7th. 85 Practice Qs on 08/09/23 Wednesday.
(62) The patient is using topical glucocorticoids. The nurse should assess for all the following systemic effects of the medication except:
Liver toxicity. Liver toxicity is not a systemic effect associated with the use of glucocorticoids. Topical glucocorticoids or corticosteroids are used in cases of dermatitis and eczema to treat symptoms of burning, itching, and inflammation. They may also be used in conjunction with other medical therapies for the treatment of psoriasis.
(63) A 22-year-old is evaluated in the emergency department for recurrent seizure activity History And Physical. A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation. Orders CT Scan of head Electroencephalogram (EEG) Magnetic Resonance Imaging (MRI) of brain Complete blood count Complete metabolic panel Loading dose of intravenous (IV) phenytoin Urine drug screen Urine pregnancy test For each physician order, click to specify the appropriate nursing intervention. Magnetic Resonance Imaging (MRI) of brain? Loading dose of intravenous (IV) phenytoin? Electroencephalogram (EEG)?
Magnetic Resonance Imaging (MRI) of brain? Assess if the client claustrophobia prior to the exam. Loading dose of intravenous (IV) phenytoin? Establish continuous cardiac monitoring during the infusion. Electroencephalogram (EEG)? Instruct the client how to remove the adhesive after the test. Claustrophobia is a concern for the client scheduled to undergo an MRI because most MRIs are closed. Claustrophobia may impede an effective exam as the client may move. While some MRIs are open, a remedy to this problem may be the physician prescribing a benzodiazepine or antihistamine prior to the exam. MRIs do not require a negative pregnancy test as they are safe during all trimesters of pregnancy. MRIs do not require a client to be NPO. For a client receiving phenytoin, continuous cardiac monitoring must be established and maintained because of the risk of arrhythmias. This medication must be infused in a large-bore IV catheter because of the risk of thrombophlebitis. Mannitol, an osmotic diuretic, may adversely cause pulmonary edema, but this medication is not intended to prevent seizures. Inserting an indwelling catheter to monitor accurate output is not an appropriate intervention for this medication. Phenytoin is a medication used for preventing seizure activity. An electroencephalogram (EEG) is a non-invasive diagnostic test utilized to look at brain waves. In this test, the client has electrodes placed around their head for a set period of time. Fasting is avoided because hypoglycemia may alter the brain waves. Additionally, the nurse should clarify the administration of central nervous stimulants and depressants prior to this exam, as this will alter brain waveforms. Finally, the nurse should instruct the client to avoid the use of hair creams, gels, and conditioners prior to the exam, as this will prevent the electrodes from adhering to the skin. The adhesive gel can be removed at the end of the procedure. The client does not need to be side lying for this procedure as this is one of the two positions used for a lumbar puncture. Finally, the client does not need to be assessed for contrast dye allergy as this contrast dye is not used in this procedure. ADDITIONAL INFO For a client experiencing
(24) The nurse is caring for a client diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse should anticipate a prescription for which of the following?
Methylphenidate. ADHD may be treated by psychostimulants such as amphetamines or methylphenidate. These medications work by projecting the dopamine and norepinephrine in the front of the brain to ameliorate the symptoms of inattention, impulsivity, and hyperactivity. Methylphenidate is a drug commonly indicated for ADHD. Client education should include the dosing of the medication, which should be earlier in the day. It is important to limit caffeine and chocolate. The nurse should monitor the client's weight as this medication has appetite suppressant effects.
(35) Which of the following are correct statements about the proper administration of polyethylene glycol prescribed for constipation?
Mix the powder with any beverage that the patient enjoys. This statement is correct. It is appropriate to mix polyethylene glycol with any beverage the patient enjoys. Soda and juice are common choices due to their ability to mask the flavor better than water. Administer at the same time every day. It is preferable to administer polyethylene glycol at the same time every day. This promotes a bowel regimen and routine, which maximizes the success of the medication. It is also useful to help the client remember to take their medication with a routine established. Instruct that the medication can take 1-3 days to work. It is not necessary to administer polyethylene glycol with meals. The client may choose to do this, but there is no increased effectiveness related to the time of day or if the medication is taken with or without food. ✓Polyethylene glycol 3350 comes in a powder form, which can be mixed with a liquid such as water, juice, or soda. The powder should be completely dissolved before administration. ✓The recommended dose for adults is one capful (17 grams) of polyethylene glycol 3350 mixed with 8 ounces of liquid, once daily or as directed by the healthcare provider. ✓For children, the dose is usually based on weight and age, and the healthcare provider should be consulted. ✓Polyethylene glycol 3350 can take 1-3 days to produce a bowel movement, and it is important to continue taking it as directed until a bowel movement occurs. It is essential to drink plenty of fluids when taking polyethylene glycol 3350 to avoid dehydration. ✓Polyethylene glycol 3350 should not be used for more than two weeks without consulting a healthcare provider. ✓If there is no bowel movement after three days of polyethylene glycol 3350 use, or if there is rectal bleeding, abdominal pain, or other symptoms, medical attention should be sought immediately.
