NURS 2220 exam 3

A client with syndrome of inappropriate antidiuretic hormone (SIADH) is admitted with a serum sodium level of 105 mEq/L. Which request by the health care provider should the nurse address first? A. Administer infusion of 150 mL of 3% NaCl over 3 hours. B. Draw blood for hemoglobin and hematocrit. C. Insert retention catheter and monitor urine output. D. Weigh the client on admission and daily.

A. Administer infusion of 150 mL of 3% NaCl over 3 hours. Correct Correct: The client with a sodium level of 105 mEq/L is at high risk for seizures and coma. The priority intervention is to increase the 105 sodium level to a more normal range. Ideally, 3% NaCl should be infused through a central line or with a small needle through a large vein to prevent irritation.

A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na 130 mEq/L, K 5.6 mEq/L, and glucose 72 mg/dL. Which of the following is the first request that the nurse should anticipate? A. Administer insulin and dextrose in normal saline to shift potassium into cells. B. Give spironolactone (Aldactone) 100 mg orally. C. Initiate H2 blocker therapy with ranitidine for ulcer prophylaxis. D. Obtain arterial blood gases to assess for peaked T waves.

A. Administer insulin and dextrose in normal saline to shift potassium into cells. Correct Correct: This client is hyperkalemic. Anticipate a request to administer 20 to 50 units of insulin with 20 to 50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells.

After receiving change-of-shift report about the following four clients, which client should the nurse attend to first? A. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL B. Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due C. Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L D. Client with pituitary adenoma who is reporting a severe headache

A. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL Correct Correct: A glucose level of 36 mg/dL is considered an emergency. This client needs to be assessed and treated immediately.

While assessing a client with Graves' disease, the nurse notes that the client's temperature has risen 1° F. Which action should the nurse take first? a. Turn the lights down and shut the client's door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client's apical-radial pulse deficit. d. Administer a dose of acetaminophen (Tylenol).

ANS: A A temperature increase of 1° F may indicate the development of thyroid storm, and the provider needs to be notified. But before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.

A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the client's level of consciousness has decreased. Which actions should the nurse take? (Select all that apply.) a. Infuse intravenous fluids. b. Cover the client with warm blankets. c. Monitor blood pressure every 4 hours. d. Maintain a patent airway. e. Administer oral glucose as prescribed.

ANS: A, B, D A client with hypothyroidism and an acute illness is at risk for myxedema coma. A decrease in level of consciousness is a symptom of myxedema. The nurse should infuse IV fluids, cover the client with warm blankets, monitor blood pressure every hour, maintain a patent airway, and administer glucose intravenously as prescribed.

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins

ANS: A, C, E The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins.

A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this client's education? (Select all that apply.) a. "Do not share utensils, plates, and cups with anyone else." b. "You can play with your grandchildren for 1 hour each day." c. "Eat foods high in vitamins such as apples, pears, and oranges." d. "Wash your clothing separate from others in the household." e. "Take a laxative 2 days after therapy to excrete the radiation."

ANS: A, D, E A client who is prescribed an unsealed radioactive isotope should be taught to not share utensils, plates, and cups with anyone else; to avoid contact with pregnant women and children; to avoid eating foods with cores or bones, which will leave contaminated remnants; to wash clothing separate from others in the household and run an empty cycle before washing other people's clothing; and to take a laxative on days 2 and 3 after receiving treatment to help excrete the contaminated stool faster.

After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional instruction? a. "I may need calcium replacement after surgery." b. "After surgery, I won't need to take thyroid medication." c. "I'll need to take thyroid hormones for the rest of my life." d. "I can receive pain medication if I feel that I need it."

ANS: B After the client undergoes a thyroidectomy, the client must be given thyroid replacement medication for life. He or she may also need calcium if the parathyroid is damaged during surgery, and can receive pain medication postoperatively.

