Level 1 Discussion Board Questions

C: A normal body temperature of an older adult person may range from 96.5 degrees to 99F degrees. Therefore, a temperature of 98F may signify a fever in an older person. Incontinence is not a normal age-related change. not all older adults have altered mobility needs, and those who do are more likely to use a cane or walker than crutches (which are used for injury). Use of blood glucose devices is generic or related to a diagnosis of diabetes and is not specifically related to normal aging changes.

153The nurse prepares to teach a class about normal aging changes to a group of nursing assistants. The nurse should select which teaching technique as most appropriate? A. Demonstrate use of incontinence pads for clients who become incontinent of urine. B. Teach crutch walking because of high risk for falls and fractures in older adults. C. Discuss a case study in which an older adult with an infection had a temperature of 98F. D. Show how to use a blood glucose monitoring device and how to disinfect it because of increased incidence of diabetes.

B: Some teens develop type 2 diabetes, especially those who are overweight. They might need to take an oral hypoglycemic with or without accompanying insulin. Warning the client about compliance does not provide the information needed about medication therapy. Insulin is not used for those who won't take oral medication. Sweets and complex carbohydrates will need to be restricted regardless of medication therapy.

A 15-year-old weighing 250 pounds has started to experience increased thirst, increased appetite, and frequent urination. After being diagnosed with diabetes mellitus (DM), he is started on oral drug therapy. What information should the nurse give the adolescent about medications as a treatment option? A. "You might receive a pill now, but you'll get insulin in the future if you don't comply with diet and medication therapy." B. "Overweight teenagers may develop type 2 diabetes, which can be treated with an oral medication. You may or may not need insulin in the future." C. "Insulin is used when people with diabetes won't take oral pills, so you can avoid this by taking your medication as ordered." D. "Your diabetes is mild, so you won't need to take medication for long. You will probably only need to restrict sweets."

A, B, C: The IPV, DTaP, Hib, and PCV vaccines are all scheduled to be given at 2 months of age. The MMR is given at 12 to 15 months, and again at 4 to 6 years. The varicella zoster vaccine is given at 12 to 18 months.

A 2-month-old client is seen in the pediatric clinic for a well-baby checkup. The nurse anticipates that which routine immunizations will be administered at this time? Select all that apply. A. Inactivated poliovirus vaccine (IPV) B. Diphtheria, tetanus and acellular pertussis (DTaP) C. Haemophilus influenza B conjugate vaccine (Hib) D. Measles, mumps, and rubella vaccine (MMR) E. Varicella zoster vaccine (Varivax)

A: To calculate the EDC using Nagele's rule, subtract 3 months, and add 7 days. This makes the EDC 8/28.

A 22-year-old woman tells a clinic nurse that her last menstrual period was 3 months ago, which began on 11/21. She has a positive urine pregnancy test. Using Nagele's rule, which date should the nurse calculate to be the woman's estimated date of confinement (EDC)? A. 8/28 B 1/28 C. 8/15 D. 1/15

B: Pyelonephritis is an upper urinary tract infection, involving the pelvis of the kidney. Lower urinary tract infections include urethritis, prostatitis, and cystitis. The most common upper urinary tract infection is pyelonephritis.

A 25-year-old male college student is diagnosed with an upper urinary tract infection (UTI). The nurse anticipates that which diagnosis is likely to be documented on the medical record? A. Cystitis B. Pyelonephritis C. Urethritis D. Prostatitis

B: The nurse should help the client identify past experiences with loss, as well as coping strategies used at those times. This will allow the nurse and client to identify strengths, social supports, and effective coping strategies that could be used at this time. It will also help the client to look at the current situation rationally while drawing from experiences of the past. Focusing on the nature of the spouse's illness will neither facilitate expression of the client's feelings nor provide an opportunity for discussing healthy coping strategies. Medical and historical facts about the ill spouse would be gathered, but the feelings of "hopelessness and helplessness" verbalized by the client would not be acknowledged, validated, or relieved. While it is indeed important to support a dying client through the anticipatory grieving of impending death, the nurse should stay focused on the client in this case (the non-dying spouse). At another time, however, the dying spouse could become the client. While relationship issues might be a part of grief counseling, the most pressing need of the client at this time is to talk about the client's own feelings about the current situation. This will assist the client to identify familiar coping strategies, such as seeking social support, that have been effective in past situations of loss and grief.

A 63-year-old male client expresses feelings of hopelessness and helplessness about his spouse's illness and anticipated death. On which issues should the nurse initially assist the client to focus? A. The nature of the spouse's present illness B. The client's response to past losses C. The dying spouse's feelings about impending loss and death D. The client's relationship with the spouse

D: Osteoporosis, a decrease in bone density, makes the older adult more prone to pathological fractures. Decreased mobility, osteoarthritis, and scoliosis do not cause pathological fractures. Scoliosis is a curvature of the spine, usually diagnosed in adolescents.

A 75-year-old woman with a pathological fracture of the arm asks, "How did I get a broken bone?" The nurse most appropriately responds by stating that which problem is most likely to be responsible for the fracture? A. Decreased mobility B. Osteoarthritis C. Scoliosis D. Osteoporosis

A: If the young woman exercises excessively - for example, as a competitive gymnast or runner - her body fat index will be so low she will become amenorrheic. Vaccination history, pet ownership or history of asthma have not been show to be related to secondary amenorrhea.

A client complaining of secondary amenorrhea is seeking care from her gynecologist. Which of the following may have contributed to her problem? A. Athletic activities B. Vaccination history C. Pet ownership D. History of asthma

D: Ondansetron is an antiemetic used to treat post-operative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy.

A client has PRN prescription for ondansetron. For which condition should the nurse administer this medication to? A. Paralytic ileus B. Incisional pain C. Urinary retention D. Nausea and vomiting

C: Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options A, B, and D.

A client has a PRN prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? A. Constipation B. Abdominal pain C. An episode of diarreha D. Hematest-positive nasogastric tube drainage

D: Administration of analgesics around the clock (ATC administration) at regularly scheduled intervals or by long-acting controlled- release transdermal patches maintains therapeutic blood levels of analgesics, which limit pain at levels of comfort acceptable to clients. Although the nurse will ask the question in option A to determine the client's level of pain tolerance, this is not the priority. The nurse will attempt to do option B, there may be significant interventions that must be performed that may precipitate pain. Although the nurse and the client may attempt to do option C, there may be unavoidable activities that may precipitate pain.

A client has a history of severe chronic pain. Which is one of the most important guidelines associated with providing nursing care to the client? A. Asking what is an acceptable level of pain. B. Providing interventions that do not precipitate pain. C. Determining the level of function that can be performed without pain. D. Focusing on pain management intervention before pain becomes excessive.

D: Major abdominal surgery involves extensive manipulation of internal organs and a large abdominal incision that require adequate pharmacological intervention to provide relief from pain. Repositioning is effective for mild, not severe, pain. A back massage is ineffective for acute, severe pain; however, it may relax the client and increase the effectiveness of analgesic medication. Guided imagery is more effective for mild pain, not acute, severe pain.

A client has had major abdominal surgery. What should the nurse do first when on the second post-operative day this client reports abdominal pain at level 5 on a 1-to-10 pain scale? A. Reposition the client B. Offer a relaxing back rub C. Use distraction techniques D. Administer the prescribed analgesic

D: Cranberries have no constituents that irritate the bladder. In addition, they produce a more acidic environment that is less conducive to the growth of microorganisms and prevents bacteria from adhering to the mucous membranes of the urinary tract, thus promoting bacterial excretion. Beer contains alcohol, which is irritating to the bladder. Coffee contains caffeine is irritating to the bladder. Milk has no impact on the bladder irritability.

A client is experiencing bladder irritability. Which fluid should the nurse teach the client to include in the diet? A. Beer B. Coffee C. Milk D. Cranberry juice

B: Sleep is a sensory experience that restores cerebral and physical functioning. Evaluations related to sleep are based on client reports because effectiveness of sleep is subjective. Option A is a planned nursing intervention, not a goal. Option C is a goal that relates to relieving pain. Four hours of sleep is not enough for most adults. Many adults require 6 to 8 hours of sleep.

A client is experiencing lack of sleep because of pain. Which is the most appropriate goal for this client? "The client will: A. Be provided with a back massage every evening before bedtime." B. Report feeling rested after awakening in the morning." C. Request less pain medication during the night." D. Experience four hours of uninterrupted sleep."

D: All the factors that affect the pain experience should be assessed, including location, intensity, quality, duration, pattern, aggravating and alleviating factors, and physical, behavioral, and attitudinal responses (assess PQRST). Assessment must precede intervention. Option A is premature without a full pain assessment, particularly obtaining information about the intensity of pain. Distraction is not effective for severe pain. There is not enough information to indicate that this intervention may be effective (option B). In addition, the position the client considers most comfortable may be contraindicated based on practitioner's orders or safety issues. Option C is a hasty, impulsive response that may or may not be necessary.

A client requests pain medication. What should the nurse do first when responding to this client's request? A. Use distraction to minimize the client's perception of pain. B. Place the client in the most comfortable position possible. C. Administer pain medication to the client quickly D. Assess the various aspects of the client's pain

C: This is referred pain, which is pain felt in a part of the body that is at a distance from the tissues causing the pain. Referred pain is related to location of pain. The pattern of pain refers to time of onset, duration, recurrence, and remissions. Duration refers to how long the pain lasts, which is an aspect of the pattern of pain. Constancy refers to whether the pain is continuous or if there are periods of relief from pain, both of which relate to the pattern of pain.

A client states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement? A. Pattern B. Duration C. Location D. Constancy

C: Reaction formation is an ego defense mechanism that causes people to act exactly opposite to the way they originally felt. The behaviors of the person utilizing this defense mechanism are often excessively intense and appear somewhat unbelievable to others. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. The client is not denying the presence or reality of the baby. Projection is a process in which unacceptable personal desires, actions, thoughts, shortcomings, or mistakes are attributed to others or the environment. There is no indication that this client is doing this. Displacement is the transferring or discharging of emotional reactions from one object or person to another. The recipient of the displaced emotion then assumes a symbolic significance to the individual who is displacing the emotion. There is no indication that the client is doing this.

A client was quite upset the entire time she was pregnant and made it clear that she did not want her unborn child. However, since the birth, she has been overly protective and refuses to let anyone else near the infant. Which ego defense mechanism does the nurse recognize in the client's behavior? A. Denial B. Projection C. Reaction formation D. Displacement

A,B: Foods high in chloride include bananas and dates, green leafy vegetables, seafood, poultry, and dairy products. Canned soups tends to be higher in sodium and chloride is combined with sodium as salt.

A client with anorexia nervosa has been taught to increase foods high in chloride. The nurse determines teaching has been effective when the client identifies to increase intake of which foods? Select all that apply. A. Bananas B. Canned soups C. Apples D. Beef E. Pasta

A,D: A magnesium level of 2.8 is elevated (normal 1.4 to 2.1mEq/L), most likely as a result of inadequate renal secretion secondary to the chronic renal failure. Foods high in magnesium include whole grains, legumes, oranges, bananas, green leafy vegetables, and chocolate

A client with chronic renal failure has a magnesium level of 2.8mEq/L. When reviewing the client's dietary history, the nurse identifies which frequently eaten foods as a possible cause of this laboratory value? Select all that apply. A. Hot chocolate B. Apples C. Pork sausage D. Spinach sald E. Swiss cheese

B: The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

A client with diabetes mellitus demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglylcemia. What is the most appropriate intervention to decrease the client's anxiety? A. Administer a sedative B. Convey empathy, trust, and respect toward the client C. Ignore the signs and symptoms of anxiety so that they will soon disappear D. Make sure that the client knows all the correct medical terms to understand what is happening.

D: The client is manifesting signs and symptoms of dehydration. Because the serum remains isotonic, this is isotonic dehydration or hypovolemia. Appropriate treatment is with an isotonic fluid to replace fluid volume. Once the dextrose is metabolized, 5% dextrose in water is a hypotonic solution that would cause fluid shifting leading to cellular edema, because the client's cells are normal size and free water is not needed by them. 0.45% sodium chloride is a hypotonic solution; because the client has an isotonic dehydration, this would cause fluid shifting leading to cellular edema. 10% dextrose in water is hypertonic and could cause fluid shifting into the vascular compartment from the cells, leading to cellular dehydration.

A client with dry skin and mucous membranes is weak, has orthostatic blood pressure changes, and has decreased urine output. The client's serum osmolality, however, is normal. Which IV fluid would the nurse anticipate being prescribed for this client? A. 5% dextrose in water (D5W) B. 0.45% sodium chloride (1/2 NaCl) C. 10% dextrose in water (D10W) D. 0.9% sodium chloride (NS)

B, C: Therapeutic communication techniques include: open-ended statements and reflection. Reassurance, agreement, and challenges are techniques that inhibit communication

A group of nursing students is preparing a class presentation on therapeutic and non-therapeutic techniques of communication. The students demonstrate understanding of the information when they select which techniques to demonstrate as therapeutic? Select all that apply. A. Confrontation B. Open-ended statements C. Reflection D. Reassurance E. Agreement F. Challenges

D: All of the females will be carriers. None of their male children will be green color blind. None of their female children will be green color blind. Males do not carry X-linked recessive traits. The male client has a genotype of "x"Y, the "x" being the recessive gene responsible for green color blindness. The female has a genotype of XX; both of her genes are normal. Father: "x" Y Mother: X. X"x" XY X. X"x" xy

A male client has green color blindness, an X-linked recessive genetic disorder. His wife has no affected genes. Which of the following statements by the nurse is true regarding the couple's potential for having a child who is color blind? A. All male children will be color blind. B. All female children will be color blind. C. All male children will be carriers for color blindness. D. All female children will be carriers for color blindness.

C: Risk management committees use statistical data about accidents and incidents to identify patterns of risk and prevent future accidents and incidents

A nurse administers an incorrect dose of a medication to a client. Which is the primary purpose of documenting this event in an Incident Report? A. Record the event for future litigation. B. Provide a basis for designing new policies. C. Prevent similar situations from happening again. D. Ensure accountability for the cause of the accident.

D: With normal aging, there is loss of cartilage and joint fluid. Overall wear and tear does occur. Sebaceous glands are less active, and older adults sweat less. Social support may decrease with deaths and fewer resources but does not relate to the question of physiologic needs. There is decreased need for sleep, with shorter REM and non-REM sleep cycles.

A nurse evaluates that a teaching plan related to normal physiologic changes of aging has been effective for a 70-year- old client if he makes which statement? A. "I have more sebaceous gland activity." B. "I have lost some of my social support systems." C. "I have an increased need for sleep." D. "I have less joint cartilage than I used to."

D: Acute pain stimulates the sympathetic nervous system, which responds by increasing pulse, respirations, and blood pressure. Chronic pain stimulates the parasympathetic nervous system, which results in lowered pulse and blood pressure. Self-focusing is associated with chronic, not acute, pain because its unrelenting, prolonged nature interferes with pursuing a normal life. As a result, there may be changes in family dynamics, sexual functioning, financial status, and self-esteem that result in introspection and depression. Pain is an internal stimulus that can interrupt sleep. Because chronic pain is unrelenting and prolonged, over time, interrupted sleep results in sleep deprivation. Guarding behaviors occur in both acute and chronic pain. However, because of the unrelenting prolonged nature of chronic pain, behavioral responses, such as guarding, stooped posture, and altered gait may become permanent adaptations.

A nurse is assessing a client experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? A. Self-focusing B. Sleep disturbances C. Guarding behaviors D. Variations in vital signs

D: The word episode refers to an incident, occurrence, or time period; therefore, the word episode refers to patterns of pain and is concerned with time of onset, duration, recurrence, and remissions. Tenderness is a sensory word that describes pain and is related to the quality of pain. The description of pain as being moderate is related to intensity of pain. Phantom pain is related to location of pain. Phantom pain is a painful sensation perceived in a body part that is missing.