(48) The nurse is caring for a client experiencing subinvolution of the placental site with bleeding. The nurse should obtain a prescription for which medication?
Oxytocin. Oxytocin is a uterotonic medication that will contract the uterus, thereby decreasing uterine bleeding. Examples of uterotonic medications include oxytocin, methylergonovine, and carboprost methamine. Subinvolution is when the uterus fails to return to its normal size and condition. Manifestations include a painful uterus, excessive lochia rubra, and a large uterus. The nurse should encourage frequent voiding, monitor the client's hemoglobin and hematocrit, and assess the uterus and fundus.
(18) The pathological process causing esophageal varices is:
Portal hypertension. Esophageal varices are enlarged veins in the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine, pancreas, and spleen to the liver. Pathology refers to the science of the cause and effects of the disease. Among the answer choices, more than once refers to a symptom that is seen with esophageal varices. However, the cause of the varices is what we are looking for. It's essential to look for clue words in NCLEX questions, such as pathology or symptom.
(40) The nurse is caring for a patient with a Sengstaken-Blakemore tube. She performs her safety checks at the beginning of the shift and ensures which one of the following priority items is readily available at the bedside?
Scissors. Scissors must be kept at the bedside of any patient with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of her shift to ensure the safety of the patient. Scissors are necessary for this patient because if the Sengstaken-Blakemore tube were to rupture the tube would move upward and could obstruct the airway. This is an emergency, and the nurse would need to immediately notify the RN so that the balloon can be cut.
(6) The nurse cares for a 41-year-old female in the emergency department (ED) Nurses' Note: 0900 - Client reports a concern for increased swelling and pain in her left lower extremity. The onset of the symptoms was yesterday evening and when she woke up the pain and swelling had increased. Two days prior, the client sustained abrasions and bruising on the extremity while attempting to get out of a swimming pool. 2+ edema was evident in the left lower extremity; area was warm to touch. Several abrasions on leg noted which were dry and appeared to be healing. Erythema noted. Peripheral pulse and sensation were intact, toe movement was evident along with distal and sensation. Pain reported with leg movement. Pain rated a '7' on a scale 0-10. Current daily medications include ortho tri-cyclen, bupropion, and a multivitamin. She denies any alcohol or drug use. Smokes 2-3 cigarettes per day. Vital Signs: Oral Temperature 98 F (36.7 C) Pulse 66/minute Respirations 16/minute Blood pressure 130/72 mm Hg O saturation 96% on room air. The nurse reviews the diagnostic results. For each possible physician order/prescription, click to indicate if it is anticipated or not anticipated
Splint the affected extremity is Not Anticipated. Clopidogrel is Not Anticipated. Strict bed rest is Not Anticipated. Elevate the affected extremity is Anticipated. EXPLANATION Splinting the affected extremity would not be anticipated as this is ordered for orthopedic injuries. Clopidogrel is antiplatelet and treatment for VTE is anticoagulants such as rivaroxaban, heparin, or warfarin. Strict bed rest is not indicated in the management of a VTE. No credible evidence exists that this degree of immobility decreases the risk of a pulmonary embolism. Further, strict bed rest would increase the risk of the client developing pneumonia. Elevating the extremity to promote venous return is a standard intervention in the care of a client with a VTE.
(53) The nurse is data collecting on a client in bilateral wrist restraints. Which observation or finding would require follow-up?
The client is in the prone position. This observation is not appropriate and requires follow-up. A client in physical restraints should not be positioned prone because it may lead to suffocation. Additionally, a client should not be positioned supine because this makes the client feel vulnerable. The head of the bed for a client in restraints should be at least 30 degrees. ADDITIONAL INFO Restraints should be used as a last resort if alternative methods are not effective. A nurse should never threaten a client with restraints. This is considered assault. The nurse may place a client who is violent in restraints without an order from the primary healthcare provider (PHCP). If this was to occur, the nurse has one hour to inform the provider and obtain an order. Restraints are never as needed (PRN). They should be discontinued at the earliest possible time. When restraining a client, the reason for the restraint must be explained to the client and the behavior the client needs to demonstrate for the restraints to be discontinued. The nurse should observe the client at frequent intervals to offer nutrition & toileting, assess their behavioral status, obtain vital signs, and provide range of motion. These intervals are determined by the facility and the type of restraint—the more restrictive the restraint and the younger the client, the more frequent assessment. Restraints must be able to quickly be removed via a quick release buckle (knots are no longer recommended). The nurses' documentation must be comprehensive, describing the reasoning for the restraints, alternatives utilized, the education provided to the client, the type of restraint utilized, how it was secured, and the ongoing behavior necessary to continue the restraint. The nurse should also document the intervals at which the restraints were released.
(42) The LPN is assisting the nurse in caring for a client who is receiving a continuous opioid infusion. The LPN should understand which of the following, if detected, is a concerning finding?
