pass point week 3

The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that the patient has been angry with God because of the worsening illness, but after talking to the hospital chaplain, the patient is ready to return to the church choir and become active again in the group at the church. What is an appropriate nursing diagnosis for this patient?

Readiness for Enhanced Spiritual Well-Being The most appropriate diagnosis for this patient is Readiness for Enhanced Spiritual Well-Being. The patient desires to experience and integrate meaning and purpose in life through connection with self, others, art, music, literature, nature, or a power greater than themself.

A nurse is caring for a client with schizophrenia who states, "I can't handle the voices anymore! It's over! I've done all I can." Which statement by the nurse is best?

"Are you thinking of hurting yourself?" Risk of suicide is greater in patients with a serious illness, including mental or emotional disorders. The nurse should recognize the client's statement as a warning for possible self-harm. With this concern, the nurse should ask the client a yes/no question regarding self-harm. Using an open-ended question is therapeutic, but assessing the risk of self-harm requires a more direct approach. Asking about medications or past feelings should wait until after the risk for self-harm is determined.

Upon assessment, the nurse identifies bronchovesicular sounds over the right peripheral lung field. What question should the nurse ask the client next?

"Do you feel pain when taking a deep breath?" Bronchovesicular breath sounds are tubular sounds (not as loud as bronchial sounds) and best heard posteriorly between the scapulae. If bronchovesicular sounds are heard in the peripheral lung field, it indicates pneumonia or tissue consolidation. If the client has pain on inspiration, pneumonia should be suspected. Asking the client to cough, if there is shortness of breath, or if a breathing treatment has been given will not provide the nurse with information regarding the cause of the bronchovesicular breath sounds.

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse?

"Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks." Paced bottle feeding allows the premature infant to have more control with feeding and mimics more natural feeding. T

The nurse has discussed sexuality issues during the prenatal period with a primigravid client who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she makes which statement?

"I shouldn't get sexually aroused or have any nipple stimulation." This client has already had one episode of preterm labor at 32 weeks' gestation. Sexual intercourse, arousal, and nipple stimulation may result in the release of oxytocin, which can contribute to continued preterm labor and early birth. The client should be advised to refrain from these activities until closer to term, which is 6 to 8 weeks later.

A client recently diagnosed with hyperparathyroidism demands to see what the healthcare provider has written in the chart. What is the nurse's best response?

"I'll get the chart and set up a time for you to review it with your healthcare provider." Every client has a right to access information that the hospital has collected about the client. However, it is in the client's best interests to have a knowledgeable professional present to explain complicated information and unfamiliar terminology that the chart might include. Having the client sign a release of medical information may be necessary, but that does not assist the client to schedule a review with the healthcare provider. Suggesting the client review the chart with the healthcare provider does not facilitate the review. Contacting medical records to set up a time for the client to review does not ensure that a knowledgeable professional is available to assist the client during the review.

A client with cerumen impaction presents to the emergency department. The client asks about supplies to perform ear irrigations at home. What is the nurse's best response?

"It is not a procedure you should do at home." Clients who need ear irrigations should not perform these at home. The procedure is one that should be performed by a healthcare professional only due to the risk of damage to the ear if performed incorrectly. Supplies are not routinely furnished by the hospital, and could be obtained from a medical supply company; however, this is not relevant because the client should not irrigate the ear.

After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which statement by a parent indicates successful teaching?

"It's a fungal infection of the scalp." Ringworm of the scalp is caused by a fungus of the dermatophyte group of the species. Overexposure to the sun would result in sunburn. Mites, such as chiggers or ticks, produce bites on the skin, resulting in inflammation. An allergic reaction commonly is manifested by hives, rash, or anaphylaxis.

A 12-year-old client is 2 days postoperative from an open reduction, internal fixation procedure for a fractured femur. The client's chart reads:

1520 Calculate the breakfast intake in milliliters: 1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml) 1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml) 1 bowl of oatmeal (n/a) 1 - 6 oz glass of orange juice (6 oz × 30 ml = 180 ml). Additional information needed: 1,000 (I.V. 125 ml/hr × 8 hr) plus 100 ml (cefazolin injection, one dose). 120 ml + 120 ml + 180 ml + 1,000 ml + 100 ml = 1,520 ml

The plan of care for an outpatient client with schizophrenia includes risperidone therapy. The nurse prepares to administer this drug based on the understanding of which factor?

Agranulocytosis is less of a risk with risperidone therapy than with clozapine With schizophrenia, negative symptoms are more prominent. Therefore, risperidone is given to help control negative symptoms. Negative symptoms do not respond to typical antipsychotics such as haloperidol. Agranulocytosis is commonly associated with clozapine. Because it is a newer drug, risperidone usually is more expensive than typical antipsychotics.

A client who has an abdominal dressing has asked to use the urinal. A nurse drops a clean glove on the floor while attempting to don gloves. In which order, from first to last, should the nurse proceed?