A nurse is assessing a client in pain. What word might the nurse use when documenting the pattern of a client's pain? A. Tenderness B. Moderate C. Phantom D. Episode

B: Current evidence suggests that the presence of fetal (not maternal) heart tones and adequate growth evaluated by measuring the fundal height are the standard to assess fetal growth and viability. Measurement of the woman's abdominal circumference does not provide information about the growth of the fetus. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is not routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus

A nurse is caring for a 32-week-pregnant client. The client asks how the nurse will monitor the baby's growth and determine if the baby is really okay." Based on current evidence, during the third trimester, which assessment should the nurse perform to evaluate the fetus for adequate growth and viability? A. Auscultate maternal heart tones B. Measure fundal height C. Measure the woman's abdominal girth D. Complete a third-trimester ultrasound

A: Psychological or affective responses to pain relate to feelings and emotional distress. Fear of being dependent on others or loss of self-control are psychological responses to pain. Tolerance to a drug is not a response to pain. Tolerance to a drug can be physiological and/or psychological. Requesting pain medication is a behavioral response to pain. Nausea is a physiological response to pain.

A nurse is caring for a client who is experiencing pain. For which most common psychological client response to pain should the nurse assess? A. Experiencing fear related to loss of independence. B. Developing an increased tolerance to the drug C. Asking for pain medication to relieve the pain. D. Verbalizing the presence of nausea.

B, A, C, D: Gonadotropin-releasing hormone stimulates the production of follicle-stimulating hormone (FSH) and lutenizing hormone (LH). FSH rises first and LH follows. After ovulation, progesterone rises.

A nurse is explaining to a client about monthly hormonal changes. Starting with day 1 of the menstrual cycle, place the following four hormones in the chronological order in which they elevate the menstrual cycle. A. Follicle-stimulating hormone B. Gonadotropin-releasing hormone C. Luteinizing hormone D. Progesterone

A: Imagery, the internal experience of memories, dreams, fantasies, or visions, uses positive images to distract, which reduces stress, limits mild pain, and promotes relaxation and sleep. The use of opioids should be a last resort. Nursing interventions or non- opioid medications usually are effective in limiting mild pain. Bathing preferences are highly individual and the client may not prefer a shower. In addition, a shower is stimulating and may be contraindicated. Although daytime activity does promote sleep at night, clients with pain may be reluctant to be active.

A nurse is helping a client who is experiencing mild pain to get ready for bed. Which nursing action is most effective? A. Assisting with relaxing imagery B. Obtaining a prescription for an opioid C. Encouraging the client to take a warm shower D. Recommending that the client be more active during the day

D CPAP devices are intended for clients who can breathe on their own but need assistance in maintaining adequate oxygenation. The CPAP device keeps the alveoli open, allowing for maximal perfusion to occur. Although oxygen can be administered with a CPAP device, it is not always necessary. CPAP is not intended to reduce intrathoracic pressure.

A nurse is helping a client with obstructive sleep apnea to apply continuous positive airway pressure (CPAP) mask before going to sleep. The nurse knows that CPAP is intended to: A. Breathe for the client during sleep. B. Reduce intrathoracic pressure. C. Deliver high concentrations of oxygen. D. Prevent alveolar collapse.

A. The breasts increase in size and weight because of hyperplasia and hypertrophy of the breast tissue in preparation for lactation. Vaginal hypertrophy occurs from the increase in estrogen levels. Tidal volume increases throughout pregnancy because of a small degree of hyperventilation that occurs during pregnancy. Hemoglobin typically decreases as the pregnancy progresses, with some women developing pregnancy-induced anemia.

A nurse is in the room during a physical examination of a client who thinks she may be pregnant. Which findings during the examination support a possibility of pregnancy? A. Increased hyperplasia and hypertrophy in the breasts B. Vaginal atrophy C. Decrease in respiratory tidal volume D. Increase in hemoglobin

A, B, D: Ultraviolet light, injury, and viral infections increase the incidence of cataract development. The nurse recommends the use of sunglasses, eye protection, and safety throughout the life span. Vitamin A and eyestrain do not increase the risk of cataract development.

A nurse is instructing an older adult client about cataract prevention. The nurse will instruct the client that which factors increase the incidence of cataract development? Select all that apply. A. Ultraviolet light B. Injury C. Vitamin A D. Viral infections E. Eyestrain

D: Each physiologic system of a person ages at a different rate. Proper diet and regular exercise can be beneficial in slowing the rate of the aging process. Free radicals do influence the aging process. Physical changes within the body can occur as a result of disuse.

A nurse is teaching a class about aging at a senior citizen center. The nurse concludes that a client needs further instruction if the client made which statement? A. "Through nutrition and exercise, we can modify the rate of aging." B. "Free radicals influence the quality of growing old." C. "Some of the physical changes within our bodies are the result of disuse." D. "Deterioration of body systems occurs at the same rate."

A: The parathyroid glands regulate calcium regulation. The glands lie just underneath the thyroid gland and may be accidentally removed when a thyroidectomy is done, leading to hypocaclcemia. An increased release of PTH would result in increased calcium release, not a decrease. Immobility contributes to osteoporosis and calcium resorption from the bones, which leads to elevated calcium levels. Hypophosphatemia is usually seen with hypercalcemia. Calcium gluconate would not be given to treat hypercalcemia.

A nurse prepares to administer calcium gluconate to a client post-thyroidectomy. The nurse explains to the licensed vocational nurse (LVN) that this medication is being given for which reason? A. Because of accidental removal of the parathyroid gland B. Because it is related to increased parathyroid hormone (PTH) release during surgery C. To prevent complications from immobility post-operatively D. Due to hypophosphatemia after this type of surgery

D: Spinnbarkeit is defined as the "thread" that is created when the vaginal discharge is slippery and elastic at the time of ovulation. The changes are in response to high estrogen levels. The woman inserts her index and middle fingers into her vagina and touches her cervix. After removing her fingers, she separates her fingers and "spins a thread" between her fingers. When she is not in her fertile period, the mucus is thick and gluey. The temperature does elevate after ovulation, but the elevation is not defined as spinnbarkeit. The breasts do become sensitive and some women do palpate tender nodules in the breasts at the time of ovulation, but those changes are not spinnbarkeit. The nipples may tingle and become sensitive, but the sensations are not indicative of spinnbarkeit.

A nurse teaches a woman who wishes to become pregnant that is she assesses for spinnbarkeit she will be able closely to predict her time of ovulation. Which technique should the client be taught to assess for spinnbarkeit? A. Take her temperature each morning before rising. B. Carefully feel her breasts for glandular development. C. Monitor her nipples for signs of tingling and sensitivity. D. Assess her vaginal discharge for elasticity and slipperiness

D: Proper self-administration of medications includes taking medications on time and,if a dose is missed, taking the next one on time. Misuses of medications by older adults includes behaviors such as combining prescribed and over-the-counter medications, having prescriptions from different physicians, failing to tell each doctor what has previously been prescribed and taking someone else's medications.

A nurse teaches an older client about misuse of medications. Which subsequent behavior by the client indicates that the instruction was effective? A. Combining prescribed medications with over-the-counter ones. B. Having prescriptions from several physicians C. Using someone else's medications D. Taking medications on time and, if a dose is missed, taking the next one on time

A: Both peanuts and hamburger are good sources of folic acid, but since the client is a vegetarian, peanuts are a better recommendation. Bananas and apple juice do not contain significant amounts of folic acid

A pregnant client, who is a vegetarian, is concerned about her folic acid intake and asks the nurse to recommend some foods that she should include in her diet. Which of the following should the nurse recommend? A. Peanuts B. Hamburger C. Bananas D. Apple juice

A: The child has a 25% probability of being normal stature. Because both parents are heterozygous ("hetero" meaning "different"), they each have one dominant gene or allele (A) and one recessive gene or allele (a). Therefore, the genotype of each parent is Aa. Because achondroplasia is a dominant disease, the recessive allele in this scenario is the normal gene. Only 1 of the 4 boxes contains 2 recessive (normal) genes; therefore, their child has a 1 in 4, or 25%, chance of being normal stature. After doing a Punnet square, it can be seen that the probability of the child being of normal stature is 1 in 4, or 25%. Father: A a Mother: A AA Aa a Aa aa

A pregnant woman and her husband are both heterozygous for achondroplastic dwarfism, an autosomal dominant disease. The nurse advises the couple that their unborn child has which of the following probabilities of being of normal stature? A. 25% probability B. 50% probability C. 75% probability D. 100% probability

B: Identification is an ego defense mechanism where a person models the actions and opinions of influential others while searching for identity or aspiring to reach a personal, social, or occupational goal. In this case the psychologist has taken up the profession as the psychologist admires an aunt who is successful in the same profession. Denial is the failure of an individual to accept his or her situation. Compensation is an ego defense mechanism where an individual tries to work hard and achieve well in one area in order to compensate for the perceived deficiencies in other area. Displacement is an ego defense mechanism where a client expresses intense feeling toward persons who are less threatening than the one who aroused those feelings.

A psychologist chose the profession because the psychologist was inspired by an aunt who was a successful psychologist. Which of Freud's ego defense mechanisms is this indicative of? A. Denial B. Identification C. Compensation D. Displacement

A: The probability of the couple having a daughter with hemophilia A is 0%. After doing a Punnett square, it can be seen that the probabilty of the couple having a daughter with hemophilia A is 0%; in recessive X-linked inheritance, girls would have to have 2 affected "x" genes to exhibit the disease. Father: X Y Mother: X XX XY "x" X"x" "x"Y

A woman is a carrier for hemophilia A, an X-linked recessive illness. Her husband has a normal genotype. The nurse can advise the couple that the probability that their daughter will have the disease is: A. 0% probability B. 25% probability C. 50% probability D. 75% probability

D: When the ovum is not fertilized, both estrogen and progesterone levels drop. The hormonal drop is followed by menstruation.

A woman is menstruating. If hormonal studies were to be done at this time, which of the following hormonal levels would the nurse expect to see? A. Both estrogen and progesterone are high. B. Estrogen is high and progesterone is low. C. Estrogen is low and progesterone is high. D. Both estrogen and progesterone are low.

A: Feeling anger when watching other children play is correct. Although the loss of a child can be devastating, the ability of a parent to reintegrate involvement in usual activities is important to successfully resolving grief and loss. The client's behavior indicates that she has not moved past the initial stage of grief in which preoccupation with feelings of loss and intense emotional pain are prevalent. The other options are more average responses to the death of a child.

A young woman arrives at a routine medical visit, appears depressed, and tells the nurse she is having difficulty dealing with the death of her infant son. The nurse learns the infant died 30 months ago in an automobile accident. The initial nursing diagnosis is Dysfunctional Grieving. Which statement by the client would support this diagnosis? A. "When children play in playgrounds, it makes me angry that my son will never be able to play like other children." B. "I sometimes cry in my son's old bedroom because he's not there anymore." C. "I watch other toddlers in the neighborhood play, and I wish my son were still alive." D. "I think of my son and I am said that my new baby will never be able to know his brother."

C: With normal aging changes, there is a decrease in vision, hearing, touch, smell, and taste. These changes can lead to falls, inability to leave a situation when called to do so, inability to distinguish temperature with resulting burns, inability to smell smoke in a fire, and inability to taste contaminated food. These changes can have a major impact on the safety needs of an older adult. Age- related changes in the cardiovascular, respiratory or integumentary systems do not necessarily lead to safety issues.

After conducting a physical assessment, the nurse would conclude that a 75-year-old client's ability to maintain personal safety would be most adversely affected by declining function in which body system? A. Cardiovascular B. Respiratory C. Sensory D. Integumentary

D: Driving at night requires caution because accommodation of the eye to light is impaired and peripheral vision is diminished. Keeping the inside of the car warm at all times is not a significant issue when driving in warm climates or during warm seasons. Peripheral vision is diminished so it is important to look to the left and right. Reflexes are slowed for older adults; thus, caution regarding speed while driving should be emphasized.

After reviewing driving safety education principles with an older adult, a nurse should recognize which behavior as evidence of a favorable response by an older adult when driving? A. Keeping car interior warm at all times because of loss of subcutaneous fat with decreased tolerance to cold. B. Not turning the head to look to the left or right because the older adult's response time is slower. C. Driving at a speed that matches the flow of traffic to facilitate increased response time. D. Driving during the day to increase use of vision capabilities.

D: Non-therapeutic communication develops when nurses respond in ways that cause clients to feel defensive, misunderstood, controlled, minimized, alienated, or discouraged from expressing thoughts and feelings

After spending 15 minutes with a client, the client leaves the interaction feeling defensive. This is evidence that the communication can be described as what? A. In an improper environment B. Blocked by external noise C. Therapeutic D. Non- therapeutic

D: This is a goal statement that is specific and measureable and contains a time frame; "maintain" implies continuously. Option A is an intervention, not a goal. Option B is an inference about the client's status, not a goal. Option C is a statement that identifies a need or an intervention in response to an identified problem, not a goal.

An example of a goal identified by a nurse when planning a client's plan of care is, "The client will: A. Be assisted with meals." B. Be at risk for weight loss." C. Need small, frequent feedings." D. Maintain a weight of 140 pounds."

D: An insulin pump provides a small continuous dose of short-duration (rapid or short-acting) insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Short- duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurses bases the response on which information about the pump? A. Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals. B. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. C. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream D. Gives a small continuous dose of short- duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal.

C: Prealbumin is a sensative indicator of changes in nutritional protein status and can also alert the nurse to clients at risk for pressure ulcer development. Serum albumin can provide data about visceral protein stores but has a relatively long half-life and may not accurately reflect recent protein losses. Total cholesterol would be assessed as a risk factor for cardiovascular disease. CBC is a hematology test commonly used for screening purposes although decreased red blood cell count would indicate anemia.

An older adult client is admitted to an extended care facility for continuing care after a total hip replacement. The nurse assesses a BMI of 20, lackluster hair, and pallor. Which laboratory assessments will the nurse review to obtain the most sensitive information about the client's current nutritional status? A. Serum albumin B. Total cholesterol C. Prealbumin D. Complete blood cell count (CBC)

B, D, A, C: The correct ranking is as follows: Expressed thoughts of being better off dead is first priority. The nurse should recognize that any person who expresses thoughts of death or being better off dead should be viewed as being at risk for self-directed violence. Safety concerns for such persons take priority over all psychological and sociologic needs, as well as many physiologic needs. A morbid preoccupation with feelings of worthlessness is second priority. Grieving and depressed persons can be excessively preoccupied with feelings of worthlessness. This statement would be of concern once safety needs are met because of the word morbid. Occasional feelings of tightness in chest is third priority. Everyone experiences grief differently and older adults often experience grief somatically. However, physiologic dysfunction is a possibility to be concerned about as cardiac problems are more common in the older age group. If the client's discomfort continues, intensifies, or evidence of organic disease presents, then this option would become the number one priority. Statements of guilt about a loved one's death is fourth priority. Following the death of a significant person, the individual often feels guilty and fears having failed to do everything possible to prevent the death. These feelings are typically not pathological, but rather part of hte normal grieving experience. With the passage of time, and the gradual acceptance of the loss, they usually diminish.

An older adult grieving the loss of a family member reports all of the following symptoms to the nurse. To plan appropriate nursing interventions, the nurse needs to determine which symptoms need to be addressed first. Put the following client symptoms in order from highest to lowest priority. A. Occasional feelings of tightness in the chest. B. Expressed thoughts of being better off dead. C. Statements of guilt about a loved one's death. D. A morbid preoccupation with feelings of worthlessness.

B: First-generation antihistamines such as chlorpheniramine have side effects such as confusion, dry mouth, and constipation in older adults. Making the older client aware of the adverse effects may be beneficial for the client. The nurse does not need to order the client to stop the prescribed drug treatment immediately. Hydroxyzine also has the same side effects, so suggesting this drug will not be beneficial. A nurse should first consult the primary healthcare provider before recommending changing the medication.

An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client? A. Chlorpheniramine needs to be stopped immediately. B. These are common side effects of chlorpheniramine. C. Hydroxyzine needs to be taken with chlorpheniramine. D. The chlorpheniramine prescription needs to be changed.

A: Assisting the nurse to help the parents express their grief fully is correct. The capacity for self-awareness allows the nurse to reflect and make choices. Nurses who understand their own feelings and beliefs will be able to be therapeutic when clients need to address issues which are disturbing and difficult. The death of a child will personally affect the nurse, and it is critical for the nurse to share these feelings with others, including the parents. The nurse must be available both physically and emotionally for the parents in discussing unpleasant and difficult feelings.