A nurse cares for a client newly diagnosed with Graves' disease. The client's mother asks, "I have diabetes mellitus. Am I responsible for my daughter's disease?" How should the nurse respond? a. "The fact that you have diabetes did not cause your daughter to have Graves' disease. No connection is known between Graves' disease and diabetes." b. "An association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease." c. "Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus." d. "Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having Graves' disease."

ANS: B An association between autoimmune diseases such as rheumatoid arthritis and diabetes mellitus has been noted. The predisposition is probably polygenic, and the mother's diabetes did not cause her daughter's Graves' disease. The other statements are inaccurate.

A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism? a. A 29-year-old female with pregnancy-induced hypertension b. A 41-year-old male receiving dialysis for end-stage kidney disease c. A 66-year-old female with moderate heart failure d. A 72-year-old male who is prescribed home oxygen therapy

ANS: B Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, and this triggers overstimulation of the parathyroid glands. Pregnancy-induced hypertension, moderate heart failure, and home oxygen therapy do not place a client at higher risk for hyperparathyroidism.

A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this client's plan of care? a. Ask the client to ambulate in the hallway twice a day. b. Use a lift sheet to assist the client with position changes. c. Provide the client with a soft-bristled toothbrush for oral care. d. Instruct the unlicensed assistive personnel to strain the client's urine for stones.

ANS: B Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this client.

A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy? a. Blurred and double vision b. Increased thirst and urination c. Profuse nausea and diarrhea d. Decreased attention and insomnia

ANS: B Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. This manifests with increased thirst and urination. Lithium has no effect on vision, gastric upset, or level of consciousness.

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)

ANS: B The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Propranolol is a beta blocker and would be contraindicated for a client with bradycardia.

A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL Sodium 144 mEq/L Magnesium 1.2 mEq/L Potassium 5.7 mEq/L Based on these results, which medications should the nurse anticipate administering? (Select all that apply.) a. Oral potassium chloride b. Intravenous calcium chloride c. 3% normal saline IV solution d. 50% magnesium sulfate e. Oral calcitriol (Rocaltrol)

ANS: B, D The client has hypocalcemia (treated with calcium chloride) and hypomagnesemia (treated with magnesium sulfate). The potassium level is high, so replacement is not needed. The client's sodium level is normal, so hypertonic IV solution is not needed. No information about a vitamin D deficiency is evident, so calcitriol is not needed.

A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care? a. Monitor the client's intravenous site every shift. b. Administer acetaminophen (Tylenol) for fever. c. Ensure that working suction equipment is in the room. d. Assess the client's vital signs every 4 hours.

ANS: C A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction equipment is available in the client's room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.

A nurse cares for a client who has hypothyroidism as a result of Hashimoto's thyroiditis. The client asks, "How long will I need to take this thyroid medication?" How should the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."

ANS: C Hashimoto's thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The client will not be able to stop taking the medication.

A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention

ANS: C Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The client's family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the client's environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, "I feel numbness and tingling around my mouth." What action should the nurse take? a. Offer mouth care. b. Loosen the dressing. c. Assess for Chvostek's sign. d. Ask the client orientation questions

ANS: C Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess the client further by testing for Chvostek's sign and Trousseau's sign. Then the nurse should notify the provider. Mouth care, loosening the dressing, and orientation questions do not provide important information to prevent complications of low calcium levels.

A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take? (Select all that apply.) a. Administer levothyroxine (Synthroid). b. Administer propranolol (Inderal). c. Monitor the apical pulse. d. Assess for Trousseau's sign. e. Initiate telemetry monitoring.

ANS: C, E The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau's sign is a test for hypocalcemia.

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism? a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 12 hours of sleep."

ANS: D Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hypothyroidism.

A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium: 2.9 mEq/L b. Serum magnesium: 1.7 mEq/L c. Serum sodium: 122 mEq/L d. Serum calcium: 6.9 mg/dL

ANS: D Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau's sign) that occur during blood pressure measurement are indicative of hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyponatremia, and hypomagnesemia.

A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.

ANS: D Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client's heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.

A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Place the client in high-Fowler's position and apply oxygen. d. Contact the provider and prepare for intubation.

