NU270 Week 5 PrepU: Nursing Process

The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated? science of nursing art of nursing conduction of research quality improvement

science of nursing The science of nursing is the knowledge base for the care provided by the nurse. In this example, the nurse is using this knowledge base to decide how best to care for the client by giving or not giving the blood pressure medication. The art of nursing is the application of the knowledge. In this example, it would be demonstrated by the nurse actually giving or holding the medication. Quality improvement activities and the conduction of research influence the science and the art of nursing by helping build the body of knowledge that is the science of nursing.

The nurse is conducting a health history when a middle-aged client states that her last menstrual period was 6 months ago. Upon further questioning, the client also states that symptoms of hot flashes and mood fluctuations. Which question should the nurse ask next? "When was your first menstrual period?" "Do you feel like hurting yourself?" "Are you finished having children?" "Are you taking any hormone replacement therapy?"

"Are you taking any hormone replacement therapy?" To ensure a thorough health history, a client who exhibits symptoms of perimenopause should be assessed for the use of hormone replacement therapy to alleviate the symptoms. This information adds to the data reported by the client. Asking if the client feels like hurting herself may be extreme with the report of mood fluctuations. Asking if the client is finished having children produces little additional data. Asking the first menstrual period is part of the health history but not the best question to ask after the client's statement.

An adult client with a history of worsening respiratory symptoms has presented for care. Which assessment question will best allow the clinician to address the possibility of chronic bronchitis? "Do you have a family history of lung disease?" "Have you ever been immunized against pneumococcal pneumonia?" "Do you tend to have a cough even when you don't feel sick?" "Do you know if you had respiratory syncytial virus as a child?"

"Do you tend to have a cough even when you don't feel sick?" A clinical diagnosis of chronic bronchitis requires the history of a chronic productive cough for at least 3 consecutive months over 2 consecutive years. This is not noted to be a strong genetic component of the disease, and childhood RSV is not a risk factor. Immunization status is normally linked to the development of bronchitis.

For a client with an acute pulmonary embolism, the physician orders heparin 25,000 units in 500 ml of dextrose 5% in water (D5W) at 1,100 units/hour. The nurse should administer how many milliliters per hour? 8 22 30 50

22 The nurse should administer 22 ml/hour. To determine the number of units per milliliter: 25,000 units of heparin divided by 50 units/ml equals 500 ml of fluid. Because each milliliter of D5W contains 50 units of heparin and the nurse must deliver 1,100 units/hour, perform this calculation to determine the milliliters per hour of I.V. solution flow: 1,100 units/hour ÷ 50 units/ml = 22 ml/hour.

The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? 500 mL 400 mL 600 mL 300 mL

300 mL An indicator of renal hypoperfusion is a urinary output of less than 30 mL/hr. An output of 300 mL in 12 hours is less than 30 mL/hr, which is indicative of oliguria. Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 316. Chapter 14: Shock and Multiple Organ Dysfunction Syndrome - Page 316

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? A weak and thready pulse A slow but steady pulse A rapid, bounding pulse A slow and imperceptible pulse

A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular. Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 14: Shock and Multiple Organ Dysfunction Syndrome, p. 315. Chapter 14: Shock and Multiple Organ Dysfunction Syndrome - Page 315

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? Administering the analgesics intravenously Administering the analgesics on an as-needed per client request Administering analgesics with increased dosage Administering the analgesics on a regular basis

Administering the analgesics on a regular basis Routine scheduling of the administration of analgesics, rather than on an as-needed basis, often affords a uniform level of pain relief. Administering the analgesics intravenously or with increased dosage is not advisable unless prescribed by the physician.