Before counseling parents who have recently lost a child to death, it is important for the nurse to have already dealt with personal feelings about death, grief, and loss in children. Having this self-awareness is important for which reason? A. It assists the nurse to help the parents express their grief fully. B. It prevents the nurse from being personally affected by the loss. C. It prevents the nurse from sharing any personal feelings with the parents. D. It assists the nurse to avoid discussing unpleasant feelings with the parents.

B: Two areas that may be uncomfortable or difficult for the nurse to assess are sexuality and self-harm behaviors, which are both very personal areas. None of the remaining options are that personal in nature .

Considering the nature of its content, which areas may be the most uncomfortable or difficult for the nurse to assess? A. Mood B. Sexuality C. Motor behavior D. Roles and relationships

A: By asking the question "What would you change about your body, if you could?" the nurse is assessing self-concept. The client's description of self in terms of physical characteristics gives the nurse information about the client's body image which is also a part of self concept. Sensory-perceptual alterations refer to a change in the client's perception of the world. Often this results in hallucinations or a false sensory perception or perceptual experience that does not really exist. When assessing roles and relationships, the nurse would ask questions such as "Do you feel close to your family?" of "Do you have a significant other?" to determine the existence and quality of the client's sources of support and/or stress. Thought process and content refers to how the client thinks and what they actually say. The aim of this component of the assessment is to determine if the client's ability to think is impaired or intact.

During the assessment of a client who has a pattern of eating disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment? A. Self-concept B. Sensory-perceptual alterations C. Roles and relationships D. Thought process and content

A: When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in option B, C, and D do not need to be avoided.

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? A. Alcohol B. Organ meats C. Whole-grain cereals D. Carbonated beverages

A: The body needs phosphorus to make ATP, which provides all the cells - especially muscles - with energy. A high calcium level is seen with a low phosphorus level, and therefore symptoms of hypercalcemia will be seen. But phosphorus is directly needed to make ATP and thus cellular energy.

Many of the signs and symptoms of hypophosphatemia are related to: A. Low energy stores B. Hypercalcemia C. Excessive diuresis D. Hypocalcemia

C: Prolonged use of laxatives can lead to dependence on them for stimulation of defecation and can actually lead to uncontrollable defecation. Laxatives are not necessarily required to stimulate defecation in older adults. A proper diet, adequate fluid intake and sufficient activity will help to maintain normal bowel function during later years. A balanced diet is important even if not using laxatives. Laxatives should be used only as needed.

On admission, a 78-year-old client states he uses laxatives three times a week for constipation. What is the nurse's best response? A. "As people age, they need laxatives to stimulate defecation." B. "Eat a balanced diet if you use laxatives." C. "Long- term use of laxatives can actually lead to constipation." D. "Use laxatives two times a week at night."

D: The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

Phenazopyridine is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with which information regarding this medication? A. Take the medication at bedtime. B. Take the medication before meals. C. Discontinue the medication if a headache occurs. D. A reddish orange discoloration of the urine may occur.

D: The word preemptive means preventive, anticipatory, and defensive. Therefore, preemptive analgesia is administered before activity or interventions that may precipitate pain in an attempt to limit the anticipated pain. Hour of sleep (h.s., hora somni) medications are usually sedatives that promote rest and sleep. Medication administered when necessary at the client's request will have a practitioner's prescription that states PRN (pro re nata). Medications administered around the clock (ATC) at regularly scheduled intervals usually maintain therapeutic drug levels regardless of other factors influencing the client.

Pre-emptive analgesia is used when a nurse medicates the client: A. Before a client goes to sleep B. As soon as a client complains of pain C. At equal distant times around the clock D. Before doing a dressing change that has been painful in the past

B: Severe osteoporosis causes bone density loss, which can result in pathologic fractures wen the client is moved. A lift sheet can reduce the risk. Vitamin and calcium are necessary to prevent further bone loss but will not prevent injury. Use of high Fowler's position will not reduce risk for pathological fractures although it would be of use with respiratory problems. Positioning on the side will not be of use to prevent pathologic fractures.

The care plan for a client who has severe osteoporosis would include which intervention to prevent injury? A. Administer vitamin D and calcium as ordered. B. Use a lift sheet to reposition the client. C. Place the client in a high Fowler's position to promote lung expansion. D. Position pillows on the client's left side when in the side-lying position.

D: Beginning around the fourth week of pregnancy, vasocongestion in the pelvic area results in a bluish color to the vulva, vagina, and cervix, known as Chadwick's sign. Hegar's sign is a softening of the lower uterine segment. Goodell's sign is a softening of the cervix. McDonald's sign is an ease in flexing the body of the uterus against the cervix.

The client has come to the clinic for her first prenatal visit. During the pelvic examination, the examiner indicates that the vaginal mucosa has a bluish color. The nurse documents which assessment as positive? A. Hegar's sign B. Goodell's sign C. McDonald's sign D. Chadwick's sign

B: Made of polyurethane, the female condom does not require a prescription but can be difficult to insert, and can cause discomfort. it is effective against both STIs/STDs and pregnancy.

The client is interested in using female condoms and wants to know if there are any disadvantages. What is the nurse's best response? A. "The female condom provides good protection against pregnancy but not against sexually transmitted infections/diseases." B. "The female condom may be difficult to insert and may be uncomfortable to both partners." C. "The female condom is very effective let me arrange to get you a prescription." D. "The female condom is made of latex and should not be used by those with latex allergies."

D: Diabetic ketoacidosis can occur in diabetic clients with infection and characterized by elevated blood glucose and ketonuria.

The client who has a long history of type 1 diabetes mellitus is being treated for bronchitis and sinusitis. The nurse observes deep, rapid, unlabored respirations, fruity odor on the client's clothes, and dry skin. Which action should the nurse take next? A. Assess breath sounds for additional signs of response to treatment of the infection. B. Assess blood glucose level for signs of hypoglycemia. C. Encourage the client to rest frequently and to drink 8 to 10 glasses of fluids daily. D. Assess blood glucose level for hyperglycemia and check urine for ketones.

B: Headache, restlessness, anxiety, sweating, and increased pulse are signs of hypoglycemia. Resolution of the symptoms should occur after the client drinks the juice. Treating the headache and obtaining a breakfast tray fail to recognize the client's actual problem. Acknowledging dissatisfaction, obtaining a snack and giving medications address the client's concerns but do not verify the client's blood glucose as a possible etiology for the symptoms. Treating the headache and checking labs fails to address the immediate risk of hypoglycemia, which can be addressed by checking blood glucose.

The client with diabetes mellitus requests a medication for headache soon after returning from an early morning X-ray procedure. The nurse observes the client is upset about the headache, angry at missing breakfast, and has moist hands. What priority action should the nurse take at this time? A. Administer the medication for headache and arrange for a breakfast tray. B. Check the blood glucose level and be prepared to give 4 ounces of juice immediately. C. Acknowledge his dissatisfaction, offer to obtain a snack, and give the medication. D. Administer the headache medication and review the day's lab test results

C: The symptothermal method combines cervical mucus and BBT measurements and results in a lower failure rate than either BBT or cervical mucus as a single assessment of the fertile period. This method is completely natural and congruent with beliefs of this religious group. Ovulation testing kits do not give enough warning of ovulation to prevent pregnancy.

The client, who is married and has three children, has come to the family planning clinic asking about a birth control method that is most effective and sanctioned by the Roman Catholic Church. What would be the nurse's best recommendation? A. Billings or cervical assessment method B. Ovulation testing kit C. Symptothermal method D. Basal body temperature (BBT) method

A, B, C, D: Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply. A. Diarrhea may occur secondary to the metformin. B. The repaglinide is not taken if a meal is skipped. C. The repaglinide is taken 30 minutes before eating. D. A simple sugar food item is carried and used to treat mild hypoglycemia episodes. E. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. F. Muscle pain is an expected effect of metformin and may be treated with acetaminophen.

A: When a client with diabetes mellitus is unable to eat normally because of illness, the client should still take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones.

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours Which additional statement by the client indicates a need for further teaching? A. "I need to stop my insulin." B. "I need to increase my fluid intake." C. "I need to monitor my blood glucose every 3 to 4 hours." D. "I need to call the health care provider because of these symptoms."

A: As part of normal psychosocial development, adolescents need to feel like part of their group, even if it means impairing their health. There is not information to support a self-destructive wish. Although some foods may not be allowed at home, it is not likely to be the motivating factor. Displaying risk-taking behaviors is not likely the primary motivation, but rather a secondary event.

The mother of an adolescent with diabetes mellitus tells the nurse that her son likes to eat cheeseburgers and french fries when he goes out with his friends. The son is aware he is exceeding the allowable carbohydrate exchanges on the diabetic diet. How could the nurse best explain why adolescents sometimes make choices that place their health at risk? A. They want to be like their peers. B. They have a self-destructive wish. C. They eat foods with friends that they can't eat at home. D. They want to show risk-taking behavior.

C: Lentigines (brown age or liver spots) represent normal aging of the skin. Prebycusis is an age-related sensorineural hearing loss that also occurs in normal aging. These changes do not require medical attention, water-soluble creams, or use of bright lighting, although it is helpful for the client to see who is speaking to use mouth movements as an aid to hearing.

The nurse assess that a 75-year-old client has lentigines and presbycusis. When plannign care for this client, the nurse should take which action? A. Refer client to an oncologist and an ophthalmologist. B. Ask a nursing assistant to use water-soluble creams and keep room brightly lit. C. Look at the client while speaking, to ensure the client can see the nurse's lips. D. Adjust the temperature and lighting of the room.

C: The normal serum calcium level is 8.5 to 10.5mg/dL. A serum calcium level lower than 8.5mg/dL indicates hypocalcemia. Electrocardiographic (ECG) changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.

The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)? A. Widened T wave B. Prominent U wave C. Prolonged QT interval D. Shortened ST segment

C: Maternal folic acid deficiency has been linked to infant neural tube defects. Folic acid may be obtained from prenatal vitamin supplements as well as foods. The other responses contain incorrect statements and do not indicate understanding of prenatal nutrition.

The nurse concludes by which client statement that the pregnant client understands prenatal nutrition education? A. "I understand that if I don't eat foods with folic acid, my baby will have birth defects." B. "I understand that eating citrus fruits, especially oranges, will help me meet my need for folic acid." C. "I understand that if my level of folic acid level is low, it could cause my baby to have a neural tube defect." D. "I understand that I should limit my intake of folic acid because it can build up in the liver and cause birth defects."

A, B, C, E: The client should inform the health care provider of illness, and then should follow "sick-day rules" as prescribed by health care provider, which include taking insulin as prescribed, or increasing insulin as prescribed, consuming extra fluids, resting, and self- monitoring glucose every 2-4 hours. Notifying the provider of blood glucose levels outside the target range, adherence to insulin therapy, and routine monitoring of blood glucose levels are correct elements of self-management of diabetes mellitus.

The nurse concludes that a client newly diagnosed with type 1 diabetes mellitus has understood discharge instructions after the client makes which statement? Select all that apply. A. "I will notify my health care provider if my glucose levels run higher or lower than the target range." B. "I will take my insulin as prescribed, and I will not miss a dose." C. "I will check my glucose level 30 minutes before I eat and at bedtime." D. "I will not take my insulin if I am sick and cannot eat." E. "I should call my health care provider if my blood glucose reaches 250 while I am ill."

A, B, C: Older adults may be at higher risk for fluid imbalances because of decreased thirst or oral intake, diagnosed health conditions that affect fluid balance, or if they have difficulty with mobility to use the bathroom. It is not necessarily true that older adults eat only canned or prepackaged foods, or that they dislike the taste of water.

The nurse explains to a group at a senior citizen center that older adults may be predisposed to fluid imbalances for which reasons? Select all that apply. A. They might not pay attention to thirst or may experience less thirst. B. They might fear too much fluid if they have a tendency for ankles to swell. C. They might not drink fluids if it is difficult to go to the bathroom. D. They eat only canned and pre-packaged foods. E. They tend to dislike the taste of water.

A: A person who does not assess personal attitudes and beliefs may hold a prejudice or bias toward a group of people because of preconceived ideas or stereotypical images of that group. This oversight may or may not cause the nurse to overlook the client's expressed desires. Manipulation results from a failure to maintain boundaries. Shock is unlikely because the nurse is evidently aware of the client's sexual orientation before caring for the client

The nurse fails to assess personal values surrounding homosexuality before caring for a client who is openly gay. The nurse is most at risk for what when working with this client? A. Holding a prejudice toward this client. B. Neglecting to include the client's desires in the plan of care. C. Being manipulated by the client. D. Expressing shock when assessing the client's history.

B: The client should use sunscreen while receiving Depo-Provera for birth control. Depo-Provera is either administered via intramuscular (150mg) or subcutaneous (Depo-SubQ Provera, 104mg) injection every 3 months. The medication is contraindicated for use by women who have breast cancer or who are pregnant. It is not contraindicated for use by those suffering from lung or esophageal cancer. There is no need to use another contraceptive method. The client should know, however, that Depo-Provera will not protect her from sexually transmitted infections.

The nurse is administering Depo-Provera (medroxyprogesterone acetate) to a postpartum client. Which of the following data must the nurse consider before administering the medication? A. Replace patch at the same time each week. B. The client must taught to use sunscreen whenever in the sunlight. C. The medicine is contraindicated if the woman has lung or esophageal cancer. D. The client must use an alternate form of birth control for the first two months.

A: The normal serum calcium level is 8.5 to 10.5mg/dL. A serum calcium level lower than 8.5mg/dL indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes

A, B, D, C, E: Without a breach in defenses, such as with injury to the skin, the other actions do not occur. Inflammatory mediators are released from damaged tissue and stimulate vasodilation. The cellular phase begins within less than an hour after the injury and is marked by movement of leukocytes into the damaged tissues. The leukocytes need to move to the area before phagocytosis occurs. Particulate matter, bacteria, damaged cells, and inflammatory exudate must be removed by phagocytosis in order for reconstruction to occur.

The nurse is caring for a client who has suffered an injury in which the skin is broken. In what order does the nurse anticipate assessing the occurrence of the following pathophysiological responses? Place the options in order. A. Breach in the barrier of defense B. Vasodilation of the arterioles and venules C. Phagocytosis D. Margination and emigration of leukocytes into the damaged tissue E. Reconstruction

C: Hyponatremia is evidenced by a serum sodium level lower than 135mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is caring for a client who is reviving high doses of a diuretic. ON assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

C: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

The nurse is caring for a client. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss B. Flat neck veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)

A: Hyponatremia is evidenced by a serum sodium level less than 135mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

The nurse is caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? A. The client who is taking diuretics B. The client with hyperaldosteronism C. The client with Cushing's syndrome D. The client who is taking corticosteroids

A: Type 1 diabetes mellitus requires lifelong exogenous replacement of insulin, because no insulin is produced from beta cells of the pancreas. Insulin therapy is not short-term, nor is insulin therapy required because oral drugs are merely less effective than injections. The pancreas will not be able to resume production of insulin.

The nurse is discussing the treatment regimen for a client newly diagnosed with type 1 diabetes mellitus. While discussing insulin administration, the client asks, "Why can't I just take a pill like my friend does?" Which follow-up client statement indicates the client understands the nurse's explanation? A. "Because my body does not produce insulin, I must receive the injections." B. "I will be on insulin for a short while, and then I can take the pills." C. "The pills are not as effective as the insulin injections." D. "When my body starts making insulin again, I can stop taking the injections."

C. By the 12th week of gestation, the uterus should have increased in size to be palpable at the symphysis pubis. Factors affecting this finding include abnormal fetal growth or the presence of multiple gestation.

The nurse is examining a client who is at 12 weeks' gestation. The examiner would expect to find the fundus at which location at this time? A. 3 cm below the sternum B. The level of the umbilicus C. The level of the symphysis pubis D. 3cm below the umbilicus

D: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Options A, B, and C are incorrect.

The nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder? A. "I take oral insulin instead of shots." B. "By taking these medications, I am able to eat more." C. "When I become ill, I need to increase the number of pills I take." D. "The medications I'm taking help release the insulin I already make."

A: Motion receptors can be stimulated with instillation of large amounts of fluid. Nausea or vomiting can result and relief will occur if the irrigation procedure is stopped. If the irrigant did not return, the nurse should reposition the head. If the cerumen becomes softer, it indicates partial success of the procedure and the irrigation should continue. A temporary reduction in the hearing is expected during the procedure in the affected ear and is not a cause for concern.

