delay in giving food will only further increase the client's anger and frustration. (Option 4) Showing a picture of the client having a meal is confrontational and will have no meaning to the client. Educational objective: Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. **EARLY STAGE Forgetting that a meal was consumed due to short-term memory loss Anorexia & weight loss secondary to depression &/or recognition of the disease MIDDLE STAGEForgetting to eat at all Not recognizing the sensations of hunger & thirst Forgetting how to use utensils Consuming nonfood items Refusing to eat Restlessness: Inability to sit long enough to consume a meal LATER STAGE Inability to feed oneself Dysphagia

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? 1. "Do you have any questions about the dx?" 2. "There are medications available to treat Alzheimer disease 3. "This is a new dx must be frightening to you" 4. "We can help you make decisoins about your care"

3 Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts. (Option 1) Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client's thoughts and feelings, information can be provided. (Option 2) Providing false reassurance is not therapeutic and can block communication. A client and family may not fully understand the progression of Alzheimer disease immediately after receiving the diagnosis. Stating that medications are available to treat the disease may lead to a false belief that it can be cured. (Option 4) A client diagnosed with Alzheimer disease may need assistance with care planning, but the nurse should first support the process of coping when the client receives the life-changing diagnosis. Educational objective: When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication. Copyright © UWorld. All rights reserved.

The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso (trunk). In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. (Option 1) Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. (Option 3) Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client's status and situation. (Option 4) Talking to the client's child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client's status to determine needed interventions. Further assessment for indications of elder abuse is the priority. Educational objective: When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect. 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing" 2. "I know you are frustrated with losing control of your life" 3. "It sounds like you are angry. Tell me what's bothering you" 4. "Okay. I will check your blood pressure and then go"

3 The client exhibits anger, which is likely a sign of grief due to loss of control from illness. However, the source of the client's anger is not clear. Therefore, further assessment is now indicated to understand more about the client's feelings and perceptions. Verbalizing feelings may also help the client to move past anger toward acceptance of the loss. The nurse's statement, "It sounds like you are angry" reflects the nurse's perception of the client's emotion and will allow the client to clarify feelings. The open-ended probing statement, "Tell me what's bothering you," facilitates assessment of the client's concerns without making any assumptions about them. This approach will promote accurate assessment of the client's needs and concerns. It will also prevent premature closure, incorrect assumptions, and escalation of the client's anger. (Option 1) This client's angry response likely indicates an unmet need. Further assessment is indicated if the client is willing to talk. This response shuts the door on further assessment. (Option 2) The nurse is making an assumption that the source of the client's frustration is loss of control. This assumption may cause the nurse to draw inaccurate conclusions about the client's concerns, contributing to further escalation of anger. (Option 4) This response will probably diffuse the situation, but further assessment of the client's concern is more important. If the client remains angry and the nurse attempts to take blood pressure after being told to leave, the client may become angrier, putting the nurse's safety at risk. Educational objective: The client with serious illness who exhibits anger may be experiencing anxiety, grief, or fear. The nurse should remain at a safe distance while attempting to diffuse the situation; assess the client's concerns using a calm, non-threatening approach; reflect the client's statements; and try to understand the client's feelings, perceptions, and beliefs to address the priority problem.

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing" 2. "I know you are frustrated with losing control of your life" 3. "It sounds like you are angry. Tell me what's bothering you" 4. "Okay. Ill just check your blood pressure and then go

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? 1. Blister with a garlic scent near the wrists 2.Circular bruised blemishes on the back 3. Markings appearing to be human bites on the arms 4. Welt-like linear lesions on the back

3 The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures in North America can present with dermatologic findings. Markings that appear to be human bites would require further follow-up as these are not common in alternative medicine. Although nurses should be aware of various cultural practices, any marks consistent with child abuse (eg, bite marks, cigarette burns, bruises in various stages of healing) should be reported to the appropriate authorities. (Option 1) Garlic application involves placing crushed garlic directly on the skin. It is thought to heal infections but can cause contact dermatitis and burns on the wrists. This is appropriate to include in a culturally competent care in-service. (Option 2) Cupping is used by many cultures to remove illness from the body. The mouth of a steam-filled cup is placed on the skin, causing circular, bruised blemishes. This is appropriate to include in a culturally competent care in-service. (Option 4) Coining is believed by some cultures (eg, Chinese, Vietnamese) to remove illness from the body. A rounded surface (eg, coin, spoon) is firmly stroked on the lubricated skin of the back and can produce weltlike linear lesions. This is appropriate to include in a culturally competent care in-service. Educational objective: To provide culturally competent care, nurses should be aware of alternative medicine practices that can present with dermatologic findings. Any marks consistent with child abuse should be reported to the appropriate authorities.

