Leadership

positive babinski reflex

dorsiflexion of the big toe and fanning of all toes

Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to

rotate staff members assigned to care for the client

Hyperemesis gravidarum s/s

Clinical features Weight loss Poor skin turgor Dry mucous membranes Hypotension Tachycardia. Laboratory abnormalities Hypokalemia/hyponatremia Ketonuria Increased urine specific gravity Hemoconcentration Metabolic alkalosis

Toddlers (age 1-3) enjoy imitative and pretend play, such as making inanimate objects (eg, dolls, stuffed or plastic animals, toy cars) perform typical actions and sounds (Option 4). Toys that are pushed or pulled and riding toys can also accommodate the toddler's developing gross motor skills.

Cloth books are appropriate for infants (Option 2). Collectible items and activities that require advanced fine motor skills are appropriate for school-age children

Puzzles would be more appropriate for the school-age child

(6-12 years).

Stacking blocks would be more appropriate for the toddler

(age 1-3 years)

Maintaining contact with peers would be more appropriate for the adolescent

(age 12-19 years)

School-age children possess concrete thinking and fear loss of control. When administering an injection to a school-age child, the nurse should offer a specific, task-based coping technique

(eg, instruct the child to count aloud or breathe deeply) to increase the child's sense of control and thereby reduce anxiety

hyperemesis gravidarum

(ie, excessive vomiting during pregnancy) leads to fluid and electrolyte imbalances (eg, hypokalemia, hypotension), weight loss of ≥5% of prepregnancy weight, nutritional deficiencies, and ketonuria. Urine ketones are expected because they are a by-product of fat breakdown, which occurs in starvation states.

Kawasaki disease

(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.

Hemoglobin lab values

*Male:* 14-18 g/dl *Female:* 12.0-16.0 g/dl

Lithium level (therapeutic)

0.6-1.2 mEq/L

Anorexia is a common side effect of lithium (therapeutic index

0.6-1.2 mEq/L [0.6-1.2 mmol/L]). Lithium toxicity produces nausea, vomiting, ataxia, and tremors.

Lithium level

0.6-1.2 over 1.5 is toxic

Digoxin (Lanoxin) level

0.8-2.0 ng/mL

Fetal sex may be determined on ultrasound as early as the end of

12 weeks gestation

NPH is an intermediate-acting insulin with a duration of

12-18 hours and typically prescribed twice a day.

The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least

2 weeks for the diagnosis of major depressive disorder to be made

The therapeutic INR for a client with a mechanical heart valve is

2.5-3.5

A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to this client about which possible side effect? 1. Constipation [18%] 2. Sedation [35%] 3. Sexual dysfunction [40%] 4. Weight loss [5%]

3 / elective serotonin reuptake inhibitors (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation

Crayons drawing

3-6 years

HbA1c levels

4%-6%

WBC count

4,500-11,000

This is the appropriate therapy for croup

4. Nebulized racemic epinephrine with a pediatric anesthesiologist standing by

If AOM symptoms do not improve within

48-72 hours of starting antibiotics, a follow-up visit is required to determine if a different antibiotic is necessary

The nurse is reinforcing teaching about how to use a metered-dose inhaler to a 9-year-old with asthma. Place the nurse's instructions in the appropriate order.

5. Shake the inhaler and attach it to spacer 1. Exhale completely 3. Place lips tightly around the mouth piece 2. Deliver one puff of medication into spacer 6. Take a slow deep breath, and hold it for 10 seconds 4. Rinse mouth with water

The normal resting heart rate for adults over the age of 10 years, including older adults, is between 60 and 100 beats per minute (bpm). Highly trained athletes may have a resting heart rate below

60 bpm, sometimes reaching 40 bpm. The resting heart rate can vary within this normal range

Fetal heart tones can be detected by

7 weeks gestation.

Intelligent Quotient (IQ)

A person's tested mental age divided by chronological age, multiplied by 100.

Osteogenesis imperfecta (brittle bone disease)

Abnormal collagen synthesis (glycosylation to form tropocollagen triple helices) causing abnormal type I collagen, multiple fractures (bone), blue sclera, hearing loss, dental imperfections (dentin); type I is AD, type II is fatal

Alprazolam (Xanax)

Benzodiazepine

botulinum toxin type A

Botox

Meckel diverticulum

Bright red rectal bleeding could be a symptom of

vesicles function

Carries materials into and out of the cell

Botulism

Clostridium botulinum

Adalimumab (Humira)

Disease-modifying antirheumatic drug (DMARD). Interrupts complex immune responses, preventing disease progression. Uses: slow joint degeneration and progression of rheumatoid arthritis.

Hydrochlorothiazide (HCTZ)

Diuretic

Veracity refers to

Duty to tell the truth

Levofloxacin (Levaquin)

Fluoroquinolone Antibiotic

Tetralogy of Fallot (TOF) is a cyanotic congenital heart defect commonly manifested by signs of irritability and clubbing of fingers due to oxygen saturation chronically remaining between 65-85% until the client can undergo surgical repair.

Further evaluation of the client's oxygenation is necessary but not urgently required.

The Pavlik harness is used in the treatment of DDH; it maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Strap adjustments should be performed by the

HCP to allow for proper positioning and avoid nerve or vascular damage

Blood loss anemia

Hemorrhagic anemia Chronic hemorrhagic anemia

petechiae/purpura

Hemorrhagic spots. Petechiae are pin sized, Purpura are larger.

Adolescent clients are at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include:

Hypersomnolence or insomnia; napping during daily activities (Option 3) Low self-esteem; withdrawal from previously enjoyable activities (Option 4) Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior (Option 1) Weight gain or loss; increased food intake or lack of interest in eating (Option 2) Depression is also a significant cause of suicide in adolescents

What does a negative Babinski test mean?

In adults or children over 2 years old, a positive Babinski sign happens when the big toe bends up and back to the top of the foot and the other toes fan out. This can mean that you may have an underlying nervous system or brain condition that's causing your reflexes to react abnormally

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage?

Infant birth weight 9 lbs 2 oz

patent ductus arteriosus

Loud machine like murmur

The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect?

Manifestations of abuse or neglect in an older adult may include development of pressure ulcers, poor hygiene, dehydration, malnutrition, weight loss, soiled bedding/clothing, missing/broken assistive devices, and missing or expired medications Breaks eye contact

malignant melanoma

Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised.

Memantine (Namenda)

NMDA receptor antagonist (Alzheimer's disease)

Pediculosis Capitis (Head Lice)

Nits that are shed into the environment are capable of hatching for up to 10 days. Pets do not transmit or carry lice.

Hypertrophic Pyloric Stenosis (HPS)

Nonbilious vomiting is seen in conditions in which the pathology is proximal to the pylorus

heart rate in beats per minute

Normal sinus rhythm has a heart rate of 60 to 100 beats per minute. A heart rate less than 60 beats per minute is bradycardia and heart rates above 100 are considered tachycardia.

This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac diseas

Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption

Pertussis infection

Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease = droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease.

The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include:

Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults

Trazodone (Oleptro)

Priapism is a known serious side effect of trazodone. A client with an erection lasting several hours should go to the hospital. (Option 2) Clients should be advised to rise from supine to standing slowly, in stages, due to the risk of orthostatic hypotension. (Option 3) The drug should be taken at bedtime to avoid daytime sedation.

hypertrophic pyloric stenosis

Projectile vomiting after feeding is a classic manifestation of

Ventriculoperitoneal (VP) Shunt

Removes excess CSF from ventricle in brain

A nurse is measuring the uterine fundal height of a client who is at 36 weeks gestation in supine position. The client suddenly reports dizziness and the nurse observes pallor and damp, cool skin. What should the nurse do first?

Reposition client into a lateral position / Supine hypotensive syndrome is usually seen in the third trimester of pregnancy when the weight of the uterine contents compresses the inferior vena cava. Resultant maternal hypotension is best treated initially by immediately turning the client to the right or left side to relieve pressure on the vena cava

The mnemonic SAD PERSONS uses known risk factors and the concept of their accumulation to help predict who is at higher risk of committing suicide

S Sex (men kill themselves more often than women; women make more attempts) A Age (teenagers/young adults, age >45) D Depression (and hopelessness) P Prior history of suicide attempt E Ethanol and/or drug abuse R Rational thinking loss (hearing voices to harm self) S Support system loss (living alone) O Organized plan; having a method in mind (with lethality and availability) N No significant other S Sickness (terminal illness)

Paroxetine (Paxil)

SSRI antidepressant

Sertraline (Zoloft)

SSRI antidepressant

negative babinski reflex in newborn

Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp. The grasp reflex lasts until about 5 to 6 months of age. Babinski reflex. When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out.

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene?

Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful

The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety

The nurse should encourage clients with posttraumatic stress disorder to talk about the experience at their own pace, listen actively to build trust, and allow clients to vent. This will assist in decreasing their feelings of isolation.

Hirschsprung disease

Thin, ribbon-like stool is characteristic of

The GTPAL system is a shorthand system of documenting a client's obstetric history

This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation

. ... This medication is used to treat eye infections. Tobramycin belongs to a class of drugs called aminoglycoside antibiotics.

Tobramycin Drops

Magnesium Sulfate Indications

Torsades De Pointes, Seizures of eclampsia (toxemia of pregnancy). Status asthmaticus refractory to beta-2 agonists, anticholinergic drugs, and steroid treatments.

Ototoxicity

Toxicity to the ears, often drug induced and manifesting as varying degrees of hearing loss that is likely to be permanent.

Mastitis is a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema).

Treatment of lactational mastitis includes antibiotic therapy, breast support, adequate hydration, analgesics, and frequent (every 2-3 hours) continued breastfeeding.

Neuroleptic Malignant Syndrome (NMS)

a potentially fatal, idiosyncratic reaction to an antipsychotic (or neuroleptic) drug

Wilms tumor

a rare type of malignant tumor of the kidney that occurs in young children

Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from

anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban).

Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, drooling, and a distended abdomen. Clients may also develop

apnea and cyanosis while feeding. These findings must be reported to the health care provider for further evaluation.

Prenatal exposure to maternal illicit drug use results in abstinence syndrome in the neonate. Neonatal abstinence syndrome affects the

autonomic nervous system (stuffy nose, frequent yawning), gastrointestinal tract (poor feeding, diarrhea), and central nervous system (irritability, restlessness, high-pitched cry)

Impetigo

bacterial skin infection characterized by isolated pustules that become crusted and rupture

percutaneous coronary intervention

balloon-tipped catheter is inserted into a coronary artery to open the artery; stents are put in place

Muffled heart tones that are heard postsurgical intervention are concerning for

cardiac tamponade

Aspiration of a foreign body occurs most often in the toddler age group. Swallowing of objects such as buttons, small parts of toys, or food particles can be life-threatening and result in airway obstruction due to the small diameter of the airway. Manifestations include

choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx

Weak lower and strong upper extremity pulses are present in

coarctation of the aorta

Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by

decreasing inflammation

New-onset confusion regarding sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy can be manifestations of

delirium

Nonmaleficence means:

do no harm

Nonpharmacological strategies for improving sleep hygiene include

exercising during the day, engaging in a relaxing activity before bedtime, dealing with worries at a set time of day, providing a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and drinking a warm cup of milk before bedtime

Compensation involves

experiencing a perceived deficit in one area and making up for it by overachieving in another. An example is someone not doing well academically who focuses on doing well in sports.

Esophageal atresia (EA)

failure of the esophagus to develop a continuous passage

Preconception care involves

folic acid supplementation; maintaining a normal weight (BMI 18.5-24.9); receiving any missed vaccinations; abstaining from tobacco, alcohol, and illicit drugs; and avoiding contact with raw or undercooked meats.

Acute Manic Episode

grandiose delusions, difficulty concentrating, agitation

Erythropoietin (EPO)

hormone secreted by the kidney to stimulate the production of red blood cells by bone marrow

Hawthorn extract is used to control

hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding.

Friends play a significant role in the adolescent's quest for identity and provide a source of support, belonging, and understanding. Interacting with friends during recuperation after surgery is

important to help counteract feelings of loneliness and isolation

Commonly used medications that are absolutely contraindicated

in pregnancy include doxycycline, isotretinoin, and ACE inhibitors

endometritis

inflammation of the inner lining of the uterus

stomatitis

inflammation of the oral mucosa

Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation

is the best indicator of treatment effectiveness as it reflects gas exchange Improvements in oxygen saturation and peak expiratory flow are the best indicators of treatment effectiveness during an acute asthma attack

Clients with hemophilia are at risk for permanent

joint destruction due to frequent bleeds into the joint spaces. Assisting clients with decreasing the incidence of bleeding episodes and prompt treatment when bleeding occurs can help minimize joint destruction

Chemotherapy and radiation therapy would

kill tumor cells and reduce tumor size

anti-infective

kills and inhibits growth of bacteria

Black cohosh is used for treatment of

menopausal symptoms. The main side effect is liver injury.

Pediculosis capitis (head lice) is a parasitic infestation that is seen often in school-age children. Measures to control the spread and reinfestation include using

nit combs, soaking hair brushes and accessories in boiling water, and vacuuming rugs/carpets frequently

Sacral counterpressure and hydrotherapy promote

pain relief, and ambulation promotes fetal descent, but none of these interventions facilitate fetal rotation, which is needed to promote a vaginal birth

patent ductus arteriosus (PDA)

passageway (ductus arteriosus) between the aorta and the pulmonary artery remains open (patent) after birth

Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if

songs, newspaper articles, and other events are personal to them.

If toddlers are not expressing themselves verbally and do not enjoy and learn as family members talk or read to them

speech and hearing deficits should be explored.

lochia

the postpartum vaginal discharge that typically continues for 4-6 weeks after childbirth

ducational objective: Otitis media, inflammation of the middle ear, commonly occurs in children under age 2. Key interventions for prevention include avoiding exposure to

tobacco smoke, obtaining routine immunizations, and discontinuing use of a pacifier after age 6 months

An 18-month-old should have a vocabulary of

≥10 words and be able to perform fine motor functions (eg, use a spoon, hold and drink from a cup).

The child will need to adhere to a gluten-free diet for life

A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW).

Nursing management of a newborn includes using standard precautions when in contact with blood or body fluids (eg, bathing), maintaining the infant's airway

suction the pharynx before the nose), thermoregulation, and administering vitamin K and prophylactic ophthalmic ointment

Electroencephalogram (EEG)

An amplified recording of the waves of electrical activity that sweep across the brain's surface. These waves are measured by electrodes placed on the scalp.

Meningococcal meningitis symptoms

Fever, chills, severe headache, altered mental status, nausea, vomiting, stiff neck, photophobia, petechiae and echymosis.

Hematocrit lab values

Male: 42%-52% Female: 37%-47%

The best response to a client or family member who expresses doubts about ECT is to ask about their concerns. Responses such as,

Tell me about your concerns," or "What do you understand about ECT?" allow the nurse to assess their knowledge and implement educational interventions to address any misinformation or knowledge gaps.

The nurse should allow a parent to interact with the toddler and assist with the examination process to encourage client cooperation. Examination of a toddler should proceed from least to most invasive, allowing the client to inspect pieces of equipment before use.

Use minimal physical contact initially.

The nurse would expect to hear a murmur with an

atrial septal defect

Metronidazole (Flagyl) is an

anti-infective assigned the pregnancy category B. Clients should be taught that metronidazole might cause their urine to turn dark.

Metronidazole (Flagyl) is an

antibiotic that can be used to treat a Trichomonas infection. There is no contraindication for its use in clients with Crohn disease.

TNF inhibitors are

antibodies made in a lab from human or animal tissue. (Your body makes antibodies to fight off infections.) Once they're put into your blood, they cause a reaction in your immune system that blocks inflammation. Your immune system makes a substance called tumor necrosis factor

Rivaroxaban (Xarelto)

blood thinner

pulmonic stenosis

calcification of pulmonic valve that restricts forward flow of blood during systole

Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect pregnant clients from illness and provide the fetus with passive immunity. Live virus vaccines are

contraindicated in pregnancy

Sumatriptan is contraindicated in clients with

coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction.

The most accurate indicator of fluid loss or gain in an acutely ill client is

daily weight measurement

Postpartum vaginal bleeding that saturates a perineal pad in <1 hour is considered excessive. Furthermore, a boggy fundus indicates uterine atony. A fundus elevated above the umbilicus and deviated to the right suggests a

distended bladder

In a child with atrial septal defect, the nurse would expect to hear a

heart murmur on auscultation of heart sounds.

Left-to-right cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) result in excess blood flow to the lungs. Manifestations include

heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure

Nitroprusside is a potent vasodilator often used for

hypertensive emergency or urgency

Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent

hypoglycemia

Using the priorities of airway, breathing, and circulation, maintenance of airway function requires

immediate intervention by a nurse

Osteomyelitis

inflammation of bone and bone marrow

The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary. Acetaminophen is the appropriate medication to reduce the discomfort of the injection. Aspirin should be avoided in children due to the risk

of Reye syndrome. Unless the rash becomes widespread, isolation of the child is unnecessary. It is unlikely that the infection will be transmitted by the 2 vesicles, but covering them with clothing or a small bandage will decrease the risk of transmission

Wilms tumor is discovered when caregivers note an unusual bulging/swelling on one side of a child's abdomen. The abdomen should not be

palpated once diagnosis is suspected or confirmed as this can disrupt the tumor and cause dissemination of tumor cells.

Creatinine lab values

same as lithium 0.6-1.2 Not a huge worry, not a dangerous lab to worry about

A heart rate of 62/min is expected in a client taking digoxin (therapeutic index

0.5-2.0 ng/mL [0.6-2.6 nmol/L]). Digoxin toxicity produces gastrointestinal symptoms (nausea, vomiting, diarrhea), bradycardia, and visual disturbances (blurred vision, yellow-green halos).

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. 1. Furosemide [46%] 2. Glipizide [14%] 3. Levofloxacin [11%] 4. Potassium chloride [26%]

1 / Decrease in blood pressure, increase in pulse rate, output greater than intake, hypernatremia, and decrease in serum potassium are manifestations that can indicate hypotonic dehydration in a client receiving diuretic therapy.

This is a recommended therapy for spontaneous tension pneumothorax, which is demonstrated by tracheal deviation, absent lung sounds, and severe abrupt hypotension and dyspnea

1. 20-gauge needle insertion at the mid-axillary line for pleural aspiration

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply

1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

The average newborn head circumference is approximately

13-14 inches (33-35 cm). The RN should be notified if a newborn has a smaller or larger head circumference, which may indicate an abnormal condition (eg, microcephaly, hydrocephalus).

Toddlers display behaviors associated with negativism and ritualism as they seek autonomy. When teaching about toddler health promotion, the nurse should tell parents to avoid giving options that allow toddlers to say "no", refrain from forcing toddlers to eat, allow toddlers a

15- to 30-minute period to calm down before meals, and use time-outs for management of temper tantrums.

Fetal movements are typically felt at around

16-20 weeks gestation

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy? 1. "I won't need a bolus dose of insulin before my meals anymore." [26%] 2. "I'm glad my blood sugars won't go way up and way down, like they did before." [36%] 3. "I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore." [34%] 4. "It'll finally be easier for me to lose some weight." [2%]

2 / client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain

The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent gastric irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption."

3 ,5 / Liquid iron supplements are best absorbed on an empty stomach. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration. Iron may be given with meals to reduce gastric irritation; however, this will decrease absorption.

A 5-year-old child is receiving morphine sulfate for pain. Which statement by the caregiver indicates that further teaching is necessary? 1. "I will call the nurse if my child begins to act aggressively." [7%] 2. "I'm concerned that my child thinks the pain is punishment." [12%] 3. "My child is playing and so does not need pain medication." [75%] 4. "The FACES pain scale seems to be working very well." [4%]

3 / A child's expression of pain varies based on developmental stage and past experiences with pain. The nurse should use age-appropriate pain scales. A child who is asleep or playing may be experiencing pain.

A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? Click on the exhibit button for additional information. 1. Epoetin [8%] 2. Sodium polystyrene sulfonate [11%] 3. Vitamin K [42%] 4. Warfarin [37%]. Laboratory results Activated partial thromboplastin time (aPTT) 53 sec International normalized ratio (INR) 2.3

3 / Vitamin K (phytonadione) is a fat-soluble vitamin that is administered as an antidote for warfarin-related bleeding. This medication prescription should be questioned as vitamin K reverses the anticoagulant effect of warfarin, and the client's coagulation studies are in the therapeutic range (aPTT 46-70 sec, INR 2-3)

The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation? 1. Bilateral bowlegs (genu varum) in a 15-month-old [7%] 2. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant [12%] 3. Lateral curvature to the spine noted on examination of a 10-year-old girl [50%] 4. Presence of an S3 heart sound in a 2-year-old [29%]

3, / An S3 heart sound is a normal finding in children. Bowlegs are common until age 18-24 months. Scoliosis is always abnormal, and its early detection and prompt treatment may reduce the need for surgical intervention./A rounded, nearly circular chest shape with the front-to-back (anteroposterior) diameter approximately equal to the side-to-side (lateral) diameter is an expected finding in a healthy infant

The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic? 1. Call the office if the toddler's temperature is higher than 100 F (37.7 C) [33%] 2. Fussiness and anorexia are common for 1 week after immunizations [4%] 3. Redness at the injection sites and a mild fever are common [59%] 4. The toddler's activity level should be restricted for 24 hours [2%]

3, / Common side effects of immunizations include a mild fever and soreness and redness at the injection site. Anorexia and fussiness can be present for the first 24 hours.

Magnesium sulfate is prescribed for clients with preeclampsia to prevent seizure activity. A therapeutic magnesium level of

4-7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client

Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention of deep vein thrombosis and pulmonary embolism after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than

6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place due to bleeding risk. The supervising registered nurse should be contacted for direction regarding holding or administering this medication in collaboration with the healthcare provider (HCP)

A client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. The clients diagnosed with blood loss anemia and anorexia nervosa are not in danger of infecting each other

A client who has fresh surgical wounds or is immunocompromised should not share a semi-private room with a client who has an active or suspected infection.

A nurse finds a client unresponsive and is unable to palpate a pulse. Resuscitation is initiated and continued by the rapid response team. The nurse then finds a do not resuscitate (DNR) prescription in the client's chart. What is the appropriate action by the nurse?

A do not resuscitate (DNR) prescription is a type of advance directive that expresses the client's wish not to be resuscitated in the event of cardiac or respiratory arrest. Many health care professionals automatically react to an emergency situation. Some states will penalize health care workers with loss of their professional license if they fail to render CPR in an emergency situation. Health care professionals will not be penalized for an honest mistake; however, resuscitation must end immediately after they are notified of a DNR prescription / Do not resuscitate prescriptions are legally binding. Failure to stop an erroneous code on a client with an advance directive in a timely fashion may result in legal action

somnolence (or "drowsiness")

A state of near-sleep, a strong desire for sleep, or sleeping for unusually long periods. It has two distinct meanings, referring both to the usual state preceding falling asleep and to the chronic condition that involves being in that state independent of a circadian rhythm. Compare with HYPERSOMNIA.

The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives.

Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting

A toddler's development centers on both fine and gross motor skills. By 18 months, the toddler should be able to manage stairs while holding a hand and turn 2 or 3 pages in a book. The direction of development is toward improving locomotion skills (Options 1 and 5). (Options 2, 3, and 4) A 24-month-old should be able to build a tower of 6 or 7 blocks, run without falling, and have a vocabulary containing over 300 words.

An 18-month-old typically is developing both fine and gross motor skills, which include going up stairs while holding a hand and turning 2 or 3 pages in a book.

Mononucleosis is caused by the Epstein-Barr virus.

Antibiotic treatment is inappropriate for a viral infection.

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" [37%] 2. "Do you wipe from front to back after urinating?" [21%] 3. "Have you found that you urinate more frequently since becoming pregnant?" [2%] 4. "Have you had a urinary tract infection in the past?" [38%]

Are you having any pain in your lower back or flank area?

Kawasaki disease (treatment)

Aspirin -- prevents platelet aggregation via COX inhibitors which block TXA2. DESPITE possibility of Reye syndrome which could cause encephalopathy

The clinic nurse is providing care for a client who underwent a mastectomy 4 weeks ago. The client states, "I cannot stand to see myself in the mirror or let my spouse see my scar." What is the best initial response by the nurse?

Body image, a personal belief about body appearance and function, is important to an individual's self-concept. Disturbed body image may occur due to perceived or actual physical changes (eg, mastectomy) and can manifest as altered mood, avoidance of one's reflection, fear of others' perception of the change, and social withdrawal. The client's discomfort with looking in a mirror and allowing her spouse to see the surgical scar indicates a disturbed body image. The nurse should initially explore the client's body image and allow for expression of feelings

Infants with bacterial meningitis can develop hydrocephalus

Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children and should be monitored to prevent long-term complications

Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. The 4 classic manifestations of nephrotic syndrome are as follows:

Edema - periorbital edema is usually the first sign; peripheral edema and ascites develop later due to fluid shifts Massive proteinuria - caused by increased glomerular permeability Hypoalbuminemia - resulting from excess protein loss in the urine Hyperlipidemia - related to increased compensatory protein and lipid production by the liver

A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age?

Fine motor skills of infants develop around the ability to grasp objects. Voluntary grasping with the palm begins around 5 months, followed by the ability to transfer an object between hands by 7 months and the development of a crude pincer grasp (using the thumb, index, and other fingers) around 8-10 months.

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following:

Gastrointestinal (GI) toxicity: Symptoms of GI bleeding, such as black, tarry stools, should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. Kidney injury: Long-term use of NSAIDs is associated with kidney injury. Hypertension and heart failure: NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension. Bleeding risk: Clients should notify the health care provider if NSAIDs are taken concurrently with aspirin, other NSAIDs, or anticoagulant/antiplatelet drugs as these can increase the risk of GI bleeding.

AOM is an infection of the middle ear resulting from dysfunction of the Eustachian tube. OM typically occurs in infants and children age <2, often following a respiratory tract infection. Clinical manifestations of AOM include high fever (up to 104 F [40 C]), ear pain, irritability/restlessness, loss of appetite, and pulling on the affected ear.

In AOM, the tympanic membrane will typically be bulging and very red. If the tympanic membrane ruptures from the buildup of fluid, the client will experience immediate pain relief and a gradually decreasing fever; purulent drainage may be observed in the external ear canal.

Infants do not start rolling until age 4 months and normally roll front to back at age 5 months. The explanation for the injury of the 2-month-old does not fit the growth capacity of the child. In addition, head injury must be ruled out as the infant is lethargic

Infants begin to roll at age 4-5 months. Reported history that does not match an infant's growth and development is a concern for abuse. Splatter burns, bruises from areas typically hit when falling, and Mongolian spots are expected findings

medication which opens up the medium and large airways in the lungs. It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. It is used by inhaler or nebulizer.

Ipratropium

Lochia rubra

Reddish or red-brown vaginal discharge that occurs immediately after childbirth; composed mostly of blood.

