Chapter 48: Next Generation – NGN FON

The nurse is caring for a 25-year-old client admitted to a medcial surgical unit after an emergency appendectomy. The newly admitted client has been assigned under the nurse's care. As part of the care plan, the nurse sets specific client goals.

Orientation Phase: The client is able to call the nurse by name and demonstrate how to use the call light. Working Phase: The client states, "I know I have to get up and moving so I do not get pneumonia." and The client states, "Using the pillow to splint my abdomen when I cough, really helps." Termination Phase: The client verbalizes understanding of what signs indicate infection and when to contact the health care provider.

The charge nurse in the oncology unit is preparing the shift assignments. The unit is fully staffed: unlicensed assistive personnel (UAP), licensed practical nurse (LPN), and registered nurse (RN).

Registered Nurse (RN): obtaining an admission assessment on a client and administering an intravesical chemotherapy Licensed Practical Nurse (LPN): administering a pain medication intramuscularly and inserting an indwelling urinary catheter Unlicensed Assistive Personnel (UAP): calculating the total intake and output for the entire shift and collecting a stool specimen for hemoccult

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system.

Cardiac: provide verbal stimulation Respiratory: Assess skin color Neurologic: Gently touch the client

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity. For each activity, click to specify whether it fulfills the circulation, motor function, or sensation section of the assessment

Motor Function- Paralysis and Pain Circulation- Pallor and Temperature Sensation- numbness

A famous actor with bipolar disorder has been admitted in the mental health unit for treatment. A well known news outlet has offered the nurse several thousand dollars to provide information or a picture of the client. The nurse knows that it is their professional duty and legal responsibility to uphold privacy and confidentiality. For each of the behaviors exhibited by the nurse, click to specify whether the behavior upholds the principle of privacy or confidentiality.

Privacy: -keeping the door closed while conducting physical assessment -obtaining the client's permission before allowing a student nurse to assist with care Confidentiality: -sharing client information only to the caregivers directly assigned to client care -logging off the electronic health record after documenting assessment information -asking the client to sign a medical release form before providing information to the health insurance company

A nurse is caring for a 3-year-old child that was admitted with pneumonia. The parent expresses concerns about the child's respirations. The nurse is providing education about respiratory-related developmental changes to help the parent differentiate what is normal from what is abnormal. For each assessment finding click to specify if the finding indicates the client's condition is normal or abnormal.

-Abnormal: thoracic breathing, inspiration longer than expiration, and round thorax -Normal: respiratory rate of 28/min and irregular respiratory pattern

An older adult was admitted to the cardiac unit following an emergency room visit for chest pain. To personalize education, the nurse is reviewing the chart to identify the client's risks of coronary vascular disease (CVD). The nurse will use this information to develop a teaching plan that will assist the client in altering factors that increase the risk of CVD.

-a high level of stress after having to recently take in a grandchild to raise -reports a 40-pack-year history of tobacco use -but cannot seem to get BMI below 36 -Current medications include metformin and insulin.

A middle-aged female client visits the clinic to confirm pregnancy. "I cannot believe this is happening. I cannot be pregnant. My parents will kill me. I was raised in a strict Roman Catholic home. I was not supposed to get pregnant before marriage." Complete the following sentence by choosing from the lists of options. The client is exhibiting signs of spiritual _________ related to the ___________.

-guilt -inability to live up to devout practices

A client with a medical history of valvular dysfunction is admitted to the medical floor for management of heart failure exacerbation. The nurse reviews the client's chart to identify related findings. Complete the following sentence by choosing from the lists of options. The nurse would differentiate ___________ and elevated ___________ as being associated with heart failure, because they are both a result of ___________.

-lower extremity edema -B-type natriuretic peptide -fluid volume excess

The nurse is providing care to a client who had abdominal surgery yesterday. Click to highlight the items in the scenario that break the cycle of infection between the infectious agent and reservoir. The nurse enters the room, performs hand hygiene and confirms the client's identity . Using a scanner system the nurse accesses the medication adiministration record and hangs prescribed intravenous antibiotics . The nurse then prepares a sterile field on which sterile items are aseptically placed . The soiled dressing is removed and both the wound and the dressing are assessed. The nurse removes the soiled gloves and then dons sterile gloves to clean the wound and applies a new sterile dressing.

-performs hand hygiene -and hangs prescribed intravenous antibiotics -prepares a sterile field on which sterile items are aseptically placed

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply.

-prescription for warfarin -diagnosis of periodontitis -current chemotherapy treatment -low platelet count

The nurse works in a unit where the staff nurses can pick their own work schedule in exchange for being on call at least one weekend in a month. However, once the staff nurse refuses to come in when called in to work, the staff nurse loses the flexibility to choose their work schedule for the next 2 months. Complete the following sentence by choosing from the lists of options. The institution implements a ___________ leadership style as evidenced by the __________.

-transactional -task-and-reward orientation

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity.

