Implementation EAQ
A nurse is preparing an intramuscular injection to be administered to a 2-year-old child. What approach is the most therapeutic? Correct1 "This might hurt, but it's important that you be very still." 2 "You're afraid of getting a shot because you think it will hurt." 3 "Don't worry—Daddy and Mommy will be back after it's over." 4 "Act like a big child and we can get this done as quickly as possible."
1 "This might hurt, but it's important that you be very still." Telling the child that the shot will hurt but that it's important for the child to remain still is an honest statement that tells the toddler what to expect and expresses the nurse's expectation that the toddler will stay still during the procedure. Emphasizing the child's fears will exacerbate these fears. The parents should be encouraged to stay with the child to provide comfort. Asking the child to be brave puts unrealistic expectations on the child.
An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period? 1 Limiting fluids until the crisis ends Correct2 Administering prescribed analgesics 3 Applying cold compresses to painful joints 4 Performing range-of-motion exercises of affected joints
2 Administering prescribed analgesics The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling. Cold will constrict blood vessels, further depleting oxygenation to affected parts; warmth is preferable. There is too much swelling and pain in the joints during a crisis for the implementation of range-of-motion exercises.
A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. Taking into consideration food preferences, the nurse encourages the client to eat: Correct1 Broccoli 2 Oatmeal 3 Fried rice 4 Cooked carrots
1 Broccoli Potassium is plentiful in green leafy vegetables; broccoli provides 207 mg of potassium per half cup. Oatmeal provides 73 mg of potassium per half cup. Rice provides 29 mg of potassium per half cup. Cooked fresh carrots provide 172 mg of potassium per half cup; canned carrots provide only 93 mg of potassium per half cup.
A nurse administers cephulac (Lactulose) to a client with cirrhosis of the liver. Which response leads the nurse to determine that the cephulac is effective? 1 Decreased amylase Correct2 Decreased ammonia 3 Increased potassium 4 Increased hemoglobin
2 Decreased ammonia Cephulac destroys intestinal flora that break down protein and in the process give off ammonia. In clients with cirrhosis, ammonia is inadequately detoxified by the liver and can build to toxic levels. Amylase levels are associated with pancreatic problems. Potassium is not directly affected by neomycin; it may increase if nephrotoxicity occurs. Hemoglobin is not influenced by neomycin.
A client is admitted with a conversion disorder. What is the primary nursing intervention? 1 Talking about the physical problems Correct2 Exploring ways to verbalize feelings 3 Explaining how stress caused the physical symptoms 4 Focusing on the client's concerns regarding the symptoms
2 Exploring ways to verbalize feelings The priority is getting the client to express feelings appropriately rather than through the use of physical symptoms. Focusing on symptoms will encourage their use by the client. An expression of feelings, not an intellectual understanding of the cause of the symptoms, is required. Avoidance of feelings resulted in the symptoms. Clients with a conversion disorder are rarely concerned about the associated physical problem; this is known as la belle indifférence.
After a subtotal gastrectomy a client is returned to the surgical unit. Which is the best nursing action to prevent pulmonary complications? 1 Ambulating the client to increase respiratory exchange Correct2 Promoting frequent turning and deep breathing to mobilize secretions 3 Maintaining a consistent oxygen flow rate to increase oxygen saturation 4 Keeping a plastic airway in place to ensure patency of the client's airway
2 Promoting frequent turning and deep breathing to mobilize secretions To promote drainage of different lung regions, clients should turn every two hours. Deep breathing inflates the alveoli and promotes fluid drainage. During physical effort, individuals with abdominal incisions often revert to shallow breathing. Oxygen administration is a dependent function and generally is not required unless there is underlying cardiac or respiratory disease. The airway is expelled when the gag reflex returns.
A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: 1 Eat a low fat, low protein diet 2 Avoid foods high in carbohydrates Correct3 Avoid ingesting alcoholic beverages 4 Eat a bland diet of six small meals a day
3 Avoid ingesting alcoholic beverages Alcohol increases pancreatic secretions, which cause pancreatic cell destruction. Although the diet should be low in fat, it should be high in protein; also, it should be high in carbohydrates. The client should be consuming a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet is not necessary, but large, heavy meals should be avoided.
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions Correct3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties
3 Increased blood pressure and decreased hormone production With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.
A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do? 1 Stay in bed, drink fluids, take a dose of aspirin, and ask the health care provider to reduce the dosage of clozapine 2 Discontinue the medication immediately and see the health care provider as soon as an appointment becomes available 3 Continue the medication, drink fluids, take aspirin, and see the health care provider in a few days if the symptoms do not improve Correct4 Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation
4 Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation Symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and can cause death. Remaining in bed, drinking fluids, taking aspirin, and asking the health care provider to decrease the dose of clozapine is unsafe because agranulocytosis may be developing, and this life-threatening side effect requires immediate treatment. Also, prescribing medications is outside the legal role of the nurse. Only a certified nurse practitioner can prescribe medications. Although discontinuing the medication is acceptable advice, delaying a health care provider's evaluation is unsafe. Continuing the medication, drinking fluids, taking aspirin, and seeing the health care provider in a few days if the condition does not improve is unsafe because agranulocytosis may be developing.
The mother of a 13-year-old child with sickle cell anemia tells the nurse that the family is going camping by a lake this summer. She asks what activities are appropriate for her child. Which activity should the nurse suggest? 1 Swimming in the lake 2 Soccer with the family 3 Climbing the mountain trails Correct4 Motorboat rides around the lake
4 Motorboat rides around the lake Motor boating is a relatively passive activity that will not increase the child's oxygen demands, which can precipitate sickling and therefore a painful episode. Mountain lakes are usually cold; temperature extremes can contribute to sickling that may precipitate a painful episode. Playing soccer may lead to increased cellular metabolism and increased tissue hypoxia, which can precipitate sickling that could progress to a painful episode. High altitudes should be avoided because the lower oxygen concentration of the air might trigger a painful episode.
