Fundamentals - Archer Review (2/3) - Basic Care and Comfort

Choice B is correct. In response to the client's statement stating they took a bath at home three days ago and, therefore, do not require an additional bath for another three to four days, the nurse would respond with, "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" This response acknowledges that the frequency of bathing, bathing routines, and practices vary among individuals and cultures. The nurse should explore the client's perspective regarding hygiene care by asking about personal care products desired and preferences such as frequency, time of day, and amount of assistance needed. Additionally, a once-weekly bath is acceptable as long as the client remains clean, without bodily odors, and is still hygienic.

After offering one of your newly admitted clients a partial bed bath, the client states, "I took a bath at home three days ago. I do not need a bath for another three or four days." How should you, the nurse, respond to this client? A. "Would it be okay with you if I teach you about the benefits and need for daily bathing?" B. "That is fine. At what time of the day do you prefer to bathe, and do you prefer a shower or tub bath?" C. "A once-a-week bath is not good. You must bathe at least every other day to protect against infection." D. "I am sorry, but we have rules here. All clients must be bathed at least every other day. Let's start the bath."

Choice D is correct. An expected outcome that is appropriate for the recipient of respite care is that "the primary caregiver will be physically and emotionally rested." Respite care provides time off for the primary caregiver of the ill client so that the caregiver gets to rest with the opportunity to renew and restore their strengths during this stressful period as they serve as the primary caregiver.

An expected outcome that is appropriate for the recipient of respite care is: A. The terminally ill client will be free of any physical, psychological, or spiritual distress. B. The terminally ill client will be free of any pain or discomfort at the end of life. C. The primary caregiver will be free of any physical, psychological, or spiritual distress. D. The primary caregiver will be physically and emotionally rested.

Choice A is correct. Ergonomic principles are most closely associated with normal bodily alignment. Ergonomics is defined as a body of knowledge and laws related to human anatomy, physiology, and proper physical alignment. Ergonomics and the ergonomic design of workplace items aim to protect the safety, comfort, and efficiency of work processes.

Ergonomic principles are most closely associated with: A. Normal bodily alignment B. The control of infection C. Preventing congenital abnormalities D. Preventing hospital-acquired infections

Choice C is correct. Ergonomically designed chairs are commonly designed to provide lumbar spine support primarily. Although the chairs often provide some level of support to various levels of the spinal column, the lumbar spine is the most common region for back pain to occur. It, therefore, is the spinal region ergonomically designed chairs routinely support. Each spine curve (including the lumbar) is shown in the image below.

Ergonomically designed chairs are best designed to provide support to which region of the spine? A. The cervical spine B. The thoracic spine C. The lumbar spine D. The sacral spine

Choice C is correct. The client's statement indicating an intent to travel "for a couple of weeks to prevent my family from receiving radiation" indicates a need for additional client education for various reasons. First, since radioactive iodine emits radiation, the client will be instructed to avoid public transportation (i.e., buses, the subway, trains, and/or planes) for a minimum of one week. Second, typically, clients are instructed to avoid close contact with pregnant women, infants, and young children for the first week following therapy. More specifically, the client should be advised to remain at least three feet (about one meter) away from these individuals, limiting exposure to these types of individuals to no more than one hour per day. Clients who receive large doses of radioactive iodine may be instructed to abide by more strict restrictions.

Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states: A. "I understand the need to avoid sharing food or utensils with others." B. "My children will miss my hugs and kisses for the next week." C. "I'll travel for a couple of weeks to prevent my family from receiving radiation from me." D. "I understand the need to flush the toilet with the lid closed two to three times after each use."

Choice A is correct. Reiki is a nonpharmacological, alternative, complementary pain management intervention for the spirit (or spiritual) domain of pain. Reiki is performed by a therapist who places their hands above or lightly on the client to promote their healing processes, including managing and controlling pain. Examples of other nonpharmacological, alternative, complementary pain management interventions for the spirit, or spiritual, domain of pain include prayer, meditation, and spiritual healing.

Select the domain of pain that is accurately paired with the appropriate nonpharmacological, alternative, complementary pain management intervention: A. The spirit domain of pain: Reiki B. The mind domain of pain: Massage C. The body domain of pain: Self-hypnosis D. The social domain of pain: Music therapy

Choice A is correct. Tympany refers to a high, loud, drum-like tone that can be heard with percussion over air-containing organs. The stomach and intestines would produce tympany in a healthy adult.

The RN performs palpation and percussion in a head-to-toe assessment. Over what organ would he/she expect to hear tympany when percussed? A. Stomach B. Liver C. Normal lung tissue D. Tympany is an abnormal finding

Choice D is correct. Choosing social activities in the facility promotes the client's freedom of choice and does not risk her safety.

The client is admitted to a long term care facility. The nurse in charge is encouraging autonomy in the client. Which activity should the nurse introduce to the client? A. Have the client plan her meals. B. Let the client decorate her room. C. Make the client in charge of setting her appointment with the hair dresser. D. Let the client choose social activities she would like to join.

Choice C is correct. A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order.

The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which prescription with the primary healthcare provider (PHCP)? See the image below. A. Urine analysis (UA) B. Head CT Scan C. Regular diet D. Ammonia level

Choice C is correct. Placing the wheelchair as close to the bed as possible on the client's affected (weaker) side requires follow-up because the client should be mobilized by having the wheelchair on their unaffected (stronger) side. This requires follow-up because the client is at risk of falling and injury.

The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse A. puts the client's affected (weaker) arm in the shirt's sleeve first. B. places shoes with velcro straps on the client's feet. C. places the wheelchair as close to the bed as possible on the client's affected (weaker) side. D. places the hairbrush in the client's unaffected (stronger) hand.

Choice D is correct. Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient's pain to determine the cause before administering medications or other interventions.

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first? A. Administer PRN analgesic. B. Obtain STAT EKG. C. Encourage ambulation. D. Discuss the pain with the patient.

Choice D is correct. Glaucoma, cataracts, and macular degeneration are all more common in the elderly.

What would the nurse emphasize as an increased risk for an older adult patient? A. Blepharitis and chalazion B. Myopia and strabismus C. Exophthalmos and presbyopia D. Glaucoma and cataracts

Choice A is correct. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with hyperpathia. Hyperpathia is synonymous with hyperalgesia and is defined as the abnormal pain processing that can lead to the appearance of neuropathic pain.

You have an adult client who has abnormally heightened responses to minor pain like the pain from sitting on a bedpan or a small skin tear. What would you suspect that this client is affected by? A. Hyperpathia B. Drug seeking behavior C. Equianalgesia D. Dysesthesia

Choice B is correct. You would respond to the client's statement of "I do not want to become a druggie" with "The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse" when your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. Responding in this manner allows you to educate the client about a misconception related to pain management in terms of fears of addiction because only a small number, approximately 5% of people, without a prior history of substance abuse that take narcotic analgesics for pain become addicted to them. This response also educates the client about some of the possible complications of unrelieved pain, such as immobility, atelectasis, and infections.

Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, "I do not want to become a druggie." How would you respond to this client's comment? A. "That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse." B. "The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse." C. "A lot of people prefer to be brave and stick it out so you are not alone." D. "You have a right to refuse any and all treatments, so just do without it."

Choices A, C, and E are correct. Celiac disease is characterized by an individual's intolerance to gluten. Grilled chicken, scrambled eggs, and avocado are all examples of foods that have no gluten

The nurse is assisting a client to choose food options appropriate for Celiac disease. Which food items would be appropriate to select? Select all that apply. Grilled chicken Wheat pasta Scrambled eggs Oatmeal Avocado

Choices A, C, and E are correct. Dumping syndrome is characterized by rapid peristalsis, especially with foods that are simple carbohydrates (refined sugars). Rice cereal, chicken breast, and scrambled eggs reflect foods that are not simple carbohydrates. Foods recommended for clients with dumping syndrome include complex carbohydrates, high protein, and high fiber.

The nurse is assisting a client to pick out food options appropriate for Dumping Syndrome. Which food items would be appropriate to select? Select all that apply. Rice cereal Pastries Chicken breast Cola Scrambled eggs

Choice B is correct. Placing the head-of-bed at 30 to 60 degrees will facilitate comfort by preventing strain on the lumbar spinal column.

The nurse is assisting a client using a fracture bedpan. Which action should the nurse take? A. Position the client prone while applying the bed pan B. Raise the head-of-bed to 30 degrees C. Place the open rim of the bedpan facing toward the head of the bed D. Lower all of the side rails

Choice B is correct. Loss of short-term memory is not an expectedcomplication of prolonged immobility and warrants further assessment. Short-term memory loss may indicate medication effects, Alzheimer's dementia, or Lewy body dementia, etc.

A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility? A. A decrease in bone density B. Loss of short-term memory C. Atelectasis D. High serum calcium level

Choice D is correct. This option gives the patient information about where he is and who is caring for him. It does not require him to answer questions or risk increasing his agitation if he does not know the answers. When a client is experiencing confusion, the nurse needs to provide a calm, predictable environment. Greeting the patient and stating where he is, who you are, and any pertinent information (without overwhelming him) will help prevent increased anxiety, which could lead to worsening confusion.

A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A. "Good morning. Do you remember where you are?" B. "Hello, my name is Susan Jones and I am your nurse for today." C. "How are you today? Remember, you're in the hospital." D. "Good morning. You're in the hospital. I am your nurse, Susan Jones."

Choice B is correct. The three-point gait is most appropriate because the client is of non-weight bearing status on the affected leg. In a three-point gait, the client bears weight on both crutches and then the unaffected leg. This gait is also appropriate because it is slower than the swing-through gait, which requires more balance and is faster.

A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-through gait

Choice D is correct. Clients with left-sided weakness should have the cane secured in their right hand (opposite to the affected side). Having a cane as an ambulation device ensures that two points of sturdy contact are on the ground at all times.

The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide? A. Advance the cane along with your stronger leg. B. Remove the rubber tip when going upstairs. C. Measure the height of the cane to your elbow. D. Secure the cane in your right hand.

Choices A, C, and E are correct. These actions are appropriate during the process of log rolling a client. It is appropriate for a client who is to be log rolled to have a pillow placed between the client's knees to prevent tension on the spinal column and adduction of the hip. Fanning out a draw sheet under the client enables staff to have strong handles to grip without slipping. The purpose of log rolling a client is to move the client in one smooth, continuous motion to prevent twisting of the spinal column.

The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply. - Place a small pillow between the client's knees. - Places the client's arms at their side. - Fanfold a drawsheet along the backside of the client. - Instruct the client to laterally flex the neck during the turn. - Roll the client as one unit in a smooth, continuous motion.

Choice A is correct. Cystic fibrosis is a multisystem disorder that may cause an individual to develop vitamin and mineral deficiencies because of dietary malabsorption. The recommended diet for a client with cystic fibrosis is a well-balanced, high-protein, high-calorie diet with high fat (impaired intestinal absorption). Dietary items rich in sodium are also encouraged because of the salt loss through the skin.

The nurse assists a client with cystic fibrosis pick out items on a menu. It will indicate effective teaching if the client selects meals that are A. High in fat B. Low in sodium C. Low in calories D. Low in protein

Choices A, B, D, and E are correct. A client with cystic fibrosis requires a well-balanced diet, rich in calories, high in protein, dense in vitamins, and unrestricted in fat. These food choices reflect one of these requirements. Chicken breast - high in protein Almonds - high in vitamin A Orange slices - high in vitamin C French Fries - high in sodium and fat

The nurse assists a client with cystic fibrosis pick out items on a menu. It will indicate effective teaching if the client selects which food items? Select all that apply. Chicken breast Almonds Fat free yogurt Orange slices French fries

Choice A is correct. The first bodily area to be washed during a complete bed bath is the inner canthus of either of the client's eyes. Washing the client's eye from the inner to the outer canthus prevents secretions from entering the nasolacrimal duct. Additionally, when washing, each of the client's eyes should be washed using different sections of the bathing mitt or cloth for each eye to reduce the risk of infection transmission. After washing both of the client's eyes, the individual performing the complete bed bath should then ask whether the client prefers to use soap on their face. Based on the client's response, wash, rinse, and dry the client's forehead, cheeks, nose, neck, and ears.

The first bodily area to be washed during a complete bed bath is the: A. Inner canthus of the eye B. Cheeks C. Forehead D. Chin

Choice B is correct. Acute pain is of short duration. There are several terms used to describe the pain. Definitions of illness emphasize that it is an unpleasant experience. Since pain can be so damaging, it is essential to understand how it is created. Acute pain is meant to warn the body that some type of insult or injury has occurred, whereas chronic pain lasts beyond the average healing period and has no useful role.

Pain of short duration with an identifiable cause is referred to as: A. Chronic pain B. Acute pain C. Complex pain D. Neuropathic pain

Choices A, B, D, and E are correct. When instructing a client to ambulate with a cane, the nurse should apply a gait belt to the client's waist. The nurse should stand on the client's left (weaker) side if the client has difficulty. The client should have the cane in their right hand (stronger side), and the height of the cane should be measured from the client's wrist crease.

The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply. - Place a gait belt around the client's waist. - Stand on the client's left side during ambulation. - Instruct the client to put the cane in the left hand. - Measure the cane from the client's wrist crease. - Instruct the client to put the cane in the right hand. - Instruct the client to look down while ambulating.