The care plan for a client experiencing an acute manic episode includes the following:

Reduction of environmental stimuli Providing a quiet, calm environment Limiting the number of people who come in contact with the client One-on-one interactions rather than group activities Low lighting A structured schedule of activities to help the client stay focused Physical activities to help relieve excess energy Providing high-protein, high-calorie meals and snacks that are easy to eat Setting limits on behavior

Key components of the nursing process (collecting data, monitoring, and assisting in planning and evaluation) and reinforcing teaching fall under the scope of practice of the nurse and should not be delegated to unlicensed assistive personnel (UAP). Some skilled tasks, such as obtaining a blood glucose level, can be delegated to UAP who have received documented training and demonstrated competency. The 5 rights of delegation are as follows:

Right task Right circumstance Right person Right direction and communication Right supervision and evaluation

Schizophrenia is commonly accompanied by delusions that cause the client to become fearful and agitated. Agitation in these clients may quickly escalate to violent behavior toward others or themselves. Immediate intervention is required to maintain a safe environment

Schizophrenia is commonly accompanied by delusions that cause the client to become fearful and agitated. Agitation in these clients may quickly escalate to violent behavior toward others or themselves. Immediate intervention is required to maintain a safe environment

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include:

Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion (Option 3) Heart murmur or extra heart sounds (Option 4) Signs of congestive heart failure Increased metabolic rate with poor weight gain

Clients have the right to refuse hospital admission and treatment. However, all states and provinces have laws and procedures for involuntary admission that require clients to receive inpatient treatment for a psychiatric disorder against their will. The legal criteria for involuntary admission include:

The individual appears to be an imminent danger to self or others (Option 3). The individual has a grave disability (ie, is unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of a mental illness (Option 2). Clients also have the right to the least restrictive environment in which treatment can be provided in a safe manner. Involuntary commitment is generally used as a last resort in dealing with a client whose illness is so severe that judgment and insight in deciding to refuse treatment are markedly impaired. The diagnosis of a mental illness alone does not justify the need for involuntary commitment.

Ketorolac (Toradol) indications (NSAID)

Treatment of moderate to severe pain

Isotretinoin (Accutane)

Treats acne. Reduces oil production from sebaceous glands. Also reduces gland size. Dries out the rest of the skin, thus SEs: blepharoconjunctivitis, dry eye, pseudotumor cerebri, nyctalopia. This drug is teratogenic!!

St. John's wort is used for treatment of

depression. It has many interactions with other prescription medications

Hirschsprung disease

high calorie, low residue, high protein

Peak Expiratory Flow Rate (PEFR)

measure of the fastest flow of exhaled air after a maximal inspiration

intussusception

telescoping of the intestines

Repositioning, collection of routine specimens, and measurement of intake and output are appropriate duties to delegate to

unlicensed assistive personnel

-emesis

vomiting

Concrete thinking

- literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply. 1. Apical heart rate of 88/min 2. Elevation of mood 3. Improved energy levels 4. Skin is cool and dry 5. Slight weight gain

1,2,3 / The expected therapeutic response to levothyroxine (Synthroid) includes an increased sense of well-being with elevated mood, greater energy levels, and a heart rate within normal limits. It takes up to 8 weeks to see the full effect of pharmacological therapy

Phenytoin level

10-20 mcg/mL

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." [15%] 2. "It prevents seizure development." [57%] 3. "It prevents blood clots in legs." [5%] 4. "It reduces swelling around the tumor." [20%]

2 / Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication

INR lab values

2-3, critical value if off, potential for patient to bleed. Use default order for order ?'s (hold all coumadin, assess for bleeding, prepare Vit K (antidote for Coumadin), Call or notify

The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today, the health care provider prescribes filgrastim. Which of the following is an expected outcome of this medication? 1. Decrease in serum uric acid [13%] 2. Increase in hemoglobin level [11%] 3. Increase in neutrophil count [58%] 4. Increase in platelet count [16%]

3 / Filgrastim (Neupogen) and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? 1. Ask if the client needs to use the bedpan [8%] 2. Assess the client's fluid intake [29%] 3. Assess the client's skin turgor [10%] 4. Palpate the client's suprapubic area [51%]

4 / Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse anticipate in this client's care plan? 1. Encourage client to drink cold beverages [1%] 2. Encourage client to eat a high-fiber diet [14%] 3. Encourage client to perform facial massage [22%] 4. Encourage client to report any fever or sore throat [61%]

4 / The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat

Proton Pump Inhibitors (PPIs)

A group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. They are the most potent inhibitors of acid secretion available today. -prazole

Corticosteroids

A group of hormones, including cortisol, released by the adrenal glands at times of stress

Hemophilia

A hereditary disease where blood does not coagulate to stop bleeding

When caring for newborns, the practical nurse should recognize abnormal findings and report them to the registered nurse (RN) for further assessment. Some abnormal newborn findings include:

Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment Jaundice, especially if noted within the first 24 hours of life (pathologic): Yellowish hues may be noted on the face or eyes initially and may progress caudally Even physiologic jaundice (>24 hr of life) requires close monitoring to ensure that it does not progress. No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration

Anorexia nervosa is a psychogenic eating disorder with potentially fatal implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and care should focus on restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes:

Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight Documenting consumed calories and protein to ensure the client meets the required calorie intake for healthy weight gain Remaining with the client during and for 1 hour following meals to ensure intake and prevent purging behaviors Establishing a weekly weight-gain goal; an appropriate goal for most clients is 2-3 lb/wk (0.91-1.36 kg/wk) Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to monitor efficacy of nutritional support Limiting physical activity initially and gradually increasing as oral intake improves Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight

A sentinel event is any unanticipated event in a health care setting that results in death or serious physical/psychological injury. Warfarin is an anticoagulant often used in clients with the following:

Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is >4

During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the client by:

Being honest and accepting of the client Presenting the reality of the condition Acknowledging the client's feelings of loss of control and anger Encouraging the client to express feelings and fears

fetal sex can often be determined by the appearance of the external genitalia on ultrasound, depending on the quality of the image

By the end of 12 weeks gestation

Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis of collagen by osteoblasts. Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be frail and easily fractured. Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal dominant inheritance. The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI includes:

Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull

Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from glutamate overexposure (excess levels of glutamate contribute to brain cell death)

Clients with moderate to severe AD may experience improvement in the following: Cognition - memory, thinking, language Daily functioning - dressing, bathing, grooming, eating Behavioral problems - agitation, depression, hallucinations

congenital hypothyroidism

Clinical manifestations Initially normal at birth Symptoms develop after maternal T4 wanes: Lethargy Enlarged fontanelle Protruding tongue Umbilical hernia Poor feeding Constipation Dry skin Jaundice Diagnosis ↑ TSH & ↓ free T4 levels Newborn screening Treatment Levothyroxine

Tasks within the licensed practical nurse (LPN) scope of practice include:

Collecting data (eg, pulse oximetry, urinary output) Monitoring client status (eg, work of breathing, mental status) Administering most medications (eg, albuterol [Proventil]) Evaluating client response to interventions performed

intussusception

Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements

Tracheoesophageal fistula (TEF)

Congenital defect resulting in a connection between the esophagus and trachea

The priority intervention for a child with ADHD who is engaging in aggressive behavior is to assist the child in calming down and gaining control

Deep breathing exercises are an easy and efficient approach to help the body and mind slow down and relax

An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are:

Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure)

Iron deficiency during infancy causes reduced hemoglobin production, resulting in anemia, decreased immune function, and delayed growth and development. During gestation, the fetus stores iron received from the mother; the amount of iron stored is dependent on the length of gestation. After birth, iron stores are progressively depleted and nutritional sources of iron are eventually required.

During gestation, the amount of iron a fetus stores is dependent on the length of gestation. Infants born at preterm gestation have lower iron stores at birth and are at an increased risk for iron-deficiency anemia. Iron supplementation (eg, oral iron drops, iron-fortified formula) is usually needed by preterm infants at an earlier age (2-3 months)

To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urine output in diapers: Diaper 1: 50 − 30 = 20 g Diaper 2: 52 − 30 = 22 g Diaper 3: 46 − 30 = 16 g Total mg of urine: 58 g = 58 mL Total output:

Emesis) + (Urine) = 120 mL + 58 mL = 178 mL Educational objective: Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid.

Leopold maneuvers would be an inappropriate method of assessment to determine:

Gender of the fetus.

Agoraphobic individuals most typically fear being in the following situations:

Outside the home alone In a crowd or standing in line Traveling in a bus, train, car, ship, or airplane On a bridge or in a tunnel Open spaces (eg, parking lots, marketplaces) Enclosed spaces (eg, theaters, concert halls, stores)

Urinary stasis, constipation, and infrequent voiding are contributing factors to urinary tract infections. The child should be encouraged to drink fluids and avoid holding in urine. Tight clothing and synthetic fabrics (eg, spandex, nylon, Lycra) should be avoided; cotton underwear is recommended.

Scented soaps, bubble baths, and antibacterial soaps should not be used for bathing a child (the tub should be filled with water only), and the hair should be washed last.

Nurses use therapeutic communication to provide support for clients and families and allow them to express thoughts and feelings. Broad openings and relevant questions can help uncover important information that will assist with decision making Therapeutic communication gives relevant information to the parents about the physical condition of the client to help alleviate their anxiety Empathetic statements establish trust and encourage expression of feelings

Self-injury (eg, cutting) in adolescence is commonly a coping mechanism used when a client is emotionally overwhelmed. Although not necessarily a suicide attempt, it is a clear indication that this client is unable to process current stressors in life and needs formal assessment by a mental health care provider with experience in adolescent psychiatry

Coarctation of the aorta (COA) is an abnormal aortic narrowing that results in decreased cardiac output.

The client will exhibit elevated pulse pressure in the upper extremities and diminished pressures in the lower extremities. Further assessment is needed, but this client is not the current priority

Botulinum toxin type A (Botox) blocks neuromuscular transmission

The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis.

Tolterodine tartrate (Detrol)

Urinary Bladder Modifier

The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond?

When discussing ethical decisions related to client care, it is important for the nurse to use open-ended questions and guiding phrases to facilitate exploration of clients'/family members' emotions, values, and beliefs regarding the topic. Nurses should avoid giving advice and influencing individuals' decisions

Hemovac drain

a closed drainage system in which a soft drain is attached to a springlike suction device

Ipratropium (Atrovent)

a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm.

Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually

abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions (Option 1). Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized

Educational objective: SBAR (situation, background, assessment, recommendation/read-back) is used to transmit complete essential information to the health care provider. Any

abnormal vital signs or current deterioration should be communicated immediately.

Hirschsprung disease (congenital aganglionic megacolon)

absence of nerve stimulation to the bowel, which produces normal peristalsis

Social isolation and impaired social interaction are common negative symptoms of schizophrenia. The client will seek to be alone to relieve anxiety associated with being around others. The nurse needs to be

accepting of the client's behavior and continue attempts at brief contact until the client is comfortable

Donepezil (Aricept) is an

acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects.

amnesia

affects short- and long-term memory loss. It can be intentionally induced by drug use or may occur as a result of trauma or underlying physical/psychological disease processes. Amnesia is not the most likely condition manifested by this client

PC abbreviation

after meals

Clostridium botulinum spores in honey can colonize an infant's

age <12 months) immature gastrointestinal system and release a toxin that causes botulism, a rare but potentially life-threatening illness

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins, increasing the risk for bleeding. The nurse should avoid procedures that can cause bleeding (eg, intramuscular injections, rectal temperature measurement). Vaccinations are administered subcutaneously whenever possible to prevent intramuscular hematoma .The smallest gauge needle is used, and firm, continuous pressure is applied at the site for 5 minutes Children with hemophilia should avoid

aspirin and nonsteroidal anti-inflammatory drugs due to the risk of bleeding. Acetaminophen is recommended for pain relief. Firm pressure should be held on the site without rubbing or massaging due to the risk of bleeding and hematoma formation. Superficial bleeding can be controlled using ice packs, which promote vasoconstriction. Applying a warm compress would cause vasodilation and prolong bleeding

This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to

assess the client's physical status

Medical power of attorney (POA) is an advance directive that allows clients to designate a specific decision-making individual who will advocate on their behalf if they become medically incompetent. Clients have the right to declare any individual they trust as their agent with medical POA, and that individual

becomes the final decision maker

Solid foods are introduced at age 4-6 months, beginning with iron-fortified cereal and progressing to soft fruits and vegetables. 5 to 7 days should elapse

before a new food is introduced to observe for allergies. Simple finger foods may be introduced at age 6-9 months. Cow's milk should not be introduced until after age 1 year

Failure to thrive is generally defined as weight less than 80% of ideal for age and/or depressed weight for length/height after correcting for gestational age, sex, and special medical conditions. Observing the child

being fed may provide information related to the cause of inadequate dietary intake, including disturbances in feeding behavior and psychosocial factors.

Clients with persecutory (paranoid) delusions

believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to think that someone is trying to poison you." When nurses attempt to understand clients' feelings and their meaning, the clients take note of this and the nurse-client relationship grows Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions

Paternalism is a type of

beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy

Flumazenil is the appropriate antidote for a

benzodiazepine (eg, lorazepam, alprazolam, diazepam) overdose

Lorazepam (Ativan) is a

benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion

Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics)

can cause lithium toxicity

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii and may be acquired from exposure to infected

cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus, potentially causing serious fetal harm (eg, stillbirth, malformations, blindness, mental disability). Pregnant clients who may be exposed to infected cats (eg, cats that live outdoors or eat raw meat) should be advised to avoid contact with cat feces (eg, litter box) and wash hands thoroughly after contact to decrease exposure risk

teratogenic effect

causal relationship between the drug use of a mother and congenital abnormalities (congenital defect)

The Bishop score is a system for the assessment and rating of

cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥8 usually indicates that induction will be successful

Oxytocin, a uterine stimulant, is frequently used to induce labor. Oxytocin infusion can result in quick delivery, but it increases the risk for unnecessary

cesarean birth (due to fetal heart rate abnormalities), postpartum hemorrhage, and placental abruption

Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause

cyanosis, which is evident shortly after birth and during periods of physical exertion.

Pioglitazone (Actos)

diabetes

Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include

diagnostic, treatment, preventive, and failure of communication, equipment, or other systems

To meet the growth needs of clients with CF, a

diet high in calories, fat, and protein is required.

Evening primrose may be used for

eczema or skin irritations

Normal for newborn Vital signs:

emperature (able to maintain stable body temperature in normal room environment) Pulse (normally 120 to 160 beats per minute in the newborn period) Breathing rate (normally 40 to 60 breaths per minute in the newborn period)

qid (abbreviation)

four times a day

Tangentiality

inability to get to the point of communication due to introduction of many new topics

Absence seizures are characterized by a brief loss of consciousness and the appearance of

inattention or daydreaming without loss of postural tone. Most absence seizures occur in children age 4-12, last less than 10 seconds, and may occur multiple times daily

Polycythemia

increased number of erythrocytes and hemoglobin in the blood

Pertussis can occur despite vaccination. Initial manifestations include cold-like symptoms with a mild fever, followed by the characteristic violent, spasmodic cough; inspiratory whooping sound; and posttussive vomiting. Treatment consists of

oral antibiotics, droplet precautions, and supportive measures (humidified oxygen and oral fluids).

unilateral

pertaining to one side

Esomeprazole (Nexium)

proton pump inhibitor

Methotrexate (Rheumatrex)

rheumatoid arthritis

Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include

setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit.

brachytherapy

the use of radioactive materials in contact with or implanted into the tissues to be treated

paranoid personality disorder

type of personality disorder characterized by extreme suspiciousness or mistrust of others

Acute glomerulonephritis is most often caused by recent streptococcal infection. Nursing care is focused on monitoring

vital signs (particularly blood pressure) and fluid status, avoiding salt in the diet, and conserving energy.

Increased intracranial pressure may occur with ventriculoperitoneal shunt malfunction. The caregiver must recognize symptoms of

vomiting, headaches, vision changes, and changes in mental status. Early intervention by the health care provider will decrease the risk of damage to brain tissue

absenteeism

when an employee doesn't show up for work

Hypoglycemia occurs commonly in newborns of mothers with diabetes due to elevated insulin levels and consumption of stored glucose. Common signs include jitteriness or tremors. Asymptomatic newborns with a low blood glucose

(<40-45 mg/dL [2.2-2.5 mmol/L]) should be fed breast milk or formula immediately.

Supportive and symptomatic treatment for vaso-occlusive sickle cell crisis includes pain management and bed rest. Nonpharmacologic measures to alleviate pain include distraction

(watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching? 1. "I can leave right after the shot as I didn't have a reaction last time." [71%] 2. "I will be back in a week for my next allergy shot." [8%] 3. "I will let the doctor know if I get any itchy hives tonight." [3%] 4. "It is okay if I have some redness at the injection site tonight." [16%]

1 / A client receiving an allergy shot is at risk for anaphylaxis immediately after the injection, so the client must remain at the facility and be monitored for 30 minutes after the injection

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? 1. Client's respiratory status 60 minutes later [47%] 2. Documenting the client's hypoxic event [14%] 3. Obtaining an order for a different analgesic [15%] 4. Potential for drug-drug interaction now [23%]

1 / The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression

A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. 1. Albuterol 2. Ibuprofen 3. Ipratropium 4. Montelukast 5. Tobramycin

1,3 / Inhaled corticosteroids and leukotriene inhibitors are typically used to achieve and maintain control of inflammation for long-term management of asthma. Quick-relief medications (eg, albuterol, ipratropium) are used to treat acute symptoms and exacerbations.

Visual acuity testing in children ages 6 and older is generally assessed by use of the Snellen letter chart. The child is positioned

10 ft (3 m) from the chart and asked to read the letters, beginning with the lines of large text to small text. Standard testing for visual acuity is at 20 ft (6 m); however, the American Academy of Pediatrics recommends testing at 10 ft as it is easier to maintain the child's attention and provides a more accurate result. If the child wears glasses, they remain in place. Both eyes should remain open while one eye at a time is covered to read the chart. The child must identify 4 of 6 letters in each line before moving to the next. A referral to an ophthalmologist is made if a child is unable to identify 4 correct letters on the 10/15 line (equivalent to 20/30 vision) with either eye.

Naegele's rule for estimating date of delivery is the last menstrual period minus 3 months plus 7 days. Fetal heart rate is detectable by Doppler at

10-12 weeks gestation. Urinary frequency is a presumptive sign of pregnancy in the first trimester.

Phenytoin (Dilantin) is an antiseizure medication with a therapeutic index of

10-20 mcg/mL (40-79 mcmol/L) (Option 1). Tube feedings decrease phenytoin absorption, which reduces serum drug concentrations and may precipitate seizures. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration to ensure adequate absorption. Phenytoin toxicity produces nystagmus, dysarthria, ataxia, and encephalopathy

BUN lab values

10-20 mg/dL

A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? 1. Amlodipine [11%] 2. Codeine [54%] 3. Ipratropium [16%] 4. Methylprednisolone [16%]

2 / Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases

A practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care? Select all that apply. 1. Activity as tolerated 2. Nonstress test 1 or 2 times a week 3. Prepare for cesarean birth at any time 4. Type and screen blood 5. Vaginal examinations twice weekly

2,3,4

The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments? 1. Attention span and activity level [35%] 2. Dental health and mouth dryness [11%] 3. Height/weight and blood pressure [35%] 4. Progress with schoolwork and in making friends [17%]

3 / A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable. Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants.

A 15-year-old client with type 1 diabetes mellitus is admitted to the hospital with a blood glucose of 460 mg/dL (25.6 mmol/L). Based on this information, the nurse understands that which factor is contributing to this client's noncompliant behavior? 1. Client has limited understanding of the disease process [43%] 2. Client is depressed and wants to die [5%] 3. Client's psychosocial developmental stage [36%] 4. Lack of supervision by the client's caregivers [13%]

3 / Adolescence in psychosocial development is marked by risk-taking behaviors, a sense of invincibility, the need for independence, and a strong connection to peers.

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? 1. Check for a history of bipolar disease [3%] 2. Determine if restraints can now be removed [26%] 3. Monitor for ECG changes [34%] 4. Obtain blood for the current blood alcohol level [36%]

3 / After ziprasidone hydrochloride (Geodon) administration, clients should be monitored for cardiac effects, hypotension, and/or seizure activity. Alcohol interacts with ziprasidone and increases the potential for an adverse effect from the drug

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information. 1. Calcium 7.4 mg/dL (1.85 mmol/L) [7%] 2. Creatinine 4.0 mg/dL (353 µmol/L) [20%] 3. Phosphorus 3.9 mg/dL (1.26 mmol/L) [10%] 4. Potassium 4.9 mEq/L (4.9 mmol/L) [61%]

4 / Clients with kidney disease are at risk for hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level.

The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? 1. "I need to avoid caffeinated products." [5%] 2. "I need to get my blood drug levels checked periodically." [12%] 3. "I need to report anorexia and sleeplessness." [8%] 4. "I take cimetidine rather than omeprazole for heartburn." [72%]

4 / Theophylline can cause seizures and life-threatening arrhythmias due to its narrow therapeutic range (10-20 mcg/mL). The dose is adjusted based on peak drug levels, obtained 30 minutes after the dose is given. Clients should avoid caffeinated products and medications that increase serum theophylline levels (eg, cimetidine, ciprofloxacin)

Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing.Accountability refers to accepting responsibility for one's actions and admitting errors Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia

Accountability is accepting responsibility for one's actions. Autonomy is making an informed decision about treatment for oneself. Confidentiality is not sharing information unless permission is given or required by law. Justice is treating every client equally. Nonmaleficence is doing no harm

A nurse is caring for a postpartum client who has breast engorgement following breastfeeding. Which instructions should the nurse reinforce regarding relief of breast engorgement?

Allow infant to nurse 10-15 minutes on each breast For breast engorgement in a client who is breastfeeding, treatments that the nurse should recommend include frequent breastfeeding with complete emptying of the breasts, avoidance of pumping and expressing breast milk between feedings, and managing pain with warm/cold compresses and anti-inflammatory analgesics.

Haloperidol (Haldol)

An antipsychotic drug thought to block receptor sites for dopamine, making it effective in treating the delusional thinking, hallucinations and agitation commonly associated with schizophrenia.

Meningococcal meningitis

An inflammation of the meningeal coverings of the brain and spinal cord; can be highly contagious.

Enoxaparin (Lovenox)

Anticoagulant

Levetiracetam (Keppra)

Anticonvulsant

Paroxetine (Paxil)

Antidepressant

glyburide/metformin (Glucovance)

Antidiabetic

Care of the infant wearing a Pavlik harness includes the following:

Assess skin 2-3 times daily for redness or breakdown under the straps Dress the child in a shirt and knee socks under the harness to protect the skin Apply diapers underneath the straps to keep the harness clean and dry Leave the harness on at all times, unless otherwise indicated by the HCP

Factors to consider during the physical assessment of school-age children (age 6-12) include the following:

Clients (even those as young as age 3) can tell and/or show the examiner where they hurt or how they feel in their own terms Clients are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually quite interested in medical equipment and how it works. Clients develop modesty during this period and some do not want a parent, especially of the opposite sex, in the room with them during a physical examination. This request should be honored. A head-to-toe sequence is appropriate for this age group

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition?

Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake

Under the GTPAL system

G - gravida indicates the number of pregnancies, delivered or undelivered; T - term deliveries are from 37 wk 0 days and beyond; P - preterm deliveries are from 20 wk 0 days to 36 wk 6 days gestation; A - abortions (spontaneous or elective) occur prior to 20 wk 0 days gestation; and L - living children are counted individually regardless of multiple birth status.

A client with terminal cancer becomes hypoxic and unresponsive. According to the client's paperwork, the client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time?

Get directions about care from the clients sister

The colostomy stoma should be beefy red in the immediate postoperative period. Any discoloration of the stoma could indicate decreased blood supply to the area; the nurse should notify the supervising registered nurse.

In Hirschsprung disease, a portion of the colon has no innervation and must be removed. Some children require a temporary colostomy. The stoma created from the surgery should remain beefy red in the immediate postoperative period. Any paleness or graying of the stoma indicates decreased blood supply to that area.

Bile made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis

It is common for newborns to vomit frequently as they learn to eat and digest. Hydration status and weight gain should be monitored. Green vomit represents bile from the intestine, which could indicate a bowel obstruction.

Fluticasone/salmeterol (Advair) is a long-acting inhaled

It is used for long-term control of asthma but not for acute attacks

Pediatric clients are at risk for lead poisoning from environmental exposure in the home (eg, paint, dust, plumbing). Clients with elevated blood lead levels require monitoring.

Lead sources in the home should be removed or mitigated (eg, handwashing, wet dusting/mopping) to prevent further exposure.

Filgrastim (Neupogen)

Leukopoietic growth factor Used for neutropenia (cancer) Can cause bone pain, leukocytosis (WBC > 100,000)

Isocarboxazid (Marplan)

MAOI. Increases norepinephrine, dopamine, and serotonin by blocking MAO-A. Avoid foods containing tryamine. Antihypertensives have additive hypotensive effect. Contraindicated with SSRIs, tricyclics, heart failure, CVA, renal insufficiency. Side effects: CNS stimulation, orthostatic hypotension, hypertensive crisis with intake of tryamine, SSRIs, and tricylics.

The practices, needs, and experiences of grief vary greatly among individuals. Nurses caring for grieving clients must skillfully use therapeutic communication techniques to strengthen the nurse-client relationship and support clients in exploring emotions and experiences. Reflection (eg, acknowledging client statements) and using open-ended questions or statements assist the client in exploring emotions and allow for expression of needs (Option 4). Nurses may also suggest strategies and share resources (eg, support group) to facilitate the client's grieving process

Nurses should use therapeutic communication techniques (eg, reflecting, asking open-ended questions, suggesting strategies or resources) to support clients' psychosocial needs and build the nurse-client relationship. Minimization, automatic responses, and leaving clients who are sharing strong emotions are nontherapeutic actions

An appropriate diet is essential to meet the needs of the pregnant client and growing fetus.

Pregnant clients should avoid deli meats and hot dogs (unless steaming hot), liver, unpasteurized milk products, unwashed fruits and vegetables, raw fish, and fish high in mercury

Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes:

Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 10 minutes to promote clot formation Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to implementing interventions and stopping bleeding

Cystic fibrosis (CF) is an inherited disorder (autosomal recessive) characterized by thickened secretions due to impaired chloride and sodium channel regulation that causes exocrine gland dysfunction. Management of a client with CF should primarily address potential complications related to the following body systems:

Pulmonary: Alterations in respiratory secretions (ie, thick sputum) make it difficult to clear the airway and can result in frequent respiratory infections and sinusitis Frequent infections and inflammation damage lung tissue and may lead to chronic hypoxemia Gastrointestinal: Thickened secretions obstruct the release of pancreatic enzymes, causing malabsorption of fat-soluble vitamins (eg, A, E, D, K) and other nutritional deficiencies High-protein, high-calorie foods and supplemental enzymes with meals are necessary. Reproductive: Thickened reproductive secretions (eg, seminal fluid, cervical mucus) or the absence of the vas deferens in men contributes to CF-related infertility.

Rotavirus is a contagious virus and the leading cause of diarrhea in children less than 5 years old; it is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Because the virus lives easily outside a human host, transmission can occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal prevent the spread of the virus

Rotavirus is a contagious infection that is easily spread via the fecal-oral route by touching contaminated objects, food, and hands. It is not treated with antibiotics as it is a viral infection. Vaccination is available for children less than 8 months old. Children with rotavirus are at risk for dehydration.