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the client's adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

3,4,5' Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak (Option 5) Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview (Option 3) Use a qualified professional interpreter whenever possible The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences (Option 4). (Option 1) The nurse should speak directly to the client, not the interpreter. (Option 2) A family member or friend may not have the vocabulary, knowledge, or skills to provide the best communication for the client. Untrained interpreters may omit or simplify critical pieces of information if they do not understand the terminology. Educational objective: When working with a medical interpreter, the nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short, simple sentences; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences. Copyright © UWorld. All rights reserved.

A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2. Non-rebreathing mask 3. Oxymizer 4. Venturi Mask

4 A Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume. The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased tidal volume, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with chronic obstructive pulmonary disease (COPD). (Option 1) A nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate tidal volume and normal vital signs. It is not the best choice in an unstable COPD client with varying tidal volumes because the inspired oxygen concentration is not guaranteed. (Option 2) A non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short-term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client. (Option 3) An Oxymizer is a nasal reservoir cannula device that conserves oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen to reach the same saturation (eg, 3 L/min nasal cannula is equivalent to 1 L/min Oxymizer). It is not the best choice in an unstable COPD client with varying tidal volumes as the inspired oxygen concentration is not guaranteed. Educational objective: Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable chronic obstructive pulmonary disease [COPD]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, COPD exacerbation).

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to UAP 3. Premedicate the client for pain 4. Verify the client's activity prescriptions

4 A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication. Educational objective: The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse? A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse?

4 After 2 years of residence, this client has expressed a desire to leave the nursing home and return home. This client with advanced MS will need maximal assistance with basic activities of daily living (bathing, grooming, toileting, transfers, locomotion), meal preparation, laundry, shopping, and other housekeeping chores. Discharging this client to care at home will require much planning and present numerous challenges related to safety, finances, support and informal caregiver system, durable medical equipment, and layout of the home. Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking "why" or "yes/no" questions is non-therapeutic and will not facilitate a meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence. (Option 1) This is important information to obtain when planning the discharge of a client who needs care at home; however, it is not the priority assessment. (Option 2) This would be an appropriate nursing action after the nurse has discussed and assessed the reasons why the client wants to return home. (Option 3) This is an appropriate response as it presents the reality of the client's situation, but it is not the priority response. Educational objective: Exploring is a therapeutic communication technique that will facilitate further assessment of a particular subject or experience. It is a technique that is especially helpful when a client makes a statement or presents a topic that alerts the nurse that there could be additional information beyond the surface of the initial communication.

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home? 1. Demonstrate the procedure using simple English phrases 2. Give the parents written instructions with picture illustrations 3. Tell the parents to have a friend or relative come into translate 4. Use an interpreter via the telephone interpretation service

4 Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information (Option 4). Hearing instructions and information in one's primary language decreases the risk of adverse clinical consequences. If a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially during situations in which sensitive information needs to be communicated (Option 3). Children should not be used as translators except in an emergency when there are no other options. (Option 1) This client's parents have very limited English language proficiency; this approach will not be effective in providing instructions about the child's care at home. (Option 2) Providing written materials without verbal teaching does not give the client (or the client's caregiver) the chance to ask questions, nor does it give the nurse the opportunity to assess the client's (or the caregiver's) understanding of the given information. Educational objective: When language is a barrier to effective communication and teaching, the nurse should use a trained medical interpreter for translation purposes.

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time? 1. Call emergeny medical services and place ice packs on the client's axilla groin 2. Encourage the client to leave the venue to visit a health care provider 3. Evaluate whether the client may be intoxicated 4. Move the client to an air-conditioned booth and provide a cool sports drink

4 Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping. If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage (eg, Gatorade), or water (Option 4). The priority is to lower the body temperature to prevent heat stroke, a potentially fatal condition associated with mental status changes (ie, indicating brain damage) and additional organ damage (eg, kidney injury, rhabdomyolysis). (Option 1) If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat; further medical help may be necessary. (Option 2) The client should not leave until the symptoms subside, especially if driving. It is not necessary to have the client visit a health care provider if symptoms resolve. (Option 3) Assessment can be continued once the client has been moved to a cooler environment and provided with hydration. Alcohol consumption may compound heat exhaustion but does not change initial management of the client. Educational objective: Initial management of heat exhaustion includes moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water. Early intervention in heat exhaustion can prevent the development of heat stroke, a potentially fatal condition leading to brain and additional organ damage.