The client's sedation level is 4. Sedation level is more indicative of respiratory depression because a drop in level usually precedes respiratory depression. A sedation level of 4 calls for immediate action because the client has minimal or no response to stimuli. Opioids, formerly called narcotic analgesics, are generally considered the primary class of analgesics used to manage moderate to severe pain because of their effectiveness. With sufficient dosage, they are deemed capable of relieving the pain of virtually every type. Opioids produce analgesia by attaching to opioid receptors in the brain. Respiratory depression is a commonly feared side effect of opioid use. It is an uncommon occurrence in long-term therapy because clients have usually developed a tolerance to the drug and its respiratory-depressant effects. Opioidinduced respiratory depression is challenging to treat and is generally preceded by sedation. Nursing assessments using the numeric sedation scale can determine those clients at risk for respiratory depression. ✓ Regular and systematic assessment of the client's sedation level using the POSS is essential. Nurses should use the scale as directed and document their findings accurately and consistently. ✓ Each client responds differently to opioids, so it's crucial to tailor pain management plans and opioid dosages to meet the individual's needs. Assess the client's pain level and response to opioids regularly to adjust the medication as necessary. ✓ Nurses should be familiar with opioid reversal agents. In cases of significant opioid-induced sedation or respiratory depression, the appropriate administration can be life-saving.
(32) The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg. The client with an ischemic stroke will require intense blood pressure monitoring because a low blood pressure will decrease cerebral perfusion, which is necessary for the unaffected areas of the brain. An optimal blood pressure for an ischemic stroke is 150/100 mm Hg to ensure cerebral perfusion. Allowing the blood pressure to be this high is considered permissive hypertension. Blood pressure lower than 150/100 mm Hg may cause further injury because of decreased cerebral perfusion. Likewise, the blood pressure should not exceed 185/110 mm Hg in an ischemic stroke because this may cause an extension of the stroke. ✓ Manifestations of a stroke include facial drooping, slurred (or absent) speech, visual disturbances, headache, and difficulty with walking (ataxia) ✓ Risk factors for a stroke include diabetes mellitus, smoking, atrial fibrillation, sickle cell anemia, hypertension, and illicit drug use (cocaine)
(30) The nurse is observing infection control practices in the nursing unit. Which of the following findings require followup? A client with
rubella and their door is kept closed. Legionnaires' disease placed on contact precautions. These observations are inappropriate and require follow-up. The door should be closed in airborne isolation precautions, not droplet precautions. A client with rubella should be placed on droplet precautions. The minimum PPE required for droplet precautions is a surgical mask. Legionnaires' disease is not transmitted personto-person but rather through infected water or soil. This bacterium requires standard precautions.
(49) The primary healthcare provider (PHCP) prescribes one liter of 0.9% saline to infuse over 6 hours. How many mL per hour will be administered to the client? Fill in the blank. Round your answer to the nearest whole number.
167. To solve this problem, the formula of volume / time (hours) will be used. First, convert the prescribed liters to milliliters to determine the total volume ordered 1 liter x 1000 mL = 1000 mL Next, divide the prescribed total volume by the infusion time 1000 mL / 6 hours = 166.66 Finally, take the mL/hour and round to the nearest whole number 166.66 = 167 mL/hr. 0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.
(9) After receiving a report on the medical-surgical floor, which of the following clients should the nurse see first?
A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep". The patient with a cast that describes her arm as feeling like it's asleep is likely experiencing impaired circulation. This patient should be assessed first, and the physician should be notified. Prioritizing patient care related to each patient's status is a critical skill. While all patients are essential and must be monitored, the ability to recognize a potential complication before it gets out of hand and causes more damage is crucial.
(11) The nurse is going over her assigned patients for the shift. She knows that which of the following patients is most at risk for experiencing a fluid volume deficit?
A patient with diabetes insipidus and an NG tube to low intermittent wall suction. A patient with DI and an NG tube to low intermittent wall suction is at very high risk for a fluid volume deficit. They have 2 risk factors and are therefore the patient at most risk. In DI, the body puts out huge amounts of dilute urine, depleting the body of fluid. Having an NG tube to suction also removes fluid from the patient, by way of their GI secretions, making it another risk factor for fluid volume deficit.
(61) The nurse is caring for a child with cystic fibrosis at the outpatient clinic. The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test?
Blood glucose. Diabetes mellitus is a common co-morbidity associated with cystic fibrosis (CF). The damage that CF may cause to the pancreas may induce diabetes. Thus, random blood glucose levels and quarterly hemoglobin A1C levels are commonly ordered throughout the course of the illness. A random blood glucose level greater than 200 mg/dL may suggest the presence of diabetes.
