NURS 1240 Clinical Judgement EAQ
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid? - Mydriasis - Bradycardia - Hypothermia - Circulatory collapse
Circulatory collapse rationale: The clinical symptoms of monoamine oxidase inhibitors (MAOls) generally appear after 12 hours of ingestion. Circulatory collapse is associated with MAOI toxicity. Mydriasis, bradycardia, and hyperthermia are not associated with an isocarboxazid overdose.
Which joint helps in the gliding movement of the wrist? - Pivot joint - Hinge joint - Biaxial joint - Ball and socket joint
Biaxial joint rationale: The biaxial joint helps in the gliding movement of the wrist. Pivot joints permit rotation in the radioulnar area. Hinge joints allow for flexion and extension. Ball and socket joints permit movement in the shoulders and hips.
Which sexually transmitted infection (STI) is most commonly reported? - Syphilis - Chlamydia - Gonorrhea - Human immunodeficiency virus
Chlamydia rationale: Chlamydial infections are the most commonly reported STIs. Syphilis, gonorrhea, and human immunodeficiency virus are not the most commonly reported STIs.
Which condition is contraindicated for St. John's wort herbal therapy? - Anxiety - Seizures - Dementia - Cardiac disease
Dementia rationale: St. John's wort is contraindicated for dementia; this herbal therapy is used to treat anxiety. Bupropion therapy is contraindicated for seizures. Valerian (Valeriana officinalis) is contraindicated for cardiac disease.
Which action would the nurse take to help a female client diagnosed with bipolar disorder in the manic episode meet personal hygiene needs? - Suggest that she wear hospital clothing. - Guide her to dress appropriately in her own clothing. - Allow her to apply makeup in whatever manner she chooses. - Keep makeup away from her because she will apply it too freely.
Guide her to dress appropriately in her own clothing. rationale: The nurse would guide the client to dress appropriately in her own clothing. Having clients who are experiencing a manic episode of bipolar disorder wear personal clothing helps keep them more in touch with reality. The client may need direction to dress appropriately. Suggesting that she wear hospital clothing does not help the client learn to follow the therapeutic milieu. Allowing her to apply makeup in whatever manner she chooses may set up the client as a target of ridicule by other clients. The client may use makeup but with supervision.
Which sexually transmitted infection causes condylomata acuminate? - Chlamydia - Gonorrhea - Herpes simplex - Human papillomavirus (HPV)
Human papillomavirus (HPV) rationale: Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.
Which statement describes a client that is in true labor? - Contractions occur every 10 minutes with no change in frequency over 2 hours, and the cervix is closed. - Contractions are not evident; the cervix is dilated 3 cm and 50% effaced, and there is no change after 4 hours of staying out of bed. - Contractions occur every 5 to 10 minutes; the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours. - Contractions are irregular, occurring every 10 to 15 minutes; the cervix is dilated one fingertip and is 50% effaced, and there is no change with 4 hours of bed rest.
Contractions occur every 5 to 10 minutes; the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours. rationale: Progressive cervical dilation and regular contractions that become progressively closer and increase in intensity are indications of true labor. The other options (that reflect no change in 2-4 hours are not indications of true labor.
Which nursing intervention assists in decreasing the potential occurrence of pressure ulcers when providing care for a client with quadriplegia? - Avoid massaging the client's legs. - Frequently reposition the client on a scheduled basis. - Increase the fiber content in the client's food. - Encourage the client to participate in weight-bearing exercises.
Frequently reposition the client on a scheduled basis rationale: Frequent repositioning of the client in bed or wheelchair on a scheduled basis will relieve pressure points, thereby decreasing potential development of pressure ulcers. Avoiding leg massages will decrease the risk of embolism, but does not prevent pressure ulcers. Increased intake of dietary fiber will relieve the immobilized client of constipation. Weight-bearing exercises will prevent the immobilized client from developing muscular atrophy or loss of calcium from the bone.
To which client would the nurse provide education regarding the pubertal growth spurt? - An 8-year-old school-age male client - A 16-year-old adolescent male client - A 12-year-old school-age female client - An 18-year-old adolescent female client
A 12-year-old school-age female client rationale: The pubertal growth spurt reaches a peak for female clients at 12 years of age; therefore the nurse would provide education to this client regarding expected growth during this time period. The 8-year-old male client would not be expected to experience the pubertal growth spurt until the age of 14 years. The 16-year-old and the 18-year-old adolescent clients would have already experienced the pubertal growth spurt.