Normal vital signs in newborn

Temperature: 36.5° to 37.3° C (97.7° to 99.1° F) axillary, 36.5° to 37.7° C (97.7° to 99.8° F) rectal • Apical pulse: 120 to 160 bpm (100 bpm sleeping, 180 bpm crying) • Respirations: 30 to 60 breaths/min

antiemetic

a medication that is administered to prevent or relieve nausea and vomiting

paranoid personality disorder

a personality disorder marked by a pattern of distrust and suspiciousness of others

Methylphenidate (Ritalin)

a stimulant used in treating ADHD

Clozapine side effects

agranulocytois (requires weekly Wbc count) and seizures

Loratadine (Claritin)

antihistamine

When a parent tells the nurse that an infant cries "all the time," the priority nursing action is to

assess the pattern, quality, and frequency of the child's crying. This will help the nurse determine if the crying is normal infant behavior or a sign of a more serious condition that requires further evaluation and treatment.

infectious mononucleosis (mono)

characterized by fever, a sore throat, and enlarged lymph nodes, caused by the epstein-barr virus

Nephrotic syndrome is

characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse.

One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay. Clients should always be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens include

disorientation, agitation, fever, tachycardia, hypertension, diaphoresis, and hallucinations

Magnesium Sulfate

is a central nervous system depressant used to prevent/control seizure activity in preeclampsia/eclampsia clients

Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor

is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control.

Sumatriptan (Imitrex)

migraine

The risk of teeth misalignment and malocclusion occurs when a child uses a pacifier or sucks the thumb after the eruption of the

permanent teeth

Melena (dark red or black, sticky stool) is an indication of an

upper gastrointestinal (UGI) bleed

viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin is used to treat varicella- or influenza-associated fever; acetaminophen or ibuprofen should be given instead

xiphoid portion of the sternum should not be compressed because this may damage the liver.

PTSD symptoms

- Flashback episodes, where the event seems to be happening again and again. - Repeated upsetting memories of the event; repeated nightmares of the event. - Emotional "numbing"; feeling detached; inability to remember important aspects of the trauma. - Having a lack of interest in normal activities. - Avoiding places, people, or thoughts that remind you of the event. - Difficulty concentrating. - Agitation or excitability; insomnia.

The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment with the health care provider? 1. Client with bronchospasm who is due to receive nebulized acetylcysteine [33%] 2. Client with chronic obstructive pulmonary disease due to receive PO prednisone [23%] 3. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast [24%] 4. Client with suspected bacterial pneumonia due to receive IV levofloxacin [18%]

1 / Acetylcysteine (Mucomyst) may be given via nebulizer to help loosen and liquefy respiratory secretions to more easily clear them from the airway. Inhaled acetylcysteine may be used for clients with cystic fibrosis or other respiratory conditions with thick bronchial mucus. Acetylcysteine has no therapeutic effect on airway smooth muscle as it works primarily on secretions and has been shown to cause and/or worsen bronchospasm. Nurses caring for clients with reactive airway diseases (eg, asthma) prescribed acetylcysteine should clarify the prescription with the health care provider

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider? 1. Diarrhea, vomiting, and mild tremor [35%] 2. Dry mouth and mild thirst [6%] 3. Hyperactivity and auditory hallucinations [33%] 4. Lithium level of 1.3 mEq/L (1.3 mmol/L) [24%]

1 / Acute lithium toxicity (>1.5 mEq/L [1.5 mmol/L]) presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurological symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. The health care provider must be notified at the earliest indication of lithium toxicity.

The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia. Which information should be included when reinforcing teaching to this client about the new medication? 1. Change positions slowly when going from lying to standing [38%] 2. Do not drink grapefruit juice when taking this drug [46%] 3. Take this medication first thing in the morning, before breakfast [7%] 4. Your stool may become darker and that's normal [6%]

1 / Alpha blockers are commonly used to treat symptoms of urinary retention in clients with benign prostatic hyperplasia. Orthostatic hypotension is a common side effect

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant notification of the supervising registered nurse? 1. "I am going for repeat testing to confirm glaucoma." [25%] 2. "I am not able to exercise as much as I used to." [7%] 3. "I started taking esomeprazole for heartburn." [49%] 4. "My bowel movements are not regular." [17%]

1 / Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and are therefore contraindicated.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops [38%] 2. Lorazepam sublingual tablet [7%] 3. Morphine sublingual liquid [46%] 4. Ondansetron sublingual tablet [6%]

1 / Atropine The "death rattle" is a noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and no longer able to manage airway secretions. Anticholinergic medications such as transdermal scopolamine or atropine sublingual drops effectively treat this symptom by drying up the excess secretions.

The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior? 1. Muscle rigidity and shuffling gait [65%] 2. Nihilistic delusions [21%] 3. Tangentiality [6%] 4. Waxy flexibility [6%]

1 / Benztropine (Cogentin) is an anticholinergic medication used to treat some extrapyramidal symptoms, which are side effects of some antipsychotic medications. These side effects include: Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia]) Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver? 1. Administer the medication around the clock even if the client denies having pain [43%] 2. Avoid administering with immediate-release opioids to prevent respiratory depression [40%] 3. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs [2%] 4. Request a tapered dose from the health care provider if pain decreases to prevent tolerance [13%]

1 / Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours.

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation? 1. "I am taking an antibiotic for a urinary tract infection." [31%] 2. "I had a negative tuberculosis skin test 2 weeks ago." [11%] 3. "I just received my yearly flu shot a week ago." [13%] 4. "I will continue taking naproxen at night to help with pain." [42%]

1 / Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage [66%] 2. Decrease the dosage [14%] 3. Discontinue the medication [7%] 4. Increase the dosage [11%]

1 / Lithium carbonate is used as a mood stabilizer in clients with schizoaffective disorder (combination of schizophrenia and a mood disorder) and bipolar disorders. Lithium has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic.

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? 1. Auscultate breath sounds to assess for crackles [39%] 2. Monitor for >50 mL/hr urine output [20%] 3. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 [26%] 4. Press over the tibia to assess for pitting edema [13%]

1 / Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema

The nurse is reinforcing instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach." [50%] 2. "I plan to eat more fruits and vegetables to prevent constipation." [12%] 3. "I should not drive until I know how this drug affects me." [16%] 4. "I will drink at least 6-8 glasses of water daily." [19%]

1 / Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: New-onset constipation Dry mouth Flushing Heat intolerance Blurred vision Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the supervisory registered nurse? 1. "I am feeling unsteady when I walk." [20%] 2. "I am getting up to urinate about 4 times during the night." [3%] 3. "I have a metallic taste in my mouth when I eat." [30%] 4. "My gums are getting so puffy and red." [45%]

1 / Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin.

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? 1. Evening primrose [14%] 2. Ginseng [16%] 3. Melatonin [55%] 4. St. John's wort [14%]

1 / Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones

A nurse is caring for a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to report to the registered nurse? 1. Bilateral pitting edema in ankles [29%] 2. Blood pressure is 140/88 mm Hg [6%] 3. Most recent HbA1c is 6.7% [15%] 4. Retinal photocoagulation in right eye [48%]

1 / Thiazolidinediones (also called glitazones; rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction.

The nurse working on a pediatric oncology unit recognizes which as a personal coping strategy for remaining effective when caring for dying children? 1. Attending a child's memorial service [33%] 2. Avoiding expressing personal feelings of grief or loss directly with the family [39%] 3. Ending personal contact with the deceased's family members after they leave the hospital [12%] 4. Increasing length of daily exercise routines [13%]

1 / To remain positive in the caring role, nurses must implement appropriate coping strategies to enhance self-care and grief processing. Attending a memorial service can demonstrate care for the grieving family while also providing closure for the nurse. Other helpful strategies for coping include the following: Taking time off from work if distancing is needed Using personal and professional support systems (eg, spouse, employee assistance programs, experienced mentors) Maintaining good health through adequate rest, regular exercise, and proper nutrition

A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider? 1. Client excitedly reports being able to go an entire work day without having to urinate [62%] 2. Client is using an over-the-counter artificial saliva product for dry mouth [12%] 3. Client reports occasional dizziness in the morning and when changing positions [18%] 4. Client reports symptoms of constipation [5%]

1 / Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP).

The nurse is caring for a 7-year-old with sickle cell crisis. The client is short of breath and vomiting and has severe generalized body and joint pains. Which assessment finding requires the most immediate intervention? 1. Blood work showing anemia [9%] 2. Enlarged spleen on palpation [43%] 3. Right arm weakness [19%] 4. Swelling of hands and feet [27%]

1, / Splenic sequestration crisis is a potentially life-threatening emergency of sickle cell disease. A rapidly enlarging spleen and hypotension are the characteristic assessment findings

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone (Solo-Medrol) 4. Montelukast 10 mg by mouth STAT 5. Salmeterol metered-dose inhaler every 20 minutes

1,2,3 / Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma.

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awaken 2. Dry skin 3. Frequent, loose stools 4. Hoarse cry 5. Tachycardia

1,2,4 / TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1) Dry skin due to alterations in skin function (Option 2) Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4) Constipation due to slowed metabolism Bradycardia due to the effect of TH on cardiac function

The nurse is reviewing skin care management for an adolescent with acne vulgaris. Which of the following teaching points are appropriate to include? Select all that apply. 1. A well-balanced diet can help support healthy skin 2. Antibacterial soap is harsh and can make acne worse 3. Scrub whiteheads vigorously when washing the face twice daily 4. Squeezing or picking lesions may increase the risk for infection and scarring 5. Use skin care products labeled as noncomedogenic to prevent clogging skin pores

1,2,4,5 / The nurse should educate clients about skin care and management of acne vulgaris, including using only noncomedogenic (nonpore-clogging) skin care products and maintaining a healthy lifestyle (eg, well-balanced diet) to promote healthy skin (Options 1 and 5). Clients should avoid antibacterial soaps, which are harsh and can alter the pH of the skin (Option 2). Scrubbing the face and picking or squeezing lesions increase inflammation and worsen acne

A nurse is reinforcing education given to the parents of a child diagnosed with chronic allergic rhinitis that is triggered by household and environmental allergens. Which statements by the parents indicate that the teaching has been effective? Select all that apply. 1. "My wife plans to wipe down our child's furniture with a damp rag every other day." 2. "Our child needs plastic covers for the mattress and pillow." 3. "We must give away the family dog." 4. "We will keep the windows open during warm weather to air out the house." 5. "We will replace the carpet with hardwood floors throughout the house."

1,2,5 / Symptoms of allergic rhinitis include sneezing, nasal drainage, nasal congestion, and pruritus of the eyes or nose. Clients and their families can help prevent these symptoms by identifying individual triggers (eg, dust, mold, pollen, dander) and implementing strategies to reduce or avoid exposure to known allergens. Key measures to reduce exposure to household and environmental allergens include the following: Installing high-efficiency particulate air filters in the home air conditioning system Keeping windows closed and staying indoors, particularly during times of heavy pollen Using hypoallergenic pillow and mattress covers to prevent exposure to dust mites Reducing or eliminating carpet and area rugs from the home Regularly mopping hard floors and damp-dusting furniture (at least weekly)

A nurse is caring for a school-age client who has fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which interventions should be implemented for this client? Select all that apply. 1. Allow the client to self-position for comfort 2. Have the client wear a mask at all times for 24 hours 3. Keep the client on NPO status 4. Minimize the environmental stimuli 5. Place the client in a negative airflow room

1,3,4

A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions does the nurse anticipate for this client? Select all that apply. 1. Cluster care to limit each staff member's time in the room to 30 minutes a shift 2. Instruct the client to be up and around in the room but not to leave the room 3. Place a sign on the client's door stating "Caution, Radioactive Material" 4. Remind family members and visitors to stay at least 6 ft (1.82 m) away from the client 5. Use a lead apron when providing direct client care to reduce exposure to radiation 6. Wear a radiation film badge while in the client's room to monitor radiation exposure

1,3,4,5,6 / Following the principles of time, distance, and shielding provides staff protection from exposure to radiation when treating a client undergoing internal radiation. Staff should spend no more than 30 minutes in the client's room, should remain at least 6 ft (1.82 m) away from the radiation source, and should wear lead aprons when providing direct client care

The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply. 1. Black tarry stools 2. Bradycardia 3. Bruising 4. Hypertension 5. Ringing in the ears

1,3,5 / Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to the decreased platelet aggregation. Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity

The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply. 1. Consult the health care provider (HCP) if you experience leg pain or swelling 2. Discontinue contraceptives if you experience spotting between menses 3. Do not smoke while taking combined contraceptives 4. Immediately report any breast tenderness to the HCP 5. Seek immediate medical treatment if you experience vision loss

1,3,5 / Clients who are prescribed oral estrogen contraceptives (with or without progestin) have an increased risk for developing blood clots. Clients should be educated on warning signs to report to the health care provider (eg, severe leg pain, vision loss) versus common side effects (eg, breast tenderness, spotting).

Which medication prescriptions should the nurse question? Select all that apply. 1. Cephalexin for a client with severe allergy to penicillin 2. Fexofenadine for a client with hives 3. Ibuprofen for a client with asthma and nasal polyps 4. Lisinopril for a client with diabetes mellitus 5. Propranolol for a client with asthma

1,3,5 / Clients with asthma and nasal polyps can have sensitivity to NSAIDs; those with an allergy to penicillin can have a cross-sensitivity to cephalosporins. Nonselective beta blockers are contraindicated in clients with asthma. H1 receptor antagonists block histamine in an allergic reaction. ACE inhibitors are protective for diabetic nephropathy. Cephalexin is a cephalosporin, which is chemically similar to penicillin. If a client has had a severe allergic reaction to penicillin, there is a 1%-4% chance of an allergic reaction (cross-sensitivity) to a cephalosporin (Option 1). Clients with nasal polyps often have sensitivity to nonsteroidal anti-inflammatory drugs (NSAIDS), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore, acetaminophen may be a better choice for these clients (Option 3). The selective beta blockers (eg, metoprolol, atenolol, bisoprolol) are generally given for heart failure and hypertension control due to their beta1-blocking effect. The nonselective beta blockers (eg, propranolol, nadolol), in addition, have a beta2-blocking effect that results in bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally contraindicated in clients with asthma (Option 5). (Option 2) H1 receptor antagonists (eg, fexofenadine, cetirizine, levocetirizine, loratadine) decrease the inflammatory response by blocking histamine receptors. Histamine is released from mast cells during a type I (immediate) hypersensitivity reaction (ie, allergic rhinitis, allergic conjunctivitis, and hives). (Option 4) Angiotensin-converting (ACE) inhibitors (ending in "pril") are the drugs of choice in diabetic clients with hypertension or proteinuria. This would be an appropriate administration.

The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply. 1. Falls asleep when the nurse is talking 2. Frequently scratches from pruritus 3. Has third emesis since taking medication 4. Monitor shows occasional premature ventricular contractions 5. Pulse oximetry reading is 92%

1,3,5 / Early signs of toxicity are nausea/vomiting and lethargy. Falling asleep with stimulation is classified as obtunded and requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening complication of severe toxicity (Options 1 and 3). A normal, healthy, nonsmoking adult should have a pulse oximetry reading of 97%-100%; 95%-100% is considered acceptable. The low pulse oximetry reading indicates inade

A nurse preceptor on a pediatric unit is reviewing interventions with a student nurse who will be caring for a toddler. What are appropriate activities to minimize the effect of hospitalization on a toddler? Select all that apply. 1. Integrate preferred snack foods in the day's routine 2. Explain the body changes that may occur 3. Plan quiet play prior to usual nap time 4. Post a daily schedule by the child's bed 5. Provide 1 or 2 options when choosing toys

1,3,5 / Toddlers react to the experience of hospitalization with a display of intense emotions, regressive behaviors, and manifestations of separation anxiety. Nursing care should focus on integrating a toddler's home routines into planned activities

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply. 1. Client with iron deficiency anemia takes iron supplements with milk 2. Client takes levothyroxine early in the morning on an empty stomach 3. Client taking phenazopyridine for urine infection states that the urine has turned orange 4. Client taking metronidazole mentions going to a wine-tasting party tonight 5. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold

1,4,5 / Iron is absorbed better on an empty stomach; ascorbic acid (vitamin C), such as found in citrus fruits and juices, increases the absorption of iron. However, milk products decrease iron absorption and should be avoided (Option 1). Metronidazole (Flagyl) is used to treat trichomoniasis and amebiasis. Consuming alcohol while taking the medication may elicit a disulfiram (Antabuse)-like reaction. Alcohol should be avoided for at least 48 hours after treatment is completed (Option 4). Many antihistamines also have anticholinergic effects. Anticholinergics have an antimuscarinic effect that can increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma. Other contraindications include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's effect on the smooth muscle in the urinary and gastrointestinal tract

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply. 1. Not taking tetracycline with dairy products 2. Taking tetracycline at bedtime 3. Taking tetracycline with food 4. Using additional contraceptive techniques 5. Using sunblock

1,4,5 / The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed

A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Select all that apply. Click on the exhibit button for additional information. 1. Dryness of the mouth and throat may occur 2. Ringing in the ears is an expected, transient side effect 3. The albuterol canister should not be shaken before use 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed

1,4,5, / A common side effect of tiotropium (Spiriva) and other anticholinergics (eg, ipratropium, benztropine) is xerostomia (dry mouth) due to the blockade of muscarinic receptors of the salivary glands, which inhibits salivation. Sugar-free candies or gum may be used to alleviate dry mouth and throat (Option 1). Tiotropium capsules should not be swallowed. These capsules are placed inside the inhaler device, and the capsule is pierced, allowing the client to inhale its contents (Option 5). Glucocorticoids (eg, prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (ie, melena) to the health care provider as they could indicate gastrointestinal bleeding (

The nurse in an ambulatory care center is reinforcing teaching to a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride SR. Which statement made by the client indicates a need for further teaching? 1. "If I have a sudden change in my mood, I should call my physician immediately." [12%] 2. "If I have trouble swallowing the tablet, I can cut it in half." [74%] 3. "If I miss a dose, I should not double the next dose to catch up." [7%] 4. "It may take several weeks before I get better." [4%]

2 / Additional instructions to a client about the use of bupropion hydrochloride include the following: Limit alcohol; inform the health care provider if you are used to consuming large amounts of alcohol Do not double up on the medication if a scheduled dose is missed (Option 3) Take the medication at the same time each day It may take several weeks to feel the effects of bupropion hydrochloride (Option 4) Weight loss may occur when taking this medication Educational objective: No form of bupropion hydrochloride should be crushed, chewed, or cut due to the risk of seizures and other adverse effects caused by the more rapid absorption and resulting higher serum levels of the drug. No medications labeled SR or XL should be altered before they are administered. This type of medication preparation should be swallowed whole

The nurse is preparing medications scheduled at 8 AM for a client with type 1 diabetes mellitus. After reviewing the client's prescriptions and morning laboratory results, which action by the nurse is most appropriate? Click on the exhibit button for additional information. 1. Administer insulin lispro per protocol and 75 units NPH [47%] 2. Contact the health care provider [21%] 3. Obtain a urine specimen to check for ketonuria [7%] 4. Recheck the client's blood glucose [22%] Laboratory results Serum glucose 328 mg/dL (18.20 mmol/L) Serum sodium 141 mEq/L (141 mmol/L) Serum potassium 3.0 mEq/L (3.0 mmol/L)

2 / Clients with diabetes mellitus receiving insulin therapy should be monitored for electrolyte shifts, especially of potassium. The nurse should clarify the prescription for insulin with the health care provider if the client is hypokalemic and should seek a prescription for supplemental potassium before giving more insulin.

The nurse reviews the medication administration records and laboratory results for assigned clients prior to drug administration. Which medication administration should the nurse question? 1. Calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L) [15%] 2. Clopidogrel for a client with a platelet count of 70,000/mm3 (70 × 109/L) [52%] 3. Magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.5 mmol/L) [14%] 4. Metformin for a client with a glycosylated hemoglobin level of 11% [17%]

2 / Clopidogrel (Plavix) is a platelet aggregation inhibitor used to prevent blood clot formation in clients with recent myocardial infarction, acute coronary syndrome, cardiac stents, stroke, or peripheral vascular disease. It can cause thrombocytopenia and increase the risk for bleeding; therefore, the nurse should notify the supervising registered nurse of the low platelet count (normal: 150,000-400,000/mm3 [150-400 × 109/L]) before administering clopidogrel.

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? 1. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." [16%] 2. "It can relieve your chronic pain and help you sleep better at night." [39%] 3. "It helps to relieve the adverse effects of your other prescribed drugs." [10%] 4. "You have the right to refuse. I will notify your health care provider (HCP)." [34%]

2 / Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well

The nurse is reinforcing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? 1. "Our child should be feeling much better in 7-10 days." [19%] 2. "Our child's condition is communicable until the rash disappears." [34%] 3. "We will ensure our child covers the mouth and nose when coughing or sneezing." [11%] 4. "We will give our child ibuprofen to treat the joint pain." [35%]

2 / Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.

The nurse is monitoring a client who has overdosed on alprazolam and alcohol. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benztropine [15%] 2. Flumazenil [25%] 3. Naloxone [49%] 4. Phentolamine [8%]

2 / Flumazenil is an antidote used to reverse the sedative effects of benzodiazepines such as alprazolam.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 g/dL (97 g/L) and hematocrit is 29% (0.29). What is the appropriate nursing action? 1. Administer the erythropoietin in the client's ventrogluteal muscle [32%] 2. Check blood pressure prior to administering the erythropoietin [35%] 3. Hold the client's next scheduled iron sucrose dose [4%] 4. Hold the erythropoietin and inform the health care provider [28%]

2 / Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin

A client with asthma and sinusitis has increased wheezing and decreased peak flow readings. The nurse recognizes that which of the following over-the-counter home medications taken by the client could be contributing to increased asthma symptoms? 1. Guaifenesin 600 mg orally twice a day as needed [39%] 2. Ibuprofen 400 mg orally every 6 hours for pain as needed [35%] 3. Loratadine 1 tablet orally every day as needed [20%] 4. Vitamin D 2,000 units orally every day [4%]

2 / Ibuprofen and aspirin are common over-the-counter anti-inflammatory drugs that can cause bronchospasm in some clients with asthma.

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." [11%] 2. "I can begin driving again after I have been on this medication for a few weeks." [70%] 3. "I need to immediately report any new or increased anxiety when on this medication." [7%] 4. "I need to immediately report any new rash when on this medication." [10%]

2 / Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers? 1. Demonstrating adequate coping skills [16%] 2. Knowing how to keep blood sugars stable [65%] 3. Understanding how to perform meal planning [13%] 4. Understanding the need for periodic follow-up visits [4%]

2 / Management of type 1 diabetes mellitus requires understanding of blood sugar regulation. If the child becomes hypoglycemic or hyperglycemic, complications could develop. The priority for caregivers should be to focus on the child's safety. Managing the child's blood sugars should be the initial goal.

A male client admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12 g/dL (120 g/L) is being prepared for surgery. Which prescription should the practical nurse validate with the registered nurse before administration? 1. Cefazolin [8%] 2. Enoxaparin [56%] 3. Morphine [20%] 4. Tetanus toxoid [13%]

2 / Medications commonly prescribed for a client with an open fracture include: Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection (Option 1). Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed. Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown (Option 4) Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? 1. "I periodically take docusate sodium for constipation." [14%] 2. "I regularly take ibuprofen for chronic low back pain." [33%] 3. "I take hydrochlorothiazide to prevent swelling around my ankles." [30%] 4. "I take omeprazole daily to prevent heartburn." [20%]

2 / NSAIDs may cause heart attack, stroke, high blood pressure, and possible heart failure after long-term use. NSAIDs decrease the effectiveness of diuretic and blood pressure medications. Long-term use is also associated with chronic kidney disease and peptic ulcers.

The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication? 1. "I can discontinue the medication if my symptoms improve." [3%] 2. "I need a healthy diet and regular exercise to combat weight gain." [76%] 3. "If I don't feel better in 1-2 weeks, then the medication is not working." [9%] 4. "This medication might increase my sexual performance." [10%]

2 / Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) often prescribed for major depression and anxiety disorders. Other SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft). Weight gain is a common side effect of long-term SSRI use. The nurse should teach the client to eat a healthy diet and engage in regular exercise to combat the weight gain. Other major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, and serotonin syndrome when taken in excess doses. The major side effects of SSRIs include increased suicide risk (at the beginning of therapy), sexual dysfunction, weight gain, and serotonin syndrome (excess doses). It may take several weeks for the therapeutic effects of SSRIs to begin; they should never be discontinued abruptl

One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 µmol/L). Which action by the health care provider does the nurse anticipate? 1. Administer phenytoin as prescribed [27%] 2. Decrease phenytoin daily dose [48%] 3. Increase phenytoin daily dose [3%] 4. Repeat serum phenytoin level in 2 hours [19%]

2 / Phenytoin (Dilantin), an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is 10-20 mcg/mL (40-79 µmol/L). In the presence of an elevated reference range (32 mcg/mL [127 µmol/L]), if no seizure activity is observed, the nurse would anticipate the health care provider prescribing a decreased daily dose. The nurse will continue to monitor for signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation).

A nurse is reinforcing teaching about herbal supplements to a group of clients in the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? 1. Clients diagnosed with heart failure [8%] 2. Clients with benign prostatic hyperplasia [40%] 3. Clients with major depressive disorder [15%] 4. Perimenopausal clients experiencing hot flashes [34%]

2 / Saw palmetto, a herbal preparation, is often used to treat benign prostatic hyperplasia. St John's wort has been used for centuries to treat depression

A behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate? 1. "I don't have much of an appetite since starting this medication." [5%] 2. "I have a lot more energy, but I'm feeling just as depressed." [40%] 3. "I have been feeling dizzy when I walk around at home." [27%] 4. "I have experienced frequent headaches lately." [25%]

2 / Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat a number of psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). Clients usually see therapeutic effects in 1-4 weeks. SSRIs may increase the risk of suicide, especially in young adults (age 18-24) during initial therapy or after a dosage increase. A client who reports increased energy without a change in depressive feelings needs to be assessed and monitored for suicidal ideation or actions as the client may now have the energy to execute the suicide plan (Option 2). Common, expected side effects of SSRIs include: Loss of appetite; weight loss or weight gain (Option 1) Gastrointestinal disturbances (nausea, vomiting, diarrhea) Headaches, dizziness, drowsiness, insomnia (Options 3 and 4) Sexual dysfunction Side effects should gradually diminish over 3 months, although some may persist. If symptoms are intolerable or a particular SSRI is ineffective, the client may be switched to a different antidepressant. Educational objective: Selective serotonin reuptake inhibitors (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). A client reporting increased energy with little or no reduction of depression needs immediate assessment for suicide risk.

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory [18%] 2. Improvement in spontaneous activity [52%] 3. Reduction in number of visual hallucinations [14%] 4. Reduction of dizziness with standing [15%]

2 / The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement)

A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive "another pain pill." The nurse reviews the medication administration record. Which intervention should the nurse implement? Click on the exhibit button for additional information. 1. Administer the hydrocodone/acetaminophen as prescribed [76%] 2. Call the health care provider to request a prescription for a different analgesic [18%] 3. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1 [2%] 4. Prepare to administer naloxone [2%]

2 / The nurse should closely monitor the medication administration record of clients receiving acetaminophen to ensure that the total 24-hour dose from all sources does not exceed 4 g. Hepatotoxicity may develop with >4 g/day

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse reinforce with this client? 1. Diet high in iron [5%] 2. Good oral care and dental follow-up [64%] 3. Shaving with an electric razor [16%] 4. Use of sunglasses for eye protection [14%]

2 / The nurse should encourage the client taking phenytoin to perform good oral hygiene and visit the dentist regularly to prevent gingival hyperplasia. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis)

The practical nurse is conducting a hospital admission history and assessment in collaboration with the registered nurse. The client reports taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response? 1. Ask the client about menopausal symptoms [26%] 2. Contact the pharmacy to see if the herb interferes with the client's medications [59%] 3. Facilitate a prescription for use of the herb during hospitalization [3%] 4. Tell the client to stop taking the herb [10%]

2 / The nurse should follow up regarding the quantity of the herb and how it is used. Black cohosh is used by some clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity. Herbs can cause harmful reactions when taken in combination with other drugs. It is most important to determine that an herb does not interfere with other medications. Herbal therapy is usually stopped 2-3 weeks before any surgery.

