HESI

severe rheumatoid arthritis becomes depressed, The best long-term goal

Decrease negative thinking about herself, others, and life.

"A man is speaking to me from the corner of the room. Can you hear him?"

"No, I don't hear him, but is it making you uncomfortable to hear him?"

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection? Occurred in conjunction with treatment for an illness.

Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications).

A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life?

2:1. The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently.

Which client should a nurse consider the greatest risk for developing hypernatremia?

63-year-old who has had watery diarrhea since traveling abroad. Watery diarrhea involves loss of water in excess of sodium; this leads to an increased sodium concentration

20. A client with multiple myeloma asks how the disease and therapy progresses. What would be appropriate to include in the client's teaching?

Blood transfusions may be necessary

a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral ?

Community-based self-help group

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client?

Decreased frequency and duration of contractions

nalbuphine (Nubain) for pain. For which side effects ?

Dry mouth Headache Abdominal cramps hypotension

A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiologic responses?

Inflammation in the myocardium causes a rise in the systemic body temperature. the inflammatory response to tissue destruction and persist as long as a week.

A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time? "pt's bp is 176/96 일때

Metoprolol (Lopresor), Metoprolol is indicated for the control of a blood pressure of 176/96, which increases the cardiac workload and may lead to myocardial ischemia. Albuterol, a bronchodilator, is not the priority at this time;

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?

Oliguria, A decreased blood volume leads to a decreased blood pressure and glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, resulting in decreased urine output.

A ruptured spleen is diagnosed, and the client is scheduled for an emergency splenectomy. What should the nurse include when providing preoperative teaching?

Presence of abdominal drains for several days. Drains usually are inserted into the splenic bed to facilitate removal of fluid that can lead to abscess formation. Bleeding occurs more commonly with splenic repair than with removal.

conduct disorder since the age of 9, history of fighting, stealing, vandalizing property, and running away from home, priority

Preventing violence, conduct disorder are at risk for inflicting physical, emotional, or sexual harm on themselves or others;

A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients?

Staying healthy promotes a quality retirement. Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved.

pulse deficit is

The difference between the heart rate and the palpable pulse, asis often seen in atrial fibrillation.

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness?

The need to follow the prescribed medication regimen. because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms.

A client with osteomyelitis is receiving antibiotic therapy via a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics and peak levels were obtained 30 minutes after the infusion was completed. trough level is higher than the peak level. this finding probably indicates that:

There was a problem with the obtaining of blood specimens. Peak levels will always be higher than trough levels; The trough"drop" level is the lowest concentration in the patient's bloodstream,

What is the nursing action, during the postpartum period, that holds the highest priority for a client with class I heart disease?

Watching for signs of cardiac decompensation. Cardiac decompensation may occur because of the increased circulating blood volume during the early postpartum period, which requires increased cardiac function.

A client diagnosed with osteomyelitis is being discharged. Which statement indicates a need for further teaching?

i will take the antibiotic regularly until my symptoms subside."

best assist a client with an obsessive-compulsive disorder to decrease the use of ritualistic behavior?

limit situations

impervious

not allowing fluid to pass through.

During early and middle adulthood the individual is concerned with the ability to produce and to care for that which is produced or created; failure during this stage leads to

self-absorption or stagnation.

It is essential to prevent infection in a client with severe bone marrow depression;

thorough hand-washing Thrombocytopenia occurs with most chemotherapy treatment programs; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia , sign of infection.

woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking an oral contraceptive. She began experiencing left calf pain 3 days ago and chest pain 15 minutes ago. she calls the emergency department and communicates What is the nurse's best response?

"Give me your name and address. I am sending an ambulance to your home. along with the history of a recent fracture, immobilization, and use of an oral contraceptive, suggest a pulmonary embolism. An ambulance will limit the woman's use of her leg, prevent further emboli.

schizophrenia, paranoid type, insistence of the family. You're one of them. Leave me alone

"I can see that you're upset. We can talk more later." client's feelings and offering an opportunity to talk in the future

"The voices are saying that I killed my husband."