ANS: D Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open.

A client with a gunshot wound is brought to the emergency department (ED). Which nursing intervention is appropriate?

Blood and body fluid precautions, The ED nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids. Screening of the client with a metal detector, placing a security guard, and admission to a negative-pressure room are not necessary.

A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take first? a. Keep the head of the bed flat and the client supine. b. Instruct the client to cough, turn, and deep breathe. c. Report clear or light yellow drainage from the nose. d. Apply petroleum jelly to lips to avoid dryness.

C

A nurse plans care for a client with Cushings disease. Which action should the nurse include in this clients plan of care to prevent injury? a. Pad the siderails of the clients bed. B. Assist the client to change positions slowly. c. Use a lift sheet to change the clients position. d. Keep suctioning equipment at the clients bedside.

C

The nurse is providing discharge instructions to the client on spironolactone therapy. Which comment by the client indicates a need for further teaching? A. "I must call the doctor if I am more tired than usual." B. "I need to increase my salt intake." C. "I should eat a banana every day." D. "This drug will not control my heart rate."

C. "I should eat a banana every day." Correct: Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium should be avoided to prevent hyperkalemia.

The client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? A. "Don't mind this. The disease is causing this." B. "I need to check the client's cortisol level." C. "The disease can sometimes affect emotional responses." D. "Medication is available to help with this."

C. "The disease can sometimes affect emotional responses." Correct: The client may have neurotic or psychotic behavior as a result of high blood cortisol levels. Being honest with the family helps them understand what is happening.

Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.)

Calcium gluconate Oxygen Suction Emergency tracheotomy kit

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed?

Clear the airway of secretions. The airway should first be cleared of any secretions or debris with a suction catheter or manually, if necessary. The primary survey for a trauma client is based on the mnemonic "ABCDE," with "A" being airway.A cervical collar will then need to be applied and respiration will need to be assisted with a bag-valve-mask (BVM) connected to 100% oxygen source. Although the leg does not have a pulse, the airway must be addressed before limb threats.

For which client will the nurse choose to perform SBIRT?

Client who continues to use alcohol. The SBIRT (screening, brief intervention, and referral to treatment) strategy is an approach in which the nurse conducts a brief, respectful conversation that offers feedback, counsel, and motivation to reduce alcohol consumption. SBIRT is not associated with recurrent admissions, extreme pain, or lack of adherence to treatment.

The nurse is caring for a client who may be the victim of domestic violence. When the health care provider discharges the client to home, what is the appropriate nursing action?

Consult with Social Services. Consulting with social workers or case managers is the appropriate course of action to investigate resource needs for this client and to plan accordingly. Contacting law enforcement, discharging the client, or telling the client to go to a neighbor's house may not be in this client's best interest.

The nurse is caring for a client in the ED who reports speaking English as a second language. Which nursing intervention is appropriate?

Contact an interpreter contracted through the hospital. Available resources such as telephone language lines and dedicated interpreters must be used when a client does not speak English fluently. Another health care provider, another nurse, nor the client's spouse should serve in any capacity to interpret.

The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? A. Client in Addisonian crisis who is receiving IV hydrocortisone B. Client admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH) secondary to lung cancer C. Client being discharged after a unilateral adrenalectomy to remove an adrenal tumor D. Client with Cushing's syndrome who has an elevated blood glucose and requires frequent administration of insulin Correct

D. Client with Cushing's syndrome who has an elevated blood glucose and requires frequent administration of insulin Correct Correct: An RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration.

The client with Cushing's disease says that she has lost 1 lb. What does the nurse do next? A. Auscultates the lungs for crackles B. Checks urine for specific gravity C. Forces fluids D. Weighs the client

D. Weighs the client Correct: Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease. Weighing the client with Cushing's disease is part of the nurse's assessment.

When teaching the client about when to call the primary health care provider if they are showing signs of hypothyroidism after a thyroidectomy, which statement made by the client shows that teaching was effective?