The nurse caring for a client reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board [3%] 2. Document the exchange in the chart [63%] 3. Report the incident to the hospital's legal team [28%] 4. Report the incident to the state medical board [4%]

2 / There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor. (Options 1, 3, and 4) It is important to first refer up the nursing hierarchy. Educational objective: The nurse should document and then report objections about a clinician's judgment to the nursing supervisor

The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first? 1. Adolescent client with coarctation of the aorta and diminished femoral pulses [41%] 2. Infant client with ventricular septal defect with reported grunting during feeding [18%] 3. Newborn client with patent ductus arteriosus and a loud machinery-like systolic murmur [13%] 4. Preschool client with tetralogy of Fallot who has finger clubbing and irritability [26%]

2 / Ventricular septal defect (VSD) is a congenital abnormality in which a septal opening between ventricles causes left-to-right shunting, leading to excess blood flow to the lungs. This places the client at risk for congestive heart failure (CHF) and pulmonary hypertension. Clinical manifestations of VSD include a systolic murmur auscultated near the sternal border at the third or fourth intercostal spaces, and hallmark CHF signs (eg, diaphoresis, tachypnea, dyspnea). The client is currently showing signs of increased respiratory exertion (eg, grunting) and requires further assessment for CHF

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? 1. Administer an analgesic [11%] 2. Assess the child's level of pain using a numeric rating scale [86%] 3. Come back later in the day [1%] 4. Tell the child, "Get up and walk if you want to go home soon." [0%]

2 / When a client is in pain, assessment is the first necessary nursing action. The pain assessment helps to determine the appropriate relief measure and serves as a baseline for evaluating the effectiveness of the chosen pharmacological or non-pharmacological measure.

The nurse reinforces medication instructions to a client with primary adrenal insufficiency (Addison disease) who is prescribed hydrocortisone 10 mg orally 3 times a day. Which instructions should be included? Select all that apply. 1. Discontinue hydrocortisone if you have mood changes or disruptions in behavior 2. Make an appointment with an optometrist yearly to assess for cataracts 3. Report even a low-grade fever to the health care provider immediately 4. Report signs of hyperglycemia, including increased urine, hunger, and thirst 5. Take the medication on an empty stomach 6. The dose of hydrocortisone may need to be decreased during times of stress

2,3,4 / Corticosteroids are the primary drugs used to treat Addison disease. It is imperative that the nurse teach the client about this medication, including to never stop it abruptly, notify the health care provider of signs and symptoms of infection, and monitor blood glucose closely if diabetes is a comorbid condition.

The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply. 1. "Chest physiotherapy is administered only if respiratory symptoms worsen." 2. "I will give my child pancreatic enzymes with all meals and snacks." 3. "I will increase my child's salt intake during hot weather." 4. "Our child will need a high-carbohydrate, high-protein diet." 5. "We will limit our child's participation in sports activities."

2,3,4 / Cystic fibrosis causes increased viscosity of exocrine gland secretions. Clients require pancreatic enzyme supplements with all meals and snacks; a diet high in carbohydrates, protein, and fat; and increased salt intake during times of significant perspiration. Clients should also incorporate chest physiotherapy and exercise into their daily routine

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohosh 2. Garlic 3. Ginger 4. Ginkgo biloba 5. Hawthorn

2,3,4 / Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew

The school nurse is discussing self-management of exercise-induced bronchoconstriction with a high school student who has asthma and just joined the football team. Which of the following actions are appropriate for the nurse to include during the discussion? Select all that apply. 1. Advise participation in a different, less strenuous sport 2. Ask the client to demonstrate use of the inhaler 3. Describe methods to warm inspired air during cold weather 4. Recommend using the inhaler 15-30 minutes before exercise 5. Reinforce that the inhaler is for personal use only

2,3,4,5 / Exercise-induced bronchoconstriction is characterized by swelling, spasms, and constriction of the airway during/after strenuous activity, primarily in clients diagnosed with asthma. This reaction is usually triggered by increased respiration of cool, dry air. The client should use the inhaler approximately 15-30 minutes before exercising to reduce bronchoconstriction during activity and warm inspired air by breathing through the nose or into a scarf or cupped hands (Options 3 and 4). The nurse should ensure proper use of the inhaler by having the client demonstrate inhaler administration; reinforcing personal use of the inhaler is also important due to the potential for abuse of inhaled bronchodilators to enhance performance, as seen in some athletes

The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply. 1. "Apply the patch when the ship starts moving and not before." 2. "Dispose of the patch out of reach of children and pets." 3. "Ensure that the old patch is removed before applying a new one." 4. "Place the patch on a hairless, clean, dry area behind the ear." 5. "Wash your hands with soap and water after handling the patch."

2,3,4,5, / To prevent motion sickness, transdermal scopolamine should be applied to a hairless, clean, dry area behind the ear ≥4 hours prior to travel. Clients should change the patch every 72 hours, discard old patches out of reach of children and pets, and wash hands after handling patches. The old patch must be removed before a new one is placed.

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refuses to feed

2,3,5 /

An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply. 1. "I'll be sure to apply sunscreen if I go outside." 2. "I'll drink at least 8 glasses of water a day." 3. "I'll drink decaffeinated coffee so I can sleep at night." 4. "I'll sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food."

2,4,5 / The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent these include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly

The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? 1. Constricted pupils [3%] 2. Heart rate of 120/min [5%] 3. Respirations of 24/min [87%] 4. Tremor [3%]

3 / Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and hypokalemia

The nurse has reinforced education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Eliminating aged cheeses and processed meats from my diet is essential." [27%] 2. "I can skip doses on days that I am not feeling anxious." [7%] 3. "I will take my daily dose at bedtime." [32%] 4. "Using sunscreen is important as this drug will make me sensitive to sunlight." [32%]

3 / Benzodiazepines have a sedative effect and should be administered at bedtime when possible. Benzodiazepines should never be stopped abruptly in long-term users as this can precipitate withdrawal symptoms.

The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Driving is not recommended until I stop taking this medication." [6%] 2. "If I experience a panic attack I should take an extra dose of medication." [2%] 3. "It will be 2-4 weeks before I feel the full effect of this medication." [55%] 4. "Withdrawal symptoms will occur if I abruptly stop taking this medication." [35%]

3 / Buspirone is an anxiolytic medication that does not have central nervous system depressant effects; therefore, it does not cause dependence, tolerance, psychomotor slowing, or withdrawal symptoms. Full therapeutic effects occur between 2 and 4 weeks of therapy.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? 1. "I need to continue to avoid eating spinach and kale." [10%] 2. "I probably will have some weakness in my legs when I take this medicine." [2%] 3. "I should avoid taking aspirin while receiving this medication." [60%] 4. "I will have to get blood drawn routinely to check my clotting levels." [26%]

3 / Clients prescribed rivaroxaban should be educated to avoid taking over-the-counter medications or supplements that increase bleeding risk, such as NSAIDs (eg, aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding (eg, epidural, intracranial, gastrointestinal) and hemorrhage

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? 1. Close monitoring for hypotension [25%] 2. Gradually increasing the prednisone dose [8%] 3. Increasing the insulin dose [44%] 4. Monitoring and recording intake and output [21%]

3 / Corticosteroids (eg, methylprednisolone, prednisone, dexamethasone) are given to combat inflammation in the lungs in clients with COPD exacerbation. All glucocorticoids can cause an increase in blood sugar. This may lead to the need for a higher dose of insulin based on the client's blood sugar level

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification? 1. Atorvastatin for hyperlipidemia in a client with angina pectoris [15%] 2. Bupropion for smoking cessation in a client with emphysema [17%] 3. Cyclobenzaprine for muscle spasms in a client with hepatitis [40%] 4. Metronidazole for trichomoniasis in a client with Crohn disease [25%]

3 / Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease

A nurse is giving medications to a client who is being evaluated for a brain malignancy. The health care provider (HCP) has ordered a computed tomography (CT) scan with intravenous (IV) iodinated contrast for the next morning. Which medication should the nurse plan to withhold from this client? 1. Amlodipine [15%] 2. Gabapentin [14%] 3. Metformin [43%] 4. Phenytoin [26%]

3 / Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin (Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld prior to the contrast exposure and can be resumed when kidney function is within normal limits

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? 1. "I've felt the need for an afternoon nap most days this week." [8%] 2. "I've gained 3 lb (1.36 kg) since I began taking this medication." [20%] 3. "I've had the stomach flu for the past couple of days." [41%] 4. "My mouth seems to be drier than usual lately." [29%]

3 / Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity

The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse? 1. Hair loss [6%] 2. Nausea [10%] 3. Petechiae [51%] 4. Stomatitis [31%]

3 / Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug prescribed to treat rheumatoid arthritis. Adverse effects associated with this medication include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia manifests as fatigue, dyspnea on exertion, and pallor. Leukopenia increases the risk for infection. Thrombocytopenia presents as petechiae, purpura, or bleeding. Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000/mm3 (150x109/L) (Option 3). Bone marrow suppression is managed with dose reduction or discontinuation of the medication

The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? 1. Need for an eye examination [20%] 2. Need for sunblock [14%] 3. Risk for infection [36%] 4. Risk for kidney injury [28%]

3 / Methotrexate (Rheumatrex) is classified as an antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (eg, influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (eg, herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate

The nurse reinforces teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug? 1. "I should get a flu shot this year as my resistance to germs will be lower." [37%] 2. "I should not get pregnant while taking this medicine." [23%] 3. "I will make sure I have my eyes checked every 6 months." [22%] 4. "It will be difficult, but I will not have wine with my dinner." [15%]

3 / Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death

The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective? 1. "An additive-free, low-sugar diet will reduce my child's symptoms." [28%] 2. "I can now manage my child's condition on my own." [10%] 3. "My child should take the last daily dose of methylphenidate before 6:00 PM." [57%] 4. "Once the medication is started, I will not have to monitor my child anymore." [2%]

3 / Methylphenidate is a stimulant drug with the potential to cause insomnia. Parents are instructed to administer the last dose no later than 6:00 PM to prevent sleep disruption.

A client with chronic kidney disease is admitted with pneumonia and pleurisy. The client's laboratory results are shown in the exhibit. Which prescription will the nurse question? Click on the exhibit button for additional information. 1. Acetaminophen 500 mg PO every 6 hours, as needed for fever [20%] 2. Epoetin alfa 15,000 units subcutaneus injection, once weekly [32%] 3. Ketorolac 15 mg IV every 6 hours, as needed for pain [21%] 4. Levofloxacin 500 mg IV, once daily [25%]

3 / Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. In addition, clients taking a NSAID medication should not take a different NSAID medication at the same time

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication? 1. Constipation [6%] 2. Difficulty sleeping [2%] 3. Discoloration of urine [76%] 4. Dry mouth [14%]

3 / Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine.

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? 1. Client has 1 emesis of green fluid [20%] 2. Client has had no bowel movement for 2 days [27%] 3. Client falls asleep while talking to the nurse [27%] 4. Client reports experiencing pruritus [24%]

3 / Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider? 1. "I don't have much interest in sex lately." [4%] 2. "I feel like I might be getting a cold." [30%] 3. "My periods have been heavy lately." [44%] 4. "These hot flashes are occurring a lot." [20%]

3 / Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3). Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis)

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? 1. "A contrast medium is administered rectally to visualize the colon via x-ray." [13%] 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." [26%] 3. "This enema assists the large intestines in removing excess potassium from the body." [39%] 4. "This enema is administered before bowel surgery to decrease bacteria in the colon." [20%]

3 / Sodium polystyrene sulfonate (Kayexalate) retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? 1. "I should not donate blood while taking this medication." [14%] 2. "I will stop taking my tetracycline prior to taking this medication." [34%] 3. "I will take vitamin A supplements." [29%] 4. "I will use condoms and birth control pills." [22%]

3 / Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication

The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects? 1. Decreased blood pressure and growth delays [15%] 2. Heart palpitations and weight gain [20%] 3. Loss of appetite and restlessness [49%] 4. Trouble sleeping and a dry cough [14%]

3 / The major problems with stimulant medications include: Decreased appetite and weight loss - can lead to growth delays Cardiovascular effects - hypertension and tachycardia (particularly in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up? 1. Also takes ibuprofen for pain [18%] 2. Frequency of urination has increased [7%] 3. Mild red rash has developed over torso [62%] 4. Nausea occurs after each dose [12%]

3 / The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics

A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse? 1. Encourage the parent to be involved with the child [72%] 2. Engage in physical contact by removing the toddler's outer clothing first [3%] 3. Have medical equipment lying on a counter within view [9%] 4. Perform an examination in a head-to-toe order [14%]

3 / The nurse should plan to assess the toddler client in a nonthreatening environment, taking time to develop rapport prior to beginning the examination. This can be achieved by talking to the toddler about favorite objects and slowly initiating contact. Parent involvement, such as holding the child and assisting the child with examination activities, reduces anxiety and encourages cooperation in toddler clients. Age-appropriate games or toys may be used if needed to gain the client's cooperation.

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function laboratory results [24%] 2. Flush tube with normal saline, not water [24%] 3. Stop the feeding for 1 to 2 hours [24%] 4. Take the blood pressure (BP) [26%]

3 / The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug.

The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed-head injury who is 1 day post craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client's medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification? Click on the exhibit button for additional information. 1. Acetaminophen 1,000 mg IV, every 6 hours [44%] 2. Gabapentin 300 mg orally, every 8 hours [11%] 3. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours prn [28%] 4. Phenytoin 100 mg orally, every 12 hours [15%]

3 / The recommended dose for acetaminophen should not exceed 4 g in 24 hours as excessive intake can lead to liver injury. The nurse should contact the health care provider (HCP) to question the prescription for the prn opioid analgesic hydrocodone/acetaminophen (5 mg/325 mg) (Vicodin). This client is already receiving acetaminophen 1,000 mg IV every 6 hours (4,000 mg). If the client needed and received the maximum possible dosage of 6 tablets of hydrocodone/acetaminophen (5 mg/325 mg), the total dose of acetaminophen (4,000 mg + 1,950 mg [6 tablets] = 5,950 mg) would exceed the recommended daily dosage

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F (38.4 C). Which action should the nurse take? Click on the exhibit button for additional information. 1. Give all medications, including acetaminophen, and reassess in 30 minutes [20%] 2. Hold the haloperidol, give acetaminophen, and reassess in 30 minutes [23%] 3. Hold the haloperidol and notify the health care provider (HCP) immediately [37%] 4. Hold the hydrochlorothiazide and notify the HCP immediately [18%]

3 / This client is exhibiting signs and symptoms of neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medicationt

A distraught parent informs the nurse of bleeding in a 1-day-old girl. What is an appropriate response by the nurse after finding a small amount of bloody mucus in the newborn's diaper? 1. "Laboratory work will need to be completed to determine your newborn's hormone levels." [15%] 2. "The health care provider will prescribe a dose of medication to stop the bleeding." [1%] 3. "We will continue to monitor the amount, color, and consistency of the drainage." [77%] 4. "What visitors have been present since the baby was born?" [6%]

3 / Understanding a child's perception of illness and death can empower caregivers (eg, parents) to support the child during the loss of a loved one. A child's developmental stage as well as the caregiver's view of death and relationship with the child will influence coping during bereavement. The nurse should educate the parent of an 8-year-old client about how to assist with coping based on the knowledge that school-aged children (age 6-12 years) most likely have both a curiosity and fear about the implications of death (eg, process of dying, funeral services) and understand that death is permanent

A client with deep vein thrombosis (DVT) is receiving a continuous infusion of unfractionated heparin. The client asks the nurse what the heparin is for. How should the nurse respond? 1. "Heparin is a blood thinner that will help to dissolve the clot in your leg." [37%] 2. "Heparin will help stabilize the clot in your leg and prevent it from breaking off and traveling to your lungs." [12%] 3. "Heparin will keep the current clot from getting bigger and help prevent new clots from forming." [49%] 4. "I'm sorry. This is something that your health care provider (HCP) can answer better upon arriving." [0%]

3 / Venous thrombosis involves the formation of a thrombus (clot) and the inflammation of the vein. Anticoagulant therapy such as heparin does not dissolve the clot. The clot will be broken down by the body's intrinsic fibrinolytic system over time. The heparin slows the time it takes blood to clot, thereby keeping the current clot from growing bigger and preventing new clots from forming

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? 1. Administer oxygen via nasal cannula for client comfort and safety [6%] 2. Clean area with povidone iodine in a circular motion moving outward [11%] 3. Hold the child with the head and knees tucked in and the back rounded out [68%] 4. Monitor and record vital signs every 15 minutes throughout the procedure [13%]

3, / The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which findings does the nurse expect to observe? Select all that apply. 1. Absent deep tendon reflexes 2. Cold, clammy skin 3. Muscle rigidity 4. Restlessness and agitation 5. Sinus tachycardia

3,4,5 / Clinical manifestations of serotonin syndrome include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1. "A high-calorie, high-protein diet is best for our child." 2. "It is extremely important that we do not allow our child to become dehydrated." 3. "Our child should wear a medical alert bracelet at all times." 4. "We should avoid giving our child over-the-counter medicine containing aspirin." 5. "We should encourage a noncontact sport such as swimming."

3,4,5 / Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties Avoid intramuscular injections; subcutaneous injections are preferred. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times. Malnutrition is not commonly associated with hemophilia; a regular diet is indicated. Clients with cystic fibrosis are at risk for malnutrition and need a high-calorie diet. Dehydration is not commonly associated with hemophilia. Avoiding dehydration is important for those with sickle cell anemia

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply. 1. Dodgeball 2. Reading a book 3. Stationary bicycling 4. Swimming 5. Yoga

3,4,5 / In general, low-impact, weight-bearing, and non-weight-bearing exercises that involve range of motion and stretching to preserve joint mobility and strengthen muscles are best. High-impact activities and those that cause overtiring and joint pain should be avoided. Swimming is often considered the ideal activity for children with JIA as it allows for exercising a large number of joints with minimal gravitational pull. Other recommended activities include riding a stationary bike, throwing or kicking a ball, low-impact aerobic dancing, walking, and yoga. Playing dodgeball places the child at risk for joint or other injury. Reading a book does not provide physical activity.

After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first? 1. Administer diphenhydramine [12%] 2. Administer injectable epinephrine [11%] 3. Examine the client's trunk and limbs [35%] 4. Reassess the client's allergy history [40%]

4 / A client with signs of a potential allergic reaction should be assessed quickly, including allergy history and physical assessment (face, trunk, and limbs) with attention to signs of anaphylaxis. The health care provider should then be notified to assess the client, and the client's allergies should be updated in the medical record.

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? 1. Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain [21%] 2. Hydromorphone IV for a client who has a fractured femur, is a known IV heroin abuser, and rates pain as 9 on a 0-10 scale [39%] 3. Tramadol for a client who is being prepared for discharge following a laparoscopic cholecystectomy and rates abdominal pain as 6 on a 0-10 scale [13%] 4. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain [25%]

4 / A transdermal fentanyl patch is indicated to treat moderate to severe chronic pain. It is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.

The practical nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the practical nurse to report to the registered nurse for evaluation? 1. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm3 (15.0 x 109/L) [14%] 2. Client with liver cirrhosis has a prothrombin time of 18 seconds [29%] 3. Client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL (13.9 mmol/L) [37%] 4. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm3 (14.0 x 109/L) [19%]

4 / Adalimumab (Humira), a tumor necrosis factor (TNF) inhibitor, is a biologic disease-modifying antirheumatic drug (DMARD) classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade]) and include immunosuppression and infection (eg, current, reactivated). An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately. Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) are common tumor necrosis factor inhibitors and biologic disease-modifying antirheumatic drugs. Major adverse effects associated with their use include immunosuppression and infection

The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? 1. "We will encourage extra fluid intake while our child is sick." [5%] 2. "We will increase the frequency of blood glucose checks." [14%] 3. "We will monitor our child's urine for ketones with each void." [10%] 4. "We will not administer insulin if our child is unable to eat." [70%]

4 / An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis). Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an acute illness (Option 4). Additional sick-day management includes: Increasing frequency of blood glucose level checks (every 1-4 hours) Increasing or decreasing the dose of insulin as needed based on blood glucose levels Maintaining adequate hydration Testing for urinary ketones frequently

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client? 1. Avoid a high-potassium diet [21%] 2. Exercise regularly and maintain a high-fiber diet [9%] 3. Maintain oral hygiene [17%] 4. Report excessive urination and increased thirst [51%]

4 / Because lithium is very similar to sodium (a "salt"), taking lithium is like taking small salt tablets: it makes you thirsty. If you don't drink more water than usual, you can have dry mouth. But when you do drink more, you will also urinate more. ... Weight gain can occur with lithium

The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse reinforce with the client? 1. Monthly calcium levels will need to be drawn [41%] 2. Stop vitamin D supplements when taking calcium [15%] 3. Take calcium at bedtime [11%] 4. Take calcium in divided doses with food [31%]

4 / Calcium and vitamin D are essential for bone strength. Calcium carbonate (Caltrate) has the most available elemental calcium of over-the-counter products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? 1. "I am not sleeping well at night and would like a sleeping aid." [9%] 2. "I do not know how well I will do on this restricted diet." [4%] 3. "I have been having quite a bit of nausea and constipation." [19%] 4. "This medicine is not working; I am so tired of being depressed." [66%]

4 / Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider? 1. "I am tired of restricting my fluids but know I need to." 2. "I feel like I am beginning to get sick with a bad cold." 3. "I have been getting a lot of nasal pain with this spray." 4. "I have recently started to experience frequent headaches."

4 / Clients taking desmopressin for diabetes insipidus are at risk for water intoxication and hyponatremia. Client reports of headache, mental status change, and/or muscle weakness may indicate hyponatremia from water intoxication and should be reported to the health care provider immediately

A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client? 1. "A diet rich in protein and vitamin D will help with absorption." [15%] 2. "If the tablet is too large to swallow, crush and take it in applesauce or pudding." [11%] 3. "Potassium tablets should be taken on an empty stomach." [15%] 4. "Take it with plenty of water and sit upright for a period of time afterward." [57%]

4 / Furosemide is considered a "potassium-wasting" diuretic, meaning that a client could experience loss of potassium. A low potassium level in a client with heart failure could be dangerous due to possible life-threatening dysrhythmias and increased susceptibility to toxicity from digoxin (if taken). Therefore, potassium supplementation is needed for this client. Potassium should be taken with plenty of water (at least 4 ounces), and the client should sit upright for a period of time after ingestion. This prevents the tablet from lodging in the esophagus, which can cause erosion and pill-induced esophagitis. Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), and clients taking these medications should be given similar instructions

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? 1. Bradycardia [12%] 2. Hypokalemia [50%] 3. Nephrotoxicity [26%] 4. Ototoxicity [10%]

4 / High doses of IV furosemide should be administered slowly to prevent ototoxicity

A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce? 1. Apply lubricating eye drops when wearing contacts [2%] 2. Do not break, crush, or chew capsules [22%] 3. Use sunscreen routinely during therapy [20%] 4. Use two forms of contraception consistently [53%]

4 / Isotretinoin is a teratogenic medication known to cause serious harm to a fetus if taken during pregnancy. The client must use two forms of contraception prior to, during, and after therapy. Negative pregnancy tests are required before initiating therapy and prior to refills.

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to reinforce to the client? 1. Report for periodic laboratory tests for kidney, liver, and blood functions [22%] 2. Store the medication in a cool, dry place away from direct heat and light [8%] 3. Take the medication after a meal to prevent gastric distress [8%] 4. Take the medication with a full glass of water and increase fluids during the day [59%]

4 / It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.

The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed? 1. "I will need to get my blood drawn to see if I'm taking the right dose." [14%] 2. "I will probably need to take this the rest of my life." [8%] 3. "I will take this once a day in the morning." [4%] 4. "If this makes my stomach upset, I will take it with an antacid." [72%]

4 / Levothyroxine should be taken on an empty stomach, preferably in the morning, separately from other medications.

An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported? 1. Auscultation of a loud heart murmur [23%] 2. Infant has been npo for 4 hours [6%] 3. Infant has polycythemia [48%] 4. Infant has severe diaper rash [20%]

4 / Severe diaper rash should be reported to the supervising registered nurse and the health care provider (HCP). The presence of a rash could delay the procedure if it is located in the groin area, where access is obtained for arterial cannulation. There is a risk of infection as Candida, a yeast, or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick.

The nurse is reading the revised medication prescriptions for a client recently admitted with type 1 diabetes mellitus. Which prescription should the nurse question and report to the health care provider? 1. 10 units regular insulin IV push for blood glucose >250 mg/dL (13.9 mmol/L) [20%] 2. 14 units glargine insulin subcutaneous injection every night at 8:00 PM [18%] 3. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast [14%] 4. 20 units NPH insulin IV push administered every morning at 7:00 AM [47%]

4 / Subcutaneous injection is the only indicated route for NPH insulin administration; it should never be administered via IV push.

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? 1. C-reactive protein (CRP) [43%] 2. Prothrombin time (PT) [33%] 3. Serum LDL cholesterol [5%] 4. Tuberculin skin test (TST) [17%]

4 / TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction? 1. "I should avoid alcohol intake with this new medication." [3%] 2. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." [11%] 3. "I should read the labels on all foods I eat, including those that say 'sugarless'." [5%] 4. "This medication will help me lose weight." [79%]

4 / The major adverse effects of sulfonylurea medications are hypoglycemia and weight gain. Alcohol must be avoided while taking these medications due to the risk of severe hypoglycemia. Glyburide can also make clients sunburn easily.

The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse? 1. "Methylphenidate is generally a safe and effective drug for children with ADHD." [16%] 2. "Methylphenidate will increase the levels of neurotransmitters in your child's brain." [16%] 3. "You should see your child's school grades improve." [4%] 4. "Your child should be able to more easily complete school assignments and other tasks." [62%]

4 / The therapeutic effects of methylphenidate can be observed very quickly in children with ADHD. Methylphenidate improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills

A 10-year-old is implementing behavioral strategies to manage nocturnal enuresis. The client tells the nurse, "I want to go to sleep-away camp during the summer, but if I have an 'accident,' I'm afraid that other kids will tease me." What is the best response by the nurse? 1. "Don't worry. Your problem will be resolved by then." [1%] 2. "It would be better if you thought about going to day camp instead." [19%] 3. "We can ask your health care provider about a medication trial that may help." [57%] 4. "You could always wear a pull-up just in case." [21%]

5 / Pharmacological interventions such as desmopressin and tricyclic antidepressants are often used for nocturnal enuresis treatment in children age >5 years when there has been little or no response to behavioral approaches and/or when short-term improvement of enuresis is desired for attending sleepovers or overnight camp.