Apply new, clean gloves. Assess the client's surgical dressing. Reposition the client's urinal. Dispose of the glove on the floor. he nurse should always work from least contaminated to most contaminated area. If the nurse picks up and disposes of the glove on the floor, the hands are contaminated and the nurse will need to repeat hand hygiene before caring for the client. The nurse should first put on a new pair of clean gloves and then assess the client's surgical dressing. The nurse can next assist the client with using the urinal, and last, the nurse can pick up and dispose of the glove on the floor. It is more time efficient to dispose of fallen objects when all client care is complete unless the fallen object is required to proceed with client care.

The nurse is teaching a client who was admitted with a new diagnosis of panic disorder. What class of medication will the nurse teach the client is first line in the treatment of panic disorder to reduce frequency of panic attacks?

Ask computer support to reset the password.

A new mother states, "My baby spits up after every feeding." Which interventions should the nurse teach to this mother first?

Burp the infant more frequently during each feeding Frequent burping decreases the amount of air the infant has in the stomach and should be the first intervention. Feeding smaller portions more frequently may help if the infant is taking large amounts. Infants should be fed every 2 to 4 hours. Elevating the head of the bed 30° may help if the cause is gastroesophageal reflux. Formula may have to be changed if it is determined that the spitting is related to milk intolerance.

A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?

I would like to sit with you and talk about your child." This choice is the focused therapeutic response that would generate client-focused discussion. Calling someone else is not client focused and nursing intervention based. Stating that this is a normal response is nontherapeutic, and calling the health care provider is incorrect because the it is within the nurse's scope of practice to resolve this issue.

Which of the following explains the influence of aging on the development of peripheral vascular disease?

Increased resistance. As people age, the accumulation of collagen in the intima of the blood vessels results in the vessels' becoming stiff and less flexible. Consequently, there is an increased resistance within the aging adult's circulatory system.

A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be most appropriate?

It's okay to cry when something hurts." It is not normal for a preschooler to be totally passive during a painful procedure. Typically, a preschooler reacts to a painful procedure by crying or pulling away because of the fear of pain. However, an abused child may become "immune" to pain and may find that crying can bring on more pain. The child needs to learn that appropriate emotional expression is acceptable.

A nurse preparing to administer medications to a client admitted to a respiratory unit is using the computerized medication-dispensing system and finds that the password is not working. What should the nurse do? Select all that apply.

Notify health care provider (HCP) about the joint prior to invasive procedures. Inform the HCP prior to having magnetic resonance imaging (MRI) scans. Notify airport security that the joint may set off alarms on metal detectors.

The nurse is assessing a pregnant client using Leopold's maneuvers. Which of the following nursing actions are appropriate for this assessment? Select all that apply.

Palpate the client's upper abdomen using both hands. Note the shape and consistency of the palpated part. Note the mobility of the palpated part. Leopold's maneuvers are used to determine the position of the fetus and the presenting part. The client should have her bladder emptied and be positioned on her back. The first maneuver is done by palpating the upper abdomen, noting the mobility, shape, and consistency of the palpated part.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg. First, perform hand hygiene. Next, secure a gait belt around client's waist. Then, place the cane in the client's right hand, because the right side is the unaffected side. Have the client advance the cane and the left leg about 4 to 8 inches (10 to 20 cm). Finally, have the client advance the right leg the same distance.

A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the catheter is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age group has a need to accomplish which goal?

Protect the image of an intact body. Preschool-age children worry about having an intact body and become fearful of any threat to body integrity. Allowing the child to participate in required care helps protect her image of an intact body. Development of trust is the task typically associated with infancy. Additionally, allowing the child to apply a dressing over the intravenous insertion site is unrelated to the development of trust. Finding diversional activities is not a priority need for a child in this age group. Separation anxiety is more common in toddlers than in preschoolers.

The nurse instructs a group of parents about emergency treatment for accidental poisoning and injury. The nurse would need to do further teaching if a participant makes which statement?

Tell the client that the cholesterol levels are within normal limits

A nurse is preparing the plan of care for a client with neurogenic flaccid bladder. Which outcome is appropriate for this client?

The client's bladder does not become over distended Flaccid bladder is a type of neurogenic bladder commonly resulting from trauma. The client's bladder continues to fill and overflow incontinence is common. Stasis of urine can lead to infection, therefore fluid intake is encouraged. The client does not feel pain or discomfort and will not have sensation or control over urination.

Which nutritional deficiency may delay wound healing?

The nurse should instruct the client to notify the dentist and other HCPs of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia.Ask computer support to reset the password.

A client with a diagnosis of bipolar disorder is energetic, impulsive, and verbalizing loudly in the community room. To prevent injury while complying with the principle of the least-restrictive environment, which action should the nurse take to prevent escalation of the client's mood?

Try to channel the client's energy into appropriate activities. Constructive activities, such as painting, are a positive way to prevent inappropriate or destructive use of the client's excessive energy.

The nurse unit manager is making rounds on a team of clients and notices a client with a color-coded armband that indicates the client is at risk for falling walking down the hall unassisted. The client is at the end of the hallway farthest from the client's room, but is not tired. What should the nurse do first?