Choice C is correct. Before executing any action, the nurse should read back the result to ensure effective and safe communication. This process mustn't be skipped to avoid client identification errors. Critical results, such as a sodium of 122 mEq/L, should be read back for accuracy.

The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L(135-145 mEq/L). The nurse should take which initial action? A. Notify the primary healthcare provider B. Implement seizure precautions C. Read back the result for verification D. Recollect the laboratory specimen

Choice C is correct. A full-liquid diet includes food items such as plain ice cream, strained soups, sherbet, milk, pudding, custard, breakfast drinks, refined cooked cereals, and strained vegetable juices. Custard is under the full liquid diet specification and is appropriate for the nurse to introduce to the client considering their diet has just been advanced.

The nurse cares for a client who has tolerated their prescribed clear liquid diet. The nurse obtains a full liquid diet order and should offer which item from this menu? A. Gelatin B. Tea C. Custard D. Apple juice

Choice B is correct. The American Nurses Association (ANA) advocates for pain management even if the life-threatening side effects hasten death. In the past, pain management agents like narcotic analgesics were not given if they caused respiratory depression that could lead to the cessation of life. This administration of respiratory system depressing drugs at the end of life is not considered euthanasia. The American Nurses Association does not encourage families to administer respiratory system-depressing drugs to hasten death but it does allow families to administer respiratory system-depressing drugs to relieve pain at the end of life.

The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life? A. Advocate for pain management unless life-threatening side effects occur. B. Advocate for pain management even if the life-threatening side effects hasten death. C. Prohibit the respiratory system from depressing drugs because this is euthanasia. D. Allow families to administer respiratory system depressing drugs to hasten death.

Choice B is correct. A transcutaneous electrical nerve stimulation (TENS) unit is an over-the-counter pain-relieving device that provides a counter-current to an area of localized pain. The electrodes are placed where the area of pain is, and the current is adjusted until the client feels a 'pins and needles sensation which is theorized to release endorphins. TENS units are commonly used as adjunctive pain relief for musculoskeletal pain.

The nurse has instructed a client who has a newly prescribed transcutaneous electrical nerve stimulation (TENS) unit. Which of the following statements by the client indicates a correct understanding of the teaching? A. "I should not take pain medications while this device is applied." B. "I will adjust the current to the point at which I experience a sensation of pins and needles." C. "The electrodes will be placed all over my body." D. "I should experience generalized twitching while this device is applied."

Choice A is correct. This statement is correct and indicates an understanding of using crutches. The client should place both crutches on the side away from the handrail and then hold the handrail for support with one hand. The client should lead with their affected leg and crutch as they descend the stairs.

The nurse has instructed a client who is being discharged with crutches about using stairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should hold the handrail for support with one hand." B. "Going up the stairs, I should lead with my crutches and weaker leg." C. "Going down the stairs, I should lead with my crutches and strong leg." D. "I should remove the rubber tip when going up and down the stairs."

Choice A is correct. For a client who is ambulating, the nurse should always be slightly behind the client and positioned on the affected (weaker) side. If a client starts to fall, the nurse should hold the gait belt, try to extend one leg, let the client slide against the leg, and gently lower the client to the floor, protecting the head. The nurse can help prevent client injury by maintaining a wide base of support.

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury? A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor. C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position. D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.

Choice B is correct. You would instruct the new UAP that the inner canthus of the eyes should be washed first, followed by the outer canthus of the eyes. Once the eyes have been cleansed in this manner, the UAP may then move on to the remainder of the face.

The nurse is assigned to supervise a new unlicensed assistive personnel (UAP) in completing personal hygiene tasks. Following the UAP gathering the needed supplies, performing hand hygiene, and donning clean gloves, you observe the UAP provide a bed bath to an elderly client on complete bed rest. The UAP begins by first washing the client's forehead. What should be the nurse's next action? A. Praise the new UAP because they have correctly washed the client's forehead first. B. Instruct the UAP that the inner canthus of the eyes should be washed first and use a new washcloth to do so. C. Instruct the new UAP that the outer canthus of the eyes should be washed first. D. Have the UAP stop and don sterile gloves for the bed bath.

Choice C is correct. According to Kohlberg's Stages of Moral Development, this pediatric client's behavior correlates to the client being in Level 2 (Conventional Morality Level), Stage 3 (Good Boy-Good Girl) stage of moral development. In this level/stage of moral development, the pediatric client is focused on living up to social expectations and roles. There is an emphasis on conformity, being "nice," and consideration of how choices influence relationships. This knowledge will be beneficial for the nurse to be aware of when caring for this client.

The nurse is caring for a 10-year-old child on the pediatric unit. The nurse, when caring for this age group, should be aware that: A. The child will do something for another person if that person does something for the child. B. The child now follows social standards for the good of all. C. The child wants to follow the rules because of a need to be seen as "good." D. The child finds satisfaction in following rules.

Choice D is correct. While most preschoolers can manage to be away from their parents for school, illness adds another stressor, making separation increasingly tricky. Parents should be encouraged to stay with their children as much as possible.

The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears? A. Provide the child with a private room B. Encourage them to play with other children in the common area C. Advise the parents to only visit during visiting hours D. Allow the parents to stay as much as they'd like

Choice B is correct. HIPAA allows directory information (client name, location in the facility, health condition expressed in general terms that do not communicate specific medical information about the individual, and religious affiliation) to be communicated. However, the client may also decide against sharing this information in the directory. If that is the case, the nurse should not acknowledge that an individual by this name is currently in the facility. The item provided does not state that the client has decided against being in the directory. No additional consent is required to share this directory information. Directory information can be released to any caller unless the client requests not to. For more information regarding this HIPAA provision, refer to theHHS website.

The nurse is caring for a client admitted to the acute care facility. The nurse takes a phone call from the client's neighbor who wants to know where the client is located. The nurse should A. inform the individual that this information cannot be released. B. provide the caller with the client's current location. C. not acknowledge the presence of this individual. D. inquire with the caller as to the reasoning for the information.

Choices B, C, D, and E are correct. Barriers that clients may have in terms of them reporting pain to the nursing staff include: Fears revolving around addiction and dependence on pain medications Not wanting to be viewed as a complainer or drug seeker A cultural bias An ethnic bias Fears about incurring more healthcare costs

The nurse is caring for a client experiencing pain. What barriers would the nurse recognize that the client may have in terms of reporting pain? Select all that apply. - A feeling that the nursing staff will not answer their call for complaints of pain. - Not wanting to be viewed as a complainer or drug seeker. - A cultural bias. - An ethnic bias. - Fears about incurring more healthcare costs.

Choice C is correct. The nurse needs to assess the situation further when conflicting information is noted. Although the client states that his pain level is 1/10, his grimace at every movement tells otherwise. The nurse should validate her observations and make further assessments.