The Centers for Disease Control and Prevention (CDC) recommends that the first dose of MMR vaccine be given to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within

72 hours of the child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis. A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and again between age 4-6 years

terine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed

90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity

Clients are diagnosed with iron deficiency anemia when hemoglobin is

<11 g/dL in the first and third trimesters and <10.5 g/dL in the second trimester

The Bishop score is a system for the assessment and rating of cervical favorability and readiness for induction of labor. A score

>8 in nulliparous women is associated with successful induction and subsequent vaginal birth.

School phobia (also known as school refusal or school avoidance) is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school. Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships

A child with school phobia needs to return to the classroom immediately. Insisting on school attendance, along with other supportive interventions, will help the child make a faster adjustment

The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate?

A client in the postoperative period who is unresponsive to painful stimuli is likely still under the effects of opioid medications used during anesthesia. Naloxone (Narcan), an opioid antagonist, will temporarily reverse the effects of any opioid medications. However, the half-life of naloxone is shorter than that of most opioid medications (ie, the effect typically wears off in 1-2 hours), and a second dose may be required. The nurse should make frequent observations of the client's respiratory rate and administer prescribed oxygen for respiratory support (Options 1 and 5). The registered nurse should be notified to fully assess the client and to administer a second dose of naloxone as prescribed (either a one-time dose or continuous drip)

Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety.

A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills

NMDA receptor

A receptor site on the hippocampus that influences the flow of information between neurons by controlling the initiation of long-term potentiation

Symptoms of attention-deficit hyperactivity disorder (ADHD) include inattention, impulsivity and/or hyperactivity and usually continue into adulthood; current research indicates that children do not outgrow the condition. However, with supportive environments, behavioral therapy, and/or medication (eg, methylphenidate, atomoxetine), individuals with ADHD can learn to cope with and manage the symptoms. These "recovered" individuals can achieve their full potential and lead healthy and satisfying personal, academic, and professional lives

ADHD, a chronic condition that starts in childhood and continues into adulthood, presents with inattention, impulsivity and/or hyperactivity. Medications and behavioral therapy help clients cope with and manage their symptoms, allowing for improved academic and workplace performance and relationships. Parents should minimize distractions and prevent overstimulation (eg, limit choices to two, avoid multitasking, advocate for individualized education plan).

Kawasaki disease (KD) is a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has the following 3 phases:

Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Initial treatment consists of IV immune globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure; signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing)

Around 6 months of age, infants begin to experience separation anxiety. This anxiety may be heightened during hospitalization because of exposure to many unfamiliar stressors. Appropriate nursing care can play a significant role in reducing the infant's physiologic and psychologic stress. Key interventions include:

Adhering to the infant's home routine (eg, meal and sleep times) as closely as possible (Option 1) Providing a favorite toy or pacifier (Option 2) Encouraging caregivers to remain whenever possible during hospitalization Providing a quiet sleep environment with reduced stimulation to promote restful sleep (Option 4) Offering a familiar object (eg, caregiver's shirt, blanket, voice recording) during stressful situations

Preterm labor (PTL) is defined as progressive, cervical dilation and/or effacement resulting from uterine contractions before 37 weeks gestation. The nurse should anticipate the following interventions for clients in PTL who are at <34 weeks gestation:

Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development Initiating an IV magnesium sulfate infusion for fetal neuroprotection in clients who are at <32 weeks gestation Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows time for antenatal glucocorticoids to have a therapeutic effect

Measles (ie, rubeola) is a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus through the air, where it remains suspended for up to 2 hours. Widespread vaccination with the measles, mumps, and rubella (MMR) vaccine, such as in the United States, has reduced measles incidence by 99%. However, increases in the frequency of international travel and the number of unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, interventions should include the following:

Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas Recommendation of post exposure prophylaxis (ie, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms in case they contract the disease Implementation of airborne precautions, including a negative-pressure isolation room and use of a N95 respirator mask, during contact with the client by health care staff

Major predisposing factors for the development of delirium in hospitalized clients include:

Advanced age Underlying neurodegenerative disease (stroke, dementia) Polypharmacy Coexisting medical conditions (eg, infection) Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) Metabolic and electrolyte disturbances Impaired mobility - early ambulation prevents delirium Surgery (postoperative setting) Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium

Fluticasone/salmeterol (Advair) is a combination drug containing a corticosteroid (fluticasone) and a bronchodilator (salmeterol). Salmeterol is a long-acting inhaled β2-adrenergic agonist that promotes relaxation of the bronchial smooth muscles over 12 hours. Fluticasone decreases inflammation. This medication is used as part of the treatment plan for prevention and long-term control of asthma. Client instructions include:

After inhalation, rinse the mouth with water without swallowing to reduce the risk of oral/esophageal candidiasis Avoid smoking and using tobacco products Receive the pneumococcal and influenza vaccines if there is a risk for infection

A client gives birth within an hour of arriving at the labor and delivery unit and delivers the placenta 5 minutes later. During assessment, the nurse notes that the uterus is midline and boggy. Which action should the nurse take first?

After placenta delivery, the fundus should be firm, midline, and at or slightly below the umbilicus. The initial nursing action to correct uterine atony with a midline, boggy uterus is fundal massage

Developmental milestones of infants

Age (months) Gross motor Fine motor Language Social/cognitive 1 Attempts to hold head up when prone Maintains fisted hands Cries when upset Gazes at parent's face when parent speaks 2-3 Gains head control when held Holds rattle when placed in hand Makes cooing sounds Smiles in response to smiling & talking 4-5 Rolls front to back, then back to front Sits with support Holds objects with palmar grasp Puts things in mouth Begins to laugh Makes some consonant sounds Becomes calmed by parent's voice 6-9 Sits without help Begins to crawl May pull to a stand Moves objects between hands Uses crude pincer grasp Babbles & imitates sounds May say "mama" Recognizes familiar faces May have stranger anxiety 10-12 May walk with help or take independent steps Crawls up stairs Uses 2-finger pincer grasp Hits 2 objects together Says 3-5 words Uses nonverbal gestures (eg, waving goodbye)

The following are important principles to teach clients with celiac disease:

All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet

Reduction of intussusception is often performed with a saline or air enema. The supervisory registered nurse should be notified if there is passage of a normal stool as this indicates reduction of intussusception

All plans for surgery should be stopped, and the plan of care should be modified.

What does positive Babinski sign mean?

An important neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe goes up, that may mean trouble. The Babinski sign is obtained by stimulating the external portion (the outside) of the sole.

Individuals with obsessive-compulsive personality disorder are typically self-willed and obstinate, punctual, pay attention to rules and regulations, and need to control both internal and external experiences. These traits are very extreme and result in rigidity and inflexibility. In this scenario, a change has been made in the client's schedule for the day and is outside of the client's control. This could cause significant distress and impaired functioning so that the client feels emotionally paralyzed.

An individual with obsessive-compulsive personality disorder is typically rigid and inflexible and has a need to control both internal and external experiences. A change in a schedule that is outside of the client's control could cause significant distress

The most common worm infection in the United States is pinworm, which is easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around the anus, resulting in

Anal itching and troubled sleep. When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is treated with anti-parasitic medications.

Odansetron (Zofran)

Antiemetic

Tamoxifen (Nolvadex)

Antineoplastic Agent, Hormonal Agent

Clopidogrel (Plavix)

Antiplatelet

Any client who cannot definitively say that he/she is not currently suicidal should be considered a "yes," and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care, and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision

Any client who expresses ambivalence about being suicidal should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone

Varicella (chickenpox) is an extremely contagious infection caused by the varicella-zoster virus. Manifestations include fatigue, fever, and a pruritic vesicular rash. Varicella is spread by airborne droplets and direct contact with lesions. Infected persons are contagious for several days before the rash appears and until all lesions have crusted. The best way to prevent outbreaks of communicable diseases (eg, varicella, measles) and protect vulnerable populations (eg, infants, immunocompromised clients) is to ensure that vaccinations are up to date (Option 3). In addition, clients with varicella should remain at home until all lesions are crusted to reduce the spread of infection (Option 4). Secondary bacterial infection is a common complication caused by scratching of the lesions. The nurse should include the following instructions to increase comfort and minimize scratching:

Apply soothing lotion (eg, calamine) to lesions Clip the child's fingernails short Place mittens on the child during sleep Keep the child cool and avoid overheating Dress the child in loose-fitting, cotton clothing Bathe the child daily and wash hands often

The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement made by the client indicates an appropriate understanding about weight gain? I should gain about 30 pounds during the entire pregnancy."

Appropriate weight gain during pregnancy decreases risks to the client and fetus. Weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI. The optimal total weight gain during pregnancy is determined by the client's prepregnancy BMI

An insulin pump is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways:

As a steady, measured, and continuous dose (basal rate) 24 hours a day As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia.

Unlicensed assistive personnel (UAP) have the skills and knowledge to perform standard procedures to prevent immobility hazards for a client in traction (eg, pneumonia, pressure ulcers, foot drop, thromboembolism). When providing care for a stable client, the nurse can safely assign the following tasks to UAP:

Assist with active and passive range of motion exercises after the client has been taught how to perform them by the registered nurse (RN) or physical therapist (Option 1) Notify the nurse of client reports of pain, tingling, or decreased sensation in the affected extremity Remind clients to use the incentive spirometer after they have been taught proper use by the RN or respiratory therapist (Option 5) Maintain proper use of pneumatic compression devices (Option 4) Remind the client to move frequently using the overhead trapeze

Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following:

Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH Report changes in vision (eg, blurred vision, vision loss) Report signs/symptoms of severe adverse effects such as: Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) Peripheral neuropathy (eg, numbness, tingling of extremities)

Lithium carbonate (Lithobid)

Bipolar medication. Produce neurochemical changes in the brain to control acute mania, depression and incidence of suicide. Uses: bipolar disorder, alcohol use disorder, bulimia, and schizophrenia. Precautions/interactions: use cautiously in clients who have renal dysfunction, heart disease, hyponatremia, and dehydration. NSAIDs will increase lithium levels. Monitor serum sodium levels.

Nurses caring for newborns must be able to distinguish between normal physiologic variations and unexpected findings that require further assessment. Expected findings and normal variations in newborns include:

Bluish discoloration of the hands, feet, and around the mouth (ie, acrocyanosis), which is a common, harmless finding during the first 24 hours after birth and through the first week of life when exposed to cold (Option 1) Heart rate of 110-160/min when awake and calm; heart rate may further range from 80/min during rest to 180/min when crying or agitated (Option 3) Firm, flat, and well-distinguished anterior and posterior fontanels (the membrane-filled spaces between the cranial bones) (Option 2) Newborns normally have increased muscle tone and will resist movement of the extremities. Decreased muscle tone (ie, hypotonia) is an abnormal finding that may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury. (Option 4) Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally. (Option 5) The presence of a single umbilical artery is associated with an increased risk of congenital defects, particularly of the kidneys and heart. Normal umbilical cords contain 2 arteries and 1 vein

Bacterial meningitis is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry. One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage.

Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis. The Babinski reflex can be present up to age 1-2 years and is a normal, expected finding; it does not indicate meningitis. Pulse pressure is the difference between systolic and diastolic blood pressures. Widening of pulse pressure is one of the signs of Cushing's triad (systolic hypertension with widened pulse pressure, bradycardia, respiratory depression). These signs occur very late if increased ICP is not treated. Fontanel assessment provides an earlier indication of increased ICP. Because meningitis clients are sensitive to light (photophobia), frequent assessment of pupillary light response will be uncomfortable. Severely increased ICP may alter pupillary response; however, this is a late complication of hydrocephalus. Fontanel assessment provides an earlier indication of a developing problem.

A woman who had a cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The practical nurse should assess for which priority problem before notifying the registered nurse?

Calf warmth and redness / The hypercoagulable state during pregnancy increases the risk for thrombus formation. The practical nurse should report any signs of deep venous thrombosis (eg, redness, swelling, warmth in the calf area) or pulmonary embolus (eg, anxiety, shortness of breath) to the registered nurse. Elevated white blood cell count and temperature are expected findings during the first 24 hours after childbirth.

Caregiver role strain (CRS) is a caregiver's perception of the multifactorial difficulties associated with providing care to another person (usually a family member). The nurse should assess caregivers for signs of physical (eg, fatigue, insomnia, weight loss/gain), emotional (eg, depression, anxiety, anger), and social (eg, isolation, loss of support systems) problems. Monitoring caregivers for CRS is important, as it can have a significant negative impact on their health and well-being. Asking about the nature and requirements of providing daily care allows the caregiver to discuss the demands of providing care and helps the nurse understand stressors and unmet needs.This type of inquiry is a therapeutic response that encourages verbalization of thoughts, feelings, and concerns. Assessment of caregiving challenges also helps to identify opportunities for assistance (eg, skills training, support groups) and community resources (eg, home health care, food/nutrition services). Giving opinions and providing false reassurance are nontherapeutic, discourage nurse-client communication, and do not help identify CRS. Restating client statements can be therapeutic because it shows that the nurse has analyzed what has been said. However, this response does not prompt the client to discuss potential difficulties in providing care

Caregiver role strain is a caregiver's perception of multifactorial difficulties associated with providing care to another person. The nurse should routinely monitor for signs of caregiver role strain (eg, fatigue, depression, isolation) because it can have a significant negative impact on a caregiver's health and well-being.

Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis of collagen by osteoblasts. Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be frail and easily fractured. Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal dominant inheritance. The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI includes:

Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs (Option 3) Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull

Haloperidol (Haldol) side effects

Chiefly Parkinsonian-like symptoms and extrapyramidal effects, which may be very dramatic. Tremors very common. Less blockade of the muscarinic and the alpha-adrenergic receptors compared to other neuroleptic agents such as Chlorpromazine. The potentially fatal neuroleptic malignant syndrome (NMS) is a significant possible side effect

The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse?

Clients demonstrating altered mental status should be assessed for intoxication and medical causes of delirium (eg, electrolyte/glucose imbalances, pneumonia, sepsis, malnutrition) prior to involving a mental health care professional. The nurse should offer therapeutic responses that provide facts and refrain from judging or offering false reassurance.

Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior

Clients with borderline personality disorder are at very high risk for suicide. Suicidal gestures and attempts must be taken seriously and evaluated for suicidal intent

Bulimia nervosa is an eating disorder common among adolescent girls and characterized by cycles of uncontrollable overeating (binging) followed by compensating behaviors to avoid weight gain (purging). Weight-maintenance behaviors include self-induced vomiting, fasting, laxative abuse, and excessive exercise. Clients may be of normal weight, which contributes to the hidden nature of this disorder. Clients with bulimia often experience extreme guilt associated with their increasing lack of control and attempt to hide evidence of their actions (eg, hidden food wrappers from binging, discarded food from unfinished meals). Clients should be monitored around meal times, and particularly for 60-90 minutes after eating to observe for purging. Purging behaviors, particularly vomiting, may result in electrolyte imbalances, such as hypokalemia, that can cause cardiac arrhythmias. Clients with bulimia nervosa often use laxatives inappropriately to rid their bodies of undigested food in an effort to control their weight. Such measures should not continue in the treatment setting. A food diary helps the client and caregivers track the type and amount of food that the client has eaten. It is also an excellent means of helping the client understand the health implications of the disorder

Clients with bulimia nervosa should be monitored for signs of hidden binging or purging activity, particularly for 60-90 minutes after meals. Excessive vomiting may result in electrolyte imbalances, including hypokalemia

Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). Symptoms of PTSD include re-experiencing the traumatic event via flashbacks, nightmares, and feelings of distress in reaction to reminders; avoiding reminders of the trauma (eg, places, activities, thoughts, other triggers); and increased anxiety and emotional arousal (eg, insomnia, hypervigilance, outbursts of rage, irritability). Clients with an anxiety level of 8/10 and pacing behavior are demonstrating distress and require immediate attention as they might harm themselves or others

Clients with post-traumatic stress disorder have periods of extreme anxiety and emotional arousal during which they can be a danger to themselves or others

Common characteristics of anorexia nervosa

Clinical features Significantly low body weight Extreme fear of weight gain Inappropriate perception of body weight or size Subtypes Binge/purge (eg, self-induced vomiting, diuretics, laxatives) Restricting (dieting, fasting, excessive exercise)

Varicella-zoster virus (VZV) infection (chickenpox) is characterized by lesions that begin as a maculopapular rash, progress to weeping vesicular lesions, and typically crust over within approximately 1 week. The lesions are often pruritic and/or painful, and clients frequently have an accompanying fever. In most cases, treatment is supportive in nature and includes:

Cool oatmeal baths and topical antihistamines (eg, diphenhydramine) applied to lesions for itching Acetaminophen as needed for fever or pain Immunocompromised clients (eg, clients with acute myelogenous leukemia [AML]) are at risk for severe varicella (eg, disseminated, pneumonia) and require aggressive therapy, including an antiviral agent (eg, acyclovir). Antiviral therapy should be continued until all the lesions have crusted over (Option 2). VZV is spread via airborne and contact transmission. Clients are most infectious in the days leading up to the rash and continue to be infectious until the entire rash reaches the crusting stage

Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures (Option 1). Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety (Option 3). Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization (Option 4). (Option 2) A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy. (Option 5) Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way.

Coping mechanisms used by hospitalized toddlers include following homes rituals and routines, having parents stay with the child (including overnight), and using the playroom for relief of anxiety and fear.

No harm/no suicide contracts are widely used in clinical practice to support a client's ability to avoid acting on suicidal thoughts. However, the practice is controversial; there is no evidence that such contracts reduce suicide, and they may provide a false sense of security.In addition, some clients may feel distrustful of a health care provider who asks a client to sign a suicide contract. If a contract is used, it should be short term with a specific stated time frame. At the end of the contract period, a new contract is negotiated. The student nurse must understand that the contract does not guarantee client safety and has no legal credibility. A more helpful strategy to support the client with suicidal ideation is safety planning. The plan is created in collaboration with the client and includes the following steps:

Creating a safe home environment - removal of firearms, sharp knives, razor blades, and unnecessary/unused medications Identifying thoughts, situations, and behaviors that could trigger a suicidal crisis Identifying ways to cope with suicidal thoughts, such as physical exercise or a distracting activity Making a list of mental health agencies or hotlines that the client can go to or call when help is needed Making a list of people who can be contacted for help or distraction

Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior (top) shoulder becomes wedged behind or under the mother's symphysis pubis. A shoulder dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes (eg, hypoxia, nerve injury, death). When a shoulder dystocia occurs, the primary nursing interventions include:

Documenting the exact time of events (eg, birth of fetal head, shoulder dystocia maneuvers) (Option 1) Verbalizing passing time to guide health care provider decision-making (eg, "two minutes have passed") Performing maneuvers to relieve shoulder impaction (eg, McRoberts maneuver, suprapubic pressure) (Option 2) Requesting additional help from staff (eg, nurses, neonatologist) immediately

Neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening adverse reaction to antipsychotic medications (eg, haloperidol). NMS can develop at any time during therapy but usually occurs within the first few weeks. NMS is characterized by high fever, mental status changes (an early sign), muscle rigidity, and autonomic dysfunction (eg, tachycardia, fluctuating blood pressure, diaphoresis)

Early recognition is critical to improve survival. The medication should be discontinued immediately, and supportive treatment (eg, cooling blankets, fluid and electrolyte replacement) should be initiated. In severe cases, dantrolene or bromocriptine may be required to counteract muscle rigidity and fever

Nursing care of hospitalized clients experiencing separation anxiety focuses on maintaining a calm environment and a supportive demeanor to build trust between the nurse and the child, and encouraging connection with family and familiar environments, even when they are absent. Key interventions include:

Encouraging the parents to leave favorite toys, books, and pictures from home Establishing a daily schedule that is similar to the child's home routine Maintaining a close, calming presence when the child is visibly upset Facilitating phone or video calls when parents are available Providing opportunities for the child to play and participate in activities

The number of plantar creases on the bottom of the feet is indicative of the neonate's age. The more creases over the greater proportion of the foot, the more mature the neonate. The Babinski reflex is present at birth and disappears at 1 year. The toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. Absent Babinski or a weak reflex may indicate a neurological defect. Epstein's pearls are white, pearl-like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks.

Expected (normal) findings for a term newborn include plantar creases up the sole of the foot, presence of Babinski reflex, and Epstein's pearls

2,3,4 What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply. 1. Both caregivers work outside the home 2. Infant lives only with mother, who is currently unemployed 3. Infant's primary caregiver has cognitive disabilities 4. Parents are socially and emotionally isolated 5. Parents live together but are not married

FTT is a state of undernutrition and inadequate growth found in infants and young children. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include poverty, social or emotional isolation, caregivers with cognitive disabilities or mental health disorders, and lack of nutritional education.

Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include:

Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? Applying counterpressure to the client's sacrum during contractions

Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate to occiput anterior position (occiput facing the mother's anterior or pubis). The nurse or labor support person can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back massager)

Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include:

Fever or possible hypothermia Irritability, frequent seizures High-pitched cry Poor feeding and vomiting Nuchal rigidity Bulging fontanelle possible but not always present

The proper method of delivering a dose via metered-dose inhaler (MDI) includes the following:

First shake the MDI and attach it to the spacer. Exhale completely to optimize medication inhalation. Place lips tightly around the mouthpiece. Deliver a single puff of medication into spacer. Take a slow deep breath and hold it for 10 seconds to allow for effective medication distribution. Rinse mouth with water to remove any leftover medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed.

Preconception health care includes assessing for risk factors and implementing interventions (as appropriate) that will have a positive impact on a woman's health and future pregnancies. Interventions include the following:

Folic acid supplementation to reduce the incidence of neural tube defects: The beneficial impact of folic acid supplementation is greatest between 1 month before pregnancy and the end of the first trimester, the period of neural tube development (Option 5). Abstaining from alcohol and illicit drugs Smoking cessation to prevent miscarriage and fetal growth retardation Maintaining up-to-date vaccinations: Significant birth defects can occur if an unvaccinated mother is exposed to the rubella virus during pregnancy. To prevent these complications, the rubella vaccine should be given at least 3 months before attempting a pregnancy (Option 4). Avoiding contact with raw/undercooked meats, cat feces, and unpasteurized foods: Toxoplasma is a protozoan parasite found in cat feces and uncooked or rare beef and lamb. Toxoplasmosis can cause intellectual disability, blindness, or fetal demise when the embryo is exposed

Therapeutic communication allows the nurse to develop a healthy interpersonal relationship with the client. A "why" question is often avoided as it is viewed negatively by clients and can make them feel defensive about their choices or emotions

For people who are anxious or overwhelmed, a "why" question asked by the nurse is often interpreted as being critical, judgmental, and intrusive. These feelings are damaging to the development of the nurse-client relationship and therapeutic communication.

The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention?

Foreign body aspiration is a leading cause of accidental injury and death in small children due to tracheal anatomy and underdeveloped swallowing mechanisms. Food items that are particularly risky for a toddler include those that are round and slippery, sticky, or hard and rough.

An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following:

Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. A routine EEG is not performed under sedation, and so the child should remember the procedure.

Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability:

Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop Performs self-care activities with some supervision Participates in simple activities May have limited speech capabilities Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud

Hearing impairment in children may be related to family history, an infection, use of certain medications, or a congenital disorder. Toddlers with hearing deficits may appear shy, timid, or withdrawn, often avoiding social interaction. They may seem extremely inattentive when given directions and appear "dreamy." Speech is usually monotone, difficult to understand, and loud. Increased use of gestures and facial expressions is also common. (Option 2) Children typically begin to use well-formed syllables such as "mama" and "dada" by approximately age 7 months. A referral for a hearing test should be made if there is an absence of well-formed syllables by age 11 months or intelligible speech is not present by 24 months. (Option 4) Lack of attentiveness and appropriate response when given a direction is characteristic of a toddler who has a hearing impairment.

Hearing impairment in infants delays development of intelligible speech. As these infants become toddlers, they often have a loud voice and monotone speech that is difficult to understand. They appear shy, timid, and inattentive.

Constipation is a common discomfort of pregnancy and is due to an increase in the hormone progesterone, which causes decreased gastric motility. Ferrous sulfate (iron) supplementation may also cause constipation. Interventions to prevent or treat constipation include:

High-fiber diet: High amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes High fluid intake: 10-12 cups of fluid daily Regular exercise: Moderate-intensity exercise (eg, walking, swimming, aerobics) Bulk-forming fiber supplements: Psyllium, methylcellulose, wheat dextrin

Risk factors for PPH include:

History of PPH in prior pregnancy Uterine distension due to: Multiple gestation Polyhydramnios (ie, excessive amniotic fluid) Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option 1) Uterine fatigue (labor lasting >24 hours) High parity Use of certain medications: Magnesium sulfate Prolonged use of oxytocin during labor Inhaled anesthesia (ie, general anesthesia)

A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk:

Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula

The off-going nurse should notify the charge nurse as this individual is responsible for staffing of the unit and would have the authority to try different options, such as asking another nurse on the unit to stay or notifying the main nursing office to obtain a nurse from another unit. In addition, there is no established time frame for the incoming nurse's actual arrival; a significant amount of time could pass before this inadequate staffing issue is resolved.

In a facility with 24-hour care, prior to leaving, an off-going nurse must have another nurse take over the responsibility for the clients' care and give an appropriate report on these clients. Leaving clients without these elements can be deemed to be an act of abandonment.

Disaster events cause a sudden increase in admissions to local hospitals. The nurse identifies clients who are safe to recommend for discharge to make room for newly admitted clients. A client with acute asthma exacerbation may require treatment in the emergency department or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids (

In response to a local disaster, the nurse identifies clients who can be safely discharged to make room for newly admitted clients. A client with acute asthma exacerbation can be safely discharged home when respiratory status has stabilized

Which nursing interventions should be included in the plan of care for a newborn with suspected esophageal atresia (EA) and tracheoesophageal fistula (TEF)?

In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected surgically. Clinical manifestations include frothy saliva, choking, coughing, and drooling. Clients may also develop apnea and cyanosis when feeding. Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from the mouth. If surgery must be staged or delayed due to the infant's condition, the priority is to maintain a clear airway and prevent aspiration. (Option 4) This client will likely require parenteral nutrition prior to surgery. A gastrostomy tube may be placed to allow for release of air and drainage of gastric contents to prevent aspiration; however, feedings or irrigations through the tube are contraindicated until after surgical correction of the TEF.

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.... I can get out of anything. There could be trouble now." Which of the following is the best response to this client?

In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: Assisting with hydration, elimination, and positioning Ensuring that circulation is not compromised Determining readiness for removal of restraints

Developmental milestones mark the achievement of expected patterns of growth and development by a specific age and are assessed at routine well-child visits. Although each child's growth and development are unique, follow-up with a health care provider is necessary for suspected delays. Infants should develop certain fine motor skills (eg, grasp) such as using their hands to bring objects to their mouth by age 4-5 months and purposefully grasping objects by age 5 months. If, by age 7 months, an infant does not use their hands to bring a pacifier or other objects (eg, toys) to their mouth, then further assessment is required (Option 3). (Option 1) Stranger anxiety begins around age 6-8 months and demonstrates age-appropriate social development. Some infants cry loudly whereas others become quiet and stare fearfully at strangers. (Option 2) Sitting alone while using the hands for support (ie, tripod sitting) is expected for a 7-month-old client. This demonstrates age-appropriate gross motor development. Sitting alone without support occurs by age 8-9 months. (Option 4) By age 6-7 months, the infant may imitate sounds (eg, "mama," "dada") without knowing the meaning of words. This demonstrates age-appropriate vocal development. Comprehension of some words occurs around age 10 months.

