Nursing Fundamentals

When interviewing and assessing a 17-year-old client, which findings alter the nurse to explore substance abuse with the adolescent?

a. Failing grades b. Blood spots on clothing c. Absenteeism from school d. Long-sleeved shirts in warm weather Rationale: Adolescents are developing independence and should be assessed for risk-taking behaviors such as drug abuse.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. One, some, or all responses may be correct.

a. Respiratory rate of 14 breaths/minute b. Blood pressure of 120/80 mm Hg c. Oxygen saturation of 95% Rationale: In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mm Hg, and oxygen saturation of 95% are normal readings. The registered nurse would reassess these vital signs. The normal temperature range is 96.8 (36C) to 100.4 (38C); this range is unaffected by a pulmonary infection. The nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular; reassessment would not be required.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgement. Which might the client's body temperature be?

33 degrees Celcius--A body temperature in the range of 36 to 38 degrees Celsius. Is normal. When skin temperature drops below 35 degrees, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgement as a result of hypothermia. A body temperature lower than 30 degrees Celsius represents severe hypothermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33 degrees.

How would the student nurse describe a quasi-intentional tort occurring during the parractice of nursing?

An act that lacks intent but involves volitional action. A quasi-intentional tort lacks intent but involves volitional actions such as invasion of privacy and defamation of character. An intentional tort is a willful act that violates another's rights. This includes assault, battery, and false imprisonment. A tort is a civil wrong made against a person or property. An unintentional tort involves negligence and malpractice.

Which role does the nurse play when helping clients identify and clarify health problems and choose appropriate courses of action to solve those problems?

As a counselor, the nurse helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. As an educator, the nurse teaches clients and their families to assume responsibility for their own health care. The nurse acts as a change agent within a family system or as a mediator for problems within a client's community; this involves identifying and implementing new and more effective approaches to problems. As a case manager, the nurse establishes an appropriate plan of care on the basis of assessment findings and coordinates needed resources and services for the client's well-being along a continuum of care.

Which basic health care ethic does the nurse follow when signing the client's consent form as a witness?

Autonomy---refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence.

The nurse is caring for an older adult client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment information best reflects the fluid balance of this client?

Blood lab tests--Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the older adult client because it is generally decreased with age.

The nurse is assessing clients with gastrointestinal problems. Which client would the nurse suspect to have shigellosis?

Client 2: Shigellosis is a food-borne disease and may be due to the ingestion of milk products, seafood, or salad. The symptoms of infection include abdominal cramps and severe diarrhea, and can occur 12 hours after ingestion. Shigellosis is suspected in Client 2. Client 1, who has symptoms of severe abdominal cramps, pain, vomiting, diarrhea, perspiration, headache, and fever after consuming custard or processed meats, may have a Staphylococcus infection. These symptoms may appear 3 days after ingestion of contaminated foods. Client 3, who has symptoms of severe diarrhea, fever, headache, and breathing difficulty after consuming soft cheese, meat, or unpasteurized milk, may have an Escherichia coli infection. These symptoms may appear 3 days after ingestion of contaminated food. Client 4 with symptoms of severe diarrhea, cramps, and vomiting after consuming milk, custards, egg dishes, or sandwich fillings may have salmonellosis. These symptoms may appear 4 days after ingestion of those foods.

The nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results?

Client C: Rationale: The dorsalis pedis is located along the top of the foot. This site is used to assess the status of circulation in the foot. The ulnar site, found on the ulnar side of the forearm at the wrist, is used to assess the status of circulation to the hand and to perform the Allen test. The carotid site is found along the medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock or cardiac arrest, with other sites are not palpable. The posterior tibial site is found below (not above_ the medial malleolus. It is used to assess the status of circulation to the foot.

After reviewing otoscope use for assessment of the ear with the nursing staff, which response from a participant reflects safe follow-up care for when there is earwax covering the tympanic membrane?

I will perform warm water irrigation to remove the wax. Rationale: Earwax in front of the tympanic membrane should be removed for assessment and proper hearing, and irrigation with warm water is a safe way to remove the wax. The wax should not be left in place, because the tympanic membrane cannot be seen and it may disrupt normal hearing. Cotton-tipped swabs and pointed objects like the tip of a hemostat should not be placed into the ear canal because they can cause damage.

What does beneficence in health ethics refer to?

Taking positive actions to help others. Rationale: Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Accountability refers to the ability to answer for one's actions. Non-malefcence refers to avoiding harm to an individual.

Which act allows the client to donate his or her organs?

Uniform Anatomical Gift Act---The Uniform Anatomical Gift Act gives the right to donate organs to any person who is at least 18 years old. The Mental Health Parity Act forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits. The National Organ Transplant Act forbids the purchase or sale of organs. The Americans with Disabilities Act protects people with physical or mental disabilities against discrimination and ensures that they get fair opportunities and services in the social and professional spheres.