nurs 406 test 1

neuro

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cardiac

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EAQs

practice questions

You notice that you look forward to talking to Becky because her dark sense of humor reminds you of your best friend in high school. You also begin to make little cynical jokes, hoping to have a good laugh together. What is this relationship showing early signs of? •Accountability •Self-reflection •Transference •Countertransference

•Countertransference Countertransference occurs when the nurse unconsciously displaces feelings related to significant figures in the nurse's past onto the patient.

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply. Pallor Agitation Tachycardia Narrow pulse pressure Decreased respirations

Pallor Agitation Tachycardia Narrow pulse pressure Pale skin (pallor), agitation, tachycardia, and narrow pulse pressure are signs of cardiogenic shock. Decreased respirations are not expected with cardiogenic shock.

The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what? Renal function Cardiac output Oxygen saturation Peripheral vascular resistance

Peripheral vascular resistance Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.

What is the term for shock associated with a ruptured abdominal aneurysm? Vasogenic shock Neurogenic shock Cardiogenic shock Hypovolemic shock

Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

A nurse is weighing a client with heart failure. The client weighed 175 lb (79.4 kg) on the last visit and has had a 5% weight gain since then. The nurse suspects that the client is retaining fluid. How many liters of fluid has the client retained? Record your answer using a whole number. ___ liters

One liter of fluid is equal to 1 kg of weight. The client has had a 5% weight gain since the previous visit; the nurse feels this weight gain is fluid retention. 79.4 kg X 5% = 3.97 kg = 3.97 L = 4 L

A client with severe breathing problems is brought to the emergency ward. Which level of Maslow's hierarchy of needs does the nurse need to follow? First level Second level Third level Fourth level

first level The first level of Maslow's hierarchy of needs includes physiological needs like air, water, and food. Since the client has difficulty breathing, sufficient air should be provided as the first step of nursing intervention. The second level is physiological security and safety needs. The third level includes social needs. The fourth level addresses the self-esteem and confidence of a client.

MASLOWS hierarchy of needs

5 levels 1 is ultimate priority 1 - physiological: oxygen, fluids, nutrition, body temperature, elimination, shelter, sex 2 - safety and security: physical and psychological safety 3 - love and belonging needs 4 - self esteem 5 - self actualization (dreams, hopes, goals)

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? Cold, clammy skin Slow, bounding pulse Increased blood pressure Hyperactive bowel sounds

Cold clammy skin The action of the sympathetic nervous system causes vasoconstriction, and as cellular and peripheral hypoperfusion progresses, the skin becomes cold, clammy, cyanotic, or mottled. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs; it has a low volume (weak, thready) because of peripheral vasoconstriction. The blood pressure decreases because of continued hypoperfusion and multiorgan failure. Bowel sounds are hypoactive or absent, not hyperactive.

therapeutic relationship

In a TR, the nurse maximizes communication skills, understanding of human behaviors, and personal strengths to enhance the client's growth •Clients are more likely to engage in a relationship when the clinician's interactions address their concerns, respect clients as partners in decision making, and use easy-to-understand language •In a TR, the focus should be on the client's ideas, needs, problems, experiences, and feelings. It's all about the welfare of the client

A client says, "I do not want to go back to school because I fear that everyone will laugh at me." Which level of need does the given scenario refer to according to Maslow's hierarchy of needs? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the second level that includes safety and security needs. The given scenario relates to the fourth level that includes self-esteem needs. The given scenario relates to the third level that includes love and belonging needs.

The given scenario relates to the fourth level that includes self-esteem needs. According to Maslow's hierarchy of needs, self-esteem needs involve self-confidence, usefulness, achievement, and self-worth. In the given scenario, the client shows low self-esteem. Therefore, this scenario relates to the fourth level.

The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the client is stabilized, what intervention should the nurse do next? Monitor the peripheral pulses. Check the level of consciousness. Take a blood sample for laboratory tests. Control the bleeding with a pressure dressing.

Take a blood sample for laboratory tests. The primary nursing intervention that should be followed in the client's condition with gastrointestinal bleeding is collection of a blood sample for laboratory diagnosis. Peripheral pulses are monitored in an ongoing manner. Level of consciousness may not be required to be monitored based on the client's condition. Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and wounds.

Identify the mitral area

The marked area in the image is the mitral area. It is a valvular outflow tract located in the fifth intercostal space at the apex of heart.

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in phytonadione and that should be avoided. What should the nurse include on the list? Select all that apply. spinach oranges broccoli chicken breast sweet potatoes

Spinach, broccoli (green leafy vegetables) The amount of phytonadione (vitamin K) in 1 cup of raw spinach is 181%, and a half cup of chopped and boiled broccoli is 138% of the Daily Value (DV) recommended by the U.S. Food and Drug Administration, according to the U.S. National Institutes of Health. Fruit, including oranges, contains minimal phytonadione. Chicken breast is high in protein, not phytonadione. Sweet potatoes are high in vitamin A but not phytonadione.

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? The body initially attempts to compensate by releasing more red blood cells. The body initially attempts to compensate by maintaining peripheral vasoconstriction. The body initially attempts to compensate by decreasing mineralocorticoid production. The body initially attempts to compensate by producing less antidiuretic hormone (ADH).

The body initially attempts to compensate by maintaining peripheral vasoconstriction. With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure.