Infants should develop certain fine motor skills (eg, grasp) such as using their hands to bring objects to their mouth by age 4-5 months. If a delay is suspected in this developmental milestone, further assessment by the health care provider is necessary

Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. In addition, birth length increases by approximately 50% during the first year. An infant who does not meet expected length/weight milestones should be reported to the registered nurse for further assessment. (Options 1 and 2) At birth, the infant has non-ossified membranes called fontanelles; these "soft spots" lie between the bones of the cranium. The anterior and posterior fontanelles are soft, non-fused, and the most noticeable. Fontanelles should be flat, but slight pulsations visible in the anterior fontanelle are normal, as is temporary bulging when the infant cries, coughs, or is lying down. The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months. (Option 4) This assessment shows tripling of the birth weight by age 12 months, a normal finding

Infants should double in birth weight by age 6 months and triple in birth weight by age 12 months. An infant who does not meet expected length or weight milestones should be reported to the registered nurse for further assessment. Fontanelles should be flat, but slight pulsation or temporary bulging of the anterior fontanelle when the infant cries, coughs, or is lying down is considered normal.

With careful monitoring of nutritional intake, a vegan diet (ie, excluding all animal-derived products [eg, meat, dairy, eggs]) can be appropriate for clients in all age groups. Pediatric clients consuming a vegan diet are at increased risk for nutritional deficiencies (eg, protein, calories, calcium, vitamin D, iron, vitamin B12) due to rapid growth and development. Nurses educating clients about preventing nutritional deficiencies in vegan diets should include information about:

Iron: Plant sources of iron, which are in smaller quantities and difficult to absorb, should be supplemented with fortified cereals and breads to decrease risk of iron-deficient anemia (Option 2) Vitamin C: Iron absorption is improved when dietary sources of iron and vitamin C are taken together (Option 4) Calcium: Without animal sources of calcium (eg, dairy, eggs, fish), vegan diets require supplementation of calcium and vitamin D for bone health/Fruits and vegetables do not provide vitamin B12. The nurse should educate the parents on the need for multivitamins or fortified grains as quality vitamin B12 sources

Memantine is a medication used in the treatment of moderate to severe Alzheimer disease (AD)

It slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living.

Infant formula is readily available in 3 forms: ready-to-feed, concentrated, and powder. Parents who feed their infants commercial formula should closely follow the manufacturer's recommendations for preparation, particularly if the product requires dilution or reconstitution. Parents should also adhere to basic guidelines for safe storage and handling. Key teaching points include:

Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or washing in the dishwasher. Wash the tops of formula cans prior to opening to prevent contamination (Option 2). Refrigerate prepared formula or opened cans of ready-to-feed or concentrated formula and discard after 48 hours if unused (Option 5). There is a risk of bacterial growth after this time. Warm prepared bottles by placing in a pan of hot water for several minutes. Never microwave formula as it can cause mouth burns (Option 3). Test temperature on the inner wrist before serving to the infant; the formula should feel lukewarm, but never hot.

Pyrosis, or heartburn, is common during pregnancy due to an increase in the hormone progesterone and uterine enlargement that displaces the stomach. Progesterone relaxes smooth muscles and causes esophageal sphincter relaxation. Gastric contents are then regurgitated, usually causing a burning sensation behind the sternum. The nurse should educate the client about lifestyle changes to reduce heartburn such as:

Keeping the head of the bed elevated using pillows Sitting upright after meals Eating small, frequent meals Avoiding tight-fitting clothing Eliminating common dietary triggers (eg, fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint)

A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness.

Major signs and symptoms of endometrial infection include temperature >100.4 F (38.0 C), chills, malaise, excessive uterine tenderness, and purulent, foul-smelling lochia. During the first 24 hours postpartum, temperature is normally elevated, but a reading of >100.4 F (38 C) requires further evaluation. (Option 4) The white blood cell count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation. Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and white blood cell count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation

Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following:

Making brief, frequent contacts Accepting the client unconditionally by minimizing expectations and demands Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients Being with or close by the client during group activities Offering positive reinforcement when the client interacts with others

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? 1. "I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped." [20%] 2. "I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding." [29%] 3. "I will begin using condoms to prevent pregnancy once menses returns." [26%] 4. "I will try to feed my baby before my partner and I engage in sexual activity." [24%]

Many postpartum clients resume sexual activity before their postpartum checkups (4-6 weeks after birth). Encouraging the use of barrier contraceptives (eg, condoms) to prevent pregnancy is important because ovulation may occur as early as 4 weeks after birth and before resumption of menses

Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur. A low-phenylalanine diet is essential in the treatment of PKU (Option 1). Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL [120-360 µmol/L] for clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimal health (Option 3). Management of the client with PKU includes:

Monitoring serum levels of phenylalanine Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet (Option 4) Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2) Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)

Nurses play an important role in identifying appropriate growth and development in all clients. Children who do not meet key developmental milestones for their age should be reported to the health care provider (HCP) to determine the need for further testing. Developmental milestones that a 2-year-old toddler should meet include:

Motor skills: Walks alone, builds block towers, draws lines, kicks a ball Language: Knows 300+ words, uses 2- to 3-word phrases, states name Cognitive/social skills: Engages in parallel play, imitates others, exerts independence

The fetal heart rate strip shows 2 accelerations and moderate variability. An acceleration of the fetal heart rate of at least 15/min above the baseline lasting for at least 15 seconds is a reassuring finding most often indicating fetal movement. Moderate variability refers to fluctuations in the baseline heart rate between 6-25/min. It is considered normal and indicates that the fetus is healthy and has adequate oxygenation and normal function of the autonomic nervous system

No immediate intervention is needed.

The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse?

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, indomethacin, or naproxen, inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or reduce a fever. Ibuprofen is assigned the pregnancy category C through 29 weeks gestation and pregnancy category D starting at 30 weeks gestation. It must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client. Prior to 30 weeks gestation, ibuprofen should be taken only if the benefits outweigh the risks and under the supervision of a health care provider.

Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include:

Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include:

Painful procedures (eg, capillary heel sticks, immunizations) are frequently required to provide optimal care but may cause considerable stress or alterations in a client's status (eg, vital sign changes, instability) without proper management. Nonpharmacological pain management is a method for stopping or reducing the sensation of pain and may eliminate or decrease the need for pharmacological intervention. Appropriate nonpharmacological pain-management interventions for infants and newborns include:

Offering concentrated sucrose, if prescribed, which is associated with reduced indicators of pain (eg, presence and duration of crying, grimacing) Assisting the parent to hold the infant skin-to-skin (kangaroo care), which provides sensory stimulation that is calming and reduces indicators of pain Offering nonnutritive sucking interventions (eg, pacifiers), which help calm the infant during painful procedures Swaddling the infant, which provides a sense of comfort and security and reduces the heart rate and incidences of crying

The Health Insurance Portability and Accountability Act (HIPAA) provides federal protection of a person's identifiable health information. Health care workers are expected to exercise reasonable precautions and use minimal necessary standards to protect a person's health information. Certain incidental disclosures are not an issue if reasonable precautions have been taken. Some common reasonable precautions include allowing access to a medical record to only those needing it to perform their job duties, locking file cabinets that contain medical records, and not discussing clients and their conditions in public areas. Some common incidental disclosures that are not punishable are coordinating services at a nurses' station (using reasonable voice tones and only clients' last names on whiteboards), and communicating using dividers, curtains, or other barriers (reasonable precautions). HIPAA is violated when information about a client's personal health is given to those without a "need to know"

Only persons needing client health information to carry out their job duties should have access to or be advised of this data. Nurses, health care providers, and hospitals should take reasonable precautions at all times to safeguard client information

A systolic murmur with a machine sound and poor feeding are expected, nonurgent findings in clients with patent ductus arteriosus (PDA)

PDA commonly resolves within 48 hours and requires no intervention in full-term newborns.

Parents of children with casts are taught to check for emergency signs of circulatory impairment, including changes in sensation and motor function, which could indicate early signs of compartment syndrome due to swelling within the confined space of the cast. However, some swelling is expected, so this symptom alone is not indicative of compartment syndrome. The 6 Ps of compartment syndrome include:

Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement. Increasing pain is an early sign and indicates muscle ischemia (Option 3). Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny. Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia (Option 1). Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion. Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late sign. Paralysis: Loss of function or inability to move extremity or digits. Muscle weakness occurs before paralysis which is also a late sign and indicates dead muscle tissue.

Impetigo is a highly contagious bacterial skin infection, most commonly occurring in children during hot, humid weather. Impetigo is characterized by itchy, burning, red pustules that rupture to form honey-colored crusts. When treated with antibiotic ointment and/or oral antibiotics, lesions are no longer contagious after 24-48 hours and typically heal within a week. Without antibiotics, impetigo typically resolves within 2-3 weeks but remains highly contagious until lesions heal. To care for and decrease transmission of impetigo, interventions include:

Performing handwashing before and after touching the infected area (Option 1) Isolating the infected person's clothing and linens and washing them in hot water (Option 3) Keeping the infected person's fingernails short and clean to prevent bacteria from collecting under them and to deter scratching (Option 4) Avoiding close contact with others for 24-48 hours after initiation of antibiotic therapy (Option 5) Keeping the infected area covered with gauze when in contact with others (eg, while at school)

The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following:

Persecutory - client thinks others are "out to get me" Ideas of reference - common events refer specifically to the client Grandiose - client has the perception of special importance or powers that are not realistic Somatic - false ideas about bodily functioning Nursing interventions include the following: Not arguing or challenging the belief Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system.

Sudden infant death syndrome (SIDS) is the leading cause of death among infants age 1 month to 1 year. Nurses play a crucial role in teaching parents about child care practices that reduce the risk of SIDS, which include the following:

Place infants age <1 year for sleep on their backs on a firm surface. The prone or side-lying position should never be used. Infants should not share a bed with parents/caregivers. Avoid soft objects such as stuffed animals, heavy blankets, and pillows in the infant's bed. A thin blanket tucked into the sides and bottom of the mattress can be used to cover the infant. Avoid bumper crib pads, which have not been shown to be effective in preventing infant injury and likely increase the risk of SIDS (Option 3). Maintain a smoke-free environment. Avoid overheating; if the infant is wearing a sleeper ("onesie") or a sleeping sack, even a tucked blanket may not be necessary. A fan may help reduce the temperature and circulate air in a warm room. Use a pacifier (age >1 month to ensure that breastfeeding has been established for those who are being breastfed) when placing the infant for sleep. Breastfeed and keep the infant's immunizations up to date.

Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include:

Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads Adding a motion sensor or alarm that goes off when someone tries to exit Placing a large stop sign on door exits Disguising a door with a curtain or wall hanging Using childproof doorknob covers Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception

Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next:

Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible.

Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be present at birth or develop during the first few years of life. There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be prevented, several interventions have been shown to help reduce the risk of DDH development. Key measures include:

Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement (Option 3) Choosing infant carriers or car seats with wide bases - infant seats should allow for proper hip positioning in an abducted manner Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together

Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). There are 3 categories of PTSD symptoms:

Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, feelings of intense distress/loss of control, and strong physical reactions to event reminders (eg, rapid heart rate, gastrointestinal distress, diaphoresis) Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of anger or rage, difficulty concentrating, hypervigilance, and exaggerated startle response Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep

This client has made a suicide attempt and is at high risk for additional suicidal behavior. Therefore, the client's priority need is for safety. The best nursing action is to provide one-on-one contact with the client to ensure constant observation and that the client does not engage in self-harm. The presence of the nurse will also convey a sense of acceptance, concern, and caring and provide an opportunity for the client to express feelings about the current situation. Additional nursing interventions for the client at high risk for suicide include the following:

Removing sharp and other potentially harmful objects (eg, belts, metal eating utensils, ties, glass items) from the client's environment Making sure the client swallows medications Supervising the client during meals Placing the client in a semiprivate room near the nurses' station (to reduce social isolation and allow easier access to the client) Making rounds at irregular intervals for the client who does not need constant observation, as well as at shift changes and when staff is unusually busy Encouraging the client to express feelings, especially anger Having an open and honest conversation with the client about changing suicide risk

Resilient people readily deal with the stress they face by using interventions such as deep breathing, meditation, thought interruption, and muscle relaxation.

Resilience plays a primary role in an individual's ability to prevent and recover from mental illness and to manage daily stressors. Resilience is strengthened by the practice of appropriate coping skills

Some effective strategies for dealing with a toddler during this stage of decreased appetite and pickiness include:

Set and enforce a schedule for all meals and snacks. Offer the child 2 or 3 choices of food items. Do not force the child to eat. Keep food portions small (1-2 teaspoons per serving) and provide an additional serving after the first serving is consumed. Expose the child repeatedly to new foods on several separate occasions. Do not allow the child to watch TV and play games during meals or snacks.

Nursing interventions for manipulative behaviors include:

Setting limits that are realistic, nonpunitive, and enforceable Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors Enforcing all unit, hospital, or center rules Ensuring consistency from all staff members in enforcing set limits

Signs & symptoms of major depression - SIGECAPS

Sleep (increased or decreased) Interest deficit (anhedonia) Guilt (worthless, hopeless) Energy deficit Concentration deficit Appetite (increased or decreased) Psychomotor retardation or agitation Suicidality

Nursing interventions for a newborn immediately after delivery include:

Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg, gloves) are implemented when contact with blood or bodily fluid is anticipated. Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps with nasal suctioning. Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact aids in thermoregulation. Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing intestinal bacteria. Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery. Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be vigorously removed

A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however, some children with ADHD behave aggressively and have difficulty controlling anger, especially when frustrated or if unable to meet demands and challenges. An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow, deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further discuss the disruptive behavior. Nursing interventions include the following:

Stay calm and remove the child from the source of frustration/anger Assist the child in calming down with deep breathing exercises Discuss what precipitated the behavior and why the behavior is wrong Discuss acceptable ways of expressing anger and frustration Acknowledge that controlling anger is difficult Provide rewards for appropriate behavior Discuss the consequences of inappropriate behavior

The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following:

Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) Not arguing with or challenging the client about the hallucinations Directing the client to a reality-oriented topic of conversation or activity

A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs?

Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty.

Not all cultures believe in the child-bearing practices and rituals associated with bonding and breastfeeding that are standard in the American health care setting. For example:

The American health care setting encourages the initiation of breastfeeding within the first hours after birth to stimulate the production of oxytocin, which promotes contraction of the uterus and assists in prevention of uterine hemorrhage. Mothers of southern Asian, sub-Saharan African, Pacific Island, Native American, and Hispanic ancestry may believe colostrum is harmful and therefore do not initiate breastfeeding until their breast milk comes in. However, some of these mothers may be willing to feed their newborn colostrum if they are taught about the antibody and laxative properties that it provides.

During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, which involves using oral rehydration solutions (ORS) to increase reabsorption of water and sodium.

The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy.

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?

The first step in the nursing process is assessment. In this situation, additional information is needed before the nurse can determine the next course of action / The nurse should further assess the situation and gather more information when a spouse calls reporting troublesome symptoms in a client. It is not a violation to obtain information about a client from a knowledgeable source

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response?

The nurse has used a nontherapeutic communication technique known as "giving reassurance" or "giving false reassurance." A nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. This technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued

The client is easily distractible and would not be able to focus on planning an activity. The client with acute mania is not ready to participate in group activities. The client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity.

The nursing care plan for clients with acute mania should include providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one and physical activities; limiting contact with other people; and providing foods of high nutritional value that are easy to eat

Anorexia nervosa is an eating disorder characterized by distorted body image, profound fear of weight gain, strong desire to be thin, and unwillingness to maintain a healthy body weight. The client engages in behaviors to lose weight, including not eating, purging, extreme exercise, and use of laxatives and diet pills. Psychosocial issues leading to anorexia are the focus of ongoing therapy, usually on an outpatient basis. However, certain criteria, including body weight below 75% of ideal, suicidal behavior, and medical conditions resulting from starvation, require hospitalization

The priority during inpatient care should be the short-term outcomes of restoring caloric intake, slow weight gain, and treating medical conditions caused by starvation.

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking, hyperventilating, and having heart palpitations. What is the priority nursing action?

The priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment, ensure the client's safety, and offer support

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?

Trisomy 21 (Down syndrome) is often associated with the cardiac anomaly AV canal defect. Findings typically include a loud murmur that requires no immediate action when vital signs are stable. After the neonate grows in size and can better tolerate the invasive procedure, surgery will correct the anomaly.

Perpetrators of child abuse have the following typical characteristics:

Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child Confuse punishment with discipline; exhibit a stern, authoritative approach to discipline Cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation Low self-esteem - a sense of incompetence or unworthiness as a parent History of substance abuse; use alcohol or drugs at the time the abuse occurs Experienced punitive treatment and/or abuse as a child Young parental age, inexperience, lack parenting skills, and have minimal knowledge about child care and development Resent or reject the child Low tolerance for frustration and poor impulse control Attempt to conceal the child's injury or are evasive when questioned about the injury; show little concern about the child's injury

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate?

Vaginal hematomas / are formed following trauma to the tissues of the perineum during vaginal delivery (eg, vacuum- or forceps-assisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal blessings

Clozapine (Clozaril) is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a

WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC. Because agranulocytosis is reversible if caught early, the client's WBC count and ANC must also be monitored regularly throughout the course of clozapine therapy (initially once a week) (Option 1). Clients should also contact the health care provider immediately if they develop fever or sore throat, which can indicate infection due to neutropenia

Newborn circumcision is a procedure that removes the foreskin from the glans penis using a clamp (eg, Gomco) or plastic ring (eg, PlastiBell). Circumcision is typically performed near discharge to ensure that the newborn is stable. Circumcision care includes:

Washing hands before providing care. Applying petroleum jelly to the glans penis at diaper changes (unless PlastiBell was used) for 3-7 days to prevent the exposed glans from adhering to the diaper until the site heals. The circumcision site typically heals within 7-10 days. Expecting yellow exudate on the penis after the first day, a normal part of the healing process Exudate should not be removed forcefully and disappears in 2-3 days. Swelling, increasing redness, odor, or abnormal discharge may indicate infection

Phenylketonuria (PKU)

a disorder related to a defective recessive gene on chromosome 12 that prevents metabolism of phenylalanine

Babinski reflex (sign)

a reflex action of the toes; in adults is indicative of abnormalities in the motor control pathways leading from the cerebral cortex

It is important for the nurse to develop a rapport with the child and the caregiver based on mutual trust and respect. Strategies for building this relationship include actively including the child in the interview, using

age-appropriate explanations, maintaining an eye level position, and asking open-ended questions.

thyrotoxicosis (thyroid storm)

an acute, sometimes fatal, incident of overactivity of the thyroid gland resulting in excessive secretion of thyroid hormone

Displacement is

an ego defense mechanism that involves transferring uncomfortable feelings, emotions, or impulses about one person or situation to a substitute person or situation

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

Epoetin (Procrit) is a synthetic hormone that stimulates the production of erythropoietin and is used to treat

anemia associated with chronic kidney disease

Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG administration as IVIG therapy may decrease the child's ability to produce the appropriate amount of

antibodies to provide lifelong immunity.

Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence (around 30%) and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use

antipyretics such as acetaminophen or ibuprofen to control fevers and make the child more comfortable. However, there is no evidence that antipyretics reduce the risk of future febrile seizures.

Anticholinergic

are a type of medication that blocks the action of a neurotransmitter, a chemical messenger in the brain, called acetylcholine. ... The medication blocks acetylcholine from causing involuntary muscle movements in the lungs, gastrointestinal tract, urinary tract, and other areas of the body

Late decelerations

are caused by uteroplacental insufficiency. A client with late decelerations should be given oxygen by facemask and placed on the right or left side; oxytocin should be stopped if it is being administered, and increased IV fluids must be provided.

Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix)

are commonly prescribed for smoking cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide); however, there is no contraindication for clients with emphysema.

Amlodipine (Calcium Channel Blocker)

are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (eg, metoprolol, atenolol).

Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is characterized by ≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which

aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms.

Bladder distension prevents the uterus from contracting sufficiently to control

bleeding at the previous placental site. The client should be assisted to void to correct bladder distension (Option 3). The nurse should then perform fundal massage and reevaluate bleeding.

Postoperative bleeding after a tonsillectomy is uncommon but can last up to 14 days after surgery. Continuous swallowing, restlessness, and frequent coughing are early indicators of

bleeding. To prevent hemorrhage, the client should avoid clearing the throat, blowing the nose, and coughing.

Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of

blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly")

Key components of the nursing process (data collection, monitoring, and assisting in planning and evaluation) and reinforcing teaching fall under the scope of practice of the nurse and should not be delegated. However, some skilled tasks, such as obtaining a

blood glucose level, can be delegated to UAP who have received documented training and demonstrated competency

According to the infant cardiopulmonary resuscitation guidelines of the American Heart Association, the

brachial artery is used to detect a pulse in an unresponsive client age <1 year

Lead poisoning can lead to many severe complications of the neurological system (eg, developmental delays, cognitive impairment, seizures). Elevated blood lead levels are particularly dangerous in young children due to immature development of the

brain and nervous system

Nurses performing painful procedures (eg, capillary heel sticks) should implement pain-management techniques to promote the client's comfort and stability. Appropriate nonpharmacological interventions for newborns and infants include

concentrated sucrose solutions, skin-to-skin contact, nonnutritive sucking (eg, pacifiers), and swaddling.

Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril, lisinopril, ramipril) and angiotensin II receptor blockers (eg, losartan, valsartan, telmisartan) should be avoided in clients who are planning to become pregnant. These drugs are teratogenic, leading to fetal renal and cardiac abnormalities, and are

contraindicated in all stages of pregnancy.

The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are

contraindicated in pregnancy.

Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be

crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy.

functional disorders are

currently undiagnosable medical issues and should not be confused with physical disorders caused by emotional factors (psychosomatic illness), attention-seeking behavior, or malingering.

Reduced appetite and low energy level are common clinical findings in major depressive disorder. The lethargy accompanying the depressed mood makes it difficult for a client with this diagnosis to even get up and out of bed. Personal hygiene and grooming are neglected, and there is no desire to interact with others. The client needs

direction and structure in performing activities of daily living (ADLs); waiting for the client to feel more energetic and initiate activity and interaction on one's own is not helpful. Assisting the client with ADLs helps convey a sense of caring, provides an opportunity for interaction with the nurse, and helps raise the client's self esteem

In Hirschsprung disease, or congenital aganglionic megacolon, a child is born with a lack of specialized nerve cells in some sections of the distal large intestine; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of

distal intestinal obstruction (eg, distended abdomen, difficulty feeding, vomiting green bile) and do not pass meconium within the expected 24-48 hours. In less severe cases of the disease, the diagnosis may not be made until the child is older. Clinical manifestations include chronic constipation that is not psychogenic in nature and ribbon- or pellet-like stools

The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from

dizziness and orthostatic hypotension, especially in elderly clients.

ruptured ectopic pregnancy include

dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequently.

Psychosis definition

does not have an acute onset. Clients with this condition are usually oriented but have auditory (not visual) hallucinations. Psychosis is unlikely in this client.

Play serves as an important part of children's emotional, social, and physical development. It is important that they be provided with toys that can help them achieve developmental tasks. Appropriate toys for preschoolers are those that encourage imitation of adults, such as

dolls, puppets, imaginative toys, dress-up clothing, medical kits, cars, and planes.

Normal developmental milestones for a child age 2 include following simple (eg, one- or two-step) instructions, mimicking adult actions, and building towers with four to seven blocks (Options 1 and 4). Toddlers can imitate straight lines and circular strokes when drawing but cannot

draw a person; in addition, they can walk unsupported and climb up stairs but cannot hop on one foot (Options 2 and 5). Toddlers play next to, not directly with, other children (parallel play)

Nursing care for a client with suspected meningococcal meningitis includes implementing safety measures such as

droplet precautions and NPO status (for somnolence), and promoting comfort by minimizing stimuli, raising the head of the bed slightly, and removing the pillow. Droplet precautions should continue for 24 hours after initiation of antibiotic therapy

Urinary stasis, constipation, and infrequent voiding are contributing factors to urinary tract infections. The child should be

encouraged to drink fluids and avoid holding in urine. Tight clothing and synthetic fabrics (eg, spandex, nylon, Lycra) should be avoided; cotton underwear is recommended. Scented soaps, bubble baths, and antibacterial soaps should not be used for bathing a child (the tub should be filled with water only), and the hair should be washed last.t

Epiglottitis should be considered first in a 3- to 7-year-old with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. The complications of epiglottitis are serious and include sudden airway obstruction. Epiglottitis is a pediatric emergency and should be managed with

endotracheal intubation. However, intubating such clients is difficult, and as a result, preparation for possible tracheostomy is also standard.

Auditory hallucinations are the most common type of hallucination and are typically experienced by individuals with a diagnosis of schizophrenia, bipolar disorder, or other psychotic illness. Antipsychotic medication therapy is the first-line treatment of hallucinations and other psychotic symptoms. However, most psychotropic drugs may take some time to be completely effective and may not eliminate hallucinatory episodes entirely. Clients should be encouraged to develop alternate methods for coping with the hallucinations. One approach is increasing the amount of external auditory stimulation in the environment. Individuals with auditory hallucinations have reported that increasing the amount of

external sound (eg, watching TV or listening to music through headphones) makes it easier to ignore internal sounds from the hallucinations. Other methods of managing auditory hallucinations include voice dismissal (telling the voices to go away) and cognitive behavioral therapy (assists clients in learning new ways to think about and deal with their symptoms)

The occiput posterior position can inhibit proper fetal rotation and descent, often resulting in back pain, prolonged second stage of labor, and maternal exhaustion. The hands and knees position is best for this client because it

facilitates fetal rotation to an occiput anterior position, which is more optimal for vaginal birth

Adolescents are at increased risk for obstetrical complications that can contribute to neonatal morbidity and mortality. Factors such as lack of

family support, sexual abuse, and poor nutritional status can negatively impact the pregnancy.

Projection involves:

feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful

Once children with KD are discharged home, parents should be instructed to check their temperature every 6 hours for the first 48 hours following the last fever and then daily until the follow-up visit. The health care provider should be notified if the child has

fever as this may indicate a need for further treatment.

The pincer grasp should be present by age 10 months. Offering small

finger foods allows the infant to develop fine motor skills. The child will also enjoy the ability to self-feed and explore a variety of nutritious foods

If the newborn latches incorrectly or needs to be removed from the breast, the client should insert a

finger to break suction before unlatching. When removed from the breast incorrectly, nipple trauma may occur, leading to sore nipples and painful breastfeeding.

Urinary tract infections (UTIs) are common during pregnancy due to physiologic renal system changes (eg, ureter dilation, urine stasis). Most UTIs are confined to the lower urinary tract (ie, cystitis, or bladder infection). Symptoms include urinary frequency, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. If cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis

flank pain, fever) in clients who report UTI symptoms to ensure appropriate diagnosis and treatment

The prevalence of epiglottitis has decreased since Haemophilus influenzae type b vaccine has been routinely administered beginning at age 2 months. Some cases of epiglottitis are preventable, and parents should be educated on the risks of

forgoing vaccinations for their children

The clinical characteristics of narcissistic personality disorder can best be explained as an attempt to maintain a

fragile self-esteem that was damaged during childhood due to an environment that was highly critical, demanding, and fostered a sense of inferiority

Bacterial meningitis is inflammation of the meninges in the brain and spinal cord caused by bacterial infection. Key characteristics of bacterial meningitis in infants under age 2 include

frequent seizures, a high-pitched cry, poor feeding, nuchal rigidity, and possible bulging fontanelles.

delirium

has a sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered level of consciousness. Dementia has a slow onset, usually with normal attention. Depression involves loss of interest in previously pleasurable activities.