The nurse is caring for a client in pain. The nurse asks the client which level of pain he is in, and the client says it's 1 out of 10. The nurse notices that the client grimaces every time he moves. What is the nurse's most appropriate action? A. Administer analgesics to the client. B. Move on to other patients. C. Ask the client about his grimacing with every movement. D. Encourage the client to watch his favorite TV show.

- apple juice - fat-free bouillon with added salt - clear hard candy - gelatin - hot tea with added sugar

The nurse is caring for a client who was prescribed a clear liquid diet. Which dietary items would be appropriate for the nurse to include? Select all that apply. sherbert chocolate pudding vanilla yogurt apple juice coffee with oat milk fat-free bouillon with added salt tomato juice clear hard candy gelatin hot tea with added sugar

Choice A is correct. This is the correct technique in getting the client transferred from the bed to the wheelchair. This would involve getting the client mobilized to the side of the bed and placing the wheelchair on the unaffected side. The nurse should not pull on any of the client's extremities because this could result in a joint dislocation or subluxation.

The nurse is caring for a client with right-sided weakness. When transferring the client from the bed to a wheelchair, the nurse should perform which action? A. Place the wheelchair as close to the bed as possible on the client's unaffected side B. Place the wheelchair as close to the bed as possible on the client's affected side C. Remove any nonskid slippers from the client's feet D. Gently pull on the client's arm to assist them to the side of the bed

Choice B is correct. Semi Fowler's position is the most appropriate position after a hyphema, or blood in the anterior chamber has been diagnosed. This position works with gravity to keep blood accumulation away from the optical center of the cornea.

The nurse is caring for a patient in the emergency department who has just received a head injury following a car accident. After a hyphema has been noted, which position should the nurse encourage this patient to be in? A. Supine B. Semi-Fowler's C. Lateral on the affected side D. Lateral on the unaffected side

Choice C is correct. The fluid and white blood cells that leak from blood vessels in response to an injury/inflammation are exudates. Exudates are present in the wounds as they heal. The nature and quantity of exudates depend on the severity of the damage and the tissues involved. For example, a surgical incision may ooze clear or pinkish (serous or serosanguinous) exudate for a day or two. If an exudate becomes purulent (thick, tan, green, or yellow), it is not normal and may suggest infection. In such cases, the nurse should immediately notify the health care provider.

The nurse is caring for a patient who is recovering from open-heart surgery. For the first 24 hours following the surgery, there is a noticeable pinkish fluid oozing from the incision site. Which phase of the inflammatory response does this represent? A. Vascular response B. Cellular response C. Exudate formation D. Healing

Choice B is correct. A hemoglobin A1C of 7.5% is elevated and requires follow-up. The normal hemoglobin A1C is any value less than 5.7% Hemoglobin A1C between 5.7% and 6.4% is considered prediabetes that warrants aggressive lifestyle modification to prevent diabetes. Hemoglobin A1C of 6.5% meets the diagnostic criteria of diabetes.

The nurse is caring for assigned clients and is reviewing laboratory data. Which laboratory data requires follow-up? A client with a A. total Cholesterol 180 mg/dl [< 200 mg/dl] B. Hemoglobin A1C 7.5% [< 7% if a client has DM] C. Calcium 9.2 mg/dl [9-10.5 mg/dL] D. Creatinine 1.0 mg/dL [0.6-1.2 mg/dL]

Choice A is correct. The pulse and respiration rate of this client is quite concerning. Tachycardia is the earliest sign of shock, and intervention is necessary before the client further deteriorates.

The nurse is caring for assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, it would be essential to follow up with which of the following clients? A. P: 109; R: 26; BP: 110/70 mmHg B. P: 90; R: 12; BP: 99/54 mmHg C. P: 100; R: 18; BP: 161/98 mmHg D. P: 88; R: 14; BP: 166/52 mmHg

Choice B is correct. It is appropriate for the nurse to advise the client to increase their fiber intake. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. The patient should ingest about 30 to 40 g of fiber each day.

The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their A. dairy intake. B. fiber intake. C. fat intake. D. calcium intake.

Choice A is correct. Primary prevention is often referred to as the true level of prevention because it occurs before disease or illness. Demonstrating the appropriate use of a car seat is primary prevention because it happens before an automobile crash, a leading cause of death for those younger than 19.

The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention? A. Primary B. Secondary C. Tertiary D. Quaternary

Choice C is correct. Instead of buying new toys, the parents should bring in toys from the child's home because it will increase familiarity and ease anxiety. The nurse aims to facilitate a transition from home to the hospital that causes minimal stress. This can be accomplished by preparing the parents and the child for what type of testing, medications, and treatments the child may receive. An essential remedy to this change is establishing a routine by having large, colorful calendars, pictures from home, familiar toys, and open visitation from parents with their children.

The nurse is developing a care plan for a child scheduled to be admitted to the oncology unit to receive treatment for leukemia. To facilitate effective transition to the hospitalized environment, the nurse should recommend that the parents A. purchase new toys for the child. B. allow flexibility in the daily routine, so it changes often. C. bring in the child's favorite toys from home. D. limit parental visitation to specific times.

Choice C is correct. For a client with stomatitis (inflammation of the oral mucosa), the client must avoid anything acidic or irritating to the oral mucosa. Saline mouthwashes or saline mouthwashes with sodium bicarbonate are recommended.

The nurse is educating a client who has stomatitis on oral care. Which of the following recommendations would be appropriate? A. Recommend the client swish and spit alcohol mouthwash. B. Provide lemon glycerin swabs in between meals. C. Recommend the client swish and spit saline mouthwash. D. Instruct the client to cleanse their mouth with chlorhexidine.

Choice A is correct. Pheochromocytoma is caused by a tumor on top of the adrenal medulla, causing a surge in catecholamines to be released, thus causing the client to experience headaches, hypertension, hyperglycemia, tremor, and unintentional weight loss. A client with pheochromocytoma is advised to modify their diet so that it does not increase blood pressure. Cheddar cheese contains tyramine and should not be included in the client's diet. Other dietary modifications include limitations of caffeinated beverages, which may also raise blood pressure.

The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove? A. Macaroni and cheddar cheese B. Watermelon slices C. Caffeine free cola D. Baked chicken

Choice C is correct. This observation requires follow-up because when a client gets up from a chair to the walker, the arm rests of the chair should help the client stand to the walker. Tilting the walker could result in falling and serious injury. When clients get up from a chair to the walker, they should hold the chair's arm rests and push up using their arms. After they stand up, they should position their arms on the walker handles with an elbow bend of 15 to 30 degrees.