(20) The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
Blood pressure. End-tidal carbon dioxide [ETCO2] level. Respiratory rate. Oxygen saturation. Moderate sedation is utilized for closed reduction procedures, which involves placing the bone back in alignment without making an incision into the skin. Moderate sedation for a closed reduction of a shoulder is quick, and pain is minimal with the use of moderate sedation. Midazolam, fentanyl, or propofol is commonly used for moderate sedation. The nurse must carefully watch the client's vital signs, end-tidal carbon dioxide, and cardiac rhythm during the procedure. ADDITIONAL INFO A procedure involving this type of sedation requires informed consent, and the nurse will serve as a witness. Common medications utilized for moderate (conscious) sedation include fentanyl, midazolam, or propofol. Anesthesia providers, other physicians, dentists, and oral surgeons are qualified to administer conscious sedation, and the nurse does not administer anesthesia intravenously. When this type of sedation is utilized for a closed reduction, it is a quick process that requires close monitoring of the client's vital signs, end-tidal carbon dioxide (normal is 20 and 40 mm Hg), cardiac rhythm, and level of consciousness.
(33) Which procedures necessitate the use of surgical aseptic techniques?
Central line intravenous medication administration. Donning gloves in the operating room. Foley catheter insertion. Surgical asepsis is used when managing central line intravenous medication administration when donning sterile gloves in the operating room and inserting an indwelling Foley catheter. Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility of transferring microorganisms from one place to another, the aseptic technique is used. The two basic types of asepsis are medical and surgical. Medical asepsis includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means the absence of almost all microorganisms; whereas, dirty (soiled, contaminated) means likely to have microorganisms, some of which may be capable of causing infection. Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques). Surgical asepsis is used for all procedures involving the sterile areas of the body. Sepsis is the condition in which acute organ dysfunction occurs secondary to infection.
(37) The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing testicular cancer?
Cryptorchidism. Human immunodeficiency virus (HIV). Family history. Risk factors for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and family history. Cryptorchidism refers to an undescended testicle where the testicle fails to descend to its normal position in the scrotum. Undescended testicles are associated with decreased fertility, testicular torsion, inguinal hernias, and an increased risk of testicular germ cell tumors. HIV-positive men have an increased risk of developing testicular cancer. A family history of testicular cancer is another risk factor, with an 8-10 times increased risk if the man has a sibling with testicular cancer. Testicular cancer, if caught early, has a high cure rate. This cancer most likely occurs between ages 15-34. ➢ Risk factors for testicular cancer include Caucasian males, ages 15-34, HIV infection, cryptorchidism, and family history. ➢ Testicular cancer may manifest as a dull ache in the scrotum or abdomen, solid mass on a testicle, scrotal swelling, or heaviness. ➢ A scrotal ultrasound is preferred if a primary healthcare provider suspects testicular cancer.
(43) The nurse in the emergency department cares for a 45-year-old female. Nurses' Note: The client reports significant fatigue that has worsened over the past eight weeks. Additionally, the client reports constipation, hair loss, and a 3-kilogram (6.6 pounds) weight gain. She reports missing work because of difficulty concentrating and persistent fatigue. The client is alert and fully oriented. She appears fatigued and reports dizziness when she moves quickly. Periorbital edema, various bruises, and facial swelling were noted on assessment. Peripheral pulses were intact and weak. The client denies any pain. Vital Signs: Oral temperature 97 F (36.1 C); Pulse 51/minute; Respirations 15/minute. BP 93/61 mm Hg; Oxygen saturation 95% on room air. Laboratory: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Hypothyroidism. Obtain a prescription for levothyroxine. Initiate fall precautions. Serum TSH/T3/T4 levels. Vital Signs. Potential Conditions This client is experiencing significant hypothyroidism and requires immediate treatment. The clinical features that the client is demonstrating supporting hypothyroidism included periorbital edema, fatigue, bradycardia, hypotension, weight gain, constipation, anemia, increased TSH and decreased T3/T4. While adrenal insufficiency may cause hypotension and fatigue, it would not alter the thyroid hormones. Graves' disease is the most common form of hyperthyroidism and manifests as tachycardia, weight loss, and heat intolerance. Lupus is an inflammatory condition marked by fatigue, muscle and joint pain, anemia, and changes to the integument. The client is not reporting any pain, and while she does have anemia, it is related to thyroid abnormalities. Cushing's syndrome would be excluded because while this does cause weight gain and edema, it would not be explained by the altered thyroid levels. Action to Take This client's hypothyroidism is significant and requires the nurse to obtain a prescription for levothyroxine. Additionally, the client has low blood pressure and endorses dizziness; this should prompt the nurse to keep the client safe and implement fall precautions. Obtaining urine cortisol levels would be done for issues with the adrenal (Addison's / Cushing's) and not for this client. Additionally, this client does have anemia, but a transfusion of packed red blood cells is indicated when the hemoglobin is 7 g/dL or less. Anemia is expected with hypothyroidism. Methimazole would be helpful for Graves' disease, which this client is not experiencing Parameters to Monitor The client arrives both with bradycardia and low blood pressure. Monitoring the vital signs is essential. Further, the nurse must monitor the serum thyroid levels. This would prevent overmedication which would cause the client to develop hyperthyroidism. While the client's sodium is marginally low, this is not a priority. The client's BUN and creatinine were within normal limits and did not require monitoring. This is not an adrenal problem, so cortisol would not be a parameter th
(58) While caring for a 4-year-old child in the PICU, you develop a care plan to address his psychosocial development during his recovery. You know that he will be in which stage of development according to Erikson's stages of psychosocial development?