Individuals with agoraphobia

have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms.

Hawthorn extract is used to treat

heart failure and is an approved treatment for this condition in some countries

Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order

hemoglobin and hematocrit levels to screen for the presence of anemia.

cystic fibrosis (CF)

hereditary disorder of the exocrine glands characterized by excess mucus production in the respiratory tract, pancreatic deficiency, and other symptoms

Disulfiram is a medication that promotes abstinence from alcohol by causing uncomfortable, potentially fatal reactions when alcohol is consumed. Clients must avoid sources of

hidden alcohol (eg, liquid cough medicine, aftershave, mouthwash). Effects of the drug can last 2 weeks after the last dose

Cystic fibrosis causes damage to the gastrointestinal tract and pancreas, leading to impaired absorption of nutrients and resulting growth deficits. Clients must consume a diet

high in calories, fat, and protein

Clostridium botulinum spores in honey or soil can colonize an infant's immature gastrointestinal system and release a toxin that causes botulism, a rare but serious illness. The toxin attacks the neuromuscular system, causing progressive muscle paralysis that can potentially lead to respiratory failure and death. Initial manifestations may include constipation, generalized weakness, difficulty feeding, and decreased gag reflex. Iron-fortified infant cereals (eg, oatmeal) mixed with formula or breastmilk are appropriate for infants >6 months; however

honey (especially raw or wild) is not recommended for infants age <12 months due to the risk of botulism

However, live vaccine preparations (eg, MMR, varicella) are contraindicated in the presence of marked immunosuppression, as determined by CD4 lymphocyte percentages and/or counts (Options 3 and 5). An individual with a CD4 lymphocyte percentage

immunosuppression as indicated by CD4 lymphocyte counts and/or percentages should not receive any live vaccines, including MMR and varicella

Clients with tetralogy of Fallot are at risk for polycythemia (ie, increased RBCs resulting in increased circulatory viscosity) due to prolonged tissue hypoxia. Hemoglobin >22 g/dL (220 g/L) or hematocrit >65% are a priority because

increased circulatory viscosity increases the risk for thrombus formation and stroke.

Treatment for a client requiring hospitalization for anorexia nervosa should focus on the short-term outcomes of

increasing caloric intake, slow weight gain, and addressing medical conditions caused by starvation.

tracheostomy tube

indwelling tube inserted directly into the trachea to assist with ventilation

glomerulonephritis

inflammation of the glomeruli of the kidney

glomerulonephritis

inflammation of the glomeruli within the kidney

peritonitis

inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it)

cystic fibrosis (CF)

inherited disorder of exocrine glands resulting in thick mucinous secretions in the respiratory tract that do not drain normally

Paranoid personality disorder is characterized by distrust and suspicion of others. Because these clients do not trust other people, they have an

intense need to control them and their environment

Nursing care for the hospitalized adolescent client needs to be developmentally appropriate and promote the elimination of stressors. The nurse should encourage adolescent clients to

interact with peers, discuss emotions or fears about treatments, and involve the client in decision-making regarding the plan of care.

The classic clinical triad of intussusception is

intermittent, severe, crampy abdominal pain; a palpable sausage-shaped mass on the right side of the abdomen; and currant jelly stools.

reaction formation

involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis

Fifth disease (erythema infectiosum)

is a childhood disease caused by the human parvovirus. This common community-acquired disease does not usually require treatment, but respiratory isolation is recommended for 7 days following the onset of symptoms. The initial stage of the disease presents as red cheeks that appear to be "slapped" or "slapped cheeks" with circumoral pallor

Sodium polystyrene sulfonate (Kayexalate)

is a sodium exchange resin administered to reduce elevated serum potassium levels in clients with chronic kidney disease and hyperkalemia. This is an appropriate prescription for this client

Methylprednisolone (Solu-Medrol)

is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD.

histrionic personality disorder

is characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration

Dementia

is gradual in onset and causes an irreversible and progressive cognitive decline. Remote memory is spared initially, and there is no impairment of consciousness until the late stages of the disease

Vehicle safety for newborns and small children

is important for reducing preventable injuries and deaths. The nurse should caution parents about buying a car seat secondhand, using an old or worn-out car seat, or reusing a car seat that was involved in a motor vehicle collision (ie, moderate to serious collision) (Option 4). The parents should dress the newborn in lightweight clothing so that the harness fits securely over the shoulders, hips, and legs. Tucking blankets between the newborn and the harness or dressing the newborn in bulky layers or coats reduces the car seat's effectiveness (Option 1). (Option 2) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides. (Option 3) A rear-facing car seat protects the newborn's head and neck from whiplash in a collision and is recommended for newborns and children to at least age 2. (Option 5) Advising parents to learn proper use and installation of their particular car seat before the newborn arrives is helpful and reduces their stress at hospital discharge. Many communities have car seat inspection programs to assist parents with installation.

Metformin is an oral antidiabetic medication that increases insulin sensitivity and inhibits liver glucose production. Metformin does not increase insulin secretion, so the risk of hypoglycemia

is minimal even when meals are skipped.

A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count likely has acute appendicitis. Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture. The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain

is relieved only temporarily and will return with full-blown peritonitis and sepsis

Information regarding the potential for development of a serious illness, such as schizophrenia, needs to be provided to clients in a realistic manner that allows for discussion and exploration of the client's feelings. The exact cause of schizophrenia

is unknown and is probably a combination of genetic, biochemical, structural, and developmental factor

To relieve a hypercyanotic episode, or "tet spell," the nurse should place the infant or child in the

knee-chest position.

Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain. Compensatory behaviors may include

laxative or diuretic use, self-induced vomiting, or excessive exercise 1-2 hours after binging (Option 1). Other signs of BN may include: Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of tooth enamel, dental caries) Preoccupation with body image, weight, food, and dieting/weight within normal range

Shaken baby syndrome is a form of child physical abuse resulting from violent shaking of an infant by the extremities or shoulder that causes bleeding within the brain and/or eyes. The clinical findings of shaken baby syndrome are nonspecific and include

lethargy, vomiting, seizures, irritability, inability to eat, and inconsolable crying. Multiple and severe shaking episodes can result in breathing difficulty and lifelessness. Caregivers typically do not report a history of trauma.

Screening for developmental dysplasia of the hip is a standard part of infant assessment. Manifestations in infants age <2-3 months include the presence of extra inguinal or thigh folds and laxity of the hip joint on the affected side. After age 3 months

limited hip abduction and limb shortening on the affected side are evident. A pelvic tilt is noted once the child learns to walk.

Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: Avoid hidden alcohol in:

liquid cold and cough medications aftershave lotions, colognes, and mouthwashes foods such as sauces, vinegars, and flavor extracts Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur Wear a bracelet alerting others of being on disulfiram therapy

Preschool children (age 3-6) are magical thinkers. Night fears are common during this period, and distinguishing between reality and fantasy is difficult. It is appropriate for parents to acknowledge their child's fears. A preschooler would be comforted and fears would be allayed if the parents

looked under the bed and reassured the child that no tigers were there

Sudden infant death syndrome (SIDS) is the leading cause of death among infants age <1 year. Risk factors for SIDS include

loose bedding, prone/side sleeping, and maternal substance abuse (eg, alcohol, tobacco). Protective factors include room sharing without bed sharing, smoking cessation, breastfeeding, up-to-date immunizations, and pacifier use

The preschool-age (3-5 years) child's view of death is related to their developmental stage. They believe death is temporary and reversible, similar to a prolonged nap. The child may ask repeatedly when the deceased individual will return, or they may feel guilty and responsible for the death because of their wishes or thoughts (magical thinking). Talking about the death in simple, accurate terms as often as needed helps the preschool-age child to process their loss. Avoiding discussion of the

loved one's death is not therapeutic and may increase anxiety or cause confusion

Neologisms

made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox."

Mononucleosis is caused by the Epstein-Barr virus. It is typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a rash. Treatment for mononucleosis is

management of symptoms and includes hydration, rest, control of pain, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches.

A negative-pressure isolation room is indicated for diseases requiring airborne precautions

measles, tuberculosis, and varicella zoster [mnemonic: airing MTV]).

Ginseng is used to promote

mental alertness and enhance the immune system.

Metallic taste in the mouth is often seen with

metronidazole

Iron deficiency anemia is the most common nutritional disorder in children. Risk factors include premature birth, cow's milk before age 1 year, and excessive

milk intake in toddlers. Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green vegetables, fortified cereal) and supplementation

A diastolic murmur is heard in

mitral stenosis and aortic regurgitation

Myelomeningocele (spina bifida)

most severe form of spina bifida in which the spinal cord and meninges protrude through the spine

UAP change the linens from the top to the bottom of the bed with assistance while clients lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require

multiple staff members, including one person to stabilize weights

Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. The focus of home care is on monitoring respiratory status and periodic

nasal suctioning using saline nose drops to ease breathing. Additional fluids should be offered.

Leukorrhea is a thin, milky white vaginal discharge that is

normal during pregnancy and caused by increased levels of estrogen. If the vaginal discharge changes color, becomes malodorous, or causes itching/burning, further investigation is needed

Acrocyanosis manifests as bluish coloration of the hands and feet in the newborn and is considered a

normal finding during the first day of life or if the newborn becomes cold. Initial nursing management is to keep the infant warm by placing skin-to-skin with the mother or under a radiant warmer

Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. For at least 30 minutes after feeding, these infants should

not be rocked or agitated by active play but should be kept calm and upright

A reward system is a behavioral strategy used in the treatment of functional incontinence (due to constipation). The reward is given to encourage the child's involvement in the treatment to restore normal bowel function. Rewards are given for the child's effort and participation,

not for having bowel movements while sitting on the toilet.

Occiput posterior (OP)

occiput is not leaning toward the right or the left side of moms pelvis ,its just posterior

delirium

or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose. Clients may manifest delirium states that can be hypoactive (eg, quiet, disorientation, change in level of consciousness, memory loss), hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed. Manifestations of delirium develop acutely and are difficult to differentiate from those associated with pain, anxiety, and medications. Early diagnosis and treatment are advantageous as delirium is associated with increased mortality (especially in critically ill clients on mechanical ventilation). Delirium is difficult to assess; it is recommended that nurses use the facility's standardized tool (eg, Confusion Assessment Method [CAM]) when assessing delirium.

Strabismus is a disorder involving misalignment of the eyes (eg, one eye deviated inward or outward) caused by a congenital or acquired defect of an eye muscle. Treatment of strabismus may include wearing a

patch over the stronger eye to develop strength in the weaker eye.

The nurse must determine the severity of a client's condition before implementing an intervention. By checking this client's

peak expiratory flow, the nurse can determine the severity of the asthma symptoms

Black cohosh is an herbal supplement often used by

perimenopausal clients experiencing hot flashes.

prophylactic

pertaining to preventing or protecting against disease or pregnancy

antineoplastic

pertaining to the prevention of the growth and spread of cancer cells

The newborn should be fully exposed, except for a diaper, when placed under

phototherapy lights. Lotions and ointments should not be applied as they can absorb heat and cause burns. Newborns should wear eye shields and be monitored for adequate hydration and urine output.

Nocturnal enuresis, or involuntary bed-wetting at night, is managed with a variety of nonpharmacologic measures that nurses should teach parents. These include use of

positive reinforcement and bed alarms, restricting fluids after the evening meal, avoiding scolding or ridiculing, awakening the child at a specified time to void, and keeping a log of wet and dry nights.

The measles-mumps-rubella vaccine is a live attenuated vaccine and is contraindicated in pregnancy due to the risk of teratogenic effects to the fetus. Clients who are nonimmune to rubella should receive the vaccine in the

postpartum period. Pregnancy should be avoided for at least 1-3 months after immunization.

Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome, a severe form of

preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental abruption, liver failure, stroke) and maternal/fetal death. Clients may have RUQ pain, nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension may or may not be present.

Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often begins or intensifies during

pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons.

Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a

private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: Using a quiet or monotone voice when speaking to the child Using eye contact and gestures carefully Moving slowly Limiting visual clutter Maintaining minimal lighting Providing the child with a single object to focus on

tonsillectomy and adenoidectomy (T&A)

procedure to remove the tonsils and adenoids in patients with chronic tonsillitis and hypertrophy of the tonsils and adenoids

eparation and stranger anxiety are common and major causes of distress for infants and toddlers. These behaviors start around age 6 months, peak from age 10-18 months, and can last until age 3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. The nurse should

promote parents' presence throughout the child's hospitalization to decrease the stress caused by separation and unfamiliar health care providers

Phenylketonuria requires lifetime dietary restrictions. Infants should be given special formulas (eg, Lofenalac). For children and adults, high-phenylalanine foods (eg, meats, eggs, milk) should be restricted and replaced with

protein substitutes

Naegele's Rule

provides a quick determination of the estimated date of birth (EDB). EDB = (LMP minus 3 months) + 7 days. If the LMP occurs in January, February, or March, the EDB will be in the current year. If the LMP occurs after March, the EDB will be in the next year.

telemetry unit

provides continuous cardiac monitoring for patients with heart problems not requiring intensive care

Delusions of grandeur are experienced by clients with a

psychotic disorder

Parallel play is typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside, rather than with, other children. Having a variety of different balls for a group of children allows each child to be present with others and participate as they desire. Other examples of parallel play activities include

pushing and pulling large toys; smearing paint; playing with dolls or toy cars; and digging in a sandbox.

who recently had surgery to repair tetralogy of Fallot, Parents of an infant or child with a repaired congenital heart should be able to recognize and report signs and symptoms of heart failure to the health care provider. These may include

rapid breathing rate; rapid heart rate at rest; dyspnea; activity intolerance; pale, cool extremities; weight gain; reduction in wet diapers; and puffiness around the eyes.

loose associations

rapid shifting from one idea to another, with little or no connection to logic or rationality

The most important treatment for suspected chilblains/pernio or frostbite is

re-warming of the affected area by immersion in warm (104 F [40 C]) water. The individual can also be given a warm liquid to drink and should be seen by an HCP as soon as possible.

Before initiating a treatment program that requires a client and family to make major lifestyle and behavior changes, the nurse needs to assess

readiness for change. Motivation and a desire for change are the keys to successful weight loss.

Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or

rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.

An infant born to an opioid-dependent mother is at risk for neonatal abstinence syndrome. Withdrawal symptoms affect primarily the central nervous (eg, jitteriness, irritability), autonomic nervous (eg, stuffy nose, sweating), and gastrointestinal (eg, poor feeding, diarrhea) systems. Nursing care is focused on

reducing stimulation and promoting nutrition and comfort

A client with a prolapsed umbilical cord should be placed on hands and knees (eg, knee-chest position) or Trendelenburg position to

relieve pressure on the cord until emergency delivery.

The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be

removed from the room to prevent further potential harm to the client or staff

Perseveration

repeating the same words or phrases in response to different questions

Echolalia

repetition of words, usually uttered by someone else

Clients with a tracheostomy should always carry two spare tubes, one the same size and one a size smaller, to ensure that the tube can be

replaced quickly and effectively.

Misoprostol (Cytotec) is a prostaglandin E1 used for cervical ripening (softening of the cervix) during labor induction. A common adverse effect of misoprostol is uterine tachysystole (ie, >5 contractions in 10 minutes), which may decrease fetal oxygenation and cause a nonreassuring fetal heart rate (FHR) (eg, late decelerations, fetal tachycardia, minimal variability). If nonreassuring FHR patterns occur, the practical nurse (PN) should notify the registered nurse (RN) and initiate intrauterine resuscitation interventions. The first intervention is to

reposition the client to a side-lying position to increase placental perfusion and improve fetal oxygenation

Expected findings for a neonate at 1-3 hours postpartum include

respirations between 30-60 breaths per minute, milia, and glucose levels <70-100 mg/dL (3.9-5.6 mmol/L) but ≥40 mg/dL (2.2 mmol/L).

Morphine administration can cause

respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min

Cystic fibrosis is an inherited disorder that results in impaired exocrine gland function and is characterized by thickened secretions that affect the pulmonary, gastrointestinal, and reproductive systems. When planning care, the nurse should monitor for priority concerns, including development of

respiratory infections, chronic hypoxemia, nutritional deficiencies, and abnormal growth (failure to thrive).

Preschool-aged children (age 3-6) are in Piaget's preoperational stage of cognitive development and therefore often ascribe inappropriate causes to phenomena. The adopted preschool-aged child may feel personally

responsible for being adopted (eg, misbehavior led to placement for adoption).

Clang associations

rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke."

Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with

right-to-left heart defects.

According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. During this stage, unlike other developmental stages, learning is a priority and completing

school work provides a sense of accomplishment and satisfaction. It is therefore important that parents provide hospitalized school-age children with missed school work on a regular basis

Chlorpheniramine (ChlorTrimeton) is a

sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly

negative babinski reflex

seen in normal adults. When stimulated, curling of toes (plantar reflex) occurs

Clients with anorexia nervosa have disturbed body image and see themselves as being fat or overweight even when they are severely underweight or even at a normal body weight. The nurse can help the client develop a more realistic

self image by presenting the situation realistically and discussing weight in terms of the client's health

Tetralogy of Fallot (TOF)

set of four congenital heart defects occurring together

The Pavlik harness maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Care of the infant with a harness includes dressing the child in a

shirt and knee socks, keeping the skin dry, regularly assessing for skin breakdown, massaging the skin to promote circulation, and applying diapers under the straps

Assessment findings of a 12-month-old child should include a weight that is approximately triple the birth weight. Expected motor skills include the ability to

sit from a standing position without assistance and to use a fully developed pincer grasp

This caregiver is experiencing high levels of stress and exhaustion related to caring for the client; without help, the caregiver could easily experience burnout. A

social worker can provide information on resources and services for assistance and support; these include adult day programs, in-home assistance, visiting nurse services, and home-delivered meals. The social worker can also provide the names of agencies that seek the support of others in similar situations (eg, local chapter of the Alzheimer's Association).

Atorvastatin (Lipitor) is a

statin prescribed for hyperlipidemia. It is used for primary and secondary prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina pectoris.

The newborn with a myelomeningocele is at risk for infection. Covering the myelomeningocele with a

sterile, moist dressing is indicated to decrease the risk of infection at the site. The infant should be placed on the abdomen (prone) with the face turned to the side.

Docusate is a

stool softener and does not increase risk of injury in the elderly

The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. A

structured environment helps these children organize their thoughts and activities.

Educational objective: Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered via

subcutaneous injections

The initial nursing action for a client experiencing cyanosis and excess oral secretions is oropharyngeal

suctioning to ensure airway patency

Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's

temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C). Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination MMRV vaccine.

Dental avulsion is a dental emergency. The nurse should gently rinse off debris and reinsert the tooth into

the gingival socket. If reimplantation is not possible, the tooth should be placed in a commercially prepared solution, cold milk, or sterile saline. The client should see a dentist immediately. Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival.

Clients with life-limiting diagnoses experience anxiety, frustration, and grief as they cope. The nurse should use

therapeutic communication (eg, active listening, reflection, focusing) to determine the client's understanding and strengthen the nurse-client relationship before discussing difficult news (eg, new cancer diagnosis)

Clients with alcoholism have a high risk of hypoglycemia and

thiamine (vitamin B1) deficiency as a result of poor nutrient intake (a healthy diet contains sufficient thiamine) and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can result in Wernicke encephalopathy (WE). Untreated WE can lead to irreversible neurologic morbidity (Korsakoff psychosis) or death. In the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate development of WE in a previously unaffected individual. Because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose

When a low oxygen saturation with apparent artifact in the pulse plethysmographic waveform is observed, the nurse should discern the accuracy of the reading to prevent unnecessary treatment. If the pulse oximeter reading is accurate, the nurse should perform a

thorough physical assessment and intervene as appropriate.

There must be a minimum of 14 days between the administration of MAOIs and SSRIs

to avoid serotonin syndrome; these medications cannot be administered concurrently.

Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water

to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of pediculicide use and removal of nits (eggs)

The nurse's role with a dying client is to aid communication. When a dying child asks about death, the parents should know about the child's concerns and be encouraged

to speak with their child about death.

Pharyngitis caused by group A β-hemolytic Streptococcus is a bacterial throat infection that can cause renal or cardiac complications if not treated. It is important to discard the child's

toothbrush 24 hours after starting antibiotics, test siblings age <3 years, and complete the full course of prescribed antibiotics.

Amitriptyline (Elavil) is a

tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias

polystyrene sulfonate (Kayexalate)

used for hyperkalemia

Warfarin (Coumadin) is a vitamin K antagonist

used for long-term anticoagulation that is started about 5 days before a continuous heparin infusion is discontinued. An overlap of the parenteral and oral anticoagulant is required for about 5 days as this is the time it takes warfarin to reach therapeutic level. This is an appropriate prescription for this client.

Plethysmographic waveform may be altered in situations that cause _____ or _____ such as temperature variations, inflammation.

vasodilatation or vasoconstriction

A harsh systolic murmur is heard in the setting of

ventricular septal defect

Reye syndrome in children is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a

viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin is used to treat varicella- or influenza-associated fever; acetaminophen or ibuprofen should be given instead

Oxytocin is a high-alert medication for labor induction requiring frequent maternal/fetal assessment (eg, fetal heart rate, contraction pattern, vital signs, fluid intake and output). Oxytocin infusion can cause maternal

water intoxication, hypotension, uterine tachysystole, and a nonreassuring fetal heart rate.

Clients who suffer from PTSD often experience feelings of guilt and shame; they believe that they are responsible for what happened and that, somehow, they could have prevented the traumatic event. Using therapeutic communication, the nurse needs to convey that

what happened was not their fault.

Postoperative tonsillectomy interventions include close observation for signs of bleeding (eg, frequent swallowing) as well as avoidance of routine oral suctioning and the use of straws. Expected findings include

white, fluid-filled exudate in the throat with halitosis, low-grade fever, and referred ear pain.

Ringworm, or tinea corporis, is a fungal infection on the superficial keratin layers of the skin, hair, and/or nails. Ringworm is a misleading name as the condition is not caused by a

worm infestation. However, it is highly contagious and spreads via contact. Management includes teaching appropriate hygiene (eg, washing hands after touching infected areas), limited contact with personal items (eg, hair brush), and treatment with the prescribed shampoos as well as topical and/or oral medications (eg, terbinafine [Lamisil], miconazole)

Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by

y fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly.

Positive Kernig's sign:

resistance to leg extension after flexing the thigh on the body; sign of meningitis

The spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and (depending on the seriousness of the result) then sending the police to contact the client

A competent adult with decision-making capacity can refuse essential treatment; the client's spouse does not have that legal authority. Treatment refusal must include awareness of the risks and benefits

Advance care planning documents may include the following:

A health care proxy (durable power of attorney for health care or medical power of attorney) is a person appointed by the client to make decisions on behalf of the client. The proxy document only goes into effect when the health care team determines that the client lacks the capacity to make decisions. This should be deactivated if the client regains decision-making capacity. A living will is an advanced directive describing the type of life-sustaining treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make decisions

The nurse is required to report suspected abuse of vulnerable clients (eg, underage, elderly, mentally ill) to appropriate authorities, regardless of what other practitioners think. A proper investigation, rather than conflicting opinions, will determine whether abuse has occurred (Option 3). The nurse should report suspected abuse of vulnerable clients even if the client denies it because other factors (eg, dependence on the abuser, dementia) could be the reason for denial (Option 4). Sexually transmitted infection (STI) in a child is sexual abuse and must be reported and investigated (Option 5). The greater good of society outweighs an individual's right to confidentiality. Gonorrhea is an STI; the client should be informed that public health will be notified and partners will be contacted to receive treatment

A nurse is required to report suspected abuse of vulnerable clients even if other practitioners do not agree or the clients deny it. A sexually transmitted infection in a child is considered sexual abuse and requires reporting. Reportable conditions by law are not protected from reporting under the confidentiality of personal health care information in Health Insurance Portability and Accountability Act (HIPAA)

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take?

A nurse who is impaired by alcohol cannot be given client responsibility. The recognizing nurse should notify the supervisor, document the incident, and not give client responsibility to the impaired nurse

The Joint Commission (2004) and Institute for Safe Medication Practices prohibit error-prone or "dangerous" abbreviations, descriptions of symptoms, and dose designations in medical documentation. "Cm" (centimeters) and "II" (2) (eg, decubitus staging) are acceptable abbreviations/notations (Option 1). The abbreviations "ac" (before meals), "pc" (after meals), and "c/o" (complains of) are acceptable (Option 4). "QID" (4 times a day) is acceptable. Abbreviations that are not acceptable include "qd" (daily) and "q1d" (daily), which can be mistaken for "qid" (4 times a day), and "qod" (every other day), which can be mistaken for "qd" (daily) (Option 5). (Option 2) A trailing zero after the decimal point is not acceptable as it could be interpreted as 40 instead of 4 if the decimal point is not noted. The use of "u" for unit is not acceptable as it can be mistaken for the number 0 or 4 (eg, 4u seen as 40). "SSRI" (sliding-scale regular insulin) is not acceptable to indicate insulin as it can be mistaken for selective serotonin reuptake inhibitor. "Mg" for milligrams is acceptable. (Option 3) A zero must precede the decimal dose. If the decimal point is missed, ".5" could be mistaken for 5 mg.

Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point

Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing

Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing

Documentation should be clear, concise, and accurate to be credible, which includes being timely, truthful, and appropriate. When charting a symptom or situation, the nurse should chart the interventions taken and the client response. An adverse event is an unusual occurrence, accident, or injury unrelated to the client's underlying condition. Adverse events must be acknowledged and documented in the chart. It is essential for the nurse to note the actions taken in response to the event (eg, client teaching, safety precautions) and the time frame in which they were performed. Documenting the key, pertinent negatives indicating that no client harm resulted and the appropriate interventions implemented to rectify or reduce harm will minimize nursing liability. If an incident report is also required, it is separate from the medical record and should never be mentioned in the client's chart.

After an adverse event, the nurse should document objective, specific assessments and interventions. These include signs/symptoms indicating a lack of client harm and any corrective actions taken

Experienced UAP can assist stable clients with activities of daily living, hygiene needs, ambulation, and turning and repositioning. UAP can also take vital signs (eg, pulse oximetry), and assist with treatments and prevention of aspiration (eg, positioning). When assigning tasks to the UAP, the PN clearly defines the task, time frame for completion, and expected outcomes (eg, report if client has difficulty breathing, tolerance of procedures, and results of vital sign measurements). The PN can safely assign these tasks to the experienced UAP:

Ambulate an oxygen-dependent client to the bathroom Check pulse oximetry for a client with respiratory rate 12/min Turn and reposition a client with pneumonia Provide oral hygiene to a client with COPD. Experienced UAP can assist stable clients with activities of daily living, hygiene needs, ambulation, transfer, and repositioning. They can also take vital signs (eg, pulse oximetry), assist with treatments, and prevent aspiration (eg, repositioning). However, the PN is responsible for ensuring the client's safety, supervision of the UAP, and evaluation of the care rendered by the UAP.