The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client A. advances the walker 6-10 inches. B. has their elbow flexed 15-30 degrees. C. tilts the walker forward to help stand up from a chair. D. advances the walker and then the affected leg.

Choice D is correct. This technique does not reflect the three-point gait. This gait pattern depicts the two-point gait, which requires at least partial weight bearing of both lower extremities. In the two-point gait, the left crutch and right leg move forward, followed by the right crutch and left leg.

The nurse is observing a client ambulate with crutches using the three-point gait. Which observation requires follow-up by the nurse? The client A. places the crutches 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot prior to walking. B. advances both crutches and the injured leg forward and then moves the non-injured leg. C. has the elbows flexed 30 degrees with the hands and arms supporting the body weight. D. moves a crutch at the same time as the opposing leg.

Choice A is correct. This observation requires follow-up because it is inappropriate. The basic crutch stance is the tripod position, formed when the crutches are placed 6 inches in front of and 6 inches to the side of each foot.

The nurse is observing a client ambulate with crutches. It would require follow up by the nurse if the client is observed A. with the crutches placed 2 inches in front of and 4 inches to the side of each foot. B. placing weight on the crutch and then steps up the first step of stairs with the unaffected leg. C. drying the rubber tips of the crutches with a paper towel after they have become wet. D. with both of their elbows flexed between 15 and 30 degrees.

Choice B is correct. This action by the student nurse requires intervention. The client should assume the chin-down position and be reminded not to tilt backward when eating or drinking. The client should be instructed to have their head turned and chin tucked to reduce the risk of aspiration. Reminding the client to tilt their head backward would increase their risk for aspiration.

The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student A. asks the client to remain sitting upright for at least 30 to 60 minutes after a meal. B. reminds the client to tilt their head backward when eating and drinking. C. avoids mixing foods of different textures in the same mouthful. D. places salt and pepper on the client's food at their request.

Choices D and E are correct. These statements about pain are appropriate to include. Self-report is considered the most accurate indicator in assessing pain. Clients are the best source of information about their own pain because they can describe its intensity, location, and quality. The oral route is the preferred method of analgesic delivery due to being easiest to administer, better tolerated, and more cost-effective than intravenous medication.

The nurse is planning a staff development conference about pain management. Which statement would be appropriate to include? Select all that apply. - Infants do not have developed pain sensors. - A lack of behavioral signs of pain negates pain. - The amount of pain has a positive correlation with the extent of tissue damage. - Self-report is the most reliable method of pain assessment. - Analgesics should be administered via the oral route when possible.

Choice B is correct. The Human Papillomavirus (HPV) vaccine is the only vaccine proven to decrease the risk of cervical cancer. Nearly all cases of cervical cancer are linked to HPV and thus, the vaccine is an effective primary prevention method.

The nurse is planning a staff development conference about vaccines. Which of the following information should the nurse include? A. MMR vaccine should be administered in the first trimester of pregnancy. B. Human Papillomavirus vaccine can reduce the risk of cervical cancer. C. Influenza vaccine may be administered to an infant at 3 months. D. Herpes zoster vaccine is recommended starting at age 40.

Choices A, B, D, and F are correct. Preparing the room and gathering necessary information, such as name, diagnosis, and anticipated length of stay, allows for more efficient greeting and admission and are appropriate ways to help establish trust with the client. The nurse should also orient the client to the room by ensuring the client understands how to use the bed controls, call lights, and any necessary equipment. Showing an interest in the client's expectations and concerns shows the client that their feelings are cared about, which helps to establish trust.

The nurse is preparing for the first interaction with a client recently admitted to the hospital. Which of the following would help establish trust during this encounter? Select all that apply. - Make sure the client's bed is set up properly ahead of time. - Review the client's name, diagnosis, and anticipated length of stay before they arrive. - Speak confidently and do not tell the client that one of the nurses providing care is a student nurse. - Show the client how to use the bed and call light. - Avoid spending too much time talking with the client. - Ask about the client's expectations and concerns when taking the health history.

Choice C is correct. Individuals with allergies to bananas are at an increased risk of developing an allergy to latex. Tropical fruit allergies may also indicate an increased risk. Working in a profession with increased exposure to latex, such as a hairdresser or house cleaner, also places a person at an increased risk for developing this allergy.

The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following? A. Penicillin B. Cat dander C. Latex D. Peanuts

Choice A is correct. It is the health care team's job to provide resources and support to the mother and her family when it comes time to discuss pregnancy and pregnancy loss.

The nurse is providing sensitivity training to new members of the health care team about the best ways to manage and care for families after a miscarriage. The nurse explains that when it comes to telling children about a woman's pregnancy or pregnancy loss, it is the health care team's job to: A. Provide available resources and ultimately support the mother's decision. B. Inform the children of the parents so that they don't have to worry over the task. C. Encourage the parent's not to inform the children of the status of their mother's pregnancy. D. Use a hands-off approach and let the family come up with a solution alone.

Choice A is correct. This client is showing evidence of metabolic syndrome and needs prompt intervention to mitigate the risk of diabetes mellitus. Nutritional intervention is necessary because this client needs to modify their diet and reduce their intake of sodium, fats, and simple carbohydrates. Thus, it would be appropriate for the nurse to initiate a referral to a registered dietician.

The nurse is reviewing clinical data for a client. Which of the following actions should the nurse take? See the exhibit. View Exhibit A. Initiate a client referral to a registered dietician. B. Inform the client that the results are within normal limits. C. Request a prescription for occupational therapy. D. Review the client's family history.

Choices B, C, and E are correct. Garlic is a food rich in phosphorus and would be an appropriate recommendation for a client that needs to incorporate more phosphorus in their diet. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts are all very high in phosphorus. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI).

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus? Select all that apply. Leafy greens Garlic Nuts Butter Turkey

Choice B is correct. After oral surgery or a tonsillectomy, the physician will order a series of labs, including hematocrit, hemoglobin, and prothrombin time. The results of these labs are evaluated to determine whether or not the patient is experiencing bleeding as a result of the surgery and if they can adequately bleed.

The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to? A. BUN level B. Prothrombin time C. Creatinine level D. Viral load

Choice A is correct. This action is incorrect and requires follow-up. This is an incorrect positioning for crutches, as the axillae should not support the client's body weight. The hands should support the client's body weight as weight supported in the axilla may cause nerve injury.

The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student A. positions the handgrips so that the axillae support the client's body weight. B. demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. C. observes two to three finger widths between the crutch pad and the client's axilla. D. instructs the client to dry crutch tips with a paper towel if they become wet.

Choices A, B, C, D, and F are correct. The crux of the vegan diet is that it excludes foods that come from animals, including dairy products and eggs. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged.

