EXAM 3 H& I crs

A client with a history of alcohol abuse presents with confusion, hallucinations, and a positive Chvostek sign. Which medication(s) should the nurse anticipate administering? 1.Magnesium sulfate 2.Potassium chloride 3.Insulin and glucose 4.Sodium bicarbonate RATIONALE: A positive Chvostek sign indicates increased neuromuscular excitability, commonly associated with both hypomagnesemia and hypocalcemia, often seen in people who abuse alcohol and who are nutritionally depleted. Additional manifestations of hypomagnesemia include confusion, hallucinations, and possible psychoses. Administration of magnesium sulfate helps restore magnesium balance and neuromuscular function. The symptoms presented are not those of potassium depletion, the need for glucose and insulin, or sodium depletion.

1

A nurse is providing client teaching to promote healthy bowel elimination. The nurse information the client that which problem could result from repeatedly ignoring the sensation of needing to defecate? 1.Constipation 2.Diarrhea 3.Incontinence 4.Hemorrhoids

1

After a client has returned from surgery, the nurse needs to report which urinary output? 1. 20 mL per hour 2. 40 mL per hour 3. 300 mL per 8 hours 4. 400 mL per 8 hours

1

The charge nurse is speaking with the new graduate nurse about kidney disease in the older adult. The charge nurse would include what piece of information about the older adult with a possible manifestation of renal failure? 1.Manifestations of renal failure can be missed in the older adult due to other chronic conditions. 2.Manifestations of renal failure exhibit as textbook symptoms of edema, hypertension, and elevated creatinine. 3.Acid-base balance compensation is as effective and prompt as in a typical adult kidney. 4.Urine concentrating ability increases.

1

The nurse is caring for a pregnant client who is in her first trimester of pregnancy. The client is having issues with nausea and vomiting. The nurse would not include which information in teaching the client how to manage nausea and vomiting during the first trimester? 1.Increase intake of dark green, leafy vegetables. 2.Snack on crackers before getting out of bed in the morning. 3.Consume small amounts of liquid frequently throughout the day. 4.Consume high-protein snacks.

1

What is the most important nursing interventions to prevent acute kidney injury in the critically ill client? 1.Maintaining fluid volume and cardiac output 2.Avoiding all potentially nephrotoxic drugs 3.Administering antihypertensive drugs 4.Assessing for a history of diabetes or systemic lupus erythematosus

1

The nurse is caring for a client who had a thyroidectomy and reports numbness and tingling around the mouth. What other assessment finding confirms the nurse's thought that the client has hypocalcemia? 1.Bone pain 2.Nausea 3.Positive Chvostek sign 4.Depressed deep tendon reflexes

3

Which nursing actions are instituted for the client with kidney trauma? 1.Monitor level of consciousness and urine output. 2.Monitor vital signs for hypotension and bradycardia. 3.Observe for hypertension and check urine for hematuria. 4.Observe urine for oliguria and proteinuria.

3

An older female client tells the nurse she is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? A. Stress Urinary Incontinence B. Reflex Urinary Incontinence C. Functional Urinary Incontinence D. Urge Urinary Incontinence

D

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1."I need to drink one and a half to two quarts of liquids each day." 2."I need to take a laxative such as Milk of Magnesia if I don't have a bowel movement every day." 3."If my bowel pattern changes on its own, I should call you." 4."Eating my meals at regular times is likely to result in regular bowel movements."

2

A nurse is caring for a client who reports problems with urinary stress incontinence. The nurse would expect the client to state that the incidence of stress incontinence occurs during which activity? 1.Reading 2.Coughing 3.Sleeping 4.Walking

2

Laboratory results for a client show a serum potassium level of 2.2 mEq/L. Which nursing action is of highest priority for this client? 1.Keep the client on bed rest. 2.Initiate cardiac monitoring. 3.Start oxygen at 2 L/min. 4.Initiate seizure precautions.

2

The nurse caring for the child with chronic kidney disease would monitor the client for which manifestations of hyponatremia? 1.Muscle tingling, positive Chvostek sign, changes in muscle tone 2.Cheyne-Stokes respirations, decreased deep tendon reflexes, and muscle cramps 3.Diarrhea, dysrhythmias, and peaked T-waves on electrocardiogram 4.Decreased urinary output, hypotension, and low-grade fever

2

The nurse is talking with a parent who states their one year old child is frequently constipated after changing from formula to cow's milk. The parent is asking how this should be addressed. Which response by the nurse is most appropriate? 1."This is abnormal. Add three servings of apple juice daily to the child's diet." 2."This is normal. Let's talk about what foods your child is eating on a daily basis." 3."This is abnormal. Switch the child to soymilk." 4."This is normal. This is just a phase and you do not need to be worried."