I will call if I get dry hair and Can't tolerate the cold.

which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal insufficiency undergoing IV therapy with hydrocortisone that the client is responding positively to this drug therapy?

serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)

Which client response is most important for the nurse in the postanesthesia care unit to monitor when caring for a client who had a thyroidectomy?

signs of respiratory obstruction

A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland asks the nurse whether the physical changes from the excessive cortisol will go away as a result of the surgery so she can look like herself again. What is the nurse's best response?

the fatty changes and acne will resolve with time but the stretch marks only fade

A nurse caring for a client with Cushing syndrome who must remain on continued glucocorticoid therapy for another health problem with use which of the following actions to prevent harm?

using nonadhesive methods to secure an IV access

Which signs, symptoms, or behaviors will the nurse expect to find when assessing a client who has just been diagnosed with hypothyroidism? (Select all that apply.)

-nonpitting edema of the hands and feet -decreased deep tendon reflexes -pulse rate below 60/minute

A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to contact to provide care for this client?

Forensic nurse examiner. The forensic nurse examiner is the best and most appropriate team member able to recognize evidence of abuse and to intervene on the client's behalf.The physician or other health care provider, a social worker, and a psychiatric crisis nurse can be contacted to assist with care after the forensic nurse examiner has seen the client.

Which statement made by a client who is undergoing therapy with radioactive iodine (RAI) for Graves disease indicates a lack of understanding about the disorder and its treatment?

"It will be great to lose my "bug-eyed" appearance. Although successful radioactive iodine (RAI) therapy for Graves disease results in reducing most physical symptoms, the exophthalmia does not respond to this therapy. Other measures, such as drug therapy targeted to the exophthalmos and not the hyperthyroidism and surgery to remove tissue from behind the eye, are needed to improve the eye appearance. All other client statements demonstrate accurate understanding of the disorder and its treatment.

The nurse suspects that a client in the ED may be a victim of human trafficking. Which signs and symptoms support this assumption? (Select all that apply.)

- reports having had three abortions in the past 2 years -missing patches of hair -allows the accompanying person to answer all nursing questions -notes various ED visits for sexually transmitted infections recorded in the electronic health record -burns in various places on the body

The nurse in the ED is preparing to discharge a client with a visual defect who needs to take an antibiotic at home. Which method will the nurse use to teach about drug therapy? (Select all that apply.)

-Verbal teaching to the client -Distribution of large-print reading material

which assessment findings in a client with hyperthyroidism indicate to the nurse that the client is in danger or thyroid storm?

-client report of increased palmar sweating -an increase in temperature from 99.5 to 101.3 -increase in premature ventricular heart contractions from 4 per minute to 28 per minute

Resuscitation for a client who sustained cardiac arrest in the emergency department (ED) was unsuccessful. Which nursing intervention is appropriate when the family members ask to view the body? (Select all that apply.)

-cover the client with a sheet, leaving the face exposed -remove lines and indwelling tubes unless a forensic investigation is anticipated

Leadership Attributes

-integrity -accountability -loyal -positive -adaptability -communication -decisiveness -friendly

which of the following are the priority precautions the nurse will teach the client who remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy to prevent harm related to the disorder?

- avoid crowds and people who are ill -check your heart rate for irregular or skipped beats twice daily -do not choose low sodium versions of prepared foods -get up slowly from sitting or lying positions -keep a source of glucose, such as candy, with you at all times -never skip your hormone replacement drugs

Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply. One, some, or all responses may be correct.

- intolerance to cold -decreased body temperature

Which statements regarding hyperthyroidism are accurate? (Select all that apply.)

-is much more common in women than men -Produces symptoms of a hypermetabolic state. -most common for is raves disease

leadership involves 3 dynamic elements

1. leader 2. follower 3. situation

A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory values should the nurse associate with this disorder? (Select all that apply.) a. Sodium: 150 mEq/L b. Sodium: 130 mEq/L c. Potassium: 2.5 mEq/L d. Potassium: 5.0 mEq/L e. pH: 7.28 f. pH: 7.50

A,C,E

A nurse assesses a client with Cushings disease. Which assessment findings should the nurse correlate with this disorder? (Select all that apply.) a. Moon face b. Weight loss c. Hypotension d. Petechiae e. Muscle atrophy

A,D,E

A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client? a. Read the label before using salt substitutes. b. Do not add salt to your food when you eat. c. Avoid exposure to sunlight. d. Take Tylenol instead of aspirin for pain.