The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. Legumes Tofu Almonds Prunes Baked fish Grapefruit

Choices A, B, and D are correct. The crux of a vegetarian diet is that it excludes foods such as meat, fish, and poultry. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged. Dairy products are generally permitted on a vegetarian diet. However, subvariants of this diet exist.

The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. Legumes Almond butter Grilled chicken Apricots Baked fish Seafood salad

Choice C is correct. This observation is correct and reflects effective teaching. The nurse should instruct the client that the height of the cane should be measured with the client facing forward, wearing their shoes, and either from their wrist crease or greater trochanter.

The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client A. position the cane on their weaker side. B. advances their weaker leg first, then the cane. C. measures the height of the cane from their wrist crease. D. advances the cane 12-16 inches with each step.

Choices A and D are correct. Strategic ways for a client to get a restful night's sleep include emptying their bladder before bed and engaging in vigorous exercise in the early morning and afternoon. Vigorous exercise within two hours of bed may increase the client's arousal level and decrease sleep induction.

The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply. - empty their bladder before bed. - take more naps throughout the day. - eat a high amount of calories before bed. - plan vigorous exercise earlier in the day. - use multiple nightlights in the bedroom.

Choice D is correct. Hot green tea contains caffeine which will worsen insomnia. The client should be instructed to avoid this product immediately before bedtime as caffeinated products (sodas, etc.) will increase the client's arousal.

The nurse is teaching a group of older adults about effective sleep. Which of the following statements, if made by the client, would require further teaching? A. "Nicotine replacement gum may make insomnia worse." B. "I should try to limit my daily naps to no more than thirty minutes." C. "Reading before bed may help me fall asleep." D. "Drinking a cup of hot green tea before bed is okay."

Choices A, C, D, and E are correct. Progressive relaxation involves rhythmic breathing and progressive tension and relaxation of one muscle group at a time. When implemented, clients typically experience decreased muscle tension and a reduction in the need for pharmacologic measures to relieve pain and anxiety. Although sensitivity may be normal for clients who are new to progressive relaxation exercises, any sensitivity or exhaustion should be reported and monitored so the nurse can decide whether the client would be better suited for passive relaxation techniques.

The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply. - "I will breathe in and out in rhythm." - "I expect my pulse to be faster afterwards." - "I expect to require less pain medication." - "I expect my muscles to feel less tense." - "I will report any increased sensitivity."

Choice D is correct. Saying, "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?" is an example of a therapeutic communication technique known as "focusing". During conversations, patients may mention certain issues that are important to them. When this happens, nurses can focus on the client's self-perceived priorities, prompting them to discuss issues further.

The nurse is using the therapeutic communication technique while caring for her prenatal client. Which phrase, when used by the nurse, is an example of "focusing"? A. "You're afraid your baby will be born after your due date. Is that correct?" B. "I've noticed a lot of bruising on your arms." C. "What would you like to talk about during our appointment today?" D. "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?"

Choices A, B, and C are correct. Adequate oral hygiene is essential for promoting a client's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of both aspiration pneumonia and ventilator associate pneumonia (VAP).

The nurse provides oral care to clients in the ICU. What are the benefits of providing oral care to a client in critical care? Select all that apply. - It promotes the patient's sense of well-being. - It prevents deterioration of the oral cavity. - It decreases the incidence of aspiration pneumonia. - It eliminates the need for regular flossing. - It decreases oropharyngeal secretions. - It compensates for an inadequate diet.

Choice A is correct. Coarse tremors would cause the blood pressure reading to be inaccurate. The nurse should not use electronic blood pressure monitoring if the client has these tremors.

The nurse reviews obtaining blood pressure with unlicensed assistive personnel (UAP). It would indicate effective teaching if the UAP states which client finding would not be appropriate for an electronic blood pressure measurement? The client A. having coarse tremors. B. wearing a watch. C. who has excessive tattoos. D. requiring a chest radiograph.

Choice A is correct. This observation requires intervention because any collected specimen should be labeled in the client's presence. This is essential because the client's presence is required to corroborate the information on the client label. As a reminder, specimen containers should not be prelabeled. Choice B is correct. This observation requires intervention because the armband in and of itself is not a client identifier but rather an example of a source of client identification. The client needs to verify their identification using their name and one other identifier (date of birth, medical record number, telephone number). Choice C is correct. Reporting critical results to a physician should not be delayed. Hence, this is why they are deemed critical results. Prior to relaying critical results to a physician, the nurse should verify the result with the laboratory to ensure accuracy. This observation requires follow-up because the client's care prioritizes hand-off report. Choice D is correct. Promoting rest and a therapeutic environment is part of a comfortable stay. The nurse should not prioritize comfort over safety. Alarms should be enabled and not altered in a way that would

The nurse manager is performing safety rounds on the medical-surgical unit. Which observation by the nurse manager requires intervention? A nurse Select all that apply. - labels the urine specimen after obtaining it outside of the client's room. - verifies the client's identify by looking at their armband. - notifies the primary healthcare provider (PHCP) of a critical laboratory result after giving handoff report to another nurse. - turns down the bedside cardiac alarm volume to allow the client to rest. - discards an unlabeled medication found at the client's bedside.

Choice B is correct. A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient's neck from flexing. A standard ICP is about 5 to 15 mmHg.

The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed? A. 25 degrees B. 30-40 degrees C. 10-20 degrees D. 5-10 degrees

Choice A is correct. When a client is ambulating upstairs using a cane, the client will face the stairs and place the cane on the side opposite the handrail. Then, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together.

The nurse observes a client go up the stairs with a cane. It would indicate effective teaching if the client grabs the handrail and A. places the stronger leg up a step, then simultaneously moves up the weaker leg and cane. B. holds the cane in one hand and hops up each stair using the stronger leg. C. places the cane up a step, then simultaneously moves up the stronger and weaker legs. D. places the weaker leg up a step, then simultaneously moves up the stronger leg and cane.

Choice C is correct. Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall.

The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client A. exercises both extremities simultaneously. B. knows their heart rate should be monitored while exercising. C. practices forced resistance against stable objects. D. swings their limbs through the full range of motion.

Choice A is correct. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. The transmission of information without the use of words is termed nonverbal communication. It is also known as body language. Nonverbal communication helps nurses to understand subtle and hidden meanings in what a patient is trying to say verbally. Additionally, nonverbal communication is reflected in a person's actions, such as the way he/she walks or uses facial expressions. Nurses must be aware of nonverbal messages that they send and the ones they receive from patients so they can identify patients who are suffering from or at risk of certain conditions.

The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient? A. Pain B. Anxiety C. Depression D. Fluid volume deficit

Choice B is correct. Taking the time to listen and ask the client questions about his life shows that the nurse is interested in the patient. It also helps increase his self-concept. Reminiscence about past life events, doing a life review, especially if the experiences were positive, is considered to be a regular psychosocial activity for older adults. It helps them to focus on past accomplishments and contributions to society, thus increasing their self-concept.