2

The nurse is working with the family of an older client with bowel incontinence. Which intervention will the nurse teach the family about bowel incontinence? 1.Place the client in a brief at all times. 2.Place the client on the commode at the same time every day. 3.Do not try to stimulate stools with suppositories. 4.Ask the client to tell the family when the urge to defecate is felt.

2

Which is the most accurate indicator of fluid volume status in the oliguric or aneuric client? 1.Intake and output 2.Weight changes 3.Level of thirst 4.BUN and creatinine levels

2

A nurse is caring for a client with hypokalemia. The nurse is aware this electrolyte is vital for which body system to function? 1.Renal 2.Respiratory 3.Cardiac 4.Hepatic

3

Following a morning shift assessment, the nurse determines which client is most likely to develop problems with constipation? 1.The client who consumes a high-fiber diet 2.The client receiving Bactrim for an infection 3.The client with history of chronic laxative use 4.The client who has 2,200 mL/day fluid intake

3

The mother of a breastfed infant calls the physician's office to report her infant is constipated. The nurse questions the mother and learns the infant last had a bowel movement 4 days ago and the stool was yellow and pasty and passed without straining. The infant has no other symptoms and has been eating, sleeping, and acting normally. The mother denies any change in the appearance of the infant's abdomen and says the infant does not cry when the abdomen is palpated. Which statement is the most appropriate response by the nurse? 1.Bring the infant to the office to be seen today. 2.Give the infant 2 tablespoons of Karo Syrup in 4 ounces of water. 3.The infant's stooling pattern is normal. 4.Feed the infant 2 ounces of prepared glucose water.

3

The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than are older children. Which parent comment would indicate that further education is needed? 1."Infants have a higher metabolic rate than older children do." 2."An infant has little body water for reserve, as compared with an adult." 3."Infants maintain their temperature by losing heat through their head." 4."Infants lose water through their skin, and they have a larger proportion of skin surface area than older children do."

3

The nurse is aware that the early postpartum woman must diuresis the extracellular fluid retained during pregnancy. What volume of urine would the nurse expect the client to void? 1. Less than 1,000 mL 2. 1 to 2 L 3. 2 to 3 L 4. 3 to 4 L

3

The nurse is caring for the older adult client with possible fluid volume deficit. The nurse is aware that this client will possibly exhibit what manifestations of fluid volume deficit specifically noted in the older adult? 1.Bounding pulse, slow respiratory rate, and hypertension 2.Bradycardia, use of accessory muscles with breathing, and dependent edema 3.Absent pedal pulses, cyanosis, and vein distention 4.Change in mental status, memory, and attention

4

Which finding would the nurse expect during assessment of a client with fluid volume deficit? 1.Increased pulse rate and blood pressure 2.Dyspnea and respiratory crackles 3.Headache and muscle cramps 4.Orthostatic hypotension and flat neck veins

4

The client is experiencing constipation. The physician orders Metamucil, a bulk-forming laxative. The nurse is aware that which is a nursing consideration when administering this medication? A) The client must always take with sufficient water. B) Can be administered orally or rectally. C) Used to treat acute constipation D) May cause tardive dyskinesia.

A

The nurse is preparing to teach a class on constipation prevention. The nurse is aware that high-fiber foods should be suggested and that which food is high in fiber? A) Raw fruits B) Cooked vegetables C) White bread D) Cooked fruits

A

You have been providing educational and supportive assistance for Brian, a 4-year-old client with encopresis. Which statement would indicate parental understanding of appropriate care? Select all that apply. A) "We established a limited schedule of activities that has many breaks so that he has the opportunity to use the toilet regularly." B) "We brought Brian to a play therapist to deal with adjusting to our new baby." C) "We didn't change his diet because we were afraid it would stress him out." D) "We've worked on regular elimination after morning and evening meals."