The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately? 1.Elevate blood pressure 2. Heart rate irregularity 3. Low oxygen saturation 4. Noisy breathing

4 Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. (Option 1) Although elevated blood pressure is important to monitor, it is a less serious symptom than stridor. (Option 2) An irregular heart rate is a less serious symptom than stridor, and it may be a baseline finding in the client with hyperthyroidism. (Option 3) Although low oxygen saturation is a sign of impending airway compromise, it is also commonly seen in all types of postoperative clients, making it a less specific sign of airway obstruction than noisy breathing in the thyroidectomy client. Educational objective: Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication 2. Call the HCP to meet with family to obtain information consent 3. Complete the preop checklist 4. Perform the morning assessment

4 The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained. Educational objective: Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client's physiologic and psychologic status, and completes the preoperative checklist.

The nurse is admitting a client who is quadriplegic. Of these 4 different types of call devices, which one should the nurse provide for this client? 1. call device that requires pushing small button 2. call device that requires pushing small button 3. Specialty call cord that has an ultra-sensitive touch surfaces and requires small amount of body pressure over a large area, client need to use head to activate signal. Or device activated by blowing through a tube or moving the eyes 4. pushing small button

A client who is quadriplegic will have limited to no functional mobility in his arms and hands and will therefore be unable to use any device that requires pushing a small button (Options 1, 2, and 4). Instead, the nurse should provide a call device that requires application of a small amount of pressure over a large area, as the client will probably need to use the head to activate the signal (Option 3). Other call devices that this client would probably be able to activate include those activated by blowing through a tube or moving the eyes. Educational objective: A key element of promoting safety when the client is in an acute care setting is to ensure that there is a method of signaling the staff for assistance at all times. The nurse should ensure that the type of call device fits the client's capabilities, that the client is able to use it, and that it is always placed where the client can activate it before the nurse leaves the room.

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply. A. Report any itching, tingling, or numbness around your incisions B. Report any redness, swelling, warmth, or drainage from your incisions C. Soak incisions in the tube once a week, then clean with hydrogen perioxide and apply lotion D. Wash incisions daily with soap and water in the shower and gently pat them dry E. Wear an elastic compression hose on your legs and elevate them while sitting

B,D,E Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Avoid tub baths due to the risk of infection (Option 3). Do not apply powders or lotions on incisions as these trap bacteria at the incision site (Option 3). Report any redness, swelling, drainage increase, or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling (Option 5). Educational objective: The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions; to report any redness, swelling, or drainage increase; and to wear an elastic compression hose on the legs.

For the past month, the nurse has been providing care to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated over the diagnosis. The client's parent stated, "Our lives will never be the same." What statement now made by the parent BEST indicates that nursing interventions have been effective? A. Our child will not be able to participate in sporting events B. Our whole family will have to make sacrifiices to deal with this disease C. We have set aside a place in the pantry foru our child's special foods D. We will not let this disease take control of our child's life

D. It is normal for parents to feel devastated when their child is diagnosed with a chronic illness (eg, diabetes). Reactions include shock, denial, helplessness, anger, fear, and anxiety. They may have feelings of guilt that they contributed to or failed to prevent the development of the disease. The parents' emotional response, adaptation, and coping strategies will greatly impact the child's perception of self and the ability to self-manage the disease. In providing diabetes education, the nurse needs to emphasize and reinforce that with planning and preparation, diabetes can be managed and controlled, regular day-to-day activities can be resumed, and the child can have a normal life. When clients feel in control rather than victimized and dependent, it increases the likelihood that they will be actively engaged in diabetes self-management activities. (Option 1) This is not a true statement. Clients with diabetes can participate in a wide variety of sports. (Option 2) The diagnosis and management of diabetes in a child will affect the whole family. The use of the word "sacrifice" suggests that the parent is feeling victimized by the disease. (Option 3) Nutritional management of diabetes does not require special foods. Nutrition education should emphasize healthy food choices and balancing food choices with medications and exercise for blood sugar control. Educational objective: The diagnosis of a chronic illness (eg, diabetes) in a child will have an impact on the entire family. When the parents see themselves and their child as capable of being independent and in control of the condition, there is an increased likelihood that the disease will be better managed and controlled

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