A

A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take? a. Wash hands when entering the room. b. Keep the client in airborne isolation. c. Observe the client for signs of infection. d. Assess the clients daily chest x-ray.

A

An emergency nurse cares for a client who is experiencing an acute adrenal crisis. Which action should the nurse take first? a. Obtain intravenous access. b. Administer hydrocortisone succinate (Solu-Cortef). c. Assess blood glucose. d. Administer insulin and dextrose.

A

The nurse routinely screens all clients in the ED for depression. Which client does the nurse identify at the highest risk for depression?

A 59-year-old Caucasian male. Depression screening in the ED is critical because suicide rates are two times higher among older adults when compared with younger adults. Older adult males who are white are at the highest risk (Touhy & Jett, 2019). Therefore, the nurse will identify the 59-year-old Caucasian male at highest risk.

clinical leadership (nursing)

A registered nurse who influences and coordinates patients, families, and healthcare team members for the purpose of integrating the patient care they provide to achieve positive patient outcomes

A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for adrenal insufficiency? (Select all that apply.) a. A 22-year-old female with metastatic cancer b. A 43-year-old male with tuberculosis c. A 51-year-old female with asthma d. A 65-year-old male with gram-negative sepsis e. A 70-year-old female with hypertension

A,B,D

Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min?

Applying oxygen by mask The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then initiate the Rapid Response Team. Although a decreased body temperature would support the findings that a client with severe hypothyroidism is worsening, assessing it would not be helpful in this situation. Increasing the IV flow rate may not even improve cardiac output because the slow heart rate is not related to a volume deficit but to reduced myocardial contractility.

A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The clients serum sodium level is 114 mEq/L. Which action should the nurse take first? a. Consult with the dietitian about increased dietary sodium. b. Restrict the clients fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for re-positioning. d. Instruct unlicensed assistive personnel to measure intake and output.

B

A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, I feel like I am going crazy. How should the nurse respond? a. I will ask your doctor to order a psychiatric consult for you. b. You feel this way because of your hormone levels. c. Can I bring you information about support groups? d. I will close the door to your room and restrict visitors.

B

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond? a. It is possible for the inflammation to recur if you stop the medication. b. Once you start corticosteroids, you have to be weaned off them. c. You must decrease the dose slowly so your hormones will work again. d. The drug suppresses your immune system, which must be built back up.

B

A nurse teaches a client with a cortisol deficiency who is prescribed prednisone (Deltasone). Which statement should the nurse include in this clients instructions? a. You will need to learn how to rotate the injection sites. b. If you work outside in the heat, you may need another drug. c. You need to follow a diet with strict sodium restrictions. d. Take one tablet in the morning and two tablets at night.

B

A nurse teaches a client with Cushings disease. Which dietary requirements should the nurse include in this clients teaching? (Select all that apply.) a. Low calcium b. Low carbohydrate c. Low protein d. Low calories e. Low sodium

B,D,E

Which statement is true regarding leadership?

Leadership is an earned honor and an action-oriented responsibility.

An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client?

Level I. A Level I Trauma Center would be most appropriate to handle the complex level of care required by this client with a potential traumatic brain injury and apparent partial amputation of both hands. A Level I Trauma Center is a regional resource facility that provides leadership and collaborative care for every type of injury. Since the airway is secure and the vital signs are stable, there is no need to stop at a Level II, II, or IV Trauma Center for stabilization. This client would require initial transfer to a Level I facility for likely surgery and rehabilitation in this situation.

There has been an explosion at a local refinery with numerous reported injuries. Which client does the nurse identify as the priority for treatment?