Which term describes the practice of placing clients with the same infection in a semiprivate room? - Isolating - Cohorting - Colonizing - Cross-referencing
Cohorting rationale: Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection. Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.
Which manifestation indicates tertiary syphilis? - Chancre - Alopecia - Gummas - Condylomata lata
Gummas rationale: Gummas are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.
Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? - Nurse - Pharmacist - Music therapist - Primary health care provider
Nurse rationale: In a palliative care setting, the health care team would comprise professionals of various disciplines to help achieve care outcomes. The nurse on the interprofessional team evaluates the physical, emotional, and spiritual needs of the client. The nurse also advocates for the client and provides referrals to other members of the team. The pharmacist supports the care of the client and the needs of the family regarding medications. Music therapists help increase the comfort of the client. The primary health care provider assesses the clinical manifestations of the client.
Which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with Parkinson disease? - Blocks the effects of acetylcholine - Increases the production of dopamine - Restores the dopamine levels in the brain - Promotes the production of acetylcholine
Restores the dopamine levels in the brain rationale: Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the effects of acetylcholine is accomplished by anticholinergic medications. Increasing the production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine production.
In which settings would the nurse perform developmental assessments for pediatric clients? Select all that apply. - Home - School - Hospital - Daycare center - Assisted living center
- Home - School - Hospital - Daycare center rationale: Pediatric developmental assessments are performed in many settings, including the home, school, hospital, and daycare center environments. It is unlikely that a pediatric developmental assessment would be performed in an assisted living center.
Which reply by the the nurse is appropriate when a client asks how psychotropic medications work? - 'These medications decrease the metabolic needs of your brain." - "These medications increase the production of healthy nervous tissue." - "These medications affect the chemicals used in communication between nerve cells." - "These medications regulate sensory input received from the external environment!"
"These medications affect the chemicals used in communication between nerve cells." rationale: Most psychotropic medications affect neurotransmitters such as dopamine and norepinephrine, which enter the synapses between neurons, allowing them to signal each other. Psychotropic medications do not work by changing the metabolic needs of the brain. They do not increase the production of nervous tissue. Although there may be some effect on sensory input, this is because of the change in neurotransmitters
Which action will the nurse take after stopping the antibiotic infusion of a client who becomes restless and flushed, and begins to wheeze during the administration of an antibiotic? - Check the client's temperature. - Take the client's blood pressure. - Obtain the client's pulse oximetry. - Assess the client's respiratory status.
Assess the client's respiratory status. rationale: The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. Checking the client's temperature and taking the client's blood pressure are not the priority; vital signs should be obtained after airway patency is ensured and maintained. Pulse oximetry is only one portion of the needed respiratory status assessment.
Which assessment finding would the nurse observe in a client with bipolar disorder, manic phase? - Constant singing - Ritualistic behavior - Flat affect - Apathetic demeanor
Constant singing rationale: Constant singing would be typical in a client with bipolar disorder, manic phase. Ritualistic behavior is indicative of obsessive-compulsive disorder. A flat affect and apathetic demeanor are more indicative of a schizophrenic or depressive disorder.
When evaluating fluid loss for a client with burns, which relationship between a client's burned body surface area and fluid loss would the nurse consider? - Equal - Unrelated - Inversely related - Directly proportional
Directly proportional rationale: There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.
Which medication may lead to bruxism? - Vilazodone - Isocarboxazid - Clomipramine - Levomilnacipran
Levomilnacipran rationale: Serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors may lead to bruxism. Levomilnacipran is a serotonin/norepinephrine reuptake inhibitor that may cause bruxism. Vilazodone is an atypical antidepressant that does not cause bruxism. Isocarboxazid is a monoamine oxidase inhibitor that does not cause bruxism. Clomipramine is a tricyclic antidepressant that does not cause bruxism.
Which action will the nurse take in a client hospitalized for uncontrolled hypertension and chest pain on a daily diuretic for 2 days whose potassium level this morning is 2.7 mEg/L (2.7 mmol/L)? - Send another blood sample to the laboratory to retest the serum potassium level. - Notify the health care provider that the potassium level is above normal. - Notify the health care provider that the potassium level is below normal. - No action is required because the potassium level is within normal limits.
Notify the health care provider that the potassium level is below normal. rationale: The health care provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEg/L to 5.0 mE/L (3.5-5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because some can cause hypokalemia, whereas others spare potassium, which can cause hyperkalemia. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client.