"You seem to be having very frightening thoughts right now."nurse understands the client's feelings

6. A nurse gave a client the prescribed sodium polystyrene sulfonate -Kayexalate To evaluate the effectiveness of this medication, the nurse should assess for:

A decrease in serum potassium level../Sodium treat hyperkalemia. determined by a decreasing serum potassium level. Sodium binds with the potassium in the gastrointestinal system and often causes diarrhea.

A nurse discusses the implications of diet and fluid intake with a client who is receiving lithium therapy. What should the nurse teach the client and family about nutrition?

A regular diet should be maintained. A regular diet maintains sodium balance; lithium decreases sodium resorption by the renal tubules. Initially, weight-reducing diets deplete body fluids;계속

The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of:

Choosing fresh or frozen vegetables instead of canned ones. decreasing sodium in their diet

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply.

Decreased heart rate, Peripheral paresthesia, Decreased bowel sounds. potassium's role in the sodium-potassium pump, hypokalemia may cause nerve and muscle weakness

A nurse is volunteering on the community crisis hotline. What is the final objective of the counseling process?

Developing constructive coping skills. new coping skills are needed to manage anxiety-producing conflicts.

On an ECG tracing the T wave will be peaked with hyperkalemia. HKHT(high K high T)

Diarrhea, not constipation, occurs with hyperkalemia. (sodium exclude potassium saved and became high)

widow with dementia who had been living with her daughter before hospitalization is being discharged with a referral to the visiting nurse. in bed sleeping at 10 am. sleeping pills to stop her wandering at night. The nurse should:

Explore hiring a home health aide to stay with the client at night. will reduce the need for sleeping pills, which frequently add to the older client's confusion. nurse's focus should be helping reduce the confusion the client experiences at night

Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.

Gastrointestinal (GI) suction, Diuretic therapy, Continuous bladder irrigation

the manic phase of a bipolar disorder. What should the nurse do to help the client with personal hygiene?

Guide her to dress appropriately in her own clothing. Having these clients wear personal clothing helps keep them more in touch with reality. Allowing her to apply makeup in whatever manner she chooses may set up the client as a target of ridicule

A nurse is concerned about a client's mother-infant bonding when on the first postpartum day she is reluctant to:

Look at her newborn's face. Looking at the face or seeking eye-to-eye contact with the infant is an early sign of the start of bonding with the infant.

What is the primary concern for grossly impaired by stimulants?

Seizure activity

Senescence meaning

grow old,

end·ar·ter·ec·to·my

surgical removal of part of the inner lining of an artery, together with any obstructive deposits, most often carried out on the carotid artery or on vessels supplying the legs.

insulin is the first-line defense against hyperkalemia. a rise in plasma k+ stimulates insulin release by the pancreatic beta cell. insulin, in turn, enhances cellular potassium uptake, returning plasma k+ towards normal.

the enhanced cellular uptake of k+ that results from increased insulin levels is thought to be largely due to the ability of insulin to stimulate activity of the sodium potassium atpase located in cell plasma membranes.

Autonomy, the ability to control the body and environment, is developed during the

toddler period;

A client had a cholecystectomy and asks whether there will be any dietary restrictions after the client's discharge. The nurse evaluates that the dietary teaching is understood when the client tells a family member:

"I need to eat smaller amounts of food at a time and they should contain low to moderate fats." ultimately most people can eat anything they want. Eating small, more frequent, and moderate- to low-fat amounts of food allow the readily available bile to mix with the food bolus

A client who had a transurethral resection of the prostate is to be discharged from the outpatient surgical department. Which client statement indicates to the nurse that discharge teaching about self-care is understood?

"I will notify my health care provider if persistent bleeding occurs."Intermittent bleeding is expected; however, the health care provider should be notified if bleeding persists. The client driving themselves home after the surgery is unsafe

The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days, trying to help this client shower?

"I'll help you take your shower now."The client is displaying a self-care deficit; stating the intention of helping the client shower is direct, does not require the client to make a decision,

After assessing a client that is in cardiac arrest, a health care provider prescribes a dose of medication that is much higher than is recommended for the clinical situation, and directs the nurse to give the medication immediately. Which response by the nurse is most appropriate?

"That dose is more than I can give legally. However, if the dose is medically indicated, please administer it yourself." informs the health care provider of the nurse's dilemma and legal position without creating an adversarial professional position.