A nurse is reviewing a female client's history, which includes the following information:Age at menarche: 14 yearsCesarean delivery: 2 pregnanciesAge at first pregnancy: 35 years. Alcohol use: approximately 1 to 2 glasses of wine/monthThe nurse identifies which as a possible risk factor for the client to develop breast cancer? Cesarean deliveries Age at first pregnancy Age at menarche Alcohol use

Age at first pregnancy Risk factors for breast cancer include an early menarche (before 12 years), nulliparity, late age at first full-term pregnancy, and an alcohol intake of 2 to 5 drinks daily. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 58: Assessment and Management of Patients With Breast Disorders, Table 58-3, p. 1731. Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1731

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Administer a prescribed medication to decrease the client's blood glucose level. Analyze the data and create an individualized nursing diagnosis. Follow up with the client later to determine whether the client's laboratory test results improve. Identify outcomes for the client with the client's input.

Analyze the data and create an individualized nursing diagnosis. The second part of the nursing process is the analysis of data that can help determine nursing diagnoses. Because the nurse has the assessment findings of polydipsia, polyphagia, polyuria, and an increased HgbA1C level, the nurse can analyze these findings to help to determine the most appropriate nursing diagnosis. Once the nursing diagnosis is determined, then the nurse, with input from the client, can identify outcomes and interventions, such as medication administration, implement the interventions and evaluate them.

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action? Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax Asking the client to say "one, two, three" while the nurse auscultates the lungs Instructing the client to take a deep breath and hold it while the diaphragm is percussed Placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax While the nurse is assessing for tactile fremitus, the client is asked to repeat "ninety-nine" or "one, two, three," or "eee, eee, eee" as the nurse's hands move down the client's thorax. Vibrations are detected with the palmar surfaces of the fingers and hands, or the ulnar aspect of the extended hands, on the thorax. The hand(s) are moved in sequence down the thorax, and corresponding areas of the thorax are compared. Asking the client to say "one, two, three" while auscultating the lungs is not the proper technique to assess for tactile fremitus. The nurse assesses for anterior respiratory excursion by placing the thumbs along the costal margin of the chest wall and instructing the client to inhale deeply. The nurse assesses for diaphragmatic excursion by instructing the client to take a deep breath and hold it while the diaphragm is percussed.

You are working on a transplant unit and you know to carefully monitor your clients. What is the rationale for closely monitoring clients taking immunosuppressive drugs? Because of an increased risk of skin and hair problems Because of an increased risk of respiratory or urinary system infection Because of an increased risk of heart failure Because of an increased risk of blood-related complications

Because of an increased risk of respiratory or urinary system infection After organ transplantation, the client's immune system may attack the new organ's cells because it recognizes them as 'nonself.' Therefore, drugs are used to intentionally suppress the immune system. For example, azathioprine (Imuran), cyclosporine (Sandimmune), and muromonab-CD3 (Orthoclone OKT3) are immunosuppressive drugs. The nurse should follow agency guidelines for controlling infectious diseases or protecting the client who is immunosuppressed. The nurse should observe such clients for signs and symptoms of infection such as fever, sore throat, productive cough, and dysuria. Immunosuppressive drugs do not cause skin or hair problems or any blood-related complications. Heart failure, infusion reactions, and life-threatening infections are associated with taking infliximab.

The nurse is monitoring a child who has been receiving long-term therapy with systemic corticosteroids. Which would be most important for the nurse to assess? Cognitive development Rectal bleeding Epistaxis Growth pattern

Growth pattern Long-term systemic corticosteroid therapy in children can increase the child's risk for growth retardation; therefore, this would be most important to assess. Rectal bleeding can occur with corticosteroids administered via a retention enema. Epistaxis can occur with the use of intranasal corticosteroids. Cognitive development is not generally impacted by corticosteroid therapy.

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? Physician's orders Client's goals Length of required treatment Invasiveness of the treatment

Client's goals When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs. Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? Imbalanced nutrition: Less than body requirements Deficient fluid volume Impaired urinary elimination Excess fluid volume

Deficient fluid volume Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

A client has been treated with abacavir for the past 6 weeks. The client contacts the physician's office with reports of diarrhea, abdominal pain, sore throat, cough, and shortness of breath. Which is the appropriate action to take for this situation? Discontinue the therapy and then reintroduce it. Discontinue the therapy. Reduce the dose. Administer the drug at bedtime.