When comparing the safety profiles of the various classes of antidepressants used in the control of panic disorder, selective serotonin reuptake inhibitors (SSRIs) are considered first line. Although risk varies based on a client's history, SSRIs generally carry less risk compared to tricyclic antidepressants, which have high risk for death with overdose, or to monoamine oxidase inhibitors, which carry risk for neuroleptic malignant syndrome and many food and drug interactions

A nurse is working in the intermediate care unit. After receiving change of shift report who should the nurse assess first?

a client with aortic stenosis who has a blood pressure of 84/52 mm Hg Hypotension in a client with aortic valve problems can indicate cardiogenic shock. The nurse should assess this client for other symptoms such as dyspnea or chest pain. The other clients are experiencing expected symptoms of their medical diagnosis and are in no acute distress.

A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis?

a low-protein diet with a prescribed amount of water Although dialysis removes water, creatinine, and urea from the blood, the client's diet must still be monitored. A high-protein diet is not recommended for renal clients. Eating too much protein may cause urea to build up more quickly. Water intake must be monitored, so unlimited water is not a correct choice. The client would be on a no-salt-added diet.

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first?

administer oxygen Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.

Which measure is likely to provide the most relief from the pain associated with renal colic?

administering morphine During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid analgesics such as morphine to control the pain. Application of heat, encouraging high fluid intake, and limitation of activity are important interventions, but they will not relieve the renal colic pain.

A nurse-manager must include which items as part of the personnel budget?

anticipated overtime payments for staff Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos are part of the operating budget.

An adolescent who is depressed and whose parents report as having difficulty in school is brought to the community mental health center to be evaluated. Which additional problem would the nurse expect the client to have?

behavioral difficulties Adolescents with depression tend to demonstrate severe irritability and behavioral problems. Anxiety disorder more commonly affects small children. Cognitive impairment is typically associated with delirium and dementia. Compulsive behaviors are more likely in a client with an anxiety disorder, specifically obsessive-compulsive disorder.

A nurse has received a change-of-shift report on four clients. Which client should the nurse assess first?

client experiencing tracheal deviation following a subclavian catheter insertion tracheal deviation suggests possible tension pneumothorax, which is a medical emergency and needs to be evaluated immediately. Edema in a client with right-sided heart failure is a chronic condition and expected, it is not an emergency. Stabbing chest pain is expected with a pleural effusion and is also not an emergency situation. Pulmonary rehabilitation is completed by respiratory therapy and does not require the attention of the nurse.

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?

droplet precautions Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets.

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms?

hypertension Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives.

A physician diagnoses a client with myasthenia gravis, and orders pyridostigmine, 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition should lead the nurse to question this drug order?

intestinal obstruction Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury aren't contraindications for use of the drug.

The nurse is preparing a teaching plan for a client who is being discharged after being admitted for chest pain. The client has had one previous myocardial infarction 2 years ago and has been taking simvastatin 40 mg for the last 2 years. After reviewing the lab results for the client's cholesterol levels (see chart), what should the nurse do?

lack of vitamin C, Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are ne cessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

Which group of characteristics should a nurse expect to see in the client with schizophrenia?

loose associations, grandiose delusions, and auditory hallucinations Loose associations, grandiose delusions, and auditory hallucinations are all characteristic of the classic schizophrenic client. These clients aren't able to care for their physical appearance.

The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addison's crisis following surgery?

methylprednisolone sodium succinate intravenously Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy.

A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which play activities would be most appropriate at this time?

pounding on a pegboard he child is angry and needs a positive outlet for expression of feelings. An emotionally tense child with pent-up hostilities needs a physical activity that will release energy and frustration. Pounding on a pegboard offers this opportunity.

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan?

recognizing the family as active participants in their care he nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience.

A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband?

the client's fluid and food intake Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted.

Two weeks after a breastfeeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she is crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which factor?

the neonate's temporary growth spurt, which requires more feedings Neonates normally increase breastfeeding during periods of rapid growth (growth spurts). These can be expected at age 10 to 14 days, 5 to 6 weeks, 2.5 to 3 months, and 4.5 to 6 months. Each growth spurt is usually followed by a regular feeding pattern. Lack of adequate intake to meet maternal nutritional needs is not associated with the neonate's desire for more frequent breastfeeding sessions. However, an intake of adequate calories is necessary to produce quality breast milk. The mother's fears about weight gain and preventing the neonate from sucking long enough are not associated with the desire for more frequent breastfeeding sessions.

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation?

use short, simple sentences Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches them about dietary sources of minerals. Which foods are good sources of zinc?

whole grains and meats Good sources of zinc include whole grains, meats, dairy products, and seafood. Fruits are good sources of vitamin C, and vegetables are a good source of many vitamins and minerals, but not zinc. Yeast is a good source of chromium, and legumes are a good source of copper, manganese, and molybdenum.

The nurse is administering an intradermal injection (see the accompanying figure). The nurse should:

withdraw the needle The nurse observes a wheal indicating that the medication has been deposited in the dermis; the nurse can now withdraw the needle. The wheal is an expected outcome of an intradermal injection. The area should not be massaged; massaging will cause the medication to move into the subcutaneous tissue. The medication has been administered correctly, and the nurse should not aspirate the medication or attempt to administer it again.