Initiative vs. Guilt. Initiative vs. Guilt is the typical development stage for preschool children, which are 3 to 5-yearolds, so this is correct for your 4-year-old client. In Initiative vs. guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. ADDITIONAL INFO ✓ Provide praise and positive reinforcement for the child's efforts and achievements. Encouragement boosts their self-esteem and promotes a sense of initiative. ✓ Observe the child for any signs of emotional distress, anxiety, or regression, and address their emotional needs accordingly. ✓ Use age-appropriate language and explanations when communicating with the child. This helps them understand their medical condition, treatment, and care plan.x
(25) The nurse is reinforcing medication teaching to a client prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching?
"I should take this medication one hour after meals." "I will remain upright for 30 minutes after taking this medicine." "I know this medication works when my nausea and vomiting are gone." These statements are false and require further teaching. Sucralfate is a medication indicated in peptic ulcer disease. This medication should be taken one hour before meals as the medication will coat the ulcer allowing a client to eat meals without pain. The client is not required to be upright 30 minutes after taking this medication. This would be applicable instruction for a client prescribed a bisphosphonate. This medication has no indication for nausea and vomiting treatment. Appropriate treatment for nausea and vomiting would be ondansetron or metoclopramide ✓ Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. ✓ This medication should be taken one hour before meals and at bedtime. ✓ This medication allows the client to eat their meal without the pain of the ulcer. ✓ Constipation is the most common side-effect associated with this medication.
(38) The nurse is providing education for a diabetic client who is given a terbinafine prescription for onychomycosis. Which statement(s) by the client demonstrates a good understanding regarding treatment with terbinafine?
"I will have to take terbinafine for 3 to 6 months." "I will need liver function tests before starting terbinafine." "It may cause taste or vision changes and, I will report vision changes to my doctor." "Dark urine, pale stools, and persistent nausea may indicate a serious side effect." Onychomycosis, also known as Tinea unguium, is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Dermatophytes cause 90% of these toenail infections. Remaining 10% are caused by non-dermatophytes (Saprophytes), and yeast (Candida). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). By inhibiting squalene epoxidase, terbinafine blocks the synthesis of ergosterol (a crucial component of the fungal cell membranes). The nurse should be aware of the interactions and essential side effects of terbinafine because it is one of the commonly prescribed antifungal drugs. Client education points include: 1. Even after prolonged treatment, failure and recurrence rate is high (20 to 50% failure rate). The cure rate with terbinafine is close to 50%. (Choice A is incorrect). 2. Duration of treatment for toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails (1 month). Educate the client regarding the prolonged duration of treatment and instruct them to be compliant. (Choice B is correct). 3. Educate the client regarding essential side effects and when to contact the healthcare provider. Common side effects include headache, gastrointestinal side effects (abdominal pain, nausea, dyspepsia, diarrhea), rash, and taste changes. 4. To minimize gastrointestinal side effects, terbinafine should be taken with food. Taking it on an empty stomach may exacerbate gastrointestinal side effects (Choice D is incorrect). 5. Vision changes may also occur. These may represent changes in the retina and must be reported immediately to the provider (Choice E is correct). 6. Rarely, terbinafine can cause severe liver toxicity. This can happen in even those without pre-existing liver disease. Yellow-colored urine, pale stools, jaundice, and persistent nausea may indicate acute liver damage (Choice F is
(15) The nurse has reinforced medication instruction to a client who has been prescribed methadone for opioid use disorder. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions?
"I will need counseling while taking this medication." "I will need periodic blood tests while on this medication." "This medication may lower my risk for Hepatitis C." "I may get drowsy while taking this medication." Methadone is an efficacious medication used in the treatment of opioid use disorder, chronic pain, and in the treatment of neonatal abstinence syndrome. This medication requires close monitoring and counseling for opioid use disorder. Periodic blood tests are required as this medication may be hepatotoxic. This medication has been shown to decrease the transmission of blood-borne pathogens such as HIV and Hepatitis C. This is because the reduction of intravenous drug use decreases the risk of the transmission of these pathogens. Drowsiness is a common side effect of this medication as it is an opioid agonist. ADDITIONAL INFO ✓ Treatment for opioid use disorder includes naltrexone, methadone, or buprenorphine ✓ These medications have proven efficacy in this disorder, and when combined with counseling and appropriate monitoring, they may assist a patient in attaining opioid abstinence.
(45) The nurse is caring for a client who is struggling with severe depression. Which of the following statements would demonstrate effective therapeutic communication with this client?