Discontinue the therapy. Hypersensitivity is a common adverse effect of abacavir that usually appears within 6 weeks of beginning therapy. Abacavir treatment should be discontinued if any signs of hypersensitivity occur. Reintroducing the drug after a hypersensitivity reaction may result in fatal hypotension and is therefore not advised. Reducing the dose and administration of the drug at bedtime will not minimize this adverse effect.

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? Continue taking the vital signs. Place the client in a secluded room until calm. Distract the client with a familiar object or music. Document the inability to assess vital signs due to client's agitation.

Distract the client with a familiar object or music. The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.

The nurse is caring for the client following surgery for a urinary diversion. The client refuses to look at the stoma or participate in its care. The nurse formulates a nursing diagnosis of: Deficient knowledge: stoma care Situational low self esteem Disturbed body image Anticipatory grieving

Disturbed body image The client is exhibiting defining characteristics of disturbed body image. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 55: Management of Patients With Urinary Disorders, Improving Body Image, p. 1645. Chapter 55: Management of Patients With Urinary Disorders - Page 1645

What would be the priority nursing diagnosis for a patient who is prescribed epoetin alfa? Impaired tissue oxygenation related to anemia Alteration in nutrition due to poor intake of iron Altered skin integrity due to the disease process Alteration in bowel elimination due to side effects of the medication

Impaired tissue oxygenation related to anemia The most appropriate priority nursing diagnosis is impaired tissue oxygenation related to anemia. The other diagnoses are not specific to the reason that epoetin is prescribed or the specific side effects of the medication.

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following? Demonstrates recovery of speech Receives adequate nutrition and hydration Shows increasing mobility Maintains effective respirations and airway clearance

Maintains effective respirations and airway clearance All outcomes are appropriate for this client, but airway/respiratory status is always the priority. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies, Medical Management, p. 2083. Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2083

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? Pleurisy Bacterial pneumonia Bronchogenic carcinoma A lung infection

Pleurisy Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration. Some patients describe the pain as being "stabbed by a knife." Chest pain associated with the other conditions may be dull, aching, and persistent. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 20: Assessment of Respiratory Function, Chest Pain, p. 490. Chapter 20: Assessment of Respiratory Function - Page 490

In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care? Delayed growth and development related to physical restrictions Risk for injury related to seizure activity Risk for acute pain related to surgical procedure Ineffective airway clearance related to history of seizures

Risk for injury related to seizure activity The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client? SpO2 at 90% with fine crackles in the lung bases Pain of 3 out of 10, 1 hour after analgesic administration Urine output of 35 to 40 mL/hour Blood tinged drainage in Jackson-Pratt drainage tube

SpO2 at 90% with fine crackles in the lung bases The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period. Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018.

A client has a nursing diagnosis of "Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client? The client will demonstrate an interest in eating during the evening snack. The client will demonstrate an ability to feed himself with a spoon at the morning meal. The client will have a staff member open all packages prior to all meals. The client will not lose any weight throughout the hospital stay.

The client will demonstrate an ability to feed himself with a spoon at the morning meal. Outcomes are expressed in terms of client behavior and have a time period in which they are to be achieved. The outcome is associated with the nursing diagnosis. In this case, the diagnosis reflects a self-feeding problem caused by weakness. Therefore, being able to feed oneself would be a client behavior the nurse would expect to see achieved.

A client is scheduled for a diagnostic test to measure blood hormone levels. The nurse expects that this test will determine which of the following? The concentration of a substance in plasma Details about the size of the organ and its location The functioning of endocrine glands The client's blood sugar level

The functioning of endocrine glands Measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma. The measurement of blood hormone levels will not reveal a client's blood sugar level. Radiographs of the chest or abdomen determine the size of the organ and its location.