A client with severe breathing problems is brought to the emergency ward. Which level of Maslow's hierarchy of needs does the nurse need to follow? First level Second level Third level Fourth level

First level The first level of Maslow's hierarchy of needs includes physiological needs like air, water, and food. Since the client has difficulty breathing, sufficient air should be provided as the first step of nursing intervention. The second level is physiological security and safety needs. The third level includes social needs. The fourth level addresses the self-esteem and confidence of a client.Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs? Level 1 Level 2 Level 3

Level 2 A nurse who assists an older client in getting to the washroom is fulfilling the safety and security need, which is the second level of need according to Maslow's hierarchy of needs. The first level involves physiological needs such as air, water, and food. Belonging needs such as friendship, social relationships, and sexual love fall under the third level of need. The fourth level of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth and achievement. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

What is the correct order in which a nurse arranges the different levels of human needs according to Maslow's hierarchy? Physiological needs Psychological security Social relationships self-esteem needs Self actualization needs

Physiological needs Psychological security Social relationships self-esteem needs Self actualization needs Maslow's hierarchy of needs include five levels of priority. The first level includes physiological needs such as air, water, and food. The second level includes safety and security needs, which involve physical and psychological security. The third level contains love and belonging needs, including friendship and social relationships. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The final level is the need for self-actualization, the state of achieving one's full potential and having the ability to solve problems and cope realistically with life situations.

A nurse is caring for an older adult with dementia who has been admitted in the special ward for further treatment. Which situation should the nurse address to meet the safety and security needs of the client according to Maslow's hierarchy of needs? Since my teeth hurt when I eat, I drink fruit juices and prefer a liquid diet." "I do not want to talk to any stranger as I fear that they might take away my things." "My blood pressure level keeps on fluctuating, although I take medications regularly." "Ever since my family members came to know about my problem they are trying to avoid me."

"I do not want to talk to any stranger as I fear that they might take away my things." The nurse should attend to the safety and security needs of the client by addressing the client's fear of strangers. When the client says that he/she is on liquid diet, the nurse should consider this as a possible lack of nutrition. This is a physiological need. When the client says that his/her blood pressure level fluctuates, the nurse should consider this as an example of physiological needs. When the client says that his/her family members avoid him/her as he/she has dementia, the nurse should understand this to be a love and belonging need.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased Pco2 levels

Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco2 level will increase in profound shock.

What is the priority nursing action when caring for a client with disseminated intravascular coagulation? Monitor for Homans sign. Avoid giving intramuscular injections. Take temperatures via the rectal route. Apply sequential compression stockings.

Avoid giving intramuscular injections. Massive amounts of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homans sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Sequential compression stockings are used to prevent thrombophlebitis.

A nursing student is citing examples of situations based on Maslow's hierarchy of needs. Which situations belong to the first level of needs? Select all that apply. "A client informs the nurse that he or she is a homeless person." "A client tells the nurse that he or she has been feeling dizzy for two days." "A client tells the nurse that he or she is beaten up repeatedly by a neighbor." "A client tells the nurse that he or she is unable to consume food because of throat pain." "A client informs the nurse that he or she is going to walk one day even after undergoing leg amputation."

"A client informs the nurse that he or she is a homeless person." "A client tells the nurse that he or she has been feeling dizzy for two days." "A client tells the nurse that he or she is unable to consume food because of throat pain." According to Maslow's hierarchy of human needs, the first level constitutes physiological needs such as air, water, food, and body temperature. A homeless client who lacks shelter probably does not receive enough food to eat. This indicates a physiological need. A client who has been feeling dizzy for two days might have some serious underlying health issue. This is an example of a first level need. A client who is unable to eat food because his or her throat hurts may need pain medication, which is a first level need. A client who may be harmed physically by a neighbor may need security. This is an example of a second level need. Fifth level needs are self-actualization needs. A client who has undergone leg amputation and wishes to be able to walk again is an example of a client with a fifth level need.

A registered nurse is explaining Maslow's hierarchy of needs to a nursing student, by examining different situations. Which examples mentioned by the nurse belong to the fifth level of needs? Select all that apply. "A client wishes to become the best swimmer in the whole world." "A client tells the nurse that he or she has the urge to urinate every 10 minutes." "A client feels like a failure for not being able to complete college education." "A client tells the nurse that he or she wishes to become a successful engineer despite having dyslexia." "A client who is bedridden requests a physical therapist consultation in order to achieve maximum mobility."

"A client wishes to become the best swimmer in the whole world." "A client tells the nurse that he or she wishes to become a successful engineer despite having dyslexia." "A client who is bedridden requests a physical therapist consultation in order to achieve maximum mobility." According to Maslow's hierarchy of needs, the fifth level of needs include self-actualization needs. At this level, the individual wishes to reach his or her maximum potential while coping realistically with the situations of life. A client who wants to become the best swimmer in the world, become a successful engineer, or achieve maximum mobility after being bedridden is displaying self-actualization needs. Feeling the urge to urinate every 10 minutes is a physiological health problem that belongs to the first level of needs. A client who feels like a failure for not being able to complete college education may have a lack of self-worth and achievement. This situation belongs to the fourth level of needs.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse caring for a client prioritizes nursing actions based on Maslow's hierarchy of needs. Which statement made by the client meets the love and belonging need? "I do not like the way I look, speak, or act." "I dream of becoming the richest person in the world." "I hardly speak to my children because they live in different countries." "I want to go back home because I am afraid of the tests you are performing."

"I hardly speak to my children because they live in different countries." If a client says that he or she hardly speaks to his or her children because they live in different countries, this statement is an example of the love and belonging need according to Maslow's hierarchy of needs. If a client says that he or she does not like the way he or she looks, speaks, or acts, this statement is an example of low self-esteem. Here, the nurse needs to address the client's self-esteem needs. If a client says that he or she dreams of becoming the richest person in the world, this statement is an example of self-actualization needs. If a client says that he or she wants to go back home because he or she is afraid of the tests being performed, this statement is an example of safety and security needs. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client would meet the self-esteem need? "I fear that my partner will leave me because of my illness." "I want to stay fit because my aim is to be a successful entrepreneur." "I do not have anyone in my life, as my family has disowned me." "I tend to get worried about every little thing because I cannot do anything successfully."