The nurse observes that an 85-year-old man at an adult daycare center fondly shares stories about traveling on the "orphan trains" prior to being adopted. The nurse should perform which intervention? A. Refer him for a geriatric psychiatric evaluation. B. Listen and ask him questions about his life. C. Distract him and change the conversation. D. Involve him in more social activities.

Choice B is correct. CHG is an effective antimicrobial agent that inhibits bacterial growth for 24 hours. The solution should not be rinsed off once it is applied, as it will leave a sticky residue. The sticky residue (sensation) is normal.

The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG) wipes. Which observation requires follow-up? A. Uses one washcloth for washing each major body part B. Rinses the skin after bathing with the CHG solution C. Washes the client's face with warm water and mild soap D. Allows the CHG solution to dry on the client's skin

Choices A, C, D, and E are correct. Subjective data is information that is perceived only by the person affected. This data cannot be seen or verified by another person. Feeling nauseous or nervous, itchiness, and pain are all examples of subjective data.

The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply. - The client reports feeling nauseated. - The client's lower extremities are swollen. - The client expresses nervousness about test results. - The client reports that their leg is itching. - The client rates pain at a 6 on a scale of 1 to 10. - The client vomits twice after eating dinner.

Choice A is correct. When blood pressure is obtained in the leg, the systolic blood pressure is increased by up to 10 to 40 mm Hg compared to blood pressure obtained over the brachial artery. The higher SBP is due to the calcification in the distal arteries, which raises the SBP. DBP in the lower extremities is usually the same when compared to the upper extremities.

The nurse reviews the vital signs of a client admitted to the medical-surgical unit. The unlicensed assistive personnel (UAP) indicates that the client's blood pressure was obtained in the client's leg. The nurse should expect which change in the blood pressure when taken in the leg? A. Systolic pressure in the legs is usually higher by 10 to 40 mm Hg B. Systolic pressure in the legs is decreased by 10 to 40 mm Hg C. Diastolic pressure is the decreased by 10 to 40 mm Hg D. Diastolic pressure is higher by 10 to 40 mm Hg

Choices A and D are correct. These actions by the UAP require follow-up. The HOB should be between 30-45 degrees to facilitate effective oral hygiene and prevent aspiration. A towel is placed across the client's chest to prevent soiling their clothes. This towel should be placed in a linen bag following its use. Items that should be deposited in a biohazard bag will be saturated with blood or blood products. This bag prevents the safe transport of products that may contaminate other areas in the facility. Gross bleeding is not expected during basic oral hygiene.

The nurse supervises unlicensed assistive personnel (UAP) assist a client who is bed-bound with oral hygiene. Which action by the UAP requires follow-up? Select all that apply. - Raises the head of the bed (HOB) to 15 degrees - Holds the toothbrush bristles at a 45-degree angle to the gum line - Performs hand hygiene and applies clean gloves - Removes the towel and places it in a biohazard bag - Applies moisturizing lubricant to the lips after brushing and rinsing

Choice A is correct. Somatic pain arises from skin and musculoskeletal structures. This type of pain is often reported as sharp, easily localized, gnawing, crushing or throbbing. Sources of acute somatic pain include (and are not limited to) incisional pain, pain at insertion sites of tubes, orthopedic injuries, and wound complications.

The nurse understands that a portion of the pain "assessment" entails the client's subjective, sensory, and emotional comments that indicate the quality or intensity of their pain. The client describes their pain as "crushing and sharp." Select the type of pain a client is experiencing based on this sensory description of their pain. A. Somatic pain B. Visceral pain C. Hurt D. Neuropathic pain

Choice D is correct. This answer choice includes items that are significant with aging. When obtaining a health history from an older adult, it is essential to be aware of the increased risk for deficits that might alter the history taking, such as loss of vision or hearing. Older adults may have more complex histories because of their increased prevalence of disease and may require some additional time to process information. It's necessary to identify the pattern of any illnesses and how they may be related. Nurses should take note of a patient's family history and lifestyle choices, as these may influence health later in life.

The nursing assessment of an older adult focuses the health history on which of the following? A. Birth history, immunizations, as well as growth and development B. Previous pregnancies, obstetrical history, and psychosocial factors C. Religion, spirituality, culture, and values D. Sensory deficits, illness history, and lifestyle factors

Choices A and E are correct. These observations require follow-up because this is inappropriate. Instructing the client to tilt their head back when eating or drinking would facilitate aspiration. The correct instruction would be to advise the client to have the client assume a chin-down position after they have chewed their food thoroughly. The client should be placed upright with their head of bed at 90 degrees to prevent aspiration.

The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply. - Instructs the client to tilt the head backward when drinking. - Reminds the client to assume a chin-down position. - Provides rest periods as needed during the meal. - Positions the client upright for 30-60 minutes after a meal. - Positions the head of the bed at a 45-degree angle during the meal.

Choice C is correct. This picture shows the Trendelenburg position. The body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. The Trendelenburg position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. This position also improves spinal anesthesia's effects and prevents air embolism during central venous cannulation.

The perioperative nurse is documenting a client's current health status. It would be correct for the nurse to document the client's current position as See the image in the exhibit. View Exhibit A. Prone B. Supine C. Trendelenburg position D. The Sims' position

Choice A is correct. To perform the Romberg test, the client should stand with arms at the sides, feet, and knees close together and eyes open. The provider will check for swaying and then ask the client to close their eyes and maintain position. If the client sways with the eyes closed but not when the eyes are open (the Romberg sign), the problem is probably related to proprioception (awareness of body position). If the client sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin.

The primary healthcare provider (PHCP) is caring for a client with a neurologic injury who wants to perform a Romberg test. The nurse should instruct the client that this test will require A. standing with your arms at your side and your feet together. B. flexing the neck, bringing chin to chest. C. both elbows on a table while keeping both forearms vertical and flexing both wrists at 90 degrees. D. placing their left heel onto their right shin and run your heel down the length of the shin to the top of the foot.

Choice A is correct. A health assessment is a method by which nurses gather both subjective and objective data. A health assessment is "gathering information about the health status of a patient, analyzing and synthesizing that data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes." A health assessment includes both a health history and physical evaluation. While a registered nurse performs the initial admissions assessment, LPN/LVNs will assess clients each shift and, if needed, more frequently.