The postoperative patient's plan of care contains an intervention to ambulate twice a day 200 feet with assistance of one member of the healthcare team. The intervention was not completed one morning due to his pain. Which of the following would be the appropriate way to document the missed event? The patient was in too much pain to complete the morning ambulation. The patient complained of too much pain to ambulate and was returned to bed. The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order. The patient was assisted to standing but reported severe pain and begged to return to bed. Patient was assisted to bed. The intervention was not completed due to patients severe pain level.

The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order. This is the correctly stated evaluation because it indicates that goal was not met, with specific documentation providing what happened, patient's response, and what follow-up was done.

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention Change the transparent dressing every 3 days. Wear a face mask during dressing changes. Assess the PICC insertion site daily. Use clean gloves when providing site care.

Wear a face mask during dressing changes. The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? Wheezes Pleural friction rub Crackles Rhonchi

Wheezes Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 20: Assessment of Respiratory Function, Table 20-7, p. 499. Chapter 20: Assessment of Respiratory Function - Page 499

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's route of excretion. steady-state duration of action. adverse effects. peak concentration time.

adverse effects. When developing a drug therapy regimen that won't interfere with a client's lifestyle, the nurse must consider the drug's adverse effects because these may result in noncompliance. A drug's excretion route, peak concentration time, and steady-state duration of action are important considerations when developing a drug therapy regimen; however, they're related to the drug's physiologic effects and don't affect the client's lifestyle.

During the planning step of the nursing process, the nurse determines the client's goal achievement. writes a statement about the client's health problem. establishes short- and long-term goals. gathers objective data.

establishes short- and long-term goals. During the planning step of the nursing process, the nurse establishes priorities and short- and long-term goals, projects measurable outcomes, and develops a care plan. The nurse determines the client's goal achievement during the evaluation step, writes statements about the client's health problem during the nursing diagnosis step, and gathers objective data during the assessment step.

A client comes to the emergency department because the client thinks the client is having a heart attack. Further assessment determines that the client is not having a heart attack but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to ask? "Are you feeling much better now that you are lying down?" "What did you experience just before and during the attack?" "Do you think you will be able to drive home?" "What do you think caused you to feel this way?"

"What did you experience just before and during the attack?" After it has been determined that the client does not have other medical problems, the nurse should assess for the characteristic symptoms of panic attack, focusing the questions on what the client was experiencing just before and during the attack. Asking the client if the client feels better provides no information for the nurse, and lying down may or may not be effective. Asking the client if the client thinks the client can drive home is a question that can be asked much later in the interview, after the attack subsides and the client is stable. Asking the client about what caused the attack is inappropriate because numerous stimuli, both external and internal, can provoke an attack. Most clients will not be able to identify a specific cause. The focus of care is on the characteristics of the attack.

A nurse works in a community setting and follows clients who have TB. Which clients would likely require the most follow-up from rifampin therapy? A new mother who is nursing An obese 45-year-old man A cancer client An HIV-positive client

An HIV-positive client The nurse should pay special attention to the HIV-positive client because this client will require rifampin therapy for a longer period of time than the other clients. An HIV-positive person is immunocompromised, and it will take longer to fight the infection. This could increase the difficulty of adherence to the drug regimen. In addition, many of the drugs used to treat HIV are contraindicated in clients who take rifampin. Rifampin can be safely administered to nursing mothers, those with cancer, and people over 65 given certain conditions. However, their therapy should not be longer than normally required unless complications occur.

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? Maintenance of SpO2 levels ≥90% using supplementary oxygen Early ambulation and the use of compression stockings Passive range of motion exercises for the upper and lower extremities Incentive spirometry and deep breathing and coughing exercises

Early ambulation and the use of compression stockings For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.

A nurse is teaching nursing assistants in an extended-care facility measures to protect the skin of elderly clients. Which of the following measures is the nurse likely to recommend? Taking the clients outside for sun exposure daily Assisting clients to soak in the bathtub several times each week Encouraging clients to avoid cigarette smoking Instructing clients to use perfumed skin creams

Encouraging clients to avoid cigarette smoking Measures to promote healthy skin function in elderly clients include not smoking. Other measures include avoiding exposure to the sun, using emollient skin cream containing petrolatum or mineral oil, and avoiding hot soaks in the bathtub.