"I tend to get worried about every little thing because I cannot do anything successfully." According to the Maslow's hierarchy of needs model, certain human needs are more basic than others. When a client says that he or she tends to worry about every little thing because he or she cannot do anything successfully, this is an example of self-esteem needs. When a client says that he or she fears that his or her partner will leave him or her because of his or her illness, this statement is an example of safety and security needs. When a client says that he or she wants to stay fit to become a successful entrepreneur, this statement is an example of self-actualization needs. When a client says that he or she does not have anyone in his or her life because of being disowned by his or her family, this statement is an example of love and belonging needs.

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement made by the client meets the self-actualization need? "I need help because I am having trouble breathing properly." "I cannot afford health care because I am homeless." "People always tend to criticize me, even if I do something good." "I want to live because I want to be a good parent to my kids."

"I want to live because I want to be a good parent to my kids." According to Maslow's hierarchy of needs, self-actualization is the highest expression of one's individual potential. When a client says that he or she wants to live because his or she wants to be a good parent to his or her kids, this statement indicates a need for self-actualization. When a client says that he or she is having trouble breathing, this statement indicates that the client has physiological needs. When a client says that he or she cannot afford health care because of homelessness, this statement indicates a deficiency in physiological needs. When a client says that people always tend to criticize him or her even if he or she does something good, this statement is an example of self-esteem needs.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

A registered nurse is teaching a nursing student about Maslow's hierarchy of needs. Which statement made by the nursing student needs correction? "The hierarchy of basic human needs includes five levels of priority." "The second level includes safety and security needs, which involve physical and psychological security." "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life."

"The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization.

It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. The client expresses concern about having an increased risk of accidental electrocution. How should the nurse respond? "No one has been electrocuted yet by a pacemaker." "New technology prevents electrocution from occurring." "The pacemaker is pretested for safety before it is inserted." "The voltage emitted is not strong enough to electrocute."

"The voltage emitted is not strong enough to electrocute." Stating that the voltage emitted is not strong enough to electrocute the client will reduce anxiety. Milliamps are used, not volts of electricity; higher voltages are needed to electrocute. Stating that "No one has been electrocuted yet by a pacemaker" is a patronizing response and minimizes the stated concern. The voltage used in pacemakers can never cause electrocution; technology is not related. Although pacemakers are pretested for safety, this does not address the concern about the possibility of electrocution.

A nurse is evaluating examples of situations pertaining to the basic needs of human beings according to Maslow's hierarchy of needs. Which situations qualify under the fourth level of needs? Select all that apply. A client laments that he or she is the ugliest person in the whole world. A client informs the nurse that he or she has been living alone for the past decade. A client tells the nurse that he or she feels out of breath even when walking slowly. A client tells the nurse that he or she is the only member in the family who does not work. A client feels that he or she has not been able to live up to his or her partner's expectations.

A client laments that he or she is the ugliest person in the whole world. A client feels that he or she has not been able to live up to his or her partner's expectations. According to Maslow's hierarchy of needs, the fourth level needs constitute the esteem and self-esteem needs. This includes self-confidence, usefulness, achievement, and self-worth. The client who believes that he or she is the ugliest person in the whole world displays a lack of self-worth. This is an example of a fourth level need. A client who informs the nurse that he or she is the only family member who does not work displays a lack of achievement and usefulness. This is another example of the fourth level needs. A client who tells the nurse that he or she has not been able to live up to his or her partner's expectations indicates a lack of achievement and self-worth. This is also an example of esteem and self-esteem needs. A client who has been living alone for a decade indicates a lack of social interactions and social relationships. This is an example of third level needs (love and belonging). Physiological needs such as difficulty breathing is a first level need.

A nurse is evaluating different situations related to Maslow's hierarchy of needs. Which situations come under the second level of needs? Select all that apply. A client tells the nurse that he or she has no friends A client tells the nurse that he or she is taunted by his or her boss every day. A client tells the nurse that his or her spouse belongs to a criminal gang. A client tells the nurse that he or she does not like interacting with people. A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals.

A client tells the nurse that he or she is taunted by his or her boss every day. A client tells the nurse that his or her spouse belongs to a criminal gang. A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals. According to Maslow's hierarchy of needs, the second level of needs involves safety and security needs. This includes both physical and psychological security and safety of the person. Clients who are taunted by their boss every day, have spouses that are part of a criminal gang, or live next to a factory that manufactures harmful chemicals are display second level needs. A client who laments about not having friends or does not like interacting with people is displaying a third level of needs (love and belonging needs).

Noah has made it clear he doesn't want to talk about his dad. But the truth is, as the interview proceeds, he becomes anxious and tries to evade all questions about why he is here. Which type of communication might be most appropriate right now? A.Stop questioning so much and just give him some good advice so he'll trust you. B.Express honest disapproval of his resistance to help. C.Ask him pointblank why he is evading you. D. Ask a miracle question

ANS: D ask a miracle question The miracle question is a goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish. While Noah is anxious about saying anything specific about what is troubling him, he may be able to talk about what he might wish for. This very basic question often gets to the source of the most important issues in a person's thinking and life. The other three solutions here are all excellent examples on nontherapeutic communication techniques.