After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response?

"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."

A client who is admitted to the high-risk unit with severe preeclampsia anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond?

"We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat." reassures the client of the well-being of the fetus at the moment and indicates that the nurses are aware of and are monitoring the fetus's status.

It is observed that at times a client with a personality disorder clings to the nurse and at other times he maintains a noticeable distance. The nurse concludes that this pattern of behavior illustrates that the client has conflicting fears of:

Abandonment versus identity loss. Alternating clinginess and distance reflects a reenactment of the mother-child relationship; behavior vacillates between distancing to avoid engulfment and clinging to avoid being rejected.

When entering the room of a client in active labor to answer the call light, the nurse sees that she ashen gray, dyspneic, and clutching her chest. What should the nurse do after pressing the emergency light in the client's room?

Administer oxygen by facemask. The client is exhibiting signs and symptoms of an amniotic fluid embolism; increasing oxygen intake is essential

Vincristine is a plant alkaloid that is cell-cycle specific. It affects cell division during metaphase by interfering with spindle formation and causing cell death. Inhibiting the synthesis of thymidine is the typical action of antimetabolites, not plant alkaloids.

Alkylating nucleic acids needed for mitosis is typical of the action of alkylating agents, not plant alkaloids. Inactivating DNA and RNA synthesis is the typical action of antineoplastic antibiotics, not plant alkaloids.

A client who has an adenocarcinoma of the descending colon with a partial obstruction is receiving doxorubicin ,Adriamycin.The nurse monitors the client for signs and symptoms of doxorubicin toxicity.

Alteration in cardiac rhythm. Doxorubicin toxicity causes severe, not minor, dermatitis. Blue-tinged urine is a side effect of doxorubicin, not a toxic effect. Feelings of nervousness are a side effect of doxorubicin, not a toxic effect.

anxiety disorder who is pacing the halls and crying, nurse suddenly feels uncomfortable and experiences a strong desire to leave

An empathic communication of anxiety , anxiety can be an interpersonal experience, it is contagious

A client with Hodgkin disease is to receive the cyclic antineoplastic vincristine (Oncovin) as part of a therapy protocol. The client asks how this medication works. The nurse explains in language that the client will understand that vincristine helps destroy the malignant cells by:

Arresting mitosis in metaphase

To be most effective when teaching colostomy care to a client, the nurse must first:

Assess barriers to learning colostomy care. Before a teaching plan can be developed, the factors that interfere with learning must be identified.

7. A client at 38 weeks' gestation is admitted with the diagnosis of placenta previa. What is the priority nursing care at this time?

Assessing for hemorrhage. To help prevent maternal and fetal complications the client must be continuously monitored for blood loss through inspections for external bleeding and counting and weighing of perineal pads.

A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part?

At the level of the ischial spines. The ischial spines are used as landmarks in relation to the fetus's head because they reflect the progression of labor; 0 station indicates that the presenting part is at the ischial spines

female client is hospitalized for a bipolar mood disorder, manic episode, is sarcastic to the staff, and taps the nurse playfully on the buttocks

Be aware of his feelings toward the client. Acting-out behavior may precipitate negative feelings toward the client. perceived negative feelings may increase the client's hostility and inappropriate behavior.

A nurse determines that a postpartum client's fundus is firm and has shifted to the right and two fingerwidths above the umbilicus 2 hours after giving birth. What should the nurse conclude about this finding?

Bladder fullness. A distended bladder usually displaces the fundus upward and toward the right because of the anatomic proximity of the bladder and uterus.

Several clients are to be admitted to the mental health unit. How can the nurse manager establish an environment that is conducive to psychological safety?

By emphasizing that there are realistic rules that must be followed. Realistic limits and controls provide a degree of security that adds to the client's emotional safety by limiting choices, reducing the need for self-regulation, and decreasing the need for decision-making.

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to:

Change the child's bed while he changes his pajamas. will not call attention to the accident and will minimize the child's embarrassment. child would probably be unable to change the bed without assistance; failure to complete the task might add to his embarrassment.

A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order?

Check health care provider's prescription. Obtain vital signs and history of transfusions. Ascertain that intravenous catheter size is 18 or 20 gauge. Change main line solution to normal saline. Check client identification before hanging unit of blood.