The nurse is irrigating the ears of an older adult man with a cerumen impaction. At which point would the nurse stop the procedure? A. If the client becomes nauseated B. If the irrigating fluid does not return C. If the cerumen becomes softer D. If the client says he can't hear well

A: Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur hypoglycemia. Options B, C, and D are not signs of hyperglycemia.

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? A. Polyuria B. Diaphoresis C. Hypertension D. Increased pulse rate

D: The level of pain tolerance is exceeded. The present pain must be relieved and the client assured that future pain also will be controlled. Option A is not the statement of greatest concern. Non-pharmacological measures to relieve pain, such as imagery and self-hypnosis, use the mind-body (psyche-soma) connection to reduce pain. The nurse should encourage the use of these measures and validate the energy expended. The concern of addiction is not the priority among these statements. The nurse can respond to this common concern through education and judicious medication administration. Option C is desirable because it keeps pain under control before it becomes excessive.

The nurse is performing an admitting interview. Which client statement about pain causes the most concern? A. "I try to pretend that it is not part of me, but it takes a lot of effort." B. "My pain medication works, but I'm afraid of becoming addicted." C. "At home I take something for pain before it gets too bad." D. "They say my pain may get worse, and I can't stand it now."

B: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options A, C, and D are not related specifically to the subject of the question.

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places highest priority on which client problem? A. Lack of knowledge B. Inadequate fluid volume C. Compromised family coping D. Inadequate consumption of nutrients

A,C,D,B,E: Anything other than water will interfere with the absorption of alendronate. It must be given on an empty stomach with a full glass of water. This should be the first step because the drug cannot be given if the client has already eaten or had fluids other than water. Alendronate is contraindicated if the client has a history of reflux disease, hiatal hernia, or esophagitis. This should be done before the medication is prepared. After determining that the drug can be administered, the drug should be prepared using three checks. The client must be upright to take the dose and remain in this position for 30 minutes following ingestion of the pill, as it can cause esophagitits. After positioning the client in an upright position, the medication must be administered with at least 8 ounces of water.

The nurse is preparing to administer alendronate to a client with osteoporosis, secondary to hypercalcemia. Place the interventions in the correct order in which the nurse should perform them. A. Ensure that the client did not eat or drink any fluids except water. B. Place client in an upright position. C. Determine if the client has a history of GERD or any condition predisposing the client to esophageal reflux. D.Prepare the correct dose of the medication. E. Instruct the client to drink a full glass of water with the medication.

B: The normal serum potassium level is 3.5mEq/L to 5.0mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires nasogatric suction C. Has a history of Addison's disease D. Is taking a potassium-retaining diuretic

B: Each dose of sulfamethoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfamethoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the HCP.

The nurse is providing discharge instructions to a client receiving sulfamethoxazole. Which instruction should be included in the list? A. Restrict fluid intake. B. Maintain a high fluid intake. C. If the urine turns dark brown, call the health care provider immediately. D. Decrease the dosage when symptoms are improving to prevent an allergic response.

A: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse is reading the health care provider's progress notes in the client's record and reads "insensible fluid loss of approximately 800mL daily." The nurse interprets that this type of fluid loss can occur through which route? A. The skin B. Urinary output C. Wound drainage D. The gastrointestinal (GI) tract

D: The normal serum sodium level is 135 to 145mEq/L. A serum sodium level of 150mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150mEq/L. The nurse reports the serum sodium level to the health care provider and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? A. Peas B. Nuts C. Cauliflower D. Processed oat cereals

A: Meiosis I occurs during puberty. At the completion of oogenesis only 1 ovum is created. At the completion of spermatogenesis, 4 sperm are created. Each ovum contains the haploid number of chromosomes. Sperm have flagella that propel them through the woman's reproductive system. Ova, however, do not have the ability to propel themselves, but rather are propelled externally by the cilia in the fallopian tubes.

The nurse is teaching a class on reproduction. When asked about the development of the ova, the nurse would include which of the following? A. Meiotic divisions begin during puberty. B. At the end of meiosis, four ova are created. C. Each ovum contains the diploid number of chromosomes. D. Like sperm, ova have the ability to propel themselves.

A: When preparing a mixture of short-acting insulin such as regular insulin with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options B, C, and D identify correct actions for preparing NPH and short-acting insulin.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? A. Withdraws the NPH insulin first. B. Withdraws the regular insulin first. C. Injects air into NPH insulin vial first. D. Injects an amount of air equal to the desired dose of insulin into each vial.

B, C, E: Shakiness, palpitations, and lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are signs of hyperglycemia.

The nurse is teaching a client with diabetes about signs of hypoglycemia. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. A. Polyuria B. Shakiness C. Palpitations D. Blurred vision E. Lightheadedness F. Fruity breath odor

B, C, D, F: The normal potassium level is 3.5 to 5.0mEq/L. Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. A. Peas B. Raisins C. Potatoes D. Cantaloupe E. Cauliflower F. Strawberries

A: A serum potassium level lower than 3.5mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic (ECG) changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms.

The nurse review a client's electrolyte laboratory report and notes that the potassium level is 2.5mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value? A. U wave B. Absent P waves C. Elevated T waves D. Elevated ST segment

D: A serum potassium level greater than 5.1mEq/L indicates hyperkalemia. Electrocardiographic (ECG) changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value? A. ST depression B. Inverted T wave C. Prominent U wave D. Tall peaked T wave

A,E: Hydrochlorothiazide (HCTZ) and furosemide are diuretics that increase the excretion of potassium, so clients should be taught to increase the intake of potassium in their diet. All of the other medications are considered potassium-sparing or combination diuretics and, as such, dietary supplementation would not be indicated.

The nurse should include dietary teaching regarding addition of potassium rich foods if the client is receiving which diuretic? Select all that apply. A. Hydrochlorothiazide B. Spironolactone C. Triamterene with hydrochlorothiazide D. Amiloride E. Furosemide

C: The client with chronic sinusitis should be instructed to take hot showers in the morning and evening to promote drainage of secretions. There is no need to limit caffeine intake. Performing postural drainage will inhibit removal of secretions, not promote it. Clients should elevate the head of the bed to promote drainage. Clients should report all temperatures higher than 100.4F, because a temperature that high can indicate infection

The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis? A. Avoid the use of caffeinated beverages. B. Perform postural drainage every day. C. Take hot showers twice daily. D. Report a temperature of 102F or higher.

A: With severe chloride and ECF losses, the blood pressure drops, potentially leading to shock if not corrected. The nurse should place the highest priority on monitoring the client to prevent development of potential complications and to maintain client safety. Although it may be necessary to assist the client to the bathroom, this is not the priority intervention. If there is sufficient ECF loss, then the client would more likely be too weak to ambulate and bedrest would be indicated. Starting IV therapy with a hypotonic solution may further exacerbate the client's clinical condition. Although it would be important to monitor the client's pulse, this again is not the priority intervention at this point in time.

The nurse should place highest priority on which intervention when caring for a client admitted with symptoms related to a chloride level of 70mEq/L and extracellular fluid (ECF) loss? A. Monitoring blood pressure for decrease in value B. Assisting client to the restroom to prevent injury C. Starting an IV with dextrose in water D. Monitoring pulse for pounding slow rate

B: Transmission of impulses is decreased through magnesium's regulation of acetylcholine in the neuromuscular synapse, producing muscle relaxation. Because magnesium acts to regulate and diminish acetylcholine, neuromuscular transmissions are decreased, not stimulated. Acetylcholine is not involved in vitamin metabolism. Magnesium and acetylcholine are not involved in blood glucose regulation.

The nurse who is teaching a review of basic nutrition is discussing the effects of various electrolytes and minerals in the body. In describing the action of magnesium, the nurse would explain it has which effect because it diminishes acetylcholine? A. Nerve stimulant B. Muscle relaxant C. Vitamin metabolizer D. Stimulant for the release of blood gluocse

D: Because of the anatomic structure of the male urethra and bacteriostatic effect of prostatic fluid, all urinary tract infections (UTIs) in male clients should be considered complicated. UTIs are more likely to be uncomplicated in females. UTIs can occur in adolescent girls who have recently become sexually active due to the irritation of the urethra. A 2-year-old child may develop a UTI due to poor hygiene habits. UTIs develop in elderly clients due to gerontological considerations of the urinary system.

The nurse would consider that a urinary tract infection (UTI) is complicated when it is present in which of the following clients? A. Adolescent girl who has recently become sexually active B. 2-year-old child C. Elderly, bedridden client D. Male client

C: E. coli from the lower GI tract is the infective organism in over 90% of first-time infections due to the proximity of the anus. The nurse should check that the organism is sensitive to the antibiotic or notify the health care provider. Staphylococcus is the second most common pathogen seen in urinary tract infections (UTIs). Klebsiella is less common in UTIs, and streptococcus is not an expected microorganism.

The nurse would expect to see which pathogen on the urine culture and sensitivity (C&S) report of a female client with an uncomplicated urinary tract infection (UTI)? A. Streptococcus B. Staphylococcus C. E. coli D. Klebsiella

B: Quickening usually begins around 16 weeks and results in enhanced attachment as the fetus becomes more real. Anxiety about early-pregnancy changes would be more appropriate for the client in the first trimester. Knowledge Deficit related to labor and delivery is an appropriate diagnosis in the third trimester. Promoting client safety is a nursing action, not a nursing diagnosis.

The nurse would formulate which wellness-oriented nursing diagnosis for a client in the second trimester of pregnancy? A. Anxiety related to lack of understanding about early prenatal physical changes B. Beginning Maternal-Fetal Attachment related to statements about perception of fetal movement C. Promoting Client Safety related to falls prevention D. Knowledge Deficit related to lack of preparation for labor and delivery

B, C, E: Fluids should be increased unless contraindicated by another condition to help flush microorganisms from the urinary system. Because caffeine and alcohol can increase bladder spasms and mucosal irritation, they should be decreased to reduce the signs and symptoms of a urinary tract infection (UTI). Fluids should be increased rather than restricted, and douches will not help a UTI. Antibiotics should be taken completely for the full course of therapy to prevent development of resistant strains of organisms. Cranberry juice may help to acidify the urine, which may inhibit bacterial growth or ability to adhere to bladder mucosa.

The nurse would teach the client who has a urinary tract infection about which helpful self-care measures? Select all that apply. A. Take anti-infective medication until feeling better B. Increasing fluids C. Decreasing caffeine drinks and alcohol D. Douching daily E. Drinking at least two 8-ounce low-sugar cranberry juice servings per day

B: Iron is absorbed best on an empty stomach (not after a full meal) and in the presence of vitamin C. It may or may not be taken at the same time as other vitamin supplementation. It does not replace the need for other vitamins.

The pregnant client has been started on an iron supplement. What information should be included by the nurse as a priority in prenatal teaching about the iron supplement? A. It should be taken 30 minutes after eating a full meal. B. It is better absorbed if taken with a liquid containing vitamin C. C. It will eliminate the need for prenatal vitamins. D. It should be taken at the same time as the prenatal vitamin.

A: An obvious response to pain is not always apparent because psychosocial-cultural factors may dictate behavior. Fear of the treatment for pain, lack of validation, acceptance of pain as punishment for previous behavior, and the need to be strong, courageous, or uncomplaining are factors that influence behavioral responses to pain. Option B - the opposite may be true. As a person experiences relief from pain, the person may be unwilling to endure previously acceptable levels of pain. Option C is not a true statement. Although a generalization, many members of Jewish, Italian, Greek, and Chinese ethnic groups, for example, are able to express pain. Pain tolerance varies widely among people and is influenced by experiential, psychological, and sociocultural factors.

What concept should the nurse consider when assessing a client's pain? A. The expression of pain is not always congruent with the pain experienced. B. Pain medication can significantly increase a client's pain tolerance. C. The majority of cultures value the concept of suffering in silence. D. Most people experience approximately the same pain tolerance

C: Potassium works to maintain cardiac contractility and normal heart rate. Hypokalemia leads to the development of potential arrhythmias that can result in ischemia and death. While the length of bedrest and actual potassium level could be associated with a complaints of dizziness, it is more likely that the dizziness is associated with orthostatic hypotension and inefficient heart pumping action due to hypokalemia. It is important for the client (and family) to understand that electrolyte imbalances may have significant compliance that can affect the entire body.

What is the best response by the nurse to the 22-year-old daughter of a 56-year-old client admitted with hypokalemia and who reports being dizzy upon standing? A. "Your mother has been lying in bed too long and when she stands up she will get dizzy." B. "Once we correct your mother's potassium level, the dizziness should improve." C. "Your mother is probably dizzy because her heart is not pumping as effectively, making her blood pressure low." D. "Your mother is dizzy because her nervous system is not functioning correctly; once her potassium level goes up, she will improve."

D: Pain is a personal experience. Margo McCaffery, a pain researcher, as indicated that pain is whatever the person in pain says it is and exists wherever the person in pain says it exists. Option A may or may not be true. Option B may or may not be true. There may be behavioral signs of pain, such as guarding, grimaces, and clenching the teeth, at the same time that there are no verbal statements indicating the presence of pain. In some cultures it is unacceptable to complain about pain or tolerance of pain signifies strength and courage. Option C is not a true statement. The judicious use of opioids does not necessarily result in addiction. In addition, there are many non-opioid drugs, such as non-steroidal anti-inflammatory drugs, antidepressants, and anticonvulsants, all of which relieve pain.

What is the most important for a nurse to consider when a client reports the presence of pain? A. The extent of pain is directly related to the amount of tissue damage. B. Behavioral adaptations are congruent with statements about pain. C. Administering opioids for pain will eventually lead to addiction. D. The person experiencing the pain is the authority about the pain.

B: Pressure on the vena cava from the gravid uterus may cause a decrease in blood flow to the right atrium and result in a decrease in blood pressure. Dizziness is a symptom of hypotension. The pulse rate could stay the same or increase as the workload of the heart increases during the course of pregnancy. There is an increase in the number of red blood cells to meet physiological demand, can be as much as 18% to 30% depending on amount of iron supplementation and prenatal vitamin intake. Plasma volume increases 50%. (The greater increase in plasma over RBCs results in physiologic anemia and is seen as a 7% decrease in hematocrit). A feeling of fullness in the chest is not a cardiovascular change during pregnancy, although abdominal fullness occurs as the pregnancy progresses.

What would the nurse include when teaching a pregnant client about normal changes in the cardiovascular system during pregnancy? A. Her pulse rate will decrease. B. She may experience dizziness if she lays on her back. C. She will have a decrease in red blood cells. D. She may experience a feeling of fullness in her chest.

C: Pain is a personal experience, and the nurse must validate its presence and severity as perceived by the client. This conveys acceptance and respect and promotes the development of trust. Clients, particularly children and those who are cognitively impaired, often have problems describing the quality of pain because of difficulty interpreting painful stimuli or having never experienced the sensation before. Psychosociocultural factors influence clients' lack of request for medication when experiencing pain. Clients may not request medication because they fear the possibility of addiction, consider the pain as punishment for previous behavior, or need to be strong, courageous, or uncomplaining. Acute pain increases vital signs because of sympathetic nervous system stimulation, but chronic pain will not.

When caring for clients in pain, it is important for the nurse to consider that clients: A. Are able to describe the qualities of their pain B. Who are in pain will request pain medication C. Need to know that the nurse believes what they say about their pain D. Will demonstrate vital signs that are congruent with the intensity of pain

C: Remaining independent is important for older adults. Older adults prefer to make their own decisions and do not appreciate others making decisions for them. Although some older adults cherish a family role, this is not necessarily the wish of every older adult. Excessive protection from injury is unnecessary and inappropriate.

When explaining the needs of older adults to children of aging parents, the nurse would include which element? A. They require help with making important decisions. B. They like an active family role and need to be with grandchildren often. C. They should be supported when feasible in their desire to remain independent. D. They must be protected from injury at all times.

C: Posture changes shift the center of gravity in an older adult client and put the client at risk for falls. Bone and cartilage changes increase the risk of injury if a fall occurs but not the risk of falling.

Which assessment finding in an older adult client should alert the nurse to an increased risk of falls? A. Decreased bone density B. Increased bone prominence C. Kyphotic posture D. Cartilage deterioration

C: An IUD is a long-term method of contraception usually recommended for women who have been pregnant and are in a monogamous relationship so that they are at a low risk for sexually transmitted infections. The clients in the incorrect options have one or more factors that should guide them to select a different contraceptive method.