Older adult with heavy bleeding. The critically injured older adult with active hemorrhage is the emergent priority in this situation. This condition is potentially life threatening. The child with an open fracture of the arm, the adult with a head injury, and the teenager with a closed fracture of the leg are urgent than the older adult with hemorrhage.

The nurse is caring for a client with a knife wound. How will the nurse document this type of injury?

Penetrating Penetrating trauma is caused by injury from sharp objects and projectiles, such as knives, ice picks, bullets, or pellets.Blunt trauma results from impact forces. Blast effects are sustained from an exploding substance. Acceleration-deceleration trauma occurs in high-speed crashes or falls.

The nurse is caring for a client after a motor vehicle crash whose vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. After assessing the Glasgow Coma Scale score as 15, and noting no apparent injuries other than a seat belt abrasion, what will the nurse do next?

Perform ongoing monitoring. Blunt force injuries are from acceleration/deceleration forces, and can cause trauma to bones, blood vessels, and soft tissue. An injury may not be evident right away. A seat belt abrasion across the chest alerts the nurse to monitor closely for signs of potential internal injuries. While the nurse is monitoring the client, routine labs, including blood alcohol levels, may be obtained, and the seat belt abrasion can be cleaned. After diagnostic testing results are complete, the health care provider will determine whether the client requires admission or can be discharged to home.

A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation?

Performing assessment. The first core competency that is essential in this situation is assessment which is the foundation of the ED nurse's skill base to determine normal from abnormal client findings. Interpretation of findings, setting of priorities, and completion of documentation can be accomplished after performing an assessment. Until the client has been accurately assessed, care can begin.

Which action by the registered nurse (RN) represents her or his leadership ability?

Supervising the tasks assigned to unlicensed nursing personnel

Why is a goiter often present in clients who have Graves disease?

The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. Graves disease is an autoimmune disorder in which antibodies (thyroid-stimulating immunoglobulins [TSIs]) are made and attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells, which enlarges the gland, forming a goiter and overproduces thyroid hormones (thyrotoxicosis).

A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. b. The government has a program for quick licensure activation wherever you are deployed. c. During a time of crisis, licensure issues would not be the governments priority concern. d. If you are deployed, you will be issued a temporary license in the state in which you are working.

a. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. When deployed, DMAT health care providers are acting as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

a. Provide a calm location for the family to cope and discuss needs. The nurse should first provide emotional support by encouraging relaxation, listening to the familys needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the familys needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the familys needs.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

a. Provide water and healthy snacks for energy throughout the event. To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

a. The Medical Reserve Corps The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone.

a. You are free to express your feelings; whatever is said here stays here. Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

leadership

an interactive process that provides needed guidance and direction

leadership styles

autocratic, democratic, laissez-faire, transactional, transformational, authentic, shared

After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control?

b. Do all areas of the hospital have the supplies and personnel they need? Before standing down, the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more walking wounded victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can stand down.

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facilitys sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

c. Arrange for critical incident stress debriefing. The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.

c. In a disaster, extensive resources are not used for one person at the expense of many others. In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I cant believe that my wife is gone and I am left to raise my children all by myself. How should the nurse respond? a. Please accept my sympathies for your loss. b. I can call the hospital chaplain if you wish. c. You sound anxious about being a single parent. d. At least your children still have you in their lives.

c. You sound anxious about being a single parent. Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the clients distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the clients feelings and situation.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

d. Multiple fractured ribs and shortness of breath Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. d. You seem upset. I have time to talk if youd like.

d. You seem upset. I have time to talk if youd like. Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment would the nurse report immediately to the health care provider?

fluttering in the chest

performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism?

measuring heart rate and rhythm

interprofessional leadership (nursing)

nurse leaders at all levels of the organization become full partners in the interprofessional care environment for the benefit of the patient.

formal leader (nursing)

nurses that hold executive-level leadership roles such as chief nursing officer or vice president of patient care partner with other executives to establish an organizational vision with aligned goals within a facility