Which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat or cold and sharp or dull sensory stimulation after a cerebrovascular accident (CVA)? - Frontal - Parietal - Occipital - Temporal
Parietal rationale: Sensory impulses from temperature, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area. The frontal area is the area of abstract thinking and muscular movements. The occipital area of the brain is where nerve impulses translate into sight. The temporal area is the area where nerve impulses translate into sound.
Which condition contraindicates the use of ginseng herbal therapy? - Pregnancy - Schizophrenia - Bipolar depression - Alzheimer disease
Pregnancy rationale: Pregnancy is contraindicated for ginseng herbal therapy. Schizophrenia, bipolar depression, and Alzheimer disease are contraindicated for St. John's Wort herbal therapy.
Which area of the client's body would the nurse consider a high risk for developing a pressure injury when caring for an older adult with Alzheimer type dementia who consistently sleeps in a semi-Fowler position in bed? - Sacrum - Scapulae - Ischial spine - Greater trochanter
Sacrum rationale: The sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.
Which stage of the human immunodeficiency virus (HI) would a client with a CD4+ T cell count of 325 cells/mm 3 be classified? - Stage 1 - Stage 2 - Stage 3 - Stage 4
Stage 2 rationale: Stage 2 describes a client with a CD4+ T cell count between 200 and 499 cells/mm 3. Stage 1 describes a client with a CD4+ T cell count of greater than 500 cells/mm 3. Stage 3 describes a client with a CD4+ T cell count of less than 200 cells/mm 3. Stage 4 describes a client with a confirmed HIV infection but no information regarding CD4+ T cell counts is available.
Which rationale supports the nursing intervention to turn the client with paraplegia every I to 2 hours? - To maintain client comfort - To prevent development of pressure injuries - To prevent flexion contractures of the extremities - To improve venous circulation in the lower extremities
To prevent development of pressure injuries rationale: Pressure injuries easily develop when maintaining a particular position; the body weight, directed continuously in one region, restricts circulation and results in tissue necrosis. Denervated tissue has less perfusion and is more prone to pressure injuries. Clients often state they are comfortable and wish to remain in one position. More effective measures to prevent contractures include proper positioning with supportive devices and range of motion. Because turning usually occurs laterally, the circulation to the lower extremities is not dramatically affected.
Which volume of solution would be prepared when the nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client? - 150 to 250 mL - 250 to 350 mL - 300 to 500 mL - 500 to 750 mL
500 to 750 mL rationale: In adolescents, the volume of solution required is 500 to 750 mL. The nurse would prepare 150 to 250 mL of warmed solution for infants. The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.
Which is the minimum number of hours of sleep the nurse would recommend for an 11-year-old client? - 8 - 9 - 10 - 11
9 rationale: A school-age client who is 11 years of age is recommended to receive 9-11 hours of sleep per night. The minimum number of hours the nurse would recommend is 9. Eight hours is the minimum number of hours recommended for an adolescent. Ten hours of sleep is the minimum recommended for a preschool age client. Eleven hours of sleep is the minimum recommended for a toddler.
Which action would the nurse take to ensure accuracy of the pulse oximeter reading when prescribed for an adolescent? - Attach the probe to a finger or earlobe. - Wait 30 minutes before obtaining a reading. - Calibrate the oximeter at least every 8 hours. - Place the probe on the abdomen or upper leg.
Attach the probe to a finger or earlobe. rationale: Capillary beds are closest to the surface in a finger or earlobe; this proximity permits more accurate measurement of arterial oxygen saturation. An almost instantaneous, accurate readout may be obtained with the use of a pulse oximeter. The pulse oximeter does not require routine calibration. Placing the probe on the abdomen or upper leg is contraindicated because the capillary beds are not close to the surface on the abdomen or upper thigh.
Which medication is the most common cause of extrapyramidal side effects (EPSs)? - Clozapine - Haloperidol - Risperidone - Aripiprazole
Haloperidol rationale: Haloperidol is a typical antipsychotic that commonly causes extrapyramidal side effects. Clozapine is an atvpical antipsychotic that has a low risk of causing extrapyramidal side effects. Risperidone and aripiprazole have a low risk of causing extrapyramidal side effects.