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first? Provide a warm, quiet, dimly lit room Assess the cause of the client's wound Evaluate the blood pressure and pulse Interview to obtain the health history

Evaluate the blood pressure and pulse In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock.

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data? How does the pain develop and progress? How would you describe your pain? How would you rate the pain on a scale of 0 to 10? What do you do to alleviate your pain and how well does it work?

How does the pain develop and progress? When assessing the chronology of the client's pain, the nurse could ask the client how the pain develops and progresses. To assess the quality of the client's pain, the nurse could ask for the client to describe the pain. To assess the quantity of the pain, the client could be asked to rate the pain on a scale of 0 to 10. To assess the alleviating factor of the pain, the nurse could ask what the client does to alleviate the pain and how well it works.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? Jugular vein distention Increased urine osmolarity Decreased serum sodium level Cool, clammy skin

Increased urine osmolarity In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 51: Assessment and Management of Patients With Diabetes, Hyperglycemic Hyperosmolar Syndrome, p. 1486. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1486

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as: Imbalanced nutrition: less than body requirements, related to treatment Impaired tissue integrity related to surgical intervention Ineffective airway clearance related to obstruction by mucus Risk for infection related to surgical intervention

Ineffective airway clearance related to obstruction by mucus All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Administering aspirin if the temperature exceeds 102° F (38.8° C) Inspecting the skin for petechiae once every shift Providing for frequent rest periods Placing the client in strict isolation

Inspecting the skin for petechiae once every shift Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

The client with chronic open-angle glaucoma is receiving timolol (Timoptic) eye drops. Which evaluation finding would indicate to the nurse the treatment is working? Decrease in nausea and vomiting Intraocular pressure 15 mm Hg Halos around lights Reduced peripheral vision

Intraocular pressure 15 mm Hg Timoptic is a beta-blocker that is used topically to decrease the flow rate of aqueous humor in the eye. As flow rate decreases, the intraocular pressure decreases. IOP of 12 to 21 mm Hg is within normal range. Reduced peripheral vision, halos around lights, and blurred vision are all symptoms of open-angle glaucoma. Nausea and vomiting are more likely to occur with acute angle-closure glaucoma. Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge Deficit: Medications related to new medical diagnosis Ineffective Airway Clearance related to bronchial constriction Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management

Knowledge Deficit: Medications related to new medical diagnosis To most appropriately address the client's health problem, the nurse should educate the client about the new medications the physician has prescribed to treat the asthma. Ineffective Airway Clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis.

An instructor is preparing for a class discussion on family health and the effects of illness on it. Which of the following would the instructor incorporate into the discussion? The provision of direct care is more important than teaching the family. The health of the family often affects the family's ability to function. The primary focus of care is on intervening in the illness cycle. Families, when faced with illness, typically respond in similar ways.

The health of the family often affects the family's ability to function. Health problems often affect the family's ability to function. Each family responds to illness and crisis in different ways depending on the nature of the health problem, the family structure and usual functioning, developmental stages and coping abilities. The primary focus of care is to maintain and improve the client's present level of health and to prevent physical and emotional deterioration. Then the nurse would intervene in the cycle that the illness creates. Therapeutic interaction, education, positive role modeling, direct care provision and teaching are all important elements to help families deal with the numerous stressors facing them.

Which nursing intervention is appropriate for a client with an arm restraint? applying the restraint loosely to prevent pressure on the skin tying the restraint to the side rail positioning the restrained arm in full extension monitoring circulatory status every 2 hours

monitoring circulatory status every 2 hours A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity? dry mouth and urine retention. taste and smell alterations. nocturia and sleep disturbances. visual disturbances.

visual disturbances. Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 29: Management of Patients With Complications from Heart Disease, Digitalis, p. 826. Chapter 29: Management of Patients With Complications from Heart Disease - Page 826