28. A client at 35 weeks' gestation is admitted to the high-risk unit with a small amount of bright-red vaginal bleeding. Once the client has been placed in a bed, what is the next nursing intervention?

Checking fetal heart tones. Because of the vaginal bleeding, the priority nursing action is determining whether a viable fetus is present. Amniotomy and vaginal examination are both contraindicated;

A nurse is assessing a newborn with congenital toxoplasmosis. What clinical finding does the nurse expect to identify on assessment?

Chest circumference larger than head circumference. is microcephaly; Reddish areas on the head are telangiectatic nevi called stork bites. they are benign and do not require treatment. A serosanguineous nasal discharge is a sign of congenital syphilis called snuffles.

GI fluids are rich in sodium ions, which are lost by gastrointestinal suction. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia.

Continuous irrigation with a hypotonic solution can precipitate water intoxication, resulting in hyponatremia.

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain one week later. What does the nurse identify as the cause of the posttherapeutic neuralgia?

Damage to the nerves.After the original infection has healed, the virus remains quiescent, or it may return. Posttherapetic neuralgia, which occurs in some individuals, results from damage to the nerves caused by the varicella-zoster virus; The rash does not cause posttherapeutic neuralgia.

For which client should the nurse conclude that a prescription for digoxin (Lanoxin) is appropriate?

Digoxin (Lanoxin) is used to treat atrial fibrillation. sinus bradycardia; digoxin is contraindicated.

An older adult tells the nurse, "I regret so many of the choices I've made during my life." Which of Erikson's developmental conflicts has the client probably failed to accomplish?

Ego integrity versus despair. The sense of ego integrity comes from satisfaction with life and acceptance of what has been and what is. Despair reflects guilt or remorse over what might have been.

A client with emotional problems is being discharged from a psychiatric unit. What should the nurse encourage the client to do?

Enroll in an aftercare program. Close follow-up and continued monitoring of medication, behavior, and emotional state are necessary to enable the client to maintain a positive behavioral change.

9. A client with a suspected placenta previa is to have a repeat sonogram at 16 weeks' gestation. What nursing intervention is needed to prepare for this procedure?

Ensuring that the client drinks two 8-oz glasses of water. A full bladder helps stabilize the uterus during sonography, allowing better visualization of the fetus;

In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent?

Fetal hypoxia. Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the developmental stage of:

Generativity versus stagnation,

needle biopsy of the liver. The nurse should monitor the client for which complication that is associated with this procedure?

Hemorrhage. with an impaired liver, blood-clotting mechanisms are disrupted and hemorrhage may occur after a liver biopsy

A client in the postanesthesia care unit after a laparoscopic cholecystectomy experiences nausea and vomiting. The nurse concludes that the nausea and vomiting probably are precipitated by:

Hydromorphone (Dilaudid). Nausea and vomiting are common side effects of hydromorphone; the nurse should notify the health care provider and obtain a prescription for an antiemetic and a different drug for pain relief.

10. A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching has been understood when the client makes what statements? Select all that apply.

I can include bran muffins in my breakfast daily.""I will walk every day as part of my exercise regimen."

The nurse is counseling a pregnant client with type 1 diabetes about medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy?

Insulin. Usually as pregnancy progresses there are alterations in glucose tolerance and in the metabolism and utilization of insulin. The result is an increased need for exogenous insulin.

10. When administering albumin intravenously, the nurse considers that body water will shift from the:

Intracellular compartment to the intravascular compartment. The interstitial compartment is part of the extracellular compartment.

depressed client is very resistive and complains about inabilities and worthlessness.

Involve the client in activities in which success can be ensured.

A nurse is counseling a client who is experiencing preterm contractions in the 35th week of gestation and whose cervix is dilated 2 cm. What should the nurse teach this client about sexual intercourse at this time?

It is prohibited because it may stimulate labor. Prostaglandins in semen may stimulate labor, and penile contact with the cervix may increase myometrial contractility. Sexual intercourse may cause labor to progress;

A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition?

Ketones as a result of rapid fat breakdown, causing acidosis. sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid, not excess base bicarbonate

A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate shows:

Late decelerations. The fetus with a borderline cardiac reserve will demonstrate hypoxia by a decreased heart rate when there is minimal stress, making the CST result positive.