A hospitalized client receiving a diet that limits sodium to 2 g complains about the bland food and refuses to eat dinner. What is an appropriate nursing response? Asking the client about what foods are eaten at home. Telling the client about several brands of low-sodium spices. Explaining to the client that the diet eventually will have to be accepted. Urging the client to eat to become accustomed to the diet that must be followed at home.

Asking the client about what foods are eaten at home. Asking the client what foods usually are eaten at home is an attempt to collect adequate data to plan the most appealing and appropriate diet. Low-sodium spices still contain salt and should be avoided when receiving a low-sodium diet. Explaining to the client that the diet eventually will have to be accepted will not guarantee compliance once the client goes home; the client has the right to accept or reject therapy. Urging the client to eat to become accustomed to the diet that must be eaten at home will not guarantee compliance once the client goes home; the client has the right to accept or reject therapy.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? Interview the client for a health history. Assess the client's heart and lung sounds. Monitor the client's pulse and temperature. Obtain the client's blood specimen for electrolytes

Assess the client's heart and lung sounds. With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

Case study: As you prepare for the initial interview with 15-year-old Noah, you learn that he has a history of cutting himself. His parents have separated and are getting a divorce; his father has left and Noah is living with his mother. Noah has been smoking for about a year and a half and his mother suspects that he has come home smelling of marijuana twice now. All three behaviors were ongoing before the father left. Which behavior from Noah would be considered a double-bind message? A.He winks at you and says, "Do you date 15-year-old guys?" B.He puts his head in his hands, shakes it, and snaps, "I don't want to do this. Just get me out of here!" C.He sneers at you and almost purrs as he says, "Oh yes. I will tell you anything you want to know, of course, I will." D.He cries and shakes, jiggling one leg, as he says softly, "Please, let's just not talk about Dad, okay?

C. He sneers at you and almost purrs as he says, "Oh yes. I will tell you anything you want to know, of course, I will." A double-bind message is a mutually contradictory message given by a person in power or attempting to gain or maintain power. In example C, Noah is in a frightening or uncomfortable position and attempts to gain or maintain some control or power. You, the nurse, want information from him. You want his cooperation, and he doesn't want to give it. So his nonverbal language—sneering and a rather mocking purr—contradicts the verbal message, or content: that of a promise to cooperate and answer "anything." In examples B and D, his actions match his verbal message. They do in "A" as well. He is trying to deflect you from the serious nature of the interview, but he's not using a double-bind message. His wink does match his words.

A nursing student is reviewing different statements as they fulfill Maslow's hierarchy of needs, from the highest level of needs to the lowest level of needs. In which order should the nursing student arrange the scenarios, from the highest the lowest level of needs? Correct1.A client says to the nurse, "I want to maintain good health as I intend to be the best soccer player on my team." Correct2.A client says to the nurse, "I do not have any skills that will help me be an achiever in life." Correct3.A client says to the nurse, "I have been feeling depressed ever since my sibling stopped speaking to me." Correct4.A client says to the nurse, "My father threatens to commit me to an asylum if I dare disobey him."

Correct1.A client says to the nurse, "I want to maintain good health as I intend to be the best soccer player on my team." Correct2.A client says to the nurse, "I do not have any skills that will help me be an achiever in life." Correct3.A client says to the nurse, "I have been feeling depressed ever since my sibling stopped speaking to me." Correct4.A client says to the nurse, "My father threatens to commit me to an asylum if I dare disobey him." According to Maslow's hierarchy of needs, self-actualization is the highest level of need for an individual. If the client intends to reach his or her full potential as a human being, this statement indicates the need to achieve self-actualization. The next level of need is self-esteem. The client displays a lack of self-esteem by conveying to the nurse that he or she lacks the skills to achieve anything in life. The next need is love and belonging. The client's statement about the cessation of contact with his or her sibling illustrates this need. The lowest level of need is safety and security. A client who voices being abused by his or her father endangers the psychological safety of the client.

A nurse is evaluating different scenarios related to addressing different levels of client needs. Arrange which nursing actions are prioritized according to Maslow's hierarchy of needs. Correct1.Administering medications to regulate the client's body temperature of the client Correct2.Collaborating with the social service department to keep the client away from abusers Correct3.Contacting the client's family members in order to help the client mend relationships Correct4.Initiating therapeutic communication to boost the client's self-esteem

Correct1.Administering medications to regulate the client's body temperature of the client Correct2.Collaborating with the social service department to keep the client away from abusers Correct3.Contacting the client's family members in order to help the client mend relationships Correct4.Initiating therapeutic communication to boost the client's self-esteem According to Maslow's hierarchy of needs, the basic level needs of a client should be met first before addressing higher level needs. The lowest level is to meet the client's physiological needs. Therefore, the nurse should first administer medications to regulate the client's body temperature. The next need is safety and security. The nurse should therefore ensure the safety of the client from abusers by collaborating with the social service department. The next level of need is love and belonging. To fulfill this need, the nurse should contact the client's family members. The next level of need is self-esteem. The nurse should use therapeutic communication strategies to bolster the client's self-esteem.

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply. Polyuria Dyspnea Diaphoresis Tachycardia Hypertension

Dyspnea Diaphoresis Tachycardia Shortness of breath and an increase in the respiratory rate occur with cardiogenic shock. Cold, clammy (diaphoresis) skin occurs because of vasoconstriction associated with stimulation of the sympathetic nervous system. The heart rate increases (tachycardia) as the heart attempts to maintain cardiac output and circulating blood volume. A decrease in circulation of blood to the kidneys results in oliguria, not polyuria. Hypotension, not hypertension, is a sign of cardiogenic shock; the systolic reading is often below 90 mm Hg.