"I'd like to just sit with you for a while Steve." In this scenario, the nurse offers to sit in silence with the client. Therapeutic silence with individuals struggling with depression can create a safe and reflective space, foster deeper communication, encourage selfreflection and emotional processing, reduce pressure and anxiety, enhance active listening, and promote selfexpression "Tell me how you're feeling Steve. I'd like to understand." Effective therapeutic communication aims to establish trust, provide support, and encourage the client's expression of thoughts and feelings. Asking open-ended questions in a supportive, non-judgmental way offers support to the depressed client. ✓Establish a trusting and empathetic relationship with the patient. ✓Use active listening to demonstrate genuine interest and understanding. ✓Use open-ended questions to encourage patients to share their thoughts and feelings. ✓Reflect and paraphrase what the patient has shared to ensure understanding. ✓Avoid judgmental or dismissive responses, maintaining a non-judgmental and accepting attitude. ✓Validate the patient's emotions and experiences to provide support and validation. ✓Provide appropriate silence to allow patients time to process and express themselves. ✓Avoid giving advice or providing simple solutions; help the patient explore their coping strategies. ✓Maintain confidentiality and respect the patient's privacy. Be aware of cultural, religious, or personal factors influencing communication and adapt accordingly.
The nurse cares for a 41-year-old female in the emergency department (ED) Nurses' Note: 0900 - Client reports a concern for increased swelling and pain in her left lower extremity. The onset of the symptoms was yesterday evening and when she woke up the pain and swelling had increased. Two days prior, the client sustained abrasions and bruising on the extremity while attempting to get out of a swimming pool. 2+ edema was evident in the left lower extremity; area was warm to touch. Several abrasions on leg noted which were dry and appeared to be healing. Erythema noted. Peripheral pulse and sensation were intact, toe movement was evident along with distal and sensation. Pain reported with leg movement. Pain rated a '7' on a scale 0-10. Current daily medications include ortho tri-cyclen, bupropion, and a multivitamin. She denies any alcohol or drug use. Smokes 2-3 cigarettes per day. Vital Signs: Oral Temperature 98 F (36.7 C) Pulse 66/minute Respirations 16/minute Blood pressure 130/72 mm Hg O saturation 96% on room air. Diagnostic Results: Venous Duplex Ultrasonography: Proximal deep vein thrombosis in the left popliteal vein Orders: Admit to Med/Surg Activity as tolerated In
Activated Partial Thromboplastin Time (aPTT) 110 seconds 30-40 seconds. EXPLANATION While a client receives a heparin infusion, the goal is to prolong the control (baseline) aPTT 1.5 to 2.5 times. 110 seconds is too prolonged and requires the nurse to review the heparin protocol to hold the infusion for a specified period or reduce the rate. The other labs are within normal limits. The client was prescribed warfarin, whose INR is now 2.7, which is therapeutic as the goal is to have the INR between 2-3. ADDITIONAL INFO Risk factors for venous thromboembolism include active cancer, reduced mobility, hormonal treatment, obesity, recent trauma/surgery, and a known thrombophilic condition. Classic symptoms of a VTE include pain, erythema, warmth, and swelling. Diagnosing a VTE is commonly done through non-invasive venous duplex ultrasonography. Treatment is either through oral or parenteral anticoagulants, and the nurse must surveil for pulmonary embolism, which can be fatal if not promptly recognized.
(12) The nurse is reviewing the medical record of a client who is pregnant at 35 gestational weeks. Click to highlight the findings in the medical record that require follow-up
Non-Stress Test (NST) Nonreactive. Contraction Stress Test (CST) Positive. Fasting Glucose 125 mg/dL. EXPLANATION This client's findings that require follow-up include the nonreactive contraction stress test, and positive construction stress test, as this is a nonreassuring finding. The fetal heart rate is normal as it falls between 110 and 160 beats per minute. The fasting glucose of 125 mg/dL (normal should be less than 100 mg/dL) is elevated and requires follow-up. ADDITIONAL INFO ✓ A nonstress test is performed in the third trimester if the client has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia ✓A reactive finding indicates fetal well-being; specifically, the fetal heart rate increased by 15 beats per minute, lasting for 15 seconds ✓ A nonreactive NST is non-reassuring and indicates decreased variability with an absence in a fetal heart rate acceleration ✓ A contraction stress test (CST) is indicated for high-risk clients in the third trimester. CST requires the client to have contractions either through oxytocin administration or nipple stimulation ✓ Positive (abnormal) indicates that late decelerations were present in the FHR in more than 50% of the contractions ✓ Negative (normal) indicates no late or variable decelerations were evident during the contractions. The normal fetal heart rate is 110 - 160
(2) The nurse cares for a 41-year-old female in the emergency department (ED) Nurses' Note: 0900 - Client reports a concern for increased swelling and pain in her left lower extremity. The onset of the symptoms was yesterday evening and when she woke up the pain and swelling had increased. Two days prior, the client sustained abrasions and bruising on the extremity while attempting to get out of a swimming pool. 2+ edema was evident in the left lower extremity; area was warm to touch. Several abrasions on leg noted which were dry and appeared to be healing. Erythema noted. Peripheral pulse and sensation were intact, toe movement was evident along with distal and sensation. Pain reported with leg movement. Pain rated a '7' on a scale 0-10. Current daily medications include ortho tri-cyclen, bupropion, and a multivitamin. She denies any alcohol or drug use. Smokes 2-3 cigarettes per day. Vital Signs: Oral Temperature 98 F (36.7 C) Pulse 66/minute Respirations 16/minute Blood pressure 130/72 mm Hg O saturation 96% on room air For each client finding, click to specify if it is consistent with deep vein thrombosis, compartment syndrome, or cellulitis. Each finding may support more than
Pain in the affected extremity are Compartment Syndrome, Cellulitis, and Venous Thromboembolism. Swelling to the affected area are Compartment Syndrome, Cellulitis, and Venous Thromboembolism. Intact sensation are Cellulitis, and Venous Thromboembolism. Warmth and erythema to the extremity are Cellulitis, and Venous Thromboembolism. EXPLANATION Most of these clinical findings overlap for compartment syndrome, cellulitis, and venous thromboembolism. The three differing clinical features are the intact sensation, warmth, and erythema to the extremity. One of the earliest findings associated with compartment syndrome is paresthesia, and because of the lack of perfusion, coolness to the extremity develops. Cellulitis is an infectious process that does not cause impairment in sensation.