The weight of a 3-month-old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain? - Cyanosis resulting in cerebral changes - Decreased arterial oxygen level resulting in polycythemia - Pulmonary hypertension resulting in recurrent respiratory infections - Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse
Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse rationale: Because of quick fatigue, it is difficult for the infant to consume sufficient calories for adequate weight gain. Increased caloric intake is needed to meet the infant's nutritional needs. Although cyanosis is present, it may not lead to cerebral changes. Cyanosis is not directly related to inadequate weight gain. Although decreased Po, does lead to polycythemia, it does not affect the infant's ability to gain adequate weight. Although there is pulmonary hypertension, it is not directly related to inadequate weight gain or respiratory infections.
Which stage of development classifies boys and girls as differing very little in terms of size? - Toddler - Preschool - School-age - Adolescence
School-age rationale: During the school-age stage of development, boys and girl differ very little in terms of size. During the toddler, preschool, and adolescence stages of development boys are often larger than girls.
Which result would the nurse expect to find when reviewing the serum screening tests of a client with acquired immunodeficiency syndrome (AIDS)? - A decrease in CD4 T cells - An increase in thymic hormones - An increase in immunoglobulin E - A decrease in the serum level of glucose-6-phosphate dehydrogenase
A decrease in CD4 T cells rationale: The human immunodeficiency virus (HIV) infects helper T-cell lymphocytes; therefore 300 or fewer CD4 T cells per cubic millimeter of blood or CD4 cells accounting for less than 20% of lymphocytes is suggestive of AIDS. The thymic hormones necessary for T-cell growth are decreased. An increase in immunoglobulin E is associated with allergies and parasitic infections. A decrease in the serum level of glucose-6-phosphate dehydrogenase is associated with drug-induced hemolytic anemia and hemolytic disease of the newborn.
Which response would the nurse implement when the spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test and is found to have an area of induration greater than 10 mm? - No further action is required at this time. - Additional tests are necessary to determine infection status. - Immediately repeat the skin test for confirmation. - Results are positive, indicating an active infection.
Additional tests are necessary to determine infection status. rationale: The test does not indicate whether TB is dormant or active. However, a client with an induration of 5 mm or greater is considered positive. If there is repeated close contact with a person diagnosed with pulmonary TB or if the client has a disease causing decreased resistance, this requires further diagnostic study, such as chest x-rays and sputum culture. A newly infected client will receive preventive therapy with isoniazid (INH). Isoniazid will be continued for 6 months if chest x-rays are normal, or 12 months if chest x-rays are abnormal. Repeating the skin test is not necessary; the test is considered positive.
When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? - Surgery - Comfort - Education - Motivation
Comfort rationale: Because pain is an all-encompassing and often demoralizing experience, the nurse would want to keep the client as pain-free as possible. Surgery corrects deformities and facilitates movement, which is not an immediate need. Concentration and motivation are difficult when a client is in severe pain.
Which action by the nurse would be priority for a male client with a history of schizophrenia who comes to the emergency department accompanied by his spouse? - Observing and evaluating his behavior - Writing a plan of care for the mental health team - Obtaining a copy of the client's past medical records - Meeting separately with his wife and exploring why he came to the hospital
Observing and evaluating his behavior rationale: The priority action is to observe and evaluate his behavior. The client and his needs are the priority, and assessment is the first step of the nursing process. Writing a plan of care for the mental health team is done after a thorough assessment is completed. The nurse must deal with the present, not the past. Although meeting separately with the wife should be done, it is not the priority; it can be done at a later time.
Which criteria would the nurse consider when determining if an infection is a health care-associated infection? - Originated primarily from an exogenous source - Is associated with a medication-resistant microorganism - Occurred in conjunction with treatment for an illness - Still has the infection despite completing the prescribed therapy
Occurred in conjunction with treatment for an illness rationale: Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a medication-resistant microorganism is not a criterion for identifying a health care associated infection. A health care-associated infection may or may not be caused by a medication-resistant microorganism. Stil having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection
For which additional defect would the nurse assess an infant with exstrophy of the bladder? - Imperforate anus - Absence of one kidney - Congenital heart disease - Pubic bone malformation
Pubic bone malformation rationale: The pubic bone and the bladder form during the same period of embryonic development. Imperforate anus, absence of a kidney, and congenital heart disease are not associated with exstrophy of the bladder.