A nurse employed in an outpatient radiology department is reviewing safety precautions with staff members. What explanation does the nurse provide to explain the reason radium is stored in lead containers?

Lead functions as a barrier. Radium atoms are unstable and spontaneously disintegrate. This disintegration produces potentially harmful radiation; lead is a barrier to radiation.

2-year-old boy's mother attempts suicide , nurse's priority when planning care

Maintaining constant observation of the client. suicide attempt increases the probability of another attempt.

at increased risk for suicide. What is a contributing factor

Overwhelming feelings of guilt,

G5 T1 P1 A2 L2. G (gravida) stands for the total number of pregnancies a client has had. Gravida 5 indicates that this is the client's fifth pregnancy. T (term) stands for the number of neonates born at the expected date of birth. The neonate born at 38 weeks' gestation was born at term.

P (preterm) stands for the number of neonates born before the expected date of birth. The neonate born at 34 weeks' gestation was born preterm. A (abortion or miscarriage) stands for the birth of a fetus before 20 weeks' gestation. Both the miscarriage and elective abortion are considered abortions. L (living) stands for the number of living children at the time of assessment. The client has two living children.

A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. What characteristic typical of placenta previa supports the nurse's conclusion?

Painless vaginal bleeding in the third trimester. As the lower uterine segment stretches and thins, tearing and bleeding occur at the low implantation site.

Excessive water in the plasma causes dilution of the serum sodium. Inadequate ADH leads to excess water loss, which causes the serum sodium to increase (hypernatremia).

Parenteral infusion of 0.9% sodium chloride is an isotonic solution that should be compatible with body fluids; if given in excess, it may lead to hypernatremia.

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at −2. For what complication should the nurse assess when caring for this client?

Prolapse of the umbilical cord. A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise

What should a nurse ensure when creating an environment that is conducive to psychological safety?

Realistic limits are set. Realistic limits and controls provide a degree of security that adds to emotional safety by limiting choices, reducing the need for self-regulation, and decreasing the need for decision-making.

The nurse is caring for a client who is receiving azathioprine (Imuran), cyclosporine, and prednisone before receiving a kidney transplant. The nurse explains that the purpose of the medication is to:

Reduce antibody production. These drugs suppress the immune system, decreasing the body's production of antibodies in response to the new organ, which acts as an antigen. 계속

diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem

Reward healthy behaviors.By realistically rewarding the healthy behaviors, the nurse provides secondary gains and encourages the continued use of healthy behaviors.

A 12-year-old child who has a history of school failure and destructive acting out, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family's pattern of relating to the child as:

Scapegoating, When all members of a family blame one member for all their problems, scapegoating is occurring.

A pregnant client arrives at the prenatal clinic, and the nurse obtains her obstetrical history. The client has two children at home, one born at 38 weeks' gestation and the second born at 34 weeks' gestation. 계속질문

She has also had one miscarriage, at 18 weeks, and an elective abortion. Using the GTPAL system, what is the client's obstetrical record?

The physician prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which measure should the nurse take during administration of blood products?

Stay with client during first 15 minutes of infusion.

When the electronic fetal monitor shows contraction occurring every 2 minutes and lasting 95 seconds, the nurse should immediately:

Stop the pitocin infusion. The contraction pattern indicates hyperstimulation of the uterus. Stopping the Pitocin infusion permits relaxation of the uterus and perfusion of the placenta. Oxygen cannot reach the placenta until the uterus is relaxed, so administering oxygen will not help. 계속

an initial concern of paranoid schizophrenia?

Suspicious feelings

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle?

T wave

A client with schizophrenia is given an antipsychotic drug. The nurse recalls that of all the extrapyramidal effects associated with this type of medication, the one that requires discontinuation of the drug is:

Tardive dyskinesia. is characterized by protrusion and vermicular movements of the tongue, chewing and puckering movements of the mouth, and a puffing of the cheeks

What nursing action should be included in the plan of care for a client who had a permanent fixed (asynchronous) pacemaker inserted?