(39) Which of the following symptoms should the nurse monitor for in her patient with a suspected diagnosis of intussusception?
Red currant jelly stool. Red, currant jelly stool is a classic finding of intussusception. When the bowel telescopes into another portion of the intestine, it causes intestinal obstruction and subsequently red, currant jelly stools. Palpable, sausage-shaped mass in the RUQ. A palpable, sausage-shaped mass in the RUQ is a classic finding of intussusception. This is due to the physical telescoping of the intestine, and the mass can sometimes be felt upon palpation. Vomiting partially digested food. The child may vomit bile or partially digested food, which can be a result of the obstruction caused by the intussusception. Intussusception can occur at any age, but it is most commonly seen in infants and young children between the ages of 3 months and 3 years. Approximately 80% of all cases of intussusception occur in children under the age of 2 years. Intussusception typically presents with a triad of symptoms in children: ✓Severe abdominal pain: The pain is usually sudden in onset, severe, and intermittent. The pain may cause the child to draw their knees up to their chest or cry inconsolably. The pain may also come and go in waves, with periods of relative calm in between. ✓Vomiting: The child may vomit bile or partially digested food, which can be a result of the obstruction caused by the intussusception. ✓Bloody stools: The child may pass stools that are mixed with blood and mucus, described as "currant jelly" stools. This is because the intussusception can cause the bowel to become inflamed and bleed. The child may also appear lethargic, irritable, or appear to be in distress. They may also have a fever, and their abdomen may feel swollen or tender to the touch. If left untreated, intussusception can cause bowel obstruction, which can lead to ischemia, perforation, and sepsis.
(21) A client with a history of hypertension and hyperlipidemia complains of shortness of breath and weakness in the legs. Which of the following may be occurring?
The patient may be having a myocardial infarction. Myocardial infarction may present with symptoms of shortness of breath and muscle weakness. Other symptoms of myocardial infarction include: Chest discomfort. Most heart attacks involve pain in the center of the chest that lasts more than a few minutes - or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness, or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, back, neck, jaw, or stomach. Shortness of breath can occur with or without chest discomfort. Other signs include breaking out in a cold sweat, nausea, or lightheadedness. Since hyperlipidemia has no symptoms, it can cause damage before an individual realizes there is a problem. It can limit blood flow, increasing the risk of heart attack or stroke. Factors that can increase your risk of bad cholesterol include a poor diet, including foods that are high in saturated fat (found in animal products), and trans fats (found in some commercially baked products) can contribute to an elevated cholesterol level. Additionally, obesity, lack of exercise, age, and history of diabetes can increase the chances of experiencing hyperlipidemia. Hypertension is often referred to as "the silent killer" because some people do not experience any significant symptoms until their blood pressure is extraordinarily elevated or if symptoms (such as headache, palpitations, and dizziness) become bothersome. It is a significant public health problem and an essential area of research due to its high prevalence and a significant risk factor for cardiovascular diseases and other complications. The combination of hypertension and hyperlipidemia can result in fatal consequences.
(27) Which of the following findings indicate a risk for developing a decubitus ulcer in an 80-year-old client who recently had a hip replacement?
The patient's age. The patient reports an inability to control urine. A scheduled hip arthroplasty. The patient reports increased pain in the right hip when repositioning in the bed or chair. The skin of older adults is more susceptible to injury (Choice B). Pressure, friction, shear, and other factors usually contribute to pressure ulcer development. Incontinence provides prolonged moisture on the surface and the resultant adverse effects of urine in contact with the skin (Choice C). Decreased physical mobility is a significant risk factor for pressure ulcers. Hip surgery involves reduced mobility during the postoperative period (Choice D). Additionally, pain with movement can contribute to immobility (Choice F).
(55) The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications?