A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data? Loss of battery power Functioning as expected Failure to stimulate the heart Ignoring the client's heartbeat

Failure to stimulate the heart If pacemaker spikes are present, the pacemaker is firing appropriately, but the lack of resulting QRS complexes indicates that it is not stimulating or "capturing" the heart. Loss of battery power is indicated by a slowing or irregular heart rate. Each pacemaker spike should be followed by a QRS complex. A fixed or asynchronous pacemaker is designed to work independently of the client's intrinsic rhythm.

Which level of Maslow's hierarchy of needs is fulfilled by the nurse fitting a client who nearly died of asphyxiation with an oxygen mask? First level Second level Third level Fourth level

First level The first level of Maslow's hierarchy of needs includes the most basic and physiologic needs like air, water, and food. Therefore fitting a client with an oxygen mask meets the basic physiological needs. The second level includes safety and security needs, which involve physical and psychological security. The third level includes love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth.

Which level of Maslow's hierarchy of needs is fulfilled by the nurse fitting a client who nearly died of asphyxiation with an oxygen mask? First level Second level Third level Fourth level

First level. The first level of Maslow's hierarchy of needs includes the most basic and physiologic needs like air, water, and food. Therefore fitting a client with an oxygen mask meets the basic physiological needs. The second level includes safety and security needs, which involve physical and psychological security. The third level includes love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth.

A nurse is auscultating a client's heart; closure of what structures produces the first heart sound (S1)?

Mitral and tricuspid valves Closure of the atrioventricular valves, the mitral (bicuspid) and tricuspid, produces S1. Neither the aortic and tricuspid valves nor the mitral and pulmonic valves close simultaneously. The aortic and pulmonic valves are the semilunar valves; closure of these valves produces the second heart sound (S2).

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which activities should the nurse perform to meet the client's safety and security needs? Select all that apply. Providing a cold bath to reduce the client's body temperature Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents Collaborating with family members to provide emotional support for the client post-surg

Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents As per Maslow's hierarchy of needs, to meet the safety and security needs of the client, the nurse should position the bed in a low position and keep the side rails up to provide physical safety for the client. Monitoring vital signs, including blood pressure to prevent risk for falls is an example of a nursing activity that meets the client's safety and security needs. Observing a client who has suicidal tendencies to prevent adverse incidents is an example of a nursing activity that meets the client's safety and security needs. Providing a cold bath to the client to reduce body temperature is an example of a nursing activity that meets the client's physiological needs. Collaborating with family members to provide emotional support to the client post-surgery is an example of a nursing activity that meets the client's love and belonging needs.

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. Rapid pulse Deep respirations Warm, flushed skin Increased blood pressure Decreased urinary output

Rapid pulse Decreased urinary output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to prevent the potential danger of inducing ventricular fibrillation during cardioversion? Energy level is set at its maximum level. Synchronizer switch is in the "on" position. Skin electrodes are applied after the T wave. Alarm system of the cardiac monitor is functioning simultaneously

Synchronizer switch is in the "on" position. The precordial shock during cardioversion must not be delivered on the T wave, or ventricular fibrillation may ensue. By placing the synchronizer in the "on" position, the machine is preset so that it will not deliver the shock on the T wave. The energy level may be set from 50 to 100 Watts/second. Skin electrodes applied after the T wave and an alarm system of the cardiac monitor functioning simultaneously will not ensure that the shock is not delivered on the T wave.

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

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

A client who has sustained an accident says, "I have a dream of conquering the world's highest mountain range." To which level of need does the given scenario refer to, according to Maslow's hierarchy of needs? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the fourth level that includes self-esteem needs. The given scenario relates to the final level that includes self-actualization needs. The given scenario relates to the second level that includes safety and security needs.

The given scenario relates to the final level of Maslow's hierarchy of needs: the self-actualization needs. The self-actualization need refers to self-fulfillment. Physiological needs refer to the need for clean air, water, and food. Self-esteem needs refer to self-confidence, usefulness, achievement, and self-worth. Safety and security needs refer to physical and psychological security. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of? Atrial fibrillation Cardiac irritability Impending heart block Ventricular tachycardia

Cardiac irritability Cardiac irritability is the cardinal reason for PVCs. Atrial fibrillation is a type of dysrhythmia, not the cause of PVCs; the source of atrial fibrillation is the atrium, not the ventricles. Impending heart block type of dysrhythmia is associated with interference with the conduction system. Ventricular tachycardia is a type of dysrhythmia, not the cause of PVCs.

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client? Obstructive Neurogenic Cardiogenic Hypovolemic

Hypovolemic Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel. Obstructive shock occurs from physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism. Neurogenic shock results from decreased neuromuscular tone, which reduces vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased Pco2 levels

Metabolic acidosis Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The Pco2 level will increase in profound shock.

An emancipated minor admitted to the healthcare setting states "I have not had proper meals since last week." Which needs should the nurse address using Maslow's hierarchy of needs? Physiological Self-actualization Safety and security Love and belonging needs

Physiological According to Maslow's hierarchy of needs, the basic human needs are food, water, safety, and love. In the given scenario, the client has not been able to eat since last week so, the nurse should address the physiological need of the client first. Self-actualization deals with the need to achieve one's highest potential. Safety and security includes the physical and psychological safety of the client. Love and belonging needs includes the need to give and receive love and affection.