Teach the client to keep daily accurate records of the pulse. A permanent fixed (asynchronous) pacemaker is set at a predetermined rate; if a pulse rate is more or less than the preset rate, the pacemaker may be malfunctioning

A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should:

Tell the client firmly that the behavior is unacceptable. A firm voice is most effective; the statement tells the client that it is the behavior, not the client, that is upsetting to others.

A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. What should the nurse say?

Tell the mother, "I'm sorry, but I need to ask you to stay in the waiting area." In many states a minor who is self supporting and living away from home, providing military service, married, pregnant, or a parent is considered a emancipated minor. responsibilities before the age of 18 years.

21. A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis?

Tender area in the posterior lower leg, Warmth along the course of the involved vessel. Thrombophlebitis, not uncommon after abdominal surgery, is inflammation of a vein; 계속

The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation. If a premature ventricular contraction strikes on the P wave, it will not cause ventricular fibrillation; the P wave represents atrial contraction.

The P-R interval represents the time it takes the impulse to travel from the sinoatrial (SA) node to the ventricular musculature. The QRS complex is the term used to represent the entire phase of ventricular contraction.

Hyperglycemia.

The client's fasting blood glucose is 180 mg/dL. The expected result for fasting blood glucose in a healthy adult is 70 to 110 mg/dL. Also, the client is reporting a small progressive weight loss over the last month and feeling lethargic and thirsty all the time.

A client with history of multiple chronic illnesses comes to the emergency department (ED) complaining of a small progressive weight loss over the last month and feeling lethargic and thirsty all the time.

The client's vital signs are blood pressure (BP) 118/78 mm Hg, oral temperature 99.6º F, pulse 72 beats per minute and regular, and respirations 22 breaths per minute and irregular. The nurse reviews the assessment findings and the client's medical record. What condition does the nurse conclude the client is experiencing?

vomiting are common with hyperkalemia. Because of potassium's role in the sodium-potassium pump, an increase in potassium interferes with muscle contractions; it results in muscle weakness and areflexia.

The heart is a muscle and hyperkalemia can cause palpitations and cardiac dysrhythmias.

A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she is leaking breast milk. The best response is to tell her that:

This can be a normal occurrence during pregnancy. Many women begin to leak breast milk (colostrum) during pregnancy. This may occur during the third trimester. It is completely normal, and there is no issue with her health

A 26-year-old homosexual client is diagnosed with AIDS. The primary nurse reports to the nursing team that the client cried when told of the diagnosis. nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." this comment most likely is a result of

Values and beliefs about sexual lifestyles. regarding homosexuality as being bad and deserving of punishment. Although there may be hostility over having to care for someone with a sexually transmitted infection, no information is given to suggest that the nursing assistant has been assigned to care for this client.

A client's membranes rupture during labor, and the amniotic fluid is meconium stained. Which heart rate pattern indicates that the fetus's status is nonreassuring?

Variable decelerations that last 60 seconds, then return to baseline tachycardia. Variable decelerations indicate cord compression; they should return to baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection,

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit?

Vomiting Muscle weakness Irregular heart rate

When the head enters the vagina it is below the ischial spines and its position is designated with positive numbers (e.g., +1 to +4).

When the presenting part is floating, the fetus is at -5 station. A position above the ischial spines is designated by a minus number (e.g., -1 to -4).

11. A client is being prepared for an emergency cesarean birth because of nonreassuring fetal signs. What is most important for the nurse to determine before surgery?

Whether a signed consent is included in the client's record

post motor vehicle crash. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client?

Whole blood products. The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive. Therefore the most appropriate parenteral fluid is whole blood.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response?

You are having difficulty deciding what to say."The correct response promotes an exploration of the client's dilemma; it encourages further communication. It is inappropriate for the nurse to give advice.

As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, she says, "I have nothing to talk about." What is the best response by the nurse?

You feel you won't be accepted unless you have something to say?" The statement about the client's feelings of acceptance is a reflective statement that allows the client to either validate the statement or correct the nurse.

Multiple myeloma is

a cancer formed by malignant plasma cells.

when internal bleeding occurs Hypokalemia, not hyperkalemia, occurs because

as sodium is retained, potassium is excreted.

During puberty adolescents attempt to find themselves and integrate their own values with those of society; an inability to solve conflict results in

confusion and hinders mastery of future roles.