Topiramate. Lorazepam. Epilepsy is an idiopathic condition that requires maintenance treatment by using anticonvulsants. Topiramate is an anticonvulsant that may be used in the prevention of seizures. Lorazepam is also indicated for epilepsy in the event of a client experiencing an acute tonic-clonic or complex partial seizure. Topiramate should be used for maintenance purposes, and lorazepam would be indicated for an acute seizure. ✓ Epilepsy is an idiopathic condition that requires management with anticonvulsants such as topiramate, valproic acid, or phenytoin ✓ Acute seizures are managed with benzodiazepines such as lorazepam or diazepam ✓ During an acute tonic-clonic or complex partial seizure, the nurse should place the client on their side, loosen restrictive clothing, and anticipate a prescription for a parenteral benzodiazepine such as diazepam or lorazepam ✓ If a client is experiencing a tonic-clonic or complex partial seizure in the chair, they should be lowered to the ground and placed on their side
(19) The nurse is caring for a client who is demonstrating signs of aggression. The nurse should plan to take which action?
Use genuineness and empathy. Use a calm, clear tone of voice. Give several clear options. Respond as early as possible. For a client demonstrating aggression, the nurse should respond quickly and calmly approach the client. The nurse should limit inflections in their voice to decrease the perception of aggression. The nurse should also maintain personal distance between themselves because if this escalates, the nurse has an appropriate distance from themselves and the client. Providing the client with several options is helpful as it decreases the client's feeling of powerlessness. ADDITIONAL INFO Deescalation Techniques: Practice Principles • Maintain the client's self-esteem and dignity • Maintain calmness (your own and the clients) • Assess the client and the situation • Identify stressors and stress indicators • Respond as early as possible • Use a calm, clear tone of voice • Invest time • Remain honest • Determine what the client considers to be needed • Identify goals • Avoid invading personal space; in times of high anxiety, personal space increases • Avoid arguing • Give several clear options • Use genuineness and empathy • Be assertive (not aggressive) • Do not take chances; maintain personal safety
(5) The nurse cares for a 41-year-old female in the emergency department (ED) Nurses' Note: 0900 - Client reports a concern for increased swelling and pain in her left lower extremity. The onset of the symptoms was yesterday evening and when she woke up the pain and swelling had increased. Two days prior, the client sustained abrasions and bruising on the extremity while attempting to get out of a swimming pool. 2+ edema was evident in the left lower extremity; area was warm to touch. Several abrasions on leg noted which were dry and appeared to be healing. Erythema noted. Peripheral pulse and sensation were intact, toe movement was evident along with distal and sensation. Pain reported with leg movement. Pain rated a '7' on a scale 0-10. Current daily medications include ortho tri-cyclen, bupropion, and a multivitamin. She denies any alcohol or drug use. Smokes 2-3 cigarettes per day. Vital Signs: Oral Temperature 98 F (36.7 C) Pulse 66/minute Respirations 16/minute Blood pressure 130/72 mm Hg O saturation 96% on room air. Complete the sentences below from the list of options. The client is at greatest risk for? The primary healthcare provider (PHCP) will likely order a _______
Venous thromboembolism. venous duplex ultrasonography. EXPLANATION This client most likely has venous thromboembolism. The triggering event of the VTE was likely the injury to her leg. Combined with the oral contraceptives and her tobacco use, these are substantial risk factors for her developing VTE. The gold standard diagnosis for VTE is using a venous duplex ultrasonography which is a non-invasive test that may be performed at the bedside.
(23) The nurse assesses a client with schizophrenia who appears to be demonstrating neologisms in their speech. Which of the following would be the expected finding?
Words or phrases with meaning only for the client. A neologism is when a client invents words or phrases that only have meaning for themselves. This is a positive symptom associated with schizophrenia. ADDITIONAL INFO Schizophrenia symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect
(7) The nurse cares for a 41-year-old female in the emergency department (ED) Nurses' Note: 0900 - Client reports a concern for increased swelling and pain in her left lower extremity. The onset of the symptoms was yesterday evening and when she woke up the pain and swelling had increased. Two days prior, the client sustained abrasions and bruising on the extremity while attempting to get out of a swimming pool. 2+ edema was evident in the left lower extremity; area was warm to touch. Several abrasions on leg noted which were dry and appeared to be healing. Erythema noted. Peripheral pulse and sensation were intact, toe movement was evident along with distal and sensation. Pain reported with leg movement. Pain rated a '7' on a scale 0-10. Current daily medications include ortho tri-cyclen, bupropion, and a multivitamin. She denies any alcohol or drug use. Smokes 2-3 cigarettes per day. Vital Signs: Oral Temperature 98 F (36.7 C) Pulse 66/minute Respirations 16/minute Blood pressure 130/72 mm Hg O saturation 96% on room air. Diagnostic Results: Venous Duplex Ultrasonography: Proximal deep vein thrombosis in the left popliteal vein Orders: Admit to Med/Surg Activity as tolerate
aPTT. Weight. Platelet count. EXPLANATION Heparin infusions require an actual and accurate weight of the client. This information, along with the baseline labs, is necessary prior to administering heparin. Platelet count also needs to be monitored during the duration of the heparin infusion because of the potential adverse event of heparin-induced thrombocytopenia (HIT).