Which client being seen in the outpatient clinic would be the best candidate for insertion of an intrauterine device (IUD)? A. A client who is married, has one child, and wants to get pregnant in about 6 months. B. A client who is unmarried, has no children, and has numerous sexual partners. C. A client who is married, has two children, and does not want more children for at least 3 years. D. A client who is unmarried, has one child, and has a history of pelvic inflammatory disease (PID)

A, B, D, E: Silence, or long pauses, in communication may indicate many different things. The client may be depressed and struggling to find the energy to talk. Sometimes, pauses indicate the client is thoughtfully considering the question before responding. At times, the client may seem to be "lost in his or her own thoughts." It is important to allow the client sufficient time to respond, even if it seems like a long time. Being unwilling to participate in conversation is not acceptable and must be addressed by the nurse

Which client situations should be viewed by the nurse as an acceptable opportunity to implement the therapeutic use of silence? Select all that apply. A. Experiencing depression B. Lost in his or her own thoughts C. Demonstrating resistance D. Constructing his or her response E. Pondering the question

D: Thin and clear cervical mucus indicates a rising level of estrogen and impending ovulation. Stretchability of the cervical mucus, or spinnbarkeit, is indicative of the fertile period and promotes motility of the sperm. Thick cervical mucus occurs during the infertile period when sexual intercourse is unlikely to result in pregnancy.

Which client statement indicates that teaching about cervical mucus changes as an indicator of ovulation has been understood? A. "If my cervical mucus is yellowish and thick, I am probably fertile." B. "The thin, clear mucus will block sperm from getting to my cervix." C. "If my cervical mucus is thick and white, I will need to avoid intercourse or use a backup method of contraception." D. "If my cervical mucus is thin and stretchable, I am probably fertile."

A; Ecchymoses are not the result of aging and should be investigated to determine whether the client is sustaining injury or taking anticoagulant therapy. Cherry hemangiomas do not require further investigation as to cause. Tenting of the skin is a normal, age- related change in an older adult. Nevi on the neck and forehead are not significant age-related findings.

Which clinical manifestation would be most significant and require further investigation when assessing the skin of an 85-year-old client? A. Ecchymoses on both forearms B. Cherry hemangiomas across the anterior and posterior trunk C. Tenting of the skin on the back of the hands D. Nevi on the neck and forehead

D: Interrupting the flow of urine assists the external urethra to contract and strengthens pelvic floor muscles. Coughing and bearing down will worsen urinary incontinence. Observing and percussing for bladder fullness after voiding are assessments, not interventions.

Which instruction, if included by the nurse in the care plan for an older adult who has "leaking urine," would be most effective in strengthening pelvic muscles? A. When coughing, bear down in the standing position. B. Percuss the lower abdomen for dull sounds, indicating a distended bladder. C. Observe for bladder fullness immediately after voiding. D. Stop the stream of urine during the middle of urination.

A: Because of loss of skin receptors, the older adult has an increased threshold to pain, touch, and temperature. When feeding or bathing, remember that the older adult may be unable to distinguish hot or cold or to determine the intensity of heat. The older adult may feel less pain than younger adults and report only pressure or a minor sensation. The older adult, however, is the only one who can identify whether he or she has pain. An older client's sensory perception is less acute than that of younger adults, so when giving a massage, less pressure is needed. Everyone, and especially the older adult, needs touch.

Which nursing intervention would be most appropriate to meet safety needs when caring for an older adult with sensory changes? A. Assist in preparing a bath because the client may be less able to feel intensity of heat. B. Use care when administering an injection because older adults experience more pain. C. Massage with additional pressure because tactile perception of older adults is diminished. D. Use minimal touch with an older adult because touch will feel uncomfortable.

B: The client's plasma is hypertonic (very concentrated) to begin with and thus serum osmolality, BUN, and hematocrit would be elevated from hemoconcentration. Once isotonic fluids are administered, the plasma concentration should decrease and all three laboratory test results should show a corresponding decrease. BUN and serum osmolality should not remain increased. An increase in all three parameters would be expected in a client who has not yet been treated for hypertonic dehydration. A decrease in hematocrit should occur with the administration of isotonic fluid therapy.

Which of the following changes in laboratory values would the nurse anticipate after administering isotonic intravenous fluids to a client experiencing hypertonic dehydration? A. Increased serum osmolality, increased BUN, and decreased hematocrit (HCT) B. Decreased serum osmolality, decreased BUN, and decreased HCT C. Increased serum osmolality, increased BUN, and increased HCT D. Decreased serum osmolality, decreased BUN, and increased HCT

A: Because some semen is released before ejaculation, coitus interruptus has an 18% failure rate and would not be considered a very effective method for a couple wanting to avoid pregnancy. An ability to withdraw before ejaculation is necessary for coitus interruptus to be effective, so the client's statement would be consistent with successful use of this method. Not having other sex partners has no effect on choice of coitus interruptus as a contraceptive method. Coitus interruptus has no cost and is completely natural.

Which statement by a client could indicate a potential problem for a couple planning to use coitus interruptus? A. "I really don't want to get pregnant right now, so need a very effective method." B. "I think I can always pull out before I ejaculate." C. "We don't have any other sex partners." D. "We want a contraceptive method that is inexpensive and completely natural."

A: IUDs can remain in place for extended periods of time. The client should expect to menstruate regularly while the IUD is in place. If dyspareunia occurs, the client should contact her health care practitioner. Women who have IUDs in place are at risk of developing pelvic infections.

Which statement by the client indicates that she understands the teaching provided about the intrauterine device (IUD)? A. "The IUD can remain in place for a year or more." B. "I will not menstruate while the IUD is in." C. "Pain during intercourse is a common side effect." D. "The device will reduce my chances of getting infected."

C: Anything that induces or aggravates pain is considered a precipitating factor of pain. For example, precipitating factors may be physical (e.g., exertion associated with activities of daily living, Valsalva manuever), environmental (e.g., extremes in temperature, noise), or emotional (anxiety, fear). Option A are physiological responses, not precipitating factors, associated with the pain experience. Option B is a statement that reflects the pattern (e.g., onset, duration, and intervals) of the pain experience. Option D is a statement that reflects the quality of the pain. Descriptive adjectives, such as knife-like, burning, or cramping explain how the pain feels.

Which statement by the client to a nurse indicates a precipitating factor associated with pain? A. "I usually feel a little dizzy and think I'm going to vomit when I have pain." B. "My pain usually comes and goes throughout the night." C. "I usually have pain after I get dressed in the morning." D. "My pain feels like a knife cutting right through me

C, E: The male condom is placed when the penis is erect, then rolled down. Leaving space at the end of the condom to collect semen can prevent breakage or spillage after ejaculation. Water-based lubricants can be used to provide additional comfort, if needed. Oil- based lubricants are contraindicated.

Which statements indicate to the nurse that a male client understands how to correctly apply a condom? Select all that apply. A. "I need to put it on before the penis is erect." B. "I should unroll the condom, then place it on the penis." C. "When putting on the condom, I need to leave some space at the tip to collect the sperm." D. "I can use oil-based lubricants if needed." E. "I can use a water-based lubricant if needed."

C: According to Maslow's hierarchy of needs, the fourth level involves the need related to esteem needs, which includes the need for self-esteem and respect from others. Hunger and sexual expression are captured within the first level of Maslow's hierarchy of needs. Feeling unsafe indicates the client is functioning on the second level and is focused on security needs.

While assessing a client, the nurse notes the client is functioning at the fourth level according to Maslow's hierarchy of needs. Which observation of the client led the nurse to conclude this? A. The client is extremely hungry. B. The client feels unsafe in the new city. C. The client longs to have validation for success and accomplishments. D. The client wants to be able to disclose the client's sexuality openly.

A: During pregnancy, increased estrogen production results in an increased amount and thickening of vaginal secretions. The uterus grows by cell hypertrophy, not by adding more cells. Red and hard breasts or a cervix dilating during the second semester are not normal findings.

With regard to normal changes in the reproductive system during pregnancy, the nurse should teach the pregnant client about which of the following? A. Vaginal secretions will increase and thicken. B. Uterus will grow by adding many new cells. C. Breasts will become red and hard. D. Cervix will begin to dilate during the second trimester.

A, B, D: Collecting subjective data, vital signs, and functional ability assessment is an essential component of an admission assessment. The development of the care plan and documentation of any education completed are done following the admission assessment.

A new client is admitted to a facility and requires an initial admission assessment. Which should be included in the admission assessment? Select all that apply. A. Collection of subjective data B. Vital signs C. Development of the care plan D. Functional ability assessment E. Documentation of education completed

B. Dyspnea and increased respiration are most likely caused by fluid accumulation in the lungs, both signs of fluid volume excess. The jugular vein distention is also a sign of fluid accumulation related to hypervolemia. The client is exhibiting signs of fluid volume excess, not fluid volume deficit. The client is receiving an isotonic solution, not a hypotonic solution. The client does not show evidence of accumulation in the abdomen related to ascites, but rather in the lungs and jugular veins.

A 78-year-old client is admitted with dehydration and urinary tract infection. After IV infusion of 750mL normal saline, the client begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. How should the nurse interpret this data? A. The fluid volume deficit is worsening. B. Hypervolemia is developing. C. Hypotonic water intoxication is beginning. D. Ascites is causing respiratory compromise

C: According to the Seventh Joint National Committee (JNC 7), a systolic blood pressure of 140 to 159mmHg or a diastolic pressure of 90 to 99mmHg represents stage 1 hypertension. A systolic pressure greater than or equal to 160mmHg or diastolic pressure greater than to equal to 100mmHg represents stage 2 hypertension. A systolic pressure of 120 to 139mmHg or diastolic pressure of 80 to 89mmHg represents prehypertension. A systolic pressure less than 120mmHg and diastolic pressure less than 80mmHg are considered normal

A client has a continuous blood pressure reading of 142/90mmHg. The reading is interpreted as indicative of what? A. Stage 2 hypertension B. Prehypertension C. Stage 1 hypertension D. Normal

C: Guaifenesin is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Extra doses should not be taken. The client should contact the health care provider if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed to decrease the viscosity of secretions. This medication does not have to be taken with meals.

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action? A. Take an extra dose if fever develops. B. Take the medication with meals only. C. Take the tablet with a full glass of water. D. Decrease the amount of daily fluid intake.

C: Ear pain is a primary or classic symptom associated with otitis media. Pus is usually located behind the tympanic membrane and drainage occurs if the membrane ruptures. Loss of balance occurs with Meniere's disease or inner ear disorders. Otitis media is a disorder of the middle ear. Tinnitus occurs with labyrinthitis and other inner ear disorders.

A client has been treated for acute otitis media. To evaluate the effectiveness of therapy, the nurse questions whether the client obtained relief from which primary symptom associated with this disorder? A. Purulent drainage from the ear B. Loss of balance C. Ear pain D. Tinnitus

C: A fluid intake of 2,500 to 3,000 mL is recommended to maintain the moisture of the respiratory mucous membranes. Adequate fluid keeps respiratory secretions thin so that they can be moved by ciliary action or coughed up and expectorated. Deep breathing mobilizes, not liquefies, respiratory secretions. Changing positions will also mobilize, not liquefy, secretions. Mucolytics, not antitussives, liquefy respiratory secretions. Antitussives prevent or relieve coughing.

A client has thick tenacious respiratory secretions. Which should the nurse do to liquefy the client's respiratory secretions? A. Change the client's position every two hours. B. Get a prescription for an antitussive agent. C. Encourage the client to drink more fluid. D. Teach effective deep breathing.

A: A clinical pathway/care plan is a standardized multidisciplinary care plan that projects the client's goals, expected course of the client's treatment, and progress over the client's hospital stay. A client education plan will include the information required for the client to understand the care and treatment related to the surgical procedure but is not a comprehensive plan for this care. A physician-initiated intervention is an individual treatment initiated by a physician related to a medical diagnosis that is then carried out by a nurse. Although discharge planning helps establish client goals and should be started at the time of admission, it will not predict the client's course during the hospital stay.

A client is admitted for heart surgery with an anticipated admission to the coronary care unit (CCU). In preparation for the client's admission to the hospital, which action will best predict the sequence and timing of care and direct the course of the client's hospital stay? A. Implementation of a clinical pathway/care plan B. Initiation of a client education plan C. Implementation of physician-initiated interventions D. Initiation of discharge planning at the time of admission

D: Stage 2 hypertension is identified by a systolic pressure of 160 to 179mmHg or a diastolic pressure more than 100mmHg. Diastolic pressure 80 to 89mmHg reflects prehypertension. Diastolic pressure 90 to 99mmHg reflects stage 1 hypertension. Less than 79mmHg reflects a diastolic blood pressure that is considered within the desirable range.

A client is admitted with stage 2 hypertension. What diastolic pressure does the nurse consider to be consistent with this diagnosis? A. 80 to 89mmHg B. 90 to 99mmHg C. Less than 79mmHg D. More than 100mmHg

A, C, E: Clonidine is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.

A client is taking clonidine for treatment of hypertension. The nurse should teach the client about which of the following common adverse effects of this drug? Select all that apply. A. Dry mouth B. Hyperkalemia C. Impotence D. Pancreatitis E. Sleep disturbance

B: Vaccines are administered to client to promote the development of specific antibodies to afford protection. This is an example of active artificial immunity. Active natural immunity implies that development of antibodies in response to a client who had an actual active infection. Passive natural immunity implies the maternal and/or placental transfer of antibodies. Passive artificial immunity implies the specific injection of an immune serum.

A client receives a polio vaccine during a clinic visit. The nurse explains that this will provide what type of immunity to the client? A. Active natural immunity B. Active artificial immunity C. Passive natural immunity D. Passive artificial immunity

A: Near drowning in saltwater often results in hypernatremia due to the high-sodium level in sea/saltwater. Hyponatremia and disturbances in calcemia are not seen in this clinical situation. Hyponatremia may be seen in fresh water near drowning.

A client was brought to the hospital following a near-drowning experience in the Atlantic Ocean. In providing care to this client, the nurse plans to carefully monitor for which of the following? A. Hypernatremia B. Hyponatremia C. Hypocalcemia D. Hypercalcemia

A, E: The client is exhibiting signs of hypernatremia and dehydration. Appropriate nursing interventions are to measure and record I&O (intake and output) and daily weight. The client is at risk to develop seizures secondary to an elevated sodium level. Administering salt tablets would further contribute to the client's hypernatremic state. Restricting fluid intake and holding feedings could worsen the hypernatremia and fluid volume deficit (hypertonic dehydration) as the client already has extensive fluid loss due to diarrhea, elevated pulse rate, and decreased skin turgor. Avoiding adding additional water would worsen the hypertonic dehydration.

A client with a feeding tube has been experiencing severe watery diarrhea. The client is lethargic with decreased skin turgor, a pulse rate of 110bpm, and hyperactive reflexes. The nurse would include which of the following interventions on the client's plan of care? Select all that apply. A. Monitor and record intake, output, and daily weights B. Administer salt tablets C. Withhold tube feedings until diarrhea subsides D. Avoid adding additional water before and after tube feedings E. Initiate seizure precautions

A, D, E: Activity intolerance in clients with anemia results from the imbalance between oxygen demand and supply. Activities should be planned to intersperse activity with periods of rest to decrease hypoxemic episodes and to decrease tissue demand for oxygen. A client with anemia may experience dizziness if there is insufficient oxygenation of red blood cells supplying the brain, which could then interfere with tolerance of activity. Providing for rest periods aids in energy conservation. Teaching nutrition to a client with anemia is appropriate but does not directly relate to the nursing diagnosis of Activity Intolerance. Promoting range of motion would be helpful for the nursing diagnosis of Impaired Mobility.

A client with anemia has a nursing diagnosis of Activity Intolerance. Which intervention should the nurse implement? Select all that apply. A. Space interventions during the day. B. Teach client the basics of good nutrition. C. Promote active or passive range of motion activities. D. Teach client to change position slowly to prevent dizziness. E. Encourage defined rest periods during the day.

B, C, D, E: The captopril does not lower the heart rate, and may be safely administered to maintain control of the hypertension. The hydrochlorothiazide does not lower the heart rate, and may be safely administered to maintain control of the hypertension. Docusate is a stool softener and may be safely administered to the client. Straining at stool could cause the client to use the Valsalava maneuver, which could temporarily lower the heart rate further. A multivitamin would not adversely affect the client's pulse rate is bradycardic, and metoprolol, a beta-blocker, decreases the heart rate. The dose of this medication should be withheld.