The purpose of a health assessment is to: A. Obtain subjective and objective data B. Outline appropriate care C. Determine whether interventions are effective D. Intervene to correct difficulties

Choice B is correct. Tympany is the percussion sound heard over the abdomen. Percussion is part of the physical assessment, which is done to produce sound or elicit tenderness. The person who is assessing will tap fingers on the patient, similar to the tapping of a drumstick on a drum. The vibrations that the fingers produce create percussion tones conducted into the patient's body. If the waves travel through dense tissue, the percussion tones are quiet or flat. If they go through air or fluid, the tones are louder. The loudest tones are over the lungs and hollow stomach. The most peaceful percussion sounds are heard over bones. Percussion sounds are described as hyperresonant (diseased lungs), full (healthy lungs), tympanic (abdomen), dull (organs), and flat (over bones).

Tympany is a percussion sound commonly located in the: A. Upper arm B. Abdomen C. Lower leg D. Thorax

Choice C is correct. The pH of IV solutions is a measure of acidity or alkalinity and usually ranges from 3.5 to 6.2. Extremes of both osmolarity and pH can cause vein damage, leading to phlebitis. The signs of phlebitis include warmth, tenderness, erythema, and swelling in the affected region. If this occurs, the nurse should discontinue the IV line and insert a new IV line at a different site.

Upon assessment, the nurse noticed that the site of a client's peripheral intravenous (IV) catheter was red, warm, painful, and slightly edematous near the insertion point of the IV catheter. After taking the appropriate steps to address the issue and provide care for the client, the nurse documents in the medical record that the client experienced which of the following? A. Hypersensitivity to an IV solution B. Infiltration of the IV line C. Phlebitis of the vein D. Allergic reaction to the IV catheter material

Choices A, B, and F are correct. Physical changes occurring with aging include fatty tissue redistribution, the skin is drier with the appearance of wrinkles, and also the visual and hearing acuity diminishes.

What characteristics best describe physical changes occurring in the aging adult? Select all that apply. - Fatty tissue is redistributed - The skin is drier and wrinkles appear - Cardiac output increases - Muscle mass increases - Hormone production increases - Visual and hearing acuity diminishes

Choice A is correct. Assessment of self-perception focuses on how the patient thinks of himself/herself.

When assessing self-perception, the nurse should ask the client which of the following? A. "How would you describe yourself?" B. "What gives you hope when times are troubled?" C. "Is your normal way of dealing with stress helpful to you?" D. "Are you having difficulty handling any family problems?"

Choices B, C, D, and E are correct. Sequential compression devices (SCDs) provide DVT prophylaxis by applying intermittent external pressure, pushing blood into deep veins, reducing stasis, and improving venous return. Range of motion exercises should be encouraged for a non-ambulatory client to encourage venous return. Thromboembolic deterrent (TED) hose promotes venous blood flow, prevents venous dilation, improves venous valve function, and stimulates endothelial fibrinolytic activity. Enoxaparin is a low molecular weight-based heparin given subcutaneously in the abdomen. This is a form of chemical VTE (venous thromboembolism) prophylaxis.

Which interventions are appropriate for venous thromboembolism prophylaxis when caring for a non-ambulatory client? Select all that apply. - Floating both of the heels using a pillow - Apply sequential compression devices to the lower extremities - Encourage range of motion exercises in the lower extremities - Apply compression hose to the lower extremities - Administer enoxaparin subcutaneously, as prescribed

Choice B is correct. The 56-year-old client with a below-the-knee amputation and phantom limb pain would be the client most likely to benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain. Unlike other cutaneous nonpharmacological comfort interventions, contralateral stimulation entails stimulating the opposite part of the body rather than directly stimulating the painful, affected area. For this reason, contralateral stimulation of the intact opposite leg will promote comfort and decrease phantom pain resulting from the amputation. Current studies suggest that contralateral stimulation of phantom limb pain represents a promising intervention, albeit in need of further evaluation.

Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain? A. A 36-year-old client with abdominal pain B. A 56-year-old client with a below-the-knee amputation and phantom limb pain C. A 76-year-old client with terminal cancer D. An 84-year-old client with severe arthritis

Choice A is correct. Vocalizations, facial grimaces, bracing, rubbing, restlessness, and vocal complaints are behaviors in patients with dementia who cannot accurately express their pain. A critical component in evaluating pain is the knowledge of the person's normal behavior and interactions with others. This information is often best provided by family, who can answer questions about typical mood and behavior, body posture, life-long history of pain, and response to pain medications. Nurses should be aware that the following challenging behaviors can all be signs of pain in a patient with dementia: Cursing Combativeness Apathy and withdrawal from activities/interactions Being high maintenance (seemingly challenging to please) Wandering Restlessness Repeating behaviors or words

Which of the following indicators would most likely signify to the nurse that a patient with dementia is in pain? A. Rubbing a body part B. Facial droop C. Falling asleep D. A relaxed body position

Choice D is correct. Hyperglycemia is a physiological alteration that can occur during a stress response among both diabetic and non-diabetic clients. More specifically, glucose is increased by various factors, including elevated levels of cortisol, glucagon, and epinephrine (often referred to the "fight or flight" phenomena). These hormones may, in turn, lead to insulin resistance, further increasing hyperglycemia.

Which of the following is a physiological alteration that can occur with stress? A. Decreased visual acuity B. Increased peristalsis C. Decreased glucocorticoids D. Hyperglycemia

Choices A, C, and D are correct. The nurse should focus on therapeutic communication techniques for a client with a poor prognosis. Sharing personal details about the diagnosis does not do anything to comfort the client. It is not appropriate or within the nurse's scope to provide recommendations to influence a client's decision regarding treatment and procedures. When discussing any diagnosis with a client, the nurse should avoid giving false hope or making promises.

Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply. - "My mother has the same thing." - "I'll sit with you for a while." - "I think you should try having surgery." - "Don't cry, everything is going to be okay." - "Do you have any questions for me right now?"

Choice B is correct. Hyperressonance is an abnormal finding over adult lung tissue. It indicates an abnormal increase in the amount of air present, such as with emphysema.

Which percussion sound would indicate further assessment is needed? A. Dull tone over the spleen B. Hyperressonance over an adult's lung tissue C. Flat tone over bone D. Hyperressonance over a child's lung tissue

Choice B is correct. This assessment determines which diagnoses will be the focus of care, the interventions that will be initiated, and those that will be reevaluated. In this way, the assessments drive care, whereas the reassessments loop back into the further assessments and revision of care planning.

Which phase of the nursing process is most foundational for delivery of care? A. Evaluation B. Assessment C. Planning D. Diagnosis

Choice B is correct. Contralateral stimulation involves stimulating the skin in an area opposite to the painful site. The stimulation may be in the form of scratching, rubbing, or applying heat or cold. This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast.

You are caring for a client who has severe burns on her right arm and is in extreme pain, despite receiving a potent analgesic. You decide to rub the client's uninjured left arm to relieve pain in the right. This approach is known as which of the following? A. Massage B. Contralateral stimulation C. TENS D. Acupressure