A B D

The nurse is caring for a client with chronic constipation. The nurse is aware that which may be causes of constipation? Select all that apply. A) Bed rest B) High-fiber foods C) Low-fiber foods D) Chronic laxative use E) Depression

A C D E

The nurse is caring for a client who has been experiencing intermittent diarrhea. The client has been advised to increase the amount of soluble fiber in the diet. The nurse has instructed the client and spouse regarding appropriate dietary choices. Which food selection by the client indicates that teaching has been effective? Select all that apply. A) Sunflower seeds B) Carrot slices C) Spinach salad D) Corn muffins E) Peas

B E

A client is being seen in an ambulatory care clinic. The client tells the nurse about experiencing frequent diarrhea. The nurse inquires about the client's diet. Which statement from the client would be of greatest concern for the nurse? A) "I like to eat a bran muffin and applesauce every morning for breakfast." B) "I like to eat popcorn for an afternoon snack." C) "I like to eat cottage cheese, peaches, and a turkey sandwich for lunch." D) "I like to eat baked chicken, yeast rolls, and a small salad for dinner."

C

For a client with a flaccid bladder, the nurse is most likely to teach which information? A. attempt voiding at specific time periods. B. Delay voiding according to a prescheduled timetable. C. Lean forward on the toilet to increase intra-abdominal pressure with external pressure on the bladder. D. Perform Kegel exercises by contracting the pelvic muscles.

C

The nurse identifies which as a high-priority goal for a client with stress incontinence? A. Identifies products for protecting clothes and furniture B. States the chronic and benign nature of the disorder C. Performs pelvic floor muscle exercises twice a day D. Limits intake of beverages with artificial sweeteners

C

The nurse is caring for a client from another culture. The client tells the nurse that he is constipated. What is the nurse's initial action? A) Encourage the client to increase fluid intake and activity. B) Assess the client's intake of fiber and fluids. C) Determine what the client means by constipation. D) Obtain an order for a laxative and an enema from the physician.

C

The nurse is preparing to discharge a client with diarrhea. The physician has ordered kaolin to manage the client's diarrhea. The nurse instructs the client concerning use of the medication. What client statement indicates the need for further teaching? A) "If my diarrhea does not get better within 2 days, I will need to call my physician for further advice." B) "I will need to take the medication after each loose stool." C) "I should continue to take this medication daily until my stools are firm and dry." D) "If I start to have a fever, I need to contact my physician about continuing to take this medication."

C

The nurse is reviewing discharge instructions with the mother of a toddler who was hospitalized for constipation due to withholding. The nurse would identify the need for further instruction when the client's mother makes which statement? A) "I should recognize that when my child walks stiffly on his tiptoes, this could indicate withholding." B) "Rocking and crossing the legs could be a sign of withholding." C) "I need to make sure my child eats a low-fiber diet." D) "Soiling could be a sign of withholding because of involuntary overflow."

C

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which response by the nurse would explain why this practice should be changed? A) "This is a common practice, and it will strengthen the reflex later." B) "You will get the urge later, so you should not worry about it." C) "If you continue to ignore the urge to defecate, it can lead to problems." D) "It is better to suppress the urge than to suffer embarrassment at work."

C

The home health nurse is visiting a client with a history of constipation. The physician has order psyllium mucilloid (Metamucil) for the client. The nurse has just completed medication teaching. Which statement by the client indicates the need for further teaching? A) "This medication is a lot more natural than other laxatives." B) "I may be able to stop my Lipitor with this medication." C) "This medication takes several days to work." D) "I don't need to drink extra fluids while I take this medication."

D

The nurse caring for a client following spinal cord injury should appropriately plan for which intervention? A. Insert Foley catheter to accurately measure output. B. Develop a bladder training schedule. C. Assess for urinary retention with each voiding. D. Catheterize with a straight catheter every 3 to 4 hours.

D

The nurse is admitting a child who has had diarrhea for 1 week. The nurse is writing the plan of care for the client. What is an appropriate goal for this client? A) The client will increase the amount of sugar in the diet. B) The client will defecate regularly by discharge. C) The client will limit fluid intake for 3 days. D) The client will regain normal stool consistency by discharge.

D

The nurse is planning care for a newly admitted bed-bound elderly client. Which nursing diagnosis would be most appropriate for a client on bed rest? A) Risk of Bowel Incontinence B) Disturbed Body Image C) Risk of Diarrhea D) Risk of Constipation

D

The nurse tells an elderly client that urinary elimination changes may occur even in healthy older adults. Which rationale supports the nurse's statement? A. The bladder distends and its capacity increases. B. Older adults ignore the need to void. C. Urine becomes more concentrated. D. The amount of urine retained after voiding increases.

D