A client with hypertension is being treated with metoprolol, hydrochlorothiazide, and captopril. Other scheduled medications include docusate and a multivitamin. The client's current blood pressure is 124/86mmHg and pulse rate is 48. Which scheduled medications does should the nurse administer? Select all that apply. A. Metoprolol B. Captopril C. Hydrochlorothiazide D. Docusate E. Multivitamin

C: A nurse can implement this immediate, independent action. Nurses are permitted to treat human responses. Raising the head of the bed facilitates the dropping of the abdominal organs by gravity away from the diaphragm, which permits the greatest lung expansion. Notifying the health care provider is premature. The client's needs must be met first. Although encouraging deep breathing might be done eventually, it is not the priority at this time. This may or may not help. Inadequate oxygenation can be caused by a variety of problems other than shallow breathing. Obtaining and setting up the equipment to administer oxygen take time that can be used for the more appropriate intervention first.

A client's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first? A. Notify the primary health care provider. B. Encourage breathing deeply. C. Raise the head of the bed. D. Administer oxygen.

C: A history of an allergic reaction to baker's yeast would be a contraindication to receiving the series of immunizations. Aminoglycoside antibiotics, mold, and egg yolks do not pose any risk to the client for allergy to the vaccine.

A newly adopted 8-year-old child is brought to the pediatric immunization clinic to begin the hepatitis B immunization series. Before providing the immunization, the nurse inquires about any known history of allergy to which item? A. Aminoglycoside antibotics B. Mold C. Baker's yeast D. Egg yolks

C: Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 beats per minute, and one discernable P wave prior to each QRS. Atrial flutter is either a regular or an irregular rhythm with multiple discernable P waves prior to each QRS complex and no measurable PR interval. Normal sinus rhythm is a regular rhythm and a ventricular rate of 60 to 100 beats per minute, and one discernable P wave prior to each QRS. Sinus arrhythmia is an irregular rhythm with a ventricular rate between 60 to 100 beats per minute, and one discernable P wave prior to each QRS, but the RR interval is irregular.

A nurse admits a client to a telemetry unit and obtains the following electrocardiogram (ECG) strip of the client's heart rhythm. What should be the nurse's interpretation of this rhythm strip? A. Atrial flutter B. Normal sinus rhythm C. Sinus bradycardia D. Sinus arrhythmia

C,D: A state's NPA serves to protect the public by setting minimum qualifications for nursing in relation to skills and competencies. One way it fulfills responsibility to protect the public is by defining the scope of nursing practice in that state. The state board of nursing approves schools to operate but does not accredit them. The state board of nursing does not enforce ethical standards. A state NPA has no role in setting liability insurance rates for nurse.

A nurse and teacher are discussing legal issues related to the practice of their professions. The teacher asks what the functions are of the Nurse Practice Act (NPA) in that state. The nurse would include which thoughts in a response? Select all that apply. A. Accreditation of schools of nursing. B. Enforcing ethical standards of behavior. C. Protecting the public. D. Defining the scope of nursing practice. E. Determining liability insurance rates.

B: An earlobe is an excellent site to monitor pulse oximetry. It is least affected by decreased blood flow, has greater accuracy at lower saturations, and rarely is edematous. This site is used for intermittent, not continuous monitoring. The use of a toe for pulse oximetry can result in inaccurate results because of concurrent problems, such as vasoconstriction, hypothermia, impaired peripheral circulation, and movement of the foot. Soap and water will not resolve edema. In addition, attaching a pulse oximeter clip sensor to an edematous finger is contraindicated because interstitial fluid interferes with obtaining an accurate oxygen saturation level. The cause of edema must be identified first because range-of-motion exercises may be contraindicated.

A nurse identifies that a client's hands are edematous when attempting to apply a pulse oximetry probe. Which action should the nurse implement? A. Attach the probe to one of the client's toes. B. Connect the probe to one of the client's earlobes. C. Wash the client's hand before attaching the probe to the finger. D. Encourage the client to perform active range-of-motion exercises of the hand.

A: Client problems/needs can be ranked in order of ascending importance according to how essential they are for survival using Maslow's Hierarchy of Needs as a framework. Maslow identifies five levels of human needs. A person must meet lower-level needs before addressing higher-level needs. Physiological needs are first-level needs: air, food, water, sleep, shelter, etc.; safety and security needs are second; love and belonging needs are third; self-esteem needs are fourth; and self-actualization is the fifth-level need

A nurse is analyzing information about a client. Which of the following does Maslow's Hierarchy of Needs theory help the nurse to identify? A. Client's problem that has top priority B. Developmental level of the client C. Coping patterns of the client D. Client's health beliefs

B: A non-rebreather mask is the only device that can deliver FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse utilize? A. Venturi mask B. Non-rebreather mask C. Nasal cannula D. Simple mask

B, C, E: Applying direct lateral pressure to the nose for 10 minutes may help to stop a nosebleed. Increases in anxiety and blood pressure may increase the bleeding. Therefore the nurse should reassure the client. Packing the client's nares with gauze and nasal tampons may also help because tampons contain an agent that promotes blood clotting. Positioning the client horizontally may not stop the bleeding. Blowing the nose may dislodge the clots and prolong the bleeding.

A nurse is caring for a client with a nosebleed originating from the anterior aspect of the nose. Which nursing interventions would help the client? Select all that apply. A. Positioning the client horizontally without a pillow. B. Applying direct pressure to the nose for 10 minutes. C. Reducing anxiety and blood pressure by providing reassurance to the client. D. Instructing the client to blow his or her nose to remove the blood. E. Loosely packing the client's nares with gauze or nasal tampons.

A, E, B, D, C: Administering 2 liters of oxygen via a nasal cannula - meeting basic physiological needs (e.g., patent airway, nutrition, elimination) are first-level needs according to Maslow. Arranging the call bell within easy reach after a client is transferred to a chair - promoting a feeling of safety and security addresses second-level needs according to Maslow. Encouraging a family member to visit as often as desired - maintaining support systems provides for love and belonging needs, third-level needs according to Maslow. Asking a client about personal preferences before beginning care - promoting self-control supports self-esteem needs, fourth-level needs according to Maslow. Arranging for a minister to visit when requested by a client - meeting spiritual needs relates to self- actualization, the highest-level need according to Maslow.

A nurse is caring for a variety of clients on a medical unit in the hospital. In which order should the nurse perform the following actions using Maslow's Hierarchy of Needs as a basis for prioritizing care? A. Administering two liters of oxygen via nasal cannula. B. Encouraging a family member to visit as often as desired. C. Arranging for a minister to visit when when requested by the client. D. Asking a client about personal preferences before beginning care. E. Placing the call bell within easy reach after a client is transferred to a chair.

D: Wrinkles exert pressure and friction against the skin, promoting the formation of pressure ulcers. A draw sheet is an additional sheet that can add to the number of wrinkles; the purpose of a draw sheet is to keep the bottom sheet clean and to aid in moving the client up in bed. A toe pleat should be placed in the top sheet and bed spread, not the bottom sheet. A toe pleat prevents footdrop and breakdown to the tips of toes. The bottom sheet does not have to be changed every day unless the sheet is wet or soiled, it is good practice to change the linens daily when giving the client a bed bath

A nurse is changing the linens for a client on bed rest. What should the nurse do to prevent pressure ulcers when putting a bottom sheet on a bed? A. Cover it with a draw sheet. B. Make it with a toe pleat. C. Change it every day. D. Keep it wrinkle free.

A: Anemia is defined as a decreased number of erythrocytes (red blood cells). Leukopenia is a decreased number of leukocytes (white blood cells - WBCs). Thrombocytopenia is a decreased number of platelets. Lastly, granulocytopenia is a decreased number of granulocytes (a type of WBC).

A nurse is reviewing the laboratory results of a client with anemia and anticipates which lab value would be decreased? A. Erythrocytes B. Granulocytes C. Leukocytes D. Platelets

B: Clients may be tempted to smoke if they visit the places where they started smoking. Listing the reasons to stop smoking may help the client to prevent smoking. Removing ashtrays and lighters from the environment may help the client to prevent smoking. When the client is tempted to smoke, sugarless mints and gum may act as good substitutes for tobacco smoking.

A nurse is teaching a client about self-management techniques for smoking cessation. Which statement made by the client indicates the need for further teaching? A. "I should list the reasons why I should stop smoking." B. "I should visit all the places where I started smoking." C. "I should remove all ashtrays and lighters." D. "I should try replacing tobacco with sugarless gum and mints."

A: Agency policy should be followed for correcting a documentation error. Common policies include drawing a single line through the entry, dating and initialing the entry, then adding the correct information. Writing void in the space above the entry is sometimes included in agency policy. While agency policy may include circling the error, option B does not include entering the correct vital signs. If medical records are copied for any reason, the highlighted information may not show up as being highlighted. Writing over (covering) an existing entry is not permitted because of the implication of covering up an error or mistake.

A nurse makes a documentation error by documenting the wrong vital signs (VS) in a client's written medical record. Which procedure should the nurse follow to correct the error? A. Draw a line through the error, initial and date the line, and then document a corrected entry. B. Circle the error and note above the error that it was an incorrect entry, and then date and initial the entry. C. Use a highlighter to highlight the error, write the correct VS above the entry, and date and initial the line. D. Cover the incorrect VS with the correct VS in such a manner that these are clearly readable.

B: To stay current with evidence-based practice after completing a nursing program, nurses must participate in ongoing education. EBP changes rapidly, and advances in health care have a strong influence on nursing practice. The other options are all reasons to attend, but the most compelling is for professional growth.

A nurse notices a posting on a bulletin board for a continuing education (CE) offering on the prevention of pressure ulcers. Which is the most compelling reason for the nurse to attend? A. The unit has experienced an increase in pressure ulcers. B. The nurse wants continuing education in order to keep up with current clinical knowledge. C. The nurse needs one more CE unit for state license renewal. D. The nurse is able to attend by coming in 1 hour earlier for the next scheduled shift.

A, B, D, E: The general survey is the first component of the health assessment, beginning at the moment contact is made with the client. Information from the general survey provides clues to the overall health of the client. It includes observing the client's overall physical appearance, body structure, mobility, and behavior; and measuring vital signs, height, weight, and waist circumference; and calculating the client's body mass index (BMI). In a general survey, the client's abdomen is not percussed. Laboratory tests are not considered to be components of the general survey.

A nurse performs a general survey on a client who is being admitted to the health care facility. Which of the following will the nurse include in this type of assessment? Select all that apply. A. Vital signs B. Gait C. Laboratory tests D. Behavior E. Body mass index (BMI) F. Percussion of abdomen

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A pregnant woman tells the nurse that she has a family history of sickle cell anemia and is afraid her baby will be born with the disease. The nurse would provide which information during a discussion with this client? A. Sickle cell anemia is a male disease and would be passed on through the man's family. B. Genetic testing will be needed to determine if her fetus is affected. C. Both mother and father must carry the defective gene for the child to have sickle cell anemia. D. The child only needs one parent to be a carrier in order for the child with sickle cell anemia.

D: Agitated, confused clients generally tolerate a nasal cannula better than a face mask. A nasal cannula is less intrusive than a mask. Masks are oppressive and may cause a client to feel claustrophobic. Tightening the strap around the head is unsafe because it can compress the capillaries under the strap, which may interfere with tissue perfusion and result in pressure ulcers and skin breakdown. Reapply the mask every time the client pulls it off may increase the client's agitation and it is impractical. Providing an explanation of why the oxygen in necessary will probably be ineffective because an agitated client often does not understand cause and effect

A primary health care provider's order reads, "6 L oxygen via face mask." The client, who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls of the mask. Which should the nurse do? A. Tighten the strap around the head. B. Reapply the mask every time the client pulls it off. C. Provide an explanation of why the oxygen is necessary. D. Request that the order for oxygen be changed to a nasal cannula.

A: After a tonsillectomy and adenoidectomy, drooling bright red blood is considered an early sign of hemorrhage. Often, because of discomfort in the throat, children tend to avoid swallowing; instead, they drool. Frequent swallowing would also be an indication of hemorrhage because the child attempts to clear the airway of blood by swallowing. Secretions may be slightly blood-tinged because of a small amount of oozing after surgery. However, bright red secretions indicate bleeding. A pulse rate of 95 beats per minute is within the normal range for a 5-year-old child, as is the blood pressure of 95/56mmHg. A small amount of blood that is partially digested, and therefore dark brown, is often present in post-operative emesis

After a tonsillectomy and adenoidectomy, which of the following findings should alert the nurse to suspect early hemorrhage in a 5-year-old child? A. Drooling of bright red secretions. B. Pulse rate of 95 beats per minute. C. Vomiting of 25mL of dark brown emesis. D. Blood pressure of 95/56mmHg.

C: Obstructive sleep apnea (OSA) is a condition in which the client may feel tired upon waking in the morning and may feel sleepy during the daytime. These clients may also snore heavily while sleeping. Smoking and enlarged tonsils increase the risk of sleep apnea. Laryngeal trauma occurs secondary to a crushing or direct blow injury, fracture, or prolonged endotracheal intubation. Vocal cord paralysis occurs in clients with neurologic disorders or with conditions that damage either the vagus nerve of the laryngeal nerves. Strep throat is an infection of the tonsils and may be a causative factor of enlarged tonsils.

An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? A. Laryngeal trauma B. Vocal cord paralysis C. Obstructive sleep apnea D. Strep throat

B: The first stage of ethical decision-making is to collect, analyze, and interpret the data. The spouse may not have enough information about pain and pain management. Education may provide the information to assist him in making a decision without compromising his cultural beliefs. Administering the analgesic without the spouse present would be unethical. It would violate the Laotian culture. Not treating the pain would also be unethical. Promoting comfort is a nursing responsibility. Reporting to the supervisor may result in an action to relieve pain, although it would cause delay

In the Laotian culture, pain may be severe before relief is requested. Traditionally, the oldest male makes health care decisions and may answer questions for female clients. A nurse is caring for a female Laotian client who is in severe pain, rating an 8 on a scale of 0 to 10. Her spouse will not allow the nurse to give any analgesics (pain medication). What is the nurse's best course of action? A. Administer the analgesic when the client's spouse leaves the room. B. Educate the client's spouse on the reason for the pain medication and action of analgesics. C. Respect the Laotian culture and do not administer the analgesic. D. Report the issue to the supervisor.

C, D, B, A, E: Assessment, the first step of the nursing process, involves collecting, verifying, and documenting client information/data; this includes information such as vital signs and physical assessments. Analysis, the second step of the nursing process, involves clustering and analyzing data and arriving at conclusions about the significance of the data. It also involves the identification of nursing diagnoses. Planning, the third step of the nursing process, involves setting goals, objectives, and expected outcomes. In addition, priorities of care are identified and interventions are planned to meet the goals, objectives, and expected outcomes. Implementation, the fourth step of the nursing process, involves the actual delivery of nursing care. It includes activities such as executing the proposed plan of care, performing dependent and independent interventions, reacting to life- threatening/adverse responses, and communicating with or teaching clients. Evaluation, the fifth step of the nursing process, involves identifying client responses to care, comparing actual client outcomes to expected outcomes, determining factors that affected outcomes, and modifying the plan of care if necessary

Place the following nursing activities in the order in which they should be performed when progressing through the nursing process. A. Changing a sterile dressing. B. Formulating a short-term goal. C. Obtaining a client's vital signs. D. Concluding a client is dehydrated. E. Identifying a need to modify the plan of care.

D: The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinjie fibers.

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? A. SA node to bundle of His to AV node to Purkinjie fibers B. SA node to AV node to Purkinjie fibers to bundle of His C. SA node to bundle of His to Purkinjie fibers to AV node D. SA node to AV node to bundle of His to Purkinjie fibers

B: The client should be placed in a private room or in a room with the client with an active infection caused by the same organism and no other infections. A mask is not necessary for contact precautions. The N95 respirator is not necessary for contact precautions. Negative air-pressure rooms are included in airborne precautions and are not necessary for contact precautions.