Advance care planning is a process that includes: Considering treatments that may be needed in the future Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option 1) Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option 3) Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option 2) The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information

An advance directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy

A power of attorney (POA) designates a representative to act on a person's behalf in the event that the individual becomes incapacitated. There are different types of POAs, including medical and financial. An advance directive or living will describes the client's health care decisions (eg, do not resuscitate). As part of an advance directive, the client may designate a representative to make health care decisions for the client - a durable POA for health care or POA for health care (Canada). This client's statement requires further clarification regarding what type of POA is in place

An advance directive makes clear a client's health care wishes (eg, do not resuscitate). A power of attorney (POA) designates a representative to act on a person's behalf. It is important to clarify that the client has the type of POA who can make health care decisions (durable POA for health care, POA for health care [Canada])

Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by applying graduated compression. When fitted properly and worn consistently, the stockings decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.

Anti-embolism stockings should be applied before ambulating while the client is in bed; this maximizes the compression effects of the stockings and promotes venous return. The UAP has performed this correctly. (Option 2) Wrinkles should be smoothed out to avoid impeding venous return. The UAP has performed this correctly. (Option 3) The toe opening should be located on the plantar side of the foot/under the toes. The UAP has performed this correctly. Anti-embolism stockings are worn by clients as part of VTE prophylaxis. It is important that the nurse verifies the stockings are correctly fitted and worn appropriately. Incorrect size and fit or alterations to the stockings can impede venous return

Incident/occurrence reports are used in a health facility to document events that pose unanticipated actual or potential risk to the health or safety of a client, visitor, or employee. Incident/occurrence reporting is a method of quality improvement and should not be considered punitive in nature or be documented in the health record. Examples of events requiring reporting include:

Assault and injury Physical, verbal, or sexual assault occurring in a health facility (Option 2) Client falls, with or without injury Staff and visitor falls, regardless of acceptance or refusal of treatment (Option 5) Treatment and intervention Failure to obtain or intervene upon the results of diagnostic procedures (Option 3) Inadequate or delayed diagnosis and monitoring Delay, omission, or incorrect performance or administration of prescribed therapies and medications Hospital equipment failure

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP?

Assign a new UAP specific tasks that do not require specialized knowledge or skills. The UAP can gather data but should not be asked to perform assessment or data interpretation.

To prevent immobility hazards for a client in skeletal traction, the nurse can assign the following tasks to unlicensed assistive personnel:

Assist with active and passive range of motion exercises Notify the nurse of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer Maintain proper use of pneumatic compression devices

Many clients with advanced Alzheimer disease reside in long-term care centers, where many routine care activities can be delegated to unlicensed assistive personnel (UAP). The role of UAP includes the following:

Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene) Assisting with feeding Reporting changes in ability to eat or difficulty swallowing Reporting changes in behavior Placing bed alarms to reduce risk of falls

Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person's consent. Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical battery. Furthermore, actions can be considered battery even if no physical injury results. Any health care provider (HCP) who performs a medical or surgical procedure without receiving the required informed consent from a competent client (or parent/legal guardian in the case of a child) is committing battery and could be legally charged A competent client has the right to refuse any treatment, even if it is for the client's benefit. The nurse should help the client understand the need (eg, informed refusal), but the client's decision should be upheld. Proceeding to administer treatment to a competent client who has refused that treatment is medical battery

Battery is touching that is legally defined as unacceptable or occurs without consent. Examples include performing a procedure despite a competent client's refusal or without obtaining proper consent from a competent client (or parent/legal guardian when the client is a child). Assault is the threat of battery

Acute hemolytic reaction during a blood transfusion usually develops within the first 15 minutes. Signs/symptoms include chills, fever, lower back pain (from damaged cells in the kidneys), tachycardia, tachypnea, and hypotension. Acute hemolytic reaction is an emergency that requires the nurse to stop the transfusion and treat shock. Normal fetal heart tones range from 110-160/min. A decrease in heart rate that occurs on or after the peak of a contraction is a late deceleration. This may indicate uteroplacental insufficiency and must be assessed. Nifedipine (Procardia) is a potent calcium channel blocker antihypertensive. It should not be administered when the client's blood pressure is on the lower end of the acceptable range as this may result in hypotension

Beta-adrenergic agonists have an expected side effect of tremor or palpitations, and narcotics can cause mild hypotension or bradycardia. Intervention is not necessary unless the values are significantly outside normal limits or the client becomes symptomatic

Unlicensed assistive personnel (UAP) can be delegated tasks that are not specific to the nursing process. Any task that involves assessment, coordination of care planning, or evaluation requires the attention of the nurse. The UAP may gather information (eg, vital signs, intake and output) about stable clients, assist stable clients with activities of daily living, and retrieve necessary supplies, but the nurse retains accountability for all of the delegated actions and outcomes. The nurse is also responsible for determining the competency level of the UAP prior to delegating tasks

Client care that is specific to the nursing process (assessment, monitoring, assisting in planning, evaluation) cannot be delegated to unlicensed assistive personnel (UAP). UAP can assist with basic care activities, check routine vital signs, document intake and output, and assist with activities of daily living, hygiene, and positioning for stable clients. The nurse is ultimately accountable for the care provided by UAP

A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. Infectious contacts include staff members with a cold or impetigo, a common, highly contagious bacterial skin infection (Options 3 and 5). Impetigo vesicles rupture and form erosions, and the fluid creates a honey-colored crust. Common sites include the mouth and hands. The nurse should be referred to occupational health and must cover the site while working. (Option 1) The medical-surgical nurse has the training to care for a client with immunosuppression and a broken leg. If chemotherapy needs to be administered during the hospitalization, a chemotherapy certified nurse will administer the medication. (Option 2) The client is not radioactive or infectious, and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. (Option 4) The injectable influenza vaccination does not contain live influenza virus; therefore, the unlicensed assistive personnel is not infectious. The inactivated vaccine is safe and recommended for clients who are immunocompromised

Clients who are immunosuppressed from chemotherapy should not be cared for by a health care provider who is infectious

Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague. These behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and blaming. However, other acts, such as refusing to help someone, sabotage, exclusion, and unfair assignments, also fall under the category of lateral violence. Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff members can take if they become victims of lateral violence include:

Documenting and keeping a file of all incidents Reporting the incidents to the immediate supervisor Informing the bully in a professional manner that the behavior will not be tolerated Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) Seeking support from within the facility or from an external source

The nurse can delegate the following tasks to experienced unlicensed assistive personnel (UAP): Post signs for airborne isolation precautions on the client's door and stock necessary equipment: UAP have the knowledge and skill to implement isolation precautions when caring for clients on contact, droplet, or airborne transmission-based precautions Remind visitors to wear a respirator mask and keep the door closed while in the client's room: UAP can help reinforce the procedures and principles of infection control related to airborne isolation precautions (eg, respirator masks, negative airflow room). However, the registered nurse should provide the initial instructions and is responsible for visitor compliance

Experienced unlicensed assistive personnel can post signs on the client's door that display airborne isolation precautions, stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room. The nurse is responsible for appropriate communication with other departments and reinforcement of instructions to clients and their families

The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client:

Falls Deteriorates significantly or dies Has critical laboratory results Needs a prescription that requires clarification Leaves against medical advice or runs away Refuses key treatments in a relevant period The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall Administration of heparin is normally discontinued prior to surgery due to the increased risk of bleeding and should be clarified with the HCP A serum sodium of 124 mEq/L (124 mmol/L) (normal: 135-145 [135-145]) represents a critical value that can lead to altered mental status and seizures

The nurse must protect clients' privacy and maintain the confidentiality of their medical information. Clients' health information should be discussed only with health care team members directly involved in those clients' care. Nurses must also ensure that documents containing clients' information are shredded after use

Floating nurses should be assigned clients who require care that can be given using skills and knowledge similar to those used for their usual client population. Obstetrical nurses should not be assigned infectious clients.

A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child's parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?

Giving children responsibilities that are beyond their capability and placing children in an unsafe situation are indicators of child abuse and neglect. As mandated by law, health care professionals are responsible for identifying suspected child abuse and neglect and reporting them to the appropriate social service and/or law enforcement agencies

Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not part of their job duties) to help injured individuals after an accident. The nurse cannot receive payment for any care given It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed

Good Samaritan laws prevent civil action if a nurse stops to assist after an accident, as long as the nurse acts competently, continues care until another appropriate caregiver takes over, and does not accept money.

A competent adult has the right to make any decision regarding the client's health care even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in level of consciousness, nuchal rigidity, and meningeal signs (positive Kernig's and Brudzinski's signs). Antibiotic treatment is essential.

Hospital administration will obtain legal protective custody of a minor child if the parents are deciding against life-saving measures for their child or when there is child abuse/neglect

The target International Normalized Ratio (INR) for most conditions in which warfarin is used is normally 2-3 and occasionally is as high as 3.5. The risk of bleeding increases as the

INR rises

The registered nurse (RN), not the licensed practical nurse (LPN), should perform initial assessments (including vital signs), review the ECG for any dysrhythmias, monitor the client for chest pain, and monitor any infusions of anticoagulants or antiplatelet drugs (Options 3 and 5). If the client is stable after the initial assessment, the RN may delegate routine vital sign measurements. After performing the initial assessment of the client post-procedure and comparing it to the pre-procedure baseline, the RN may assign the following tasks to the LPN: Administer medications (Option 1) Monitor neurovascular status of involved extremity Check for bleeding at catheter site every 15 minutes for the first hour, then according to institution policy (Option 2) Report any changes in neurovascular status or bleeding to the RN Reinforce important teaching (eg, keep affected extremity straight, maintain bedrest)

In the client who has had a percutaneous coronary intervention, after the initial assessment and its comparison to pre-procedure baseline, the registered nurse may assign the following tasks to the practical nurse: medication administration, monitoring of neurovascular status of the involved extremity, checking for bleeding at the catheter insertion site, and reinforcing important teaching

The nurse is caring for a client with end-stage heart failure who is not a candidate for a heart transplant. The client is considering participation in a research study investigating an experimental device. In discussing possible enrollment in the study, which of the following statements by the client indicate understanding of ethical rights related to the study?

Informed consent is required when enrolling clients in a clinical trial. Prior to obtaining consent to participate in the study, the researcher or a member of the research team should first ensure that the participant is fully capable of understanding the terms of the study. The client must be informed of the study's purpose, procedures, and all potential side effects or discomforts; risks and benefits; and the participant's responsibilities (eg, time commitment, evaluations). The nurse should assure the participant that personal information will remain confidential and that the client can withdraw from the study at any time

Thyrotoxicosis, or thyroid storm, is a complication of hyperthyroidism that occurs when excessive amounts of thyroid hormone are released into the circulation. Manifestations include tachycardia and hyperthermia. Keeping the client and room temperature cool is a therapeutic action that the nurse can delegate to unlicensed assistive personnel (UAP). Reinforcing teaching falls within the scope of practice of the licensed practical nurse and should not be delegated to UAP

Keeping the client and room temperature cool during thyrotoxicosis is a therapeutic action that the nurse can delegate to unlicensed assistive personnel (UAP). Reinforcing education falls under the scope of practice of the licensed practical nurse and should not be delegated to UAP

Mature minors" are adolescents who are age 14-18 and are deemed able to understand treatment risks. They are legally allowed to give independent consent to receive/refuse treatment for some limited conditions. Classically, these conditions include testing and treatment for STIs, family planning, drug and alcohol abuse, blood donation, and mental health care. A minor who is a parent, pregnant, or an emancipated minor can also give consent. An emancipated minor is a self-supporting adolescent under age 18 who is married, on active duty in the military, granted emancipation by the court, or not living at home

Mature minors are adolescents between age 14-18 who can give independent consent for limited conditions such as STIs, family planning, drug and alcohol abuse, blood donation, and/or mental health care

According to federal and state guidelines, all members of the health care team providing direct care for clients in protective restraints are required to demonstrate competency by completing an educational training program. They must be able to demonstrate competency in applying and caring for a client in restraints. Therefore, unlicensed assistive personnel (UAP) have the knowledge, skills, and competency to perform range of motion (ROM) exercises, reapply the restraints, report changes in skin integrity to the nurse, and turn and reposition the client in bed

Members of the health care team providing direct care for clients in physical restraints are required to complete an educational training program and demonstrate competency in caring for a client in restraints. Therefore, the nurse can safely assign the following tasks to unlicensed assistive personnel: performing range of motion exercises, reapplying restraints, repositioning a restrained client in bed, and immediately reporting changes observed in the skin or any other problems

The licensed practical nurse (LPN) can safely delegate the following duties to unlicensed assistive personnel (UAP) to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it minimizes the distance between the bed and the floor in the event of a fall. Provide nonskid footwear before the client ambulates. Keep the environment dry and free of clutter and obstacles (eg, IV infusion device tubing and poles, electronic device wires and cords)

Most client falls are unobserved and occur in the client's room or bathroom. Assessment, evaluation, client orientation, and teaching are not appropriate to delegate to unlicensed assistive personnel

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity

Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound clinical judgment to prevent harm, even if it is unintentional, to their client

The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions

Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement

The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law

Practicing outside of the scope of the license is reportable even if the practice meets quality standards Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable in all states

Professional boundaries set limits to maintain a therapeutic professional relationship between the nurse and client. However, the line between professional and personal interactions is sometimes blurred in extended relationships or when care is given in the client's home. The nurse should always put the client's needs first and never seek personal gain (eg, accepting gift worth >$20, asking for financial investment/loan) (Options 1 & 5). The nurse should follow a facility's policy on professional standards of behavior. In the absence of a formal policy, the nurse should consider if the action would be appropriate to include in the medical record. If the nurse is unsure, it may be indicative of a violation of professional boundaries (eg, flirting with client, consuming alcoholic beverages with client) (Option 6). (Option 2) An occasional visit to a previous client in a different circumstance (hospital, nursing home) is considered appropriate and caring. (Option 3) It is appropriate for the nurse to offer assistance in meeting a client's spiritual needs if the client desires it. The nurse should not force their own beliefs, religion, or practices on the client. (Option 4) Sending a sympathy card to acknowledge a family's loss is a holistic and therapeutic measure

Professional boundaries involve maintaining a relationship that benefits the client, not the nurse, and to which the nurse would not be reluctant to admit. It is generally not appropriate to socialize with a current client after hours, ask for a financial investment/loan, or accept a valuable gift

Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. If a relationship is started, the nurse has a duty to continue care until the visitor is stable or other health care personnel can take over. If proper care is not continued, the nurse could be accused of negligence (ie, failure to act in a prudent manner as would a nurse with similar education/experience). This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half of the body may indicate stroke. In the event of a visitor emergency, the nurse should not establish a caregiver relationship but rather implement facility protocol to help the visitor get to the emergency department promptly to receive immediate assessment and further evaluation

Providing care establishes a legal caregiver obligation/relationship between the nurse and a visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get the visitor promptly to the emergency department

Nontherapeutic Communication Techniques

Technique Definition Example Asking personal questions Attempting to gather client information for personal curiosity "Why don't you & your spouse have children yet?" Giving personal opinions Stating a personal judgment or choice that takes away client decision-making "If I were you, I would stop taking my child there." Changing the subject Attempting to focus on a different topic, which shows lack of empathy & stalls communication "Let's talk about what you want for lunch instead." Automatic responses Making generalized, stereotyped statements or clichés that lack empathy "You can't win them all." False reassurance Offering hope when the outcome is unsure "Everything is going to be all right." Asking for explanations Attempting to gather information inappropriately, causing the client to feel tested or accused "Why" questions Approval or disapproval Imposing one's values or beliefs on the client's statements "You shouldn't consider plastic surgery; it's wrong." Defensive responses Avoiding or challenging criticism, which implies that the client doesn't have a right to the stated opinion "I know what I am doing. I wouldn't intentionally hurt you." Arguing Challenging or disagreeing, which implies that the client's thoughts are not real or valid "You can't be tired; you slept all night."

A nurse who is impaired by alcohol cannot be given client responsibility. The recognizing nurse should notify the supervisor, document the incident, and not give client responsibility to the impaired nurse

The Patient Care Partnership (formerly known as the Patient's Bill of Rights) is a set of standards developed by the American Hospital Association. It informs patients/clients about what they should expect during their hospital stay with regard to their rights and responsibilities. Client rights originate in laws or desirable ethical principles but have limitations. Clients have the right to know the names and positions of their health care providers (HCPs). These individuals should introduce themselves by name and discipline (Option 4). Clients have the right to access information within their own medical record. A release form may need to be signed, or the HCP can review information (eg, biopsy results) with the client. In 2014, the Department of Health and Human Services further strengthened the rights of clients to access their test results (Option 1). Pain management is also addressed by the Joint Commission and is considered a basic client right. Although success in pain relief is not guaranteed, the issue is to at least be addressed with the goal of successful management Basic client rights include knowing the identity of their health care providers, access to the information in their medical records, and having pain assessed and addressed appropriately.

When a client is unable to make decisions, the health care proxy is legally able to make decisions for the client. In the event that the health care proxy is unable to fulfill this role, the responsibility goes to the alternate proxies identified on the advance directive. If the client does not have a health care proxy, the family members would make decisions for the client. Occasionally, there is no family and no proxy. If this happens, a proxy may be appointed, an ethics board may make the decision, or the HCP may be responsible for making the decision

The role of the health care proxy is to make decisions for a client who is unable to do so. Ideally, the proxy will have a good understanding of the client's wishes and will be emotionally capable of fulfilling this important role

The nurse should report to the appropriate authorities for investigation any death that meets the local medical examiner's criteria for reportable deaths. These criteria may include death suspected to be the result of a crime, trauma, suicide, illicit drug use, medical procedure, or unexplainable cause (Option 2). Suspected elder abuse should be reported to the appropriate authorities for investigation. However, the nurse has a duty to advocate for clients who may be unable to speak adequately for themselves for any reason, including fear of retaliation or financial dependency on the abuser (Option 4). Nurses should report an impaired health care worker regardless of the worker's position in the institution. For client safety, the nurse must take steps to prevent an impaired person from caring for clients

The nurse is required to report an impaired coworker, a suspicious death, and elder abuse to appropriate authorities. The nurse should not report health care information to employers or family members without the client's permission

Nifedipine (Procardia)

Tocolytic. Side effects: hypotension, fatigue, nausea, flushing, uteroplacental perfusion complications. Monitor BP, avoid concurrent use with magnesium sulfate, monitor contractions and FHT, prevent complication with hypotension.

Although unlicensed assistive personnel (UAP) can perform procedures that require observing principles of infection control and transmission of microorganisms, UAP should not change sterile dressings or perform drain care. These are the responsibility of the nurse. (Options 2, 3, and 4) During care of a client with a closed-wound, vacuum-assisted drainage system (Hemovac), emptying and compressing the Hemovac drainage device to reestablish negative pressure and measuring and recording the drainage output are tasks that can be assigned to an experienced UAP. The nurse can safely assign these tasks as the knowledge, skills, and competency of the UAP have been established and the tasks and time frames are clearly defined. Measuring intake and output from drainage devices (eg, Foley, Hemovac, Jackson-Pratt), documenting in the electronic medical record in the place designated for UAP, observing infection-control principles, and maintaining asepsis while providing client care are within the UAP scope of practice.

The nurse is responsible for evaluating the client's wound and wound drainage (amount, type, color, and odor) and maintaining the Hemovac drainage device, including sterile dressing changes and drain site care. These tasks require nursing judgment and cannot be assigned to unlicensed assistive personnel

The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?

The nurse must assess a client personally, rather than delegate the task, when a potentially ominous report is made by unlicensed assistive personnel

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. Clients' health information should be shared only with other health care team members directly involved in those clients' care. Report sheets used by nursing staff often include clients' private health information and must be shredded at the end of the shift (Option 2). Without the client's permission, information about the diagnosis or diagnostic tests cannot be shared with a hospital roommate

The nurse must protect clients' privacy and maintain the confidentiality of their medical information. Clients' health information should be discussed only with health care team members directly involved in those clients' care. Nurses must also ensure that documents containing clients' information are shredded after use

A nurse assigns a task to unlicensed assistive personnel. They state, "We can't do that." Which is the best initial response for the nurse to make?

The nurse should first assess management situations, just as would be done in clinical situations. The unlicensed assistive personnel (UAP) may not have the skills or ability to do the task or availability if doing something else. The nurse may need to reprioritize the tasks that the UAP have been assigned or provide additional instructions/education. However, determining the reason for the response is the first step.

Although acetaminophen is an over-the-counter drug, the nurse should not give it without a prescription. By doing so, the nurse would be functioning outside the job description. There has not been a proper assessment (eg, allergies, liver disease), and a legal caregiving relationship would be established by administering the medication. If the employee does not want to go to the employee's health care provider, the nurse can suggest that the employee purchase acetaminophen in the gift shop

The nurse should not give medication to an employee without a prescription, even if it is an over-the-counter drug, as a legal caregiving relationship will be established by doing so. The employee should be referred to the employee's health care provider

All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form. Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim. The nurse should not document that an incident report was filed, or refer to the incident report in the medical record

The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system, using an electronic form. The nurse should not document that an incident report was filed or refer to the incident report in the medical record

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially?

The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stop. The offending HCP may have erroneously perceived a mutual attraction. If that is not effective, additional action should be taken. The American Nurses Association cites 4 tactics to fight workplace sexual harassment: confront, report, document, and support

Which of the following are violations of the Health Insurance Portability and Accountability Act regarding confidentiality of privileged health information?

Under the Health Insurance Portability and Accountability Act (HIPAA), a client's information regarding medical treatment is private and cannot be released without the client's permission. There must be a reasonable effort to limit the use of, disclosure of, and requests for privileged health information (PHI) to the minimum necessary to accomplish the intended purpose. The client's PHI is to be shared with the spouse only with the client's permission. Lawsuits have resulted when findings a client wanted private were given to the spouse (eg, the husband was not the father of the baby). PHI is shared with an employee on a "need-to-know" basis. A transporting employee does not need to know the client's diagnosis. The employee would need to know if there was a need for personal protective equipment related to infectious precautions. A transporting ambulance paramedic who is managing care would need to know the diagnosis

The nurse should always observe the 5 rights of delegation when considering appropriate task assignments. Bathing along with mouth and skin care are standardized routine procedures. A client who is 2 days postoperative hip arthroplasty is usually stable; therefore, the nurse can delegate the task of assisting this client with morning care. However, the nurse should reassess the delegated tasks if the client's condition changes

Unlicensed assistive personnel (UAP) with the skills and knowledge can perform standardized procedures on stable clients (eg, assisting a client with morning care, emptying a colostomy bag in a client with an established stoma). However, sterile procedures, enteral feedings, or standardized procedures in an unstable client should not be delegated to UAP as these skills require nursing knowledge, judgment, and skill

Unlicensed assistive personnel (UAP) may perform routine tasks under the direction of the licensed practical nurse (LPN). Tasks requiring trained knowledge, critical thinking, and individualized application by the LPN cannot be delegated. A client 1 day post surgery must first be evaluated by the LPN to establish safety and readiness for ambulation; the UAP can then assist ambulating (Option 1). UAP can perform clinical tasks (eg, empty, measure, and record output from a surgical drain). However, the LPN is responsible for assessing drainage quality (eg, type, odor, color) and maintaining the wound drainage device (Option 2). Under the direction and supervision of the LPN, UAP can bring extra blankets to the client and escort family members to the waiting area, as these are noncomplex tasks that pose no risk for harm to clients

Unlicensed assistive personnel may perform noncomplex tasks (eg, escorting family members, providing additional blankets) and clinical tasks (eg, emptying, measuring, and recording output) related to the care of clients under the direction of the licensed practical nurse. Assist client in ambulating a client 1 day post abdominal surgery

Removing a dressing that has been on the client's skin is not a sterile procedure (unlike applying a new dressing, when sterile technique is commonly used). The gloves need to be removed and changed prior to application of a new dressing. There is no need to use the more expensive sterile gloves. The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile field if properly opened, with the other aspects of asepsis/sterile field observed (eg, do not get it wet, do not reach over it).

Use clean, rather than sterile, gloves when removing contaminated dressings. The inside of a sterile glove wrapper is sterile. Do not return items in clients' rooms to central supplies, discard sterile solution after 24 hours, and do not reuse tourniquets between clients

Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions

When a caregiver's performance is below the standard of care needed to provide safe and quality care to clients, the appropriate authority should be notified so that the situation can be handled

Therapeutic communication is used to establish trust, encourage communication, and display respect for the client. Validating the client's feelings and offering self convey concern and understanding by the nurse and help establish a therapeutic dialogue (Option 3). Together, these techniques can be helpful for diffusing negative emotions

When a client is angry and upset, therapeutic communication skills such as giving recognition, validating feelings, and offering self may help deescalate the situation. The nurse should not initially ignore the client, use threats or cite rules, or make defensive statements

When asked to "float" to help out in another unit, the nurse should clarify the duties to be performed. Many skills/knowledge, such as vital signs and routine medication administration, are the same in all units. The nurse should be given a unit orientation. The nurse should then clarify applicable skills. For instance, the nurse could perform basic care but not feel comfortable watching the telemetry cardiac monitors or assisting with insertion of a pacemaker. These limitations are usually understood and respected. The qualified and experienced nurses on the unit perform specialized client needs, and the "float" nurse performs basic client needs. The nurse is liable to provide safe care for the assigned duties and perform them in a competent manner. The nurse should personally document any concerns raised with the supervisor and avoid discussing personal feelings about the "float" with clients or other staff

When a nurse is asked to care for clients in an unfamiliar population ("float"), the duties to be performed and the nurse's limitations in skills or knowledge of specialized care should be clarified. Refusing to go can result in disciplinary action, including termination

The clinic nurse is reinforcing teaching to a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information?

When the advance directive is completed, a copy should be placed in the client's medical record and copies should be given to everyone listed as health care proxies. The client should also keep a copy in a safe place. / An advance directive is placed in the client's medical record and copies are given to health care proxies. Two witnesses are required for completion of the advance directive, but they should not be the health care proxies listed in the document or the client's health care provider

The nurse should first verify the accuracy of the client's statement with the unlicensed assistive personnel (UAP). The client could be mistaken. It is also important to make the UAP accountable for completing the action or reporting the inability to do so. Initially, the nurse should attempt to handle this situation alone, which can likely be resolved without administrative involvement. If a pattern of neglect is revealed or the UAP is belligerent or refuses to perform the assigned task, management should be contacted.

When the completion of an assigned task is questioned, the nurse should first confirm the status of the task with the designated personnel.

health care proxy

a person chosen by another person to make medical decisions if the second person becomes unable to do so

AC abbreviation

before meals

Lateral violence in the workplace (acts of aggression by an employee toward another employee) should not be tolerated or ignored. Victims can take action against bullying, including

documenting and reporting incidents, standing up to the bully in a professional way, and seeking support. / The chain of command should be followed when reporting incidents of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain

Client care that involves assessment, care planning, and initial teaching must be completed by the registered nurse. The practical nurse may perform care activities for the client with an established ostomy

emptying pouch and documenting drainage characteristics, changing pouches, providing skin care, observing for skin breakdown, and irrigation

hemorrhagic anemia

excessive blood loss

While caring for a client with Alzheimer disease, the role of unlicensed assistive personnel includes

helping with activities of daily living and reporting changes in the client

Beneficence

is a nurse's duty to promote good and do what is best for the client

autonomy

is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions

The nurse should not document that an incident report was filed, or refer to the incident report in the

medical record

Nurse offenses reportable to the state board of nursing include criminal acts (such as theft), practicing outside of the scope, falsification of records, and client abandonment. Any individual may file a complaint regarding an action that is

potentially unethical, incompetent, impaired, or in violation of nursing law

When managing a team, the nurse should assess situations prior to intervening. If a team member refuses an assignment, the nurse should determine

the reason for refusal prior to taking further action