The nurse is interpreting an electrocardiogram rhythm. What part of the electrical pattern represents ventricular contraction? P wave T wave PR interval QRS interval

QRS interval Atrial and ventricular depolarization and repolarization are represented on the electrocardiogram (ECG) as a series of waves: the P wave followed by the QRS complex and the T wave. The first deflection is the P wave associated with right and left atrial depolarization followed by the QRS complex that reflects ventricular depolarization.

the "miracle" question

a clarifying technique (along with paraphrasing, restating, reflecting, exploring, and projective questions) The miracle question is a goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish. The question should be asked deliberately and dramatically Example: "Now, I want to ask you a strange question. Suppose that while you are sleeping tonight...a miracle happens. The miracle is that the problem that brought you here is solved... When you wake up tomorrow morning, what will be different that will tell you that a miracle has happened?"

double bind messages

Bateson and colleagues (1956) coined the term double-bind messages. They are characterized by two or more mutually contradictory messages given by a person in power or someone attempting to gain or maintain power. Opting for either choice will result in displeasure of the person in power. Example: Dr. Shepard asks Dr. Onori to teach one of the topics in nursing research because she knows Dr. Onori teaches that topic very well. On the day of the lecture, Dr. Onori just informs Dr. Shepard that he is going to the beach with his family and thus can't teach the topic. Dr. Shepard looks into the eyes of Dr. Onori and says, okay, that's fine, enjoy your vacation knowing very well that she has not prepared to teach the research topic for that day. The content from Dr. Shepard becomes contradictory to Dr. Onori.

Peplau's model of nurse patient relationship

POWT Phases: Preorientation orientation working termination

Morally, legally, and ethically trained nurses and nursing students do not have ______________ relationships with patients

intimate these are forbidden among nurses/students with patients/clients

Which ECG report shows atrial fibrillation?

irregularly irregular different distance between R waves Image 4 shows a wavy baseline with atrial electrical activity and an irregular ventricular rhythm which indicates atrial fibrillation. Image 1 shows normal sinus rhythm in which both atrial and ventricular rhythms are essentially regular. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology or shape. Image 2 shows sinus tachycardia. Image 3 shows sinus bradycardia.

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

social relationship

primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task •Participants share ideas, feelings, and experiences during SRs to facilitate meeting of mutual needs •There is little emphasis on the evaluation of the interaction during SRs •SRs do not benefit patients because the nurse unconsciously ignores the concerns of patients

Which basic human needs belongs to the fourth level as per Maslow's hierarchy of needs? Select all that apply. Self worth Achievement Security needs Belonging needs Self actualization

self worth achievement Fourth level of Maslow's hierarchy of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth, and achievement. Security needs are included in the second level. Belonging needs such as friendship, social relationships, and sexual love come under the third level. Self-actualization is the basic human need, which belongs to the final level.

You are about to initiate your first contact with Becky. Which is the most suitable goal in establishing the therapeutic relationship? •Establish friendship and a sense of fun •Ensure that mutual needs will be met •Establish clear boundaries while identifying patient needs •Ensure two-way communication to give or ask for help

•Establish clear boundaries while identifying patient needs A therapeutic relationship demonstrates the following qualities: Needs of patient identified and explored Clear boundaries established Problem-solving approaches taken New coping skills developed Behavioral change encouraged The other choices listed here are more appropriate to a social relationship.

A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse's best response? "Hot drinks such as coffee are not good for your heart." "Coffee is not permitted on the diet that was prescribed for you." "You cannot have coffee. I can bring you a cup of tea if you like." "Coffee has caffeine that can affect your heart. It should be avoided."

"Coffee has caffeine that can affect your heart. It should be avoided." Caffeine is a stimulant that causes vasoconstriction and is contraindicated for a client with a dysrhythmia. Although "Hot drinks such as coffee are not good for your heart" is a true statement, it does not provide information as to why it is not good for the heart. Adherence to a medical regimen increases when the client understands the rationale for recommendations. Tea contains caffeine and should be avoided by a client with a dysrhythmia.

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle? P wave T wave P-R interval QRS complex

The T wave The T wave is the period of repolarization of the ventricles; stimulation of the ventricles during this vulnerable period often causes ventricular fibrillation. If a premature ventricular contraction strikes on the P wave, it will not cause ventricular fibrillation; the P wave represents atrial contraction. The P-R interval represents the time it takes the impulse to travel from the sinoatrial (SA) node to the ventricular musculature. The QRS complex is the term used to represent the entire phase of ventricular contraction.

To prevent septic shock in the hospitalized client, what should the nurse do? Maintain the client in a normothermic state. Administer blood products to replace fluid losses. Use aseptic technique during all invasive procedures. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

the backbone of a nurse-client relationship is

patient centered care (gold standard) -dignity and respect -information sharing -pt and family participation -collaboration in policy and program development

A nurse is assessing a client by using Maslow's hierarchy of needs. In which order should the nurse prioritize care?

1.Physiological 2.Safety and security 3.Love and belonging 4.Self-esteem 5.Self-actualization According to Maslow's hierarchy of needs, the nurse should prioritize physiological needs because these are basic human needs. The nurse should then address safety and security, which includes physical and psychological safety. Next, the nurse should address love and belonging needs. After this, the nurse should attend to the client's self-esteem needs. Finally, the nurse should address self-actualization needs.