The client is admitted with a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which precaution should be implemented to prevent spreading the infection to health care workers and other clients? A. Wearing a mask within 3 feet of the client B. Placing the client in a private room C. Wearing a N95 respirator mask D. Ensuring a negative air-pressure room

A: Gloves should be donned by the nurse upon entry into the room of the client requiring contact precautions.

The client is placed on contact precautions. When should the nurse caring for the client plan to put on disposable examination gloves? A. As soon as the nurse enters the client's room B. Only if anticipating contact with the client's wound C. Only if anticipating contact with blood or body fluids D. Only if providing care within 3 feet of the client

C: Ferritin levels reflect the available iron stores in the body and are specific to iron-deficiency anemia. A level less than 10ng/ml is diagnostic of iron-deficiency anemia. As the condition improves, ferritin levels rise. In iron deficiency, the body cannot synthesize Hgb, but Hgb levels drop fairly late in the development of iron-deficiency anemia. Other nutrient deficiencies and medical conditions can affect Hgb levels. Serum folate is specific to folate-deficiency, and not iron-deficiency, anemia. Vitamin B12 deficiency is one cause of anemia and may be associated with iron deficiency, but a rise in Vitamin B12 levels does not indicate that the iron-deficiency anemia is resolved.

The client with early-stage iron-deficiency anemia is on a high-iron diet. An increase in the level of which specific serum laboratory test should indicate to the nurse that the diet has been effective? A. Hemoglobin B. Folate C. Ferritin D. Vitamin B12

A: Pilocarpine hydrochloride is a cholinergic agent used to treat glaucoma. It causes miosis (pupillary constriction), which then increases the angle of the channel in the anterior chamber of the eye. This improves the outflow of aqueous humor. Vision is limited in dimly lit environments, not improved due to pupillary constriction from pilocarpine. When the pupil is constricted, less light reaches the retina to stimulate optic nerve function in sending impulses to the brain. Pilocarpine does not increase production of aqueous humor; and it causes pupillary constriction, not dilation.

The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes four times per day. The nurse knows that this medication has which expected action? A. Increases the outflow of aqueous humor B. Improves vision in dimly lit environments C. Increases production of aqueous humor D. Increases ability of both pupils to dilate

C, D: Difficulty seeing in dimly lit environments is from the slow breakdown of the outer layer of retina and the formation of drusen within the macula. The macula is the area of central vision. With macular degeneration there is the loss or distortion of central vision. A curtain appearance over the vision is associated with retinal detachment. Peripheral vision deficits result from progressive glaucoma. A cataract is the clouding of the

The client with macular degeneration is told the condition is progressing to an advanced stage. Which findings should the nurse expect when completing the assessment? Select all that apply. A. Curtain appearance over part of the visual field. B. Loss of peripheral vision in the affected eye. C. Difficulty seeing in dimly lit environments. D. Visual distortions in the central vision. E. Clouding of the lens in both eyes.

C: Being African American is a known risk factor for hypertension. Starting to have the BP taken more often demonstrates awareness of having a risk factor for hypertension. A BMI of 25 or higher is considered a risk factor for hypertension. A BMI of 23 is normal. A BP of 118/70 is within normal range for an adult. Excessive alcohol intake is a risk factor for hypertension; consuming two glasses of wine daily increases the risk for hypertension. Having frequent colds and taking the influenza vaccine does not increase the risk for hypertension. Medications for treating colds, if taken frequently, can increase the risk for hypertension.

The client's BP is being taken at a screening clinic. Which client statement to the nurse demonstrates awareness of having a risk factor for hypertension? A. "My doctor told me my body mass index (BMI) is 23 and my blood pressue is 118/70." B. "I usually have a glass of wine to unwind when I come home from work." C. "I plan to get my blood pressure checked more often, as I am African American." D. "I have colds during the winter, so I plan to get the influenza vaccine every year."

C: The Snellen chart is used to test distance vision. The numbers recorded indicate that at 20 feet (the first number) the client is able to read what a person with normal vision can read at another distance (second number). The left eye's vision recorded as 20/30 has better vision that the right eye with vision recorded as 20/40. The Snellen chart is not used to measure intraocular pressure. There is no information suggesting that the client needs glaucoma testing. The Snellen chart alone is not used to determine astigmatism, an abnormal curvatures of the cornea. Testing for astigmatism

The client's eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye and 20/30 in the left eye. How should the nurse interpret these results? A. The client has elevated intraocular pressure in both eyes. B. The client needs testing for glaucoma with a tonometer. C. The left eye is closer to normal vision than the right eye. D. The client has errors of refraction indicating astigmatism.

D: The WBC count is elevated, suggesting an infection. Clients with a respiratory tract infection may have lung sounds that include crackles, rhonchi, or wheezes. An infection would increase the respiratory rate. The normal appearance of a healing incision is pink and crusty. It should be intact. Dark amber urine may indicate that the client is dehydrated. Dehydration can result from an infection if the temperature is elevated, but this is not the finding that should be most associated with the elevated WBC.

The client's total WBC count is 20,000/mm3 two days after surgery. Which assessment finding should the nurse most associate with this laboratory result? A. Respiratory rate slow and shallow B. Skin incision pink, crusty, and intact C. Dark amber urine per urinary catheter D. Diminished lung sounds with crackles

C, D: At age 32, the client is in the middle adult stage of life. The repeated discussions about death and reflections back on life are not appropriate or expected for this stage of development and should be investigated further. An interest in civic responsibilities and the establishment of hobbies is expected. During this developmental period, the greatest concern typically relates to establishing gainful employment and significant relationships. This is being demonstrated by the client's willingness to discuss family, which includes spouse and children

The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitis who will be receiving home service IV therapy for the next month. The client is 32 years old and happily married. Which of the following findings will warrant further investigation? Select all that apply. A. The client reports many hobbies and interests outside the home. B. The client voices concern about recovering quickly and returning to work in the next month. C. The client talks repeatedly about death. D. The client spends a great deal of time reflecting back on teen years. E. The client is talkative about the spouse and children.

A, B, C, E: The nurse should provide the current Vaccine Information Statement (VIS) to parents for each vaccine the child will receive, as required by the National Vaccine Injury Act of 1986 and 1993. The sheet will include information about the specific vaccine, side effects, how to manage them, and when to seek further care (such as with allergic reaction or anaphylaxis). Aspirin is contraindicated due to the risk of Reye syndrome but acetaminophen is acceptable for use as needed for discomfort.

The mother of a 15-month-old child is anxious about the immunizations her child is about to receive. What information should the nurse provide to the parents about immunizations? Select all that apply. A. Possible localized reactions to injection sites B. Administration of acetaminophen as needed after vaccine administration C. Informed consent or refusal form signed per parent D. Administration of aspirin every four hours post-vaccine administration E. Symptoms of anaphylaxis reaction with immediate access to emergency care

C, D, E: The experienced nurse should recommend having the client lean forward during auscultation because this position brings the heart closer to the chest wall and accentuates sounds from the aortic and pulmonic areas. The experienced nurse should recommend feeling the pulse beat and listening at the same time because it helps to focus on the rhythm and sounds, and aids in filtering extraneous stimuli. The experienced nurse should recommend a left side-lying position during auscultation of heart sounds; this brings the heart closer to the chest wall and accentuates sounds produced at the mitral valve. Heart sounds are more difficult to auscultate through clothing; auscultate under the gown. Auscultating from the right side, not the left, allows stretching of the stethoscope across the chest and reduces interference from the tubing.

The new nurse is experiencing difficulty hearing the client's heart sounds during auscultation and consults an experienced nurse. Which techniques should the experienced nurse recommend to identify the heart sounds correctly? Select all that apply. A. Auscultate over the client's gown B. Auscultate from the left side of the client C. Ask the client to sit and lean forward D. Feel the radial pulse while listening to heart sounds E. Turn the client to the left side-lying position

B, C, E, F: The saturated dressing represents a risk for contamination since microorganisms can move through the moist environment through the dressing to the wound and back. Recommendations for IV tubing changes are every 72 to 96 hours. If the date of the tubing change is unknown, it represents a potential infection risk. Opened packages of dressing are considered contaminated and should not be used for dressing changes. Although figs have special meaning to someone who is Muslim, uncovered food items can harbor microorganisms. This finding requires the immediate attention of the nurse. The nurse should discuss the food items with the client. Open bottles of solutions for wound care are considered aseptic and suitable for use with wound care for about 24 hours. Care equipment, especially items contaminated with body fluids, should be labeled and used for just one client.

The nurse assesses the hospitalized client and surveys the client's room. The client is Muslim. Which findings require the nurse's immediate attention to remove possible sources of infection? Select all that apply. A. A capped bottle of saline solution with a label stating that it was opened 10 hours ago. B. The abdominal dressing is saturated and seeping through to the client's gown and bed. C. An infusing intravenous (IV) tubing has no notation of the date when it was last changed. D. A container located in the bathroom that is labeled urine and has the client's initials. E. Opened packages of gauze sponges and abdominal pads sitting on the window sill. F. An uncovered cup of figs on the bedside table brought by a family member last evening.

D, E: Patching the eye for the first 24 hours reduces irritation and promotes resting of the eye for optimal healing. Rubbing the affected eye or eye patch may cause the healing abrasion to become reinjured. Some eye discomfort is expected with a corneal abrasion, but the client's pain should gradually diminish as the abrasion heals. The eye is usually covered to protect it and reduce irritation from blinking. It is recommended to allow more than 10 to 15 seconds between drops for more complete absorbance.

The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply. A. "I should promptly report a sudden absence of pain." B. "I should keep my affected eye uncovered when up." C. "I should insert the eye drops 10 to 15 seconds apart." D. "I should leave the eye patch in place for 24 hours." E. "I will avoid rubbing my affected eye or the eye patch."

D: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? A. Slow deep respirations B. Rapid deep respirations C. Paradoxical respirations D. Pain with inspiration

46mmHg. Pulse pressure is the difference between systolic and diastolic pressure

The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure is 122/76mmHg, what is the client's pulse pressure?

A: As sodium levels decrease, fluid shifts in the brain can lead to cerebral edema and seizures. Clients should be assessed for headaches, lethargy, decreased responsiveness, and seizure activity. Hyponatremia will also cause weakness and fatigue, and the client needs to conserve energy, but neurological status is of highest priority. Energy conservation is important with fatigue, but is not the greatest concern at this time. Oral and skin care are routine aspects of care.

The nurse is caring for a client who is experiencing a steady decline in sodium level. The nurse places highest priority on which of the following interventions? A. Close monitoring of neurological status B. Preventing weakness and fatigue C. Spacing activities to conserve energy D. Providing oral hygiene and skin care

C: The nurse should contact the health care provider and secure an ophthalmological evaluation promptly. Flushing the eye and applying a pressure bandage may cause further injury and delay treatment. These actions will delay securing treatment. Blurred vision will not stop until the detachment is addressed.

The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first? A. Flush the eye thoroughly with saline solution and apply a pressure bandage. B. Apply an eye shield to the affected eye and give a prescribed oral analgesic. C. Notify the health care provider; prepare for transport to a facility for ophthalmological care. D. Patch both eyes and place the client in a prone position until blurring stops.

D, A, C, B, E: The client is first positioned in a manner that allows easy access and visualization of the ear. Starting with the ear to be treated upward decreases the amount of movement required by the client. After positioning the client, the nurse cleans the pinna and meatus of the ear. Cleaning prior to administering the mediation decreases the risk of flushing an external infection or debris to the inside of the auditory canal. The pinna is then pulled up and back in order to straighten the ear canal. The medication is administered. Pressure is applied to the tragus to assist the flow of medication into the ear canal.

The nurse is demonstrating to a client how to administer ear drops. Place the steps of the procedure in the proper order. A. Clean the pinna of the ear and the meatus of the ear canal. B. Administer the ear drops. C. Pull the pinna upward and backward. D. Position the client with the ear being treated uppermost. E. Press gently but firmly a few times on the tragus of the ear.

B: Characteristics of normal sinus rhythm include the presence of uniform P waves preceding each QRS complex, a heart rate between 60 and 100 beats per minute, and regular rhythm. This is not sinus tachycardia because the heart rate is below 100; not first-degree block because the PR interval is 0.20 seconds, which is in the normal range, and not sinus bradycardia because the heart rate is above 60 beats per minute.

The nurse is evaluating the following telemetry strip from one of her clients. Which of the following would the nurse document? A. Sinus tachycardia with a heart rate of 86 to 100 beats per minute. B. Normal sinus rhythm with a heart rate of about 80 beats per minute. C. First-degree heart block with a heart rate of about 70 beats per minute. D. Sinus bradycardia with a heart rate of about 60-70 beats per minute.

A: processed and canned foods (tuna, soup, tomato juice) and sodas are high in sodium. Fresh foods (grilled chicken, fruits, and vegetables) are lower in sodium.

The nurse is helping a client who was recently placed on a low-sodium diet to reduce fluid retention to choose foods for lunch. The nurse recommends which lunch menu that would be most beneficial for this client? A. Grilled chicken sandwich on white bread, apple salad, and iced tea B. Tuna salad sandwich on wheat bread, canned fruit cocktail, salad and a soda C. Ham and bean soup, fresh fruit salad, low-sodium crackers, and a diet soda D. Cheeseburger, grapes, fresh pineapple, and tomato juice

A: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

The nurse is informed while receiving report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? A. Confusion B. Decreased blood pressure C. Decreased respiratory rate D. Hyperactivity

B: Since Meniere's disease is a condition of the ear, the nurse would plan to include the otolaryngologist. The rheumatologist treats arthritic and immune conditions. The physical therapist focuses on exercises and care for physical rehabilitation. The oncologist treats clients with cancer.

The nurse is planning the care of the client with Meniere's disease. With which member of the interdisciplinary team should the nurse expect a consultation? A. Rheumatologist B. Otolaryngologist C. Physical therapist D. Oncologist

D: Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 and 30 degrees. Increased pressure can't be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowler's position, the veins would be barely discernible above the clavicle.

The nurse is preparing to assess a client for jugular vein distention. How should the nurse position the head of the client's bed? A. High Fowler's B. Supine C. Raised 10 degrees D. Raised 30 degrees

B: Aplastic anemia is a pathology of bone marrow dysfunction. Red blood cells, white blood cells, and platelets are decreased.

The nurse is reviewing a client's complete blood count and notes a decreased number of erythrocytes, leukocytes, and platelets. The nurse interprets this as indicative of what condition? A. Pernicious anemia B. Aplastic anemia C. Sickle cell anemia D. Polycythemia

A, F: Sickle cell anemia is one of a group of diseases termed hemoglobinopathies. In which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. A. Restrict fluid intake. B. Position for comfort. C. Avoid strain on painful joints. D. Apply nasal oxygen at 2L/minute. E. Provide a high-calorie, high-protein diet. F. Give meperidine, 25mg IV every 4 hours for pain.

D: Elderly people are most at risk for developing anemia, often due to financial concerns affecting protein intake or poor dentition that interferes with chewing meat.

The nurse is reviewing client's charts. Select the client who would be most at risk for developing anemia. A. A 2-year-old in day care. B. A 22-year-old college student. C. A 55-year-old neighbor. D. A 80-year-old nursing home resident.

A: The anticholinergic and antihistamine properties of meclizine treat the symptom of vertigo. Megestrol, an antineoplastic agent, is used to treat advanced breast cancer. The antibiotic meropenem treats intra-abdominal infections. The beta blocker metoprolol is used in treatment of hypertension and heart disease.

The nurse is reviewing the medication list of the client with Meniere's disease. Which medication was likely prescribed for treating the client's vertigo? A. Meclizine B. Megestrol C. Meropenem D. Metoprolol

B: A MAP of less than 60mmHgHg indicates that there is inadequate perfusion to organs. The MAP is calculated by the sum of the SBP + 2DBP and then dividing by 3. Thus the MAP of 98/36mmHg is (98 + 72)/3 = 170/3 = 56.7. The MAP of 94/60 is 71.3. The MAP of 110/50 is 70. The MAP of 140/78 is 98.7.

The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the health care provider because the client's MAP is abnormal? A. 94/60mmHg B. 98/36mmHg C. 110/50mmHg D. 140/78mmHg

C: Glaucoma is a chronic progressive disease; annual eye examinations should be completed by an eye specialist physician. Fluid restriction is not an effective treatment modality for open-angle glaucoma. Consuming foods high in omega-3 fatty acids will not affect intraocular pressure. Elevated intraocular pressure cannot be felt; timolol maleate is a nonselective beta-adrenergic receptor blocking agent (beta blockers) and should be used as prescribed.