Place the following nursing actions in the correct order for a client with esophageal varices prescribed a blood transfusion. - Check the client's vital signs. - Establish intravenous (IV) access with IV normal saline. - Verify the blood product with another nurse against the client's identification (ID) bracelet. - Monitor the client's vital signs and status according to agency policy
- Check the client's vital signs. - Establish intravenous (IV) access with IV normal saline. - Verify the blood product with another nurse against the client's identification (ID) bracelet. - Monitor the client's vital signs and status according to agency policy rationale: Baseline vital signs should be obtained immediately before administering the blood product for future comparison purposes. Before obtaining the blood, it is important to have IV access because if there is difficulty establishing an IV after blood is obtained, the blood cannot be returned to the blood bank. Two licensed nurses would confirm the verifying data between the client and the blood product. The nurse would remain with and monitor the client's vital signs during the first 15 minutes of administration of the blood product and then follow the institution's protocol to monitor for a transfusion reaction or fluid overload.
Which action would the nurse take for a client with an obsessive-compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted? - Distract the client, which will help the client forget about touching the chairs. - Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in. - Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one. - Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed.
Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed. rationale: The nurse would allow the behavior to continue for a specified time, letting the client help set the time limits. It is important to set limits on the behavior, but it is also important to involve the client in the decision-making. Distracting the client, which will help the client forget about touching the chairs, is nontherapeutic; rarely can a client be distracted from a ritual when anxiety is high. Encouraging the client to continue touching the chairs for as long the client desires until fatigue sets in is a nontherapeutic approach; some limits must be set by the client and nurse together. Removing chairs from the hall, thereby relieving the client of the necessity of touching every other one, will increase the client's anxiety because the client uses the ritual as a defense against anxiety.
Which property of acetylsalicylic acid would a nurse recall when administering to a client? - Sedative - Hypnotic - Analgesic - Antibiotic
Analgesic rationale: Acetylsalicylic acid (aspirin) acts as an analgesic by inhibiting production of inflammatory mediators. Acetylsalicylic acid does not act as a sedative to calm individuals. Acetylsalicylic acid does not act as a hypnotic to induce sleep. Acetylsalicylic acid does not destroy or control microorganisms.
Which product would the nurse instruct intravenous drug users (IDUs) to use for cleaning of needles and syringes between uses? - Bleach - Hot water - Ammonia - Rubbing alcohol
Bleach rationale: IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.
Which statement is true regarding antipsychotic medications? - All first- and second-generation antipsychotics are equally effective. - Second-generation antipsychotics pose a risk of extrapyramidal symptoms. - First-generation antipsychotics pose a significant risk of metabolic side effects - Clozapine is more effective than other second-generation antipsychotics.
Clozapine is more effective than other second-generation antipsychotics. rationale: Clozapine is a second-generation antipsychotic medication that is more effective than other second-generation antipsychotics. Most (but not all) first- and second-generation antipsychotics are equally effective. Second-generation antipsychotics may cause metabolic side effects such as diabetes and dyslipidemia. First-generation antipsychotics may cause extrapyramidal side effects.
Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)? - Humidified cool air and adequate hydration - Postural drainage and oxygen by hood - Bronchodilators and cough suppressants - Corticosteroids and broad-spectrum antibiotics
Humidified cool air and adequate hydration rationale: Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.
Which antibody forms first, after exposure to an antigen? - Immunoglobulin A (|gA) - Immunoglobulin E (IgE) - Immunoglobulin G (| gG) - Immunoglobulin M (IgM)
Immunoglobulin M (IgM) rationale: 1gM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell. IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts. IgE has variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.
Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit? - Make the client mop the floor. - Restrict the client's fluids for the rest of the day. - Toilet the client more frequently with supervision. - Withhold the client's privileges each time the client voids on the floor.
Toilet the client more frequently with supervision. rationale: The nurse would toilet the client more frequently with supervision. The client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently reduces the risk of voiding in inappropriate places. Making the client mop the floor is a form of punishment for something the client cannot control. Restricting the client's fluids for the rest of the day is not realistic; it will have no effect on the problem and may lead to physiological problems. If the client were doing this to express hostility, withholding privileges might be effective, but not when the client is unable to control the behavior.
Which action would the nurse take for a withdrawn client who suddenly screams, bursts into tears, and runs from the room to the far end of the hallway? - Walk to the end of the hallway where the client is standing. - Accept the action as the impulsive behavior of a sick person. - Ask another client in the dayroom why the client acted in this way. - Document objectively the incident in the client's record immediately.
Walk to the end of the hallway where the client is standing. rationale: The nurse would walk to the end of the hallway where the client is standing. This lets the client know that the nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person... Another client's perception of the incident may or may not be valid and it is not that client's responsibility, it is the nurse's responsibility. Although it is important to document the incident in the client's record, this does not take precedence over letting the client know the nurse is available if needed.