A nurse is evaluating different situations related to addressing different levels of client needs. According to Maslow's hierarchy of needs, in which order should the nurse prioritize his or her actions? 1.Encouraging the client to talk about his or her fears and feelings 2.Providing a warm bath to the client to promote a good night's sleep 3.Praising the client for administering insulin accurately 4.Assisting the client in getting out of bed to join family members for meals

1.Providing a warm bath to the client to promote a good night's sleep 2.Encouraging the client to talk about his or her fears and feelings 3.Assisting the client in getting out of bed to join family members for meals 4. Praising the client for administering insulin accurately According to Maslow's hierarchy of needs, the basic needs of the client should be addressed first before moving toward the highest level of need. Thus, providing a warm bath to promote a good night's sleep addresses the physiological (basic) need of the client. The next level of need is the safety and security need. The nurse encourages the client to talk about his or her fears and feelings to meet this need. The next level is the love and belonging need. The nurse assists the client in getting out of bed and joining family members for meals meets this need. Finally the nurse addresses the self-esteem need by praising him or her for administering insulin accurately.

A nurse is prioritizing client-care by using Maslow's hierarchy of needs. Which situation should the nurse address to meet the self-actualization needs of the client? A client says, "I want to be a world class athlete." A client says, "I do not want to go home because no one there cares." A client says, "I am not feeling good. Can you please check if I have fever?" A client says, "Whatever I do for my family or for my loved ones does not actually help them."

A client says, "I want to be a world class athlete." According to Maslow's hierarchy of needs, self-actualization is the desire to reach one's full potential. In the given scenario, the nurse should address the client who wants to be a world class athlete to address self-actualization needs. When a client says that he/she does not want to go back home as there is no one there that cares, this comes under love and belonging needs. When a client says that he/she is feeling feverish, this comes under physiological needs, which address the basic requirements of an individual. When a client says that whatever he/she does for his/her family and loved ones do not actually help them, it is an example of low self-esteem. Here, the nurse should address the self-esteem needs of the client.

Becky tells you, "I have something secret to tell you, but you can't tell anyone else." The nurse agrees. What is the likely consequence of the nurse's action? A.Healthy feelings of sympathy by the nurse toward the client. B.Blurred boundaries in the nurse-client relationship. C.Improved rapport between the nurse and client. D.Enhanced trust between the nurse and client

ANS: B Keeping secrets indicates that the nurse is overly involved and is one aspect of blurred boundaries.

After your first conversation, Becky withdraws from you again before you've even really begun. Which statement will contribute most to establishing Becky's trust? A."Weren't you complying with your medication regimen?" B."It must be discouraging to be readmitted to the hospital so soon." C."Everyone with bipolar disorder ends up in the hospital occasionally." D."You must take your drugs as prescribed or you will be rehospitalized."

ANS: B When the nurse shows genuine concern for another's circumstances (has positive regard and empathy), even a short encounter can have a powerful effect.

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? Septic shock Cardiogenic shock Neurogenic shock Anaphylactic shock

Anaphylactic shock Anaphylactic shock occurs when the body has a hypersensitivity to an antigen. This may lead to death quickly. Common causes are blood products, insect stings, antibiotics, and shellfish. Septic shock is caused by a systemic infection and release of endotoxins. Cardiogenic shock is when the heart fails to pump and demonstrates symptoms of heart failure, such as pulmonary edema. Neurogenic shock is caused by problems with the nervous system and usually occurs because of damage of the spinal cord.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? Arteriolar constriction occurs. The cardiac workload decreases. Contractility of the heart decreases. The parasympathetic nervous system is triggered.

Arteriolar constriction occurs. The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain. The cardiac workload will increase, not decrease, as the heart attempts to pump more blood to the vital organs. The heart compensates by increasing its contractility, which will increase, not decrease, the cardiac output. The sympathetic, not parasympathetic, nervous system is triggered to produce vasoconstriction.

Patient is receiving an IV infusion of heparin and was started on warfarin therapy the night before. which statement is most correct? A. the patient is receiving a double dose of anticoagulants B. the heparin therapy was ineffective, so the warfarin was started. C. the heparin provides anticoagulation until therapeutic levels of warfarin are reached. D. the heparin and warfarin work together synergistically to provide anticoagulation

C. the heparin provides anticoagulation until therapeutic levels of warfarin are reached. coumadin (warfarin) takes a few days for therapeutic levels to be reached. we may end up putting a pt on both of these initially to get the anticoagulation under control, and then once the coumadin levels are okay, the pt will come off of heparin

A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. Oliguria Bradypnea Diaphoresis Tachycardia Hypertension

Decreased blood volume leads to decreased glomerular filtration; compensatory antidiuretic hormone (ADH) and aldosterone secretion cause sodium and water retention, thereby decreasing urinary output. Diaphoresis and tachycardia occur because of the sympathetic nervous system-mediated response. Respirations become rapid and shallow, not slow, because of the sympathetic nervous system-mediated response. Hypotension, not hypertension, is the response to a decrease in circulating blood volume.

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply. Stridor Fissuring Hypotension Dyspnea Cracking of the skin

Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea. Fissuring and cracking of the skin occurs in individuals with a type IV contact dermatitis.

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? An irreversible phenomenon A failure of the circulatory pump Usually a fleeting reaction to tissue injury Generally caused by decreased blood volume

In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia will lead to hypovolemic shock; cardiogenic refers to the heart capabilities.

A client with a history of hypertension and left ventricular failure arrives for a scheduled clinic appointment and tells the nurse, "My feet are killing me. These shoes got so tight." What is the nurse's best initial action? Weigh the client. Notify the primary healthcare provider. Take the client's pulse rate. Listen to the client's breath sounds.

Listen to the client's breath sounds. After the assessment protocol of airway, breathing, and circulation (ABCs), the nurse should assess the client's breath sounds for crackles that may indicate the development of heart failure. Although the client should be weighed, it is not the priority. Shoes that become too tight indicate pedal edema, which is a sign of fluid retention; 1 L of fluid weighs 2.2 pounds (1 kilogram). Eventually the primary healthcare provider will be notified, but the nurse should have more data for the primary healthcare provider. Taking the client's pulse rate will happen, but not as a priority.

Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement? Lowering of the T wave Elevation of the ST segment Shortening of the QRS complex Increased deflection of the Q wave

Lowering of the T wave Hypokalemia causes a flattening of the T wave on an electrocardiogram, as observed on the monitor, because of its effect on muscle function. Hypokalemia causes a depression of the ST segment. Hypokalemia causes a widening of the QRS complex. Hypokalemia does not cause a deflection of the Q wave.

During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid associated with the progressive stage of shock. Respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis occurs as a result of hyperventilation during early shock.

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? Oliguria Crackles Dyspnea Bounding Pulse

Oliguria Urine output decreases to less than 20 to 30 mL/hr (oliguria) because of decreased renal perfusion secondary to a decreased circulating blood volume. Crackles are associated with pulmonary edema, not hypovolemic shock. Dyspnea may be associated with hypervolemia, not hypovolemia, as well as with pulmonary edema and respiratory disorders. Bounding pulse will occur with hypervolemia.

Which action is the least likely to prevent sleep disturbances? Avoiding reading, writing, and eating in bed Getting out of bed if unable to fall sleep after 20 minutes Performing strenuous exercise within an hour before going to bed Lowering the temperature of the bedroom and keeping it dark and quiet

Performing strenuous exercise within an hour before going to bed To prevent sleep disturbances, a client should not perform strenuous exercise within six hours before bedtime. A client should avoid reading, writing, and eating in bed. To prevent sleep disturbances, a client should get out of bed if he or she is not able to fall sleep after 20 minutes. The client should also lower the temperature of the bedroom and keep it dark and quiet.

An emancipated minor admitted to the healthcare setting states "I have not had proper meals since last week." Which needs should the nurse address using Maslow's hierarchy of needs?

Physiological According to Maslow's hierarchy of needs, the basic human needs are food, water, safety, and love. In the given scenario, the client has not been able to eat since last week so, the nurse should address the physiological need of the client first. Self-actualization deals with the need to achieve one's highest potential. Safety and security includes the physical and psychological safety of the client. Love and belonging needs includes the need to give and receive love and affection.

A client with a severe allergy has been administered a high dose of antihistamine. The nurse finds that the client is drowsy and dizzy. Which type of need would the nurse prioritize in the client according to Maslow's hierarchy of needs? Safety need Belonging need Self-esteem need Self actualization need

Safety need Clients suffering from the effects of a high dose of antihistamines have strong safety needs. The belonging need is fulfilled when the client is provided love and compassion. Self-esteem needs are fulfilled by providing recognition. Self-actualization needs may not be the priority of the client in the current situation.

A client says "I feel frustrated because I do not spend enough time with my partner because of my job." According to Maslow's hierarchy of needs, which level of need does the given scenario refer? The given scenario relates to the first level that includes physiological needs. The given scenario relates to the second level that includes safety and security needs. The given scenario relates to the third level that includes love and belonging needs. The given scenario relates to the final level that includes self-actualization needs.

The given scenario relates to the third level that includes love and belonging needs. The love and belonging need is the third level of need in the Maslow's hierarchy of needs. This includes maintaining friendships, social relationships, and intimate relationships. In the given scenario, the client demonstrates that he or she wants to spend more time with his or her partner. Thus, this is an example of the third level of needs.

A client in the emergency department is diagnosed with atrial fibrillation. Initially the primary healthcare provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm? The vagus nerve is stimulated. The glottis closes momentarily. Thoracic pressure decreases. Respiratory pattern is interrupted.

The vagus nerve is stimulated. Inhaling and forcing the diaphragm and chest muscles against a closed glottis increase intrathoracic pressure, which affects the vagus nerve and slows the heart. Although the glottis closes, this does not interrupt the dysrhythmia. Thoracic pressure increases, not decreases, during the Valsalva maneuver. Although the respiratory pattern is interrupted briefly, this does not interrupt the dysrhythmia.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? Diuresis, irritability, and fever Lethargy, cold skin, and hypertension Thirst, cool skin, and orthostatic hypotension Bounding pulse, restlessness, and slurred speech

Thirst, cool skin, and orthostatic hypotension With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? Lactated Ringer solution Serum albumin Blood replacement high molecular dextran

blood replacement Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. Lactated Ringer solution does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level

metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

As a nurse assesses a new client, the nurse makes sure the door remains open. Which type of communication factor is this action? A.Environmental B.Relationship C.Personal

A. Environmental Environmental factors that may affect communication include physical factors (e.g., background noise, lack of privacy, uncomfortable accommodations) and societal determinants (e.g., sociopolitical, historical, and economic factors, the presence of others, expectations of others).

During auscultation of the heart, where does the nurse expect the first heart sound (S1) to be the loudest? Base of the heart Apex of the heart Left lateral border Right lateral border

Apex of the heart The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apex of the heart. The base of the heart is where the second heart sound (S2) is best heard; S2 is produced by closure of the aortic and pulmonic valves. The left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. The right lateral border covers a large area; the only auscultatory area near it is the aortic area.

To determine the status of a client's carotid pulse, where should the nurse palpate? Below the mandible In the lateral neck region Along the clavicle at the base of the neck At the anterior neck, lateral to the trachea

At the anterior neck, lateral to the trachea The carotid artery is located along the anterior edge of the sternocleidomastoid muscle at the level of the lower margin of the thyroid cartilage. Below the mandible, in the lateral neck region, and along the clavicle at the base of the neck are not the anatomic landmarks for locating the carotid artery.