The nurse is teaching the client with open-angle glaucoma. Which instruction should the nurse include? A. Limit oral fluid intake to 1000mL daily. B. Eat foods that are high in omega-3 fatty acids. C. Have annual eye exams with an eye specialist. D. Use timolol maleate eye drops when feeling eye pressure.

C: Hand washing with soap and water is the most effective way of removing potentially infectious material. Bleeding will help flush the wound, and pressure should not be applied to stop bleeding. Bleach should be used on contaminated objects but not on the skin. It damages tissues. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs.

The nurse is using contact precautions to change the soiled bed sheet of the client with Clostridium difficile. In the process, the nurse's right glove and skin on a finger is torn. After removing the soiled gloves, which action is priority? A. Hold pressure to stop any bleeding. B. Use a bleach wipe to clean the hands. C. Wash the hands with soap and water. D. Cleanse hands using alcohol-based hand rub.

C: Closed-angle glaucoma causes an increased, not normal, intraocular pressure. This documentation finding should be questioned. In closed-angle glaucoma the flow of aqueous is blocked when the iris moves against the cornea (closed angle). The sudden rise in intraocular pressure causes eye pain. Reduced central visual acuity is caused from the obstruction of aqueous outflow. The sudden rise in intraocular pressure and vision changes contribute to nausea and vomiting

The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the health care provider? A. Sudden onset of eye pain B. Reduced central visual acuity C. Normal intraocular pressure D. Nausea and vomiting

A: Although there is reduced vision with beginning cataract development, a person can wait until vision worsens before having surgery. When vision is reduced to the extent that ADLs are affected, surgery should be performed as soon as possible. If both eyes have cataracts, usually the eyes are treated in separate procedures. Surgery for a cataract involves removal of the client's lens. Although in most situations the client's lens is replaced with an intraocular lens at the time of surgery, other options include postoperative contact lenses or aphakic glasses.

The nurse speaks with the client who recently learned that cataracts are developing in both of client's eyes. Which statement made by the client should the nurse correct? A. "It is important that I schedule my surgery as soon as possible." B. "Usually surgery is performed on each eye at different times." C. "My own lens will be removed when I have cataract surgery." D. "An intraocular lens may be inserted with the surgical procedure."

D: Sneezing allows transmission by droplet contact. By sneezing into the bend of the elbow the "method of transmission" link is interrupted.

The nurse teaches a client to sneeze into the bend of the elbow. Which link in the chain of infection does this help interrupt? A. Etiologic agent B. Reservoir C. Portal of exit from reservoir D. Method of transmission E. Portal of entry to the susceptible host F. Susceptible host

D: A significant reduction in vision may indicate a complication such as infection or retinal detachment. Pain relieved by prescribed pain medication is within normal assessment parameters. Decreasing redness is within normal assessment parameters. No swelling is within normal assessment parameters

The nurse telephones the client 1 day post-cataract surgery. Which client statement necessitates an evaluation by an ophthalmologist? A. "My eye starts hurting about 4 hours after a pain pill." B. "The redness in my eye is a little less than yesterday." C."There has never been any swelling around my eye." D. "I can't see as well as I could yesterday after surgery."

B, E: Fever is objective because it can be measured with a thermometer. Hypertension (increased blood pressure) can be measured with a sphygmomanometer and therefore is objective information. Pain, nausea, and fatigue are subjective, based on a client's feelings, perceptions, sensations, or ideas

What are examples of objective data collected during a nursing history and physical examination of a newly admitted client? Select all that apply. A. Pain B. Fever C. Nausea D. Fatigue E. Hypertension

A, B: The consistency of the RR intervals indicates a regular rhythm. A normal P wave before each complex indicates the impulse originated in the sinoatrial (SA) node. Elevation of the ST segment is a sign of cardiac ischemia and unrelated to the rhythm. The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100 beats per minute. Fewer than 6 complexes per 6 seconds equals a heart rate less than 60 beats per minute. The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 seconds.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. A. The RR intervals are relatively consistent. B. One P wave precedes each QRS complex. C. The ST segment is higher than the PR interval. D. Four to eight complexes in a 6-second strip. E. The QRS complexes range from 0.12 to 0.2 seconds.

A: The NCLEX-RN examination is designed to identify whether a candidate has met a minimum level of performance to safely practice as a licensed registered nurse. State boards of nursing, the National League for Nursing Accrediting Commission, and the American Association of Colleges of Nursing accredit schools of nursing. Controlling nursing education is not the purpose of NCLEX- RN. A degree or diploma, not NCLEX-RN verifies that the student has met the criteria for graduation form the granting institution

What is the purpose of the National Council Licensure Examination for Registered Nurses (NCLEX-RN)? A. Identifying minimal safe practice. B. Accredit schools of nursing. C. Control nursing education. D. Verify graduation.

B, E: A bed bath supports the client's physiological need to be clean and is related to the first level, physiological needs, in Maslow's Hierarchy of Needs. Elimination is a basic physiological need according to Maslow. Basic needs relate to food, air, water, elimination, rest, sex, physical activity, temperature regulation, and cleanliness. Raising the side rails relates to the client's need for safety and security, the second level in Maslow's Hierarchy of Needs. Conversing with a client relates to the need for love and belonging, the third level in Maslow's Hierarchy of Needs. Explaining procedures relates to the client's need for safety and security; clients have a right to know what is happening to them and why.

What should the nurse do to meet a client's basic physiological needs? Select all that apply. A. Raise the side rails. B. Provide a bed bath. C. Converse with the client. D. Explain procedures to the client. E. Ambulate the client to the bathroom.

D: Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? A. Wear support hose continuously. B. Lie down for 30 minutes after taking medication. C. Avoid tasks that require high-energy expenditure. D. Sit on the edge of the bed for 5 minutes before standing.

A, D: A mild fever can be treated safely and effectively with acetaminophen. Sometimes children act as if they do not feel well because of mild discomfort after receiving immunizations. The immunizations are not given together, they are separated into multiple injections. The physician does not need to be called unless the fever is high. Itching or rash are of concern because they could indicate hypersensitivity, and needs to be addressed rather than treated at home.

What should the nurse tell a mother whose child is receiving the immunizations required at 1 year of age? Select all that apply. A. "You can give your child acetaminophen if he develops a mild fever." B. "We give all these immunizations at the same time because they are more effective if given together." C. "If your child develops a mild fever, you need to call the physician." D. "You can expect your child to not feel well for a couple of days." E. "Some children develop itching or a rash after immunizations are given. This can be treated at home with an antihistamine."

A: Dysrhythmias are abnormal and are associated with acute or chronic pathologic conditions. An equal apical and radial pulse is expected; the radial pulse reflects ventricular contractions. The expected range in adults is 60 to 100 beats per minute. An apical rate obtainable at the fifth intercostal space and midclavicular line are the anatomical landmarks for locating the apex of the heart; they are unaffected by aging.

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process? A. A pulse rate irregularity B. Equal apical and radial pulse rates C. A pulse rate of 60 beats per minute D. An apical rate obtainable at the fifth intercostal space and midclavicular line

D: Communicating important assessment data to other health-care team members is a component of the assessment phase of the nursing process. Planning involves setting goals, establishing priorities, identifying expected outcomes, identifying interventions designed to achieve goals and outcomes, ensuring that the client's health-care needs are met appropriately, modifying the plan as necessary, and collaborating with other health-care team members to ensure that care is coordinated. Planning does not include the communication of data collected during assessment. Analysis involves interpretation of data, collection of additional data, and identification and communication of nursing diagnoses. Analysis does not include the communication of data collected during the assessment phase of the nursing process. Evaluation involves identifying a client's response to care, comparing a client's actual responses with the expected outcomes, analyzing factors that affected the actual outcomes for the purpose of drawing conclusions about the success or failure of specific nursing activities, and modifying the plan of care when necessary; evaluation does not include the communication of data collected during the assessment phase.

When obtaining a health history, the nurse identifies that a client has gained 10 pounds in the past week. Which step of the nursing process is performed when the nurse documents this information in the client's clinical record? A. Planning B. Analysis C. Evaluation D. Assessment

A, C: Ambulation of a client requires a health care provider's order. Client activity (e.g., bed rest, out of bed to chair, out of bed) is a dependent function of a nurse. Dependent activities of the nurse are those activities that require a health-care provider's order; changing a sterile dressing requires a health-care provider's order. Documenting nursing care is an independent function of the nurse and does not require a health-care provider's order. In an emergency, the nurse may administer oxygen to a client experiencing acute shortness of breath until a health-care provider's order is obtained. Selecting among choices of foods offered within a diet is an interdependent function; however, the type of diet is a dependent function.

Which activities are dependent functions of the nurse? Select all that apply A. Ambulating a client down the hall B. Documenting perioperative nursing care C. Changing a sterile dressing that is soiled D. Providing oxygen for acute shortness of breath E. Assisting with selection of choice on the menu

A, B, D: The normal findings of a chest examination include a midline trachea, pink-colored nasal mucosa, and nonlabored respirations of 14 breaths per minute. The nasal septum should be straight; a deviated nasal septum is an abnormal finding. The anteroposterior diameter should be less than the side-to-side or transverse diameter by a ratio of (1:2).

Which assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply. A. A midline trachea B. Pink nasal mucosa C. Deviated nasal septum D. Nonlabored respirations of 14 breaths per minute E. Anteroposterior to lateral chest diameter (2:1)

A: Every individual is influenced by family, ethnic, and cultural beliefs and values. These beliefs and values influence a person's lifestyle through how one perceives, experiences, and copes with health, illness, and disability. The nurse must assess the impact of these influences on the patient's health and health practice.

Which concept about health do nurses need to appreciate? A. Perceptions of health vary among cultures. B. To be considered healthy a person needs to be productive. C. There must be an absence of illness for a person to be considered healthy. D. Underlying consensus exists among theorists about the definition of health.

C: Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis (rhinosinusitis). Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.

Which disorder would the nurse state is related to the tonsils? A. Rhinitis B. Sinusitis C. Pharyngitis D. Pneumonia

D: Only malpractice is misconduct performed in professional practice, where there is a contractual relationship between the client and the nurse that results in harm to the client. There is a violation of standards of care with both negligence and malpractice. Negligence and malpractice both involve acts of either commission or omission. The client must have sustained injury, damage, or harm with both negligence and malpractice.

Which factor is unique to malpractice when comparing negligence and malpractice? A. The action did not meet the standards of care. B. The inappropriate act is an act of commission. C. There is harm to the client as a result of the care. D. There is a contractual relationship between the nurse and the client.

B, E: Subjective data is collected directly from the client. During the focused respiratory assessment, the nurse should ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse though physical examination and laboratory reports. The nurse should palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.

Which interventions should the nurse perform while collecting subjective data from a client during a focused respiratory assessment? Select all that apply. A. Palpate the chest and back for masses B. Question the client about shortness of breath C. Check the hematocrit and hemoglobin values D. Inspect the skin and nails for integrity and color E. Ask the client about color and quantity of sputum

A: The National Council of State Boards of Nursing is responsible for the NCLEX examinations; however, the licensing authority in the jurisdiction in which the graduate takes the examination verifies the acceptable score on the examination. The American Nurses Association (ANA) is the national professional organization for nursing in the United States. IT fosters high standards of nursing practice; it does not grant licensure. Sigma Theta Tau International, Honor Society of Nursing, recognizes academic achievement and leadership qualities, encourages high professional standards, fosters creative endeavors, and supports excellence in the profession of nursing. This organization does not grant licensure. The National League for Nursing (NLN) is committed to promoting and improving nursing service and nursing education; it does not grant licensure

Which organization is responsible for ensuring that Registered Nurses are minimally qualified to practice nursing? A. State Boards of Nursing B. American Nurses Association C. Sigma Theta Tau International D. Constituent Leagues of the National League of Nursing

A: adventitious breath sounds are abnormal breath sounds that occur when pleural linings are inflamed or when air passes through narrowed airways or through airways filled with fluid. The absence of abnormal sounds is desirable. To expectorate secretions, coughing must be productive, not non-productive. A non-productive cough is dry, which means that no respiratory secretions are raised and spat out (expectorated) because of coughing. Drinking fluid is an intervention that will liquefy respiratory secretions, thus facilitating their expectoration. However, just drinking fluid will not ensure that the secretions will be expectorated. Although spitting out sputum reflects achievement of the goal in relation to expectorating lung secretions, it does not address the absence of respiratory complications, which is the ultimate goal of decreasing stasis of respiratory secretions

Which outcome best reflects achievement of the goal, "The client will expectorate lung secretions with no signs of respiratory complications"? A. Absence of adventitious breath sounds B. Deep breathing and coughing non-productively C. Drinking 3,000mL of fluid in the last 24 hours D. Expectorating sputum three times between 1500 and 2300.

B: Humidification of the oxygen prevents drying of the client's nasal passages. Oxygen does not cause a burning sensation, but it is combustible. Oxygen does not produce a chemical reaction with the tubing and is not contaminated by environmental gases.

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 3 liters of oxygen by nasal cannula? A. Prevents the burning sensation of direct oxygen on the nares. B. Prevents drying of the nasal passages. C. Prevents a chemical reaction between the tubing and oxygen. D. Prevents contamination with environmental gases.

C, D: The combination of high fever and severe dehydration leads to insensible water loss. This indicates a loss of pure water and does not contain electrolytes. Therefore, excessive amounts of insensible water loss result in a hypertonic dehydration that leads to a state of hypernatremia and hyperchloremia. Calcium levels usually decrease in the presence of dehydration and fever. Phosphate levels usually increase in the presence of dehydration and fever. Potassium levels can usually remain normal in the serum and are increased in the urine. Sodium and chloride usually go hand-in-hand.

Which serum electrolyte imbalances would the nurse assess for in a child admitted with a high fever and severe dehydration? Select all that apply. A. Hypercalcemia B. Hypokalemia C. Hypernatremia D. Hyperchloremia E. Hypophosphatemia

B: There was a significant change in both blood pressure and heart rate with position change. This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for an increase in heart rate of 5 to 20bpm, a possible slight decrease of less than 5mmHg in the systolic blood pressure, and a possible slight increase of less than 5mmHg in the diastolic blood pressure.

Which set of postural vital signs indicate inadequate blood volume (i.e. dehydration)? A. Supine 124/76mmHg, 88bpm Sitting 124/74mmHg, 92bpm Standing 122/74mmHg, 92bpm B. Supine 120/70mmHg, 70bpm Sitting 102/64mmHg, 86bpm Standing 100/60mmHg, 92bpm C. Supine 138/86mmHg, 74bpm Sitting 136/84mmHg, 80bpm Standing 134/82mmHg, 82bpm D. Supine 100/70mmHg, 72bpm Sitting 100/68mmHg, 74bpm Standing 98/68mmHg, 80bpm

C: Early signs of hypoxia are restlessness, agitation, and irritability resulting from reduced oxygen to brain cells. A partial or completely obstructed airway prevents the passage of gases into and out of the lungs. The ABCs (Airway, Breathing, Circulation) of emergency care identify airway as the priority. Administering oxygen may or may not be necessary. The need for oxygen administration will depend on the results of other interventions that should be done first. Suctioning the oropharynx is premature. Mucus or sputum may not be the cause of the problem. Reducing environmental stimuli will serve no purpose at this time and is not the priority.

Which should the nurse do first when caring for a non-verbal client who is restless, agitated, and irritable? A. Suction the oropharynx B. Reduce environmental stimuli C. Determine patency of the airway D. Administer oxygen

A: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume is the additional air that can be forcefully inhaled after normal inhalation. Expiratory reserve volume is the additional air that can be forcefully exhaled after normal exhalation.

Which statement appropriately describes tidal volume? A. It is the volume of air inhaled and exhaled with each breath. B. It is the amount of air remaining in the lungs after forced expiration. C. It is the additional air that can be forcefully inhaled after normal inhalation. D. It is the additional air that can be forcefully exhaled after normal exhalation.

C: Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricuspid valve abnormalities are heard at the third and fourth intercostal spaces along the sternal border.

While assessing a client's heart sounds, the nurse auscultates a murmur at the second left intercostal space along the left sternal border. Which valve is most likely involved? A. Aortic B. Mitral C. Pulmonic D. Tricuspid