Sensation: numbness Motor Function: paralysis and pain Circulation: pallor and temperature

The nurse is reviewing the care plan of a client and notes a risk for altered bowel elimination. For each assessment finding, click to specify which alteration in bowel function the finding is consistent with. Each finding may be consistent with more than 1 alteration. 1.)AsConstipation 2.)Distention 3.)Impaction

incontinence of liquid stool- 2 reports of abdominal fullness- 1,2,3 inability to voluntarily evacuate stool- 2 straining with deficiation- 1 feelings of an inability to pass stool- 2,3

The nurse reviews the medical records of several clients scheduled for routine follow-up at the gynecology clinic. The nurse determines that a conventional Papanicolaou (Pap) test is indicated for which client(s)? Select all that apply.

-45-year-old client who had a negative Pap test 4 years ago -21-year-old client who has never had a Pap test done before -25-year-old client who has never had sex -32-year-old client who has been vaccinated with human papillomavirus and has never had a Pap test done

An older adult who experienced a complication during an open cardiac surgery 4 weeks ago has been on prolonged bed rest during recovery. The nurse is new to the client and is reviewing the chart prior to assuming care.

-Client reports inability to sleep at night and subsequently sleeps during the day -often verbalizes sadness associated with missing out on so much. -shallow -Capillary refill is 4 seconds equally on the nails of both hands -Last bowel movement reported as hard to pass occuring 2 days ago.

The hospice nurse is caring for a client who is dying. Which intervention(s) should be included in the plan of care? Select all that apply.

-Cluster nursing activities. -Provide cool foods and fluids. -Gently massage the arms and legs. -Routinely administer pain medications.

While the nurse conducts a comprehensive cultural assessment on a client with metastatic colon cancer the client states, "The pain with this cancer is God's way of punishing me for all the drinking and bad things I did in the military. I lost so many friends in the war that I look forward to having a few beers with them after I die." The nurse will use questions to explore the client's statement. Click to specify whether the nurse's question obtains information about health beliefs and practices or cultural sanctions/restrictions.

-Cultural Sanctions/Restrictions: Have you experienced flashbacks to your military years?, Are you part of a faith community?, How do you express emotions or feelings? -Health Beliefs/Practices: How much alcohol do you use daily?, How do you control your pain?

The nurse obtains a health history interview on a client with lung cancer. The client states, "I became too focused at work; I did not have time to rest. I usually work 8 hours per day but, for the past few months, I have been spending at least 12 hours per day at the office. That is probably the reason why I was diagnosed with cancer. Maybe when I try to go back to my usual schedule, the cancer will go away. I did not want to be here but my wife is insistent. I do not think medications work. My brother-in-law died of cancer. He took a lot of medicines and prayed really hard, but he died just the same." The nurse determines that the client believes in the ____________ cause of illness as manifested by _____________.

-Holistic -believing one can be cured of cancer by limiting work hours

A new prescription has been noted in the medical record for an adult client with chest pain to receive a medication that comes in the form of a transdermal patch. The nurse will consider which precaution(s) to ensure safety with this form of drug use? Select all that apply.

-May cause injury with defibrillation. -Fold the patch in half before disposal. -Assess for fever prior to application. -Remove the patch prior to magnetic resonance imaging (MRI). -Monitor the client for early identification of adverse effects.

A 2-year-old child with specialized nutritional needs is receiving care in the home. The plan of care includes provision of enteral nutrition through a gastrostomy tube every 3 hours. For each nursing intervention below, click to specify the associated rationale. Note: Each nursing intervention must have at least one associated rationale.

-Measure the length of the external tube. : *reduces the risk of aspiration -Elevate the head of bed at least 30 degrees. : *facilitates the flow of feeding to the gut -Confirm pH of aspirate is less than 5.5. : *useful in verifying correct placement -Replace all gastric contents following measurement of aspirate. : *prevents electrolyte imbalance

A parent brings a child into the pediatric office with reports of an itchy red rash with fluid filled blisters. Two siblings at home are reported to have the same rash. Drag words from the choices below to fill in each blank in the following sentence. The nurse knows that since the parent had the same virus during childhood they will have ________ immunity in the form of _______.

-humoral -antibodies

A 19-year-old male college student accompanies the pregnant partner to the emergency department. The client states, "My parents are not aware that I am having a child with my partner. If they do, they might not send me to school anymore. What is the best thing to do?" The nurse responds, "What do you think is the best thing to do?" Complete the following sentence by choosing from the lists of options. The therapeutic communication technique employed by the nurse is _________ as evidenced by ___________.

-reflection -directing the client's response back to the client

The school nurse is providing health education about sexuality and reproduction to a group of young adolescents. The male sexual response is included in the teaching plan. Select three physical changes that occur during the plateau phase.

-secretion of pre-ejaculatory fluid -increased heart rate and blood pressure -penile circumference at the coronal ridge thickens

The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss.

Radiation: infrared heat waves Conduction: the air itself Evaporation: through sweating Convection: exposure to a fan