Relevant Questions P2

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? "When did your pain begin?" "Can you describe the type of pain you are having?" "Could you please rate your pain on a 1-10 scale?" "How long have you experienced this pain?"

"Can you describe the type of pain you are having?" Explanation: Asking the client to describe the pain establishes quality. Asking the client to rate pain on a 1-10 scale reflects intensity. Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset.

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation? "How are you feeling?" "Have you been more confused?" "Do you know what day this is?" "Can you tell me where you are right now?"

"Can you tell me where you are right now?" Explanation: Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation? "How are you feeling?" "Have you been more confused?" "Do you know what day this is?" "Can you tell me where you are right now?"

"Can you tell me where you are right now?" Explanation: Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

The nurse takes the health history of a soldier who lost the right leg in a roadside bomb. Which question will the nurse ask the client while performing the health history? "How has the loss of your leg affected your body image?" "Has your family been a good support for you?" "Do you attend a support group of people who lost limbs?" "Will you show me how you ambulate?"

"How has the loss of your leg affected your body image?" Explanation: The human body is the self's physical manifestation. How a person pictures and feels about the body describes body image. Any deviation from the ideal body, such as the loss of a limb, might affect a person's body image. Asking how the client feels about family and friends would be part of the social history assessment. Watching the client ambulate is not part of the health history and may be performed during the physical assessment. A support group would be helpful for a client who lost a limb but would not be included in the health history.

A nursing instructor is discussing burnout with a group of graduating nursing students. Which statement might lead the instructor to believe that the particular student has not developed needed coping mechanisms for nursing practice? "I know that I am not prepared to take on a leadership role right now since I am new and need to learn." "I can handle absolutely any situation now. You teachers have trained us well." "I hope I get a good preceptor. I know that will help me get used to this transition." "There's so much to learn. I have to find a way to balance these new challenges with settling back into my regular life."

"I can handle absolutely any situation now. You teachers have trained us well." Explanation: Anxiety over the uncertainty of succeeding in a new life role is to be expected. Recognizing that this will be a stressor is an important step in positive coping and adaptation. Erroneously thinking that this will not be a challenge is a form of denial, may lead to role conflict and disillusionment, and later can become a burnout situation.

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis? "A lot of the time I'm terrified that I'm going to die the same way." "I haven't let my children out of my sight. I am afraid something will happen to them." "I had a good time at my class reunion. It was nice to be out with other people again." "I feel like I have absolutely no idea what to do next."

"I feel like I have absolutely no idea what to do next." Explanation: In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, decreased resistance to illness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, neglect of appearance, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased, and return to previous level of ability.

A client asks the nurse how cortisol works. What is the appropriate nursing response? "It strengthens lymphoid tissue." "It increases capillary permeability to prevent tissue swelling." "It suppresses the immune response." "It causes release of proinflammatory mediators."

"It suppresses the immune response." Explanation: Cortisol suppresses the immune response, causes atrophy of lymphoid tissues, decreases capillary permeability to prevent tissue swelling, and prevents release of proinflammatory mediators. It does not strengthen lymphoid tissue, increase capillary permeability, or cause the release of proinflammatory mediators.

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate? "The amount of stimuli different people consider optimal is consistent from person to person." "Adulthood tends to increase sensory functioning." "Religious norms within a culture influence the amount of sensory stimulation a person seeks." "Opioids and sedatives increase awareness of sensory stimuli."

"Religious norms within a culture influence the amount of sensory stimulation a person seeks." Explanation: Ethnic norms, religious norms, income group norms, and the norms of subgroups within a culture all influence the amount of sensory stimulation a person seeks and perceives as meaningful. The amount of stimuli different people consider optimal appears to vary considerably. Sensory functioning tends to decline progressively throughout adulthood. Opioids and sedatives decrease awareness of sensory stimuli.

A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response? "You should follow your health care provider's recommendation and have the surgery." "When you see the health care provider this morning, request more information about the surgery." "It is a minimally invasive surgery with rapid recovery time, so you will do fine." "Share with me the advantages and disadvantages of your options as you see them."

"Share with me the advantages and disadvantages of your options as you see them." Explanation: When it comes to treatment decisions, the nurse should avoid giving advice, thus reserving the right of each person to make one's own choices on matters affecting health and illness care. The nurse should share information on potential alternatives, promote the client's freedom to choose, and support the client's ultimate decision. Giving advice, avoidance, and providing false reassurance are all nontherapeutic forms of communication.

The new hospice nurse is reviewing the concepts of loss and grief with the preceptor. Which statement leads the preceptor to believe that the nurse has an understanding of grief and loss? "People only experience grief when someone dies." "Older adult clients who are lamenting their loss of youth are demonstrating actual loss." "The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." "Clients can experience a sense of loss when their child leaves for college. This is a type of situational loss."

"The client who is isolating himself from social contact after the death of his spouse is demonstrating a social expression of grief." Explanation: Normal expressions of grief may be physical, emotional, social (feeling detached from others and isolating oneself from social contact), and spiritual. Grief is an internal emotional reaction to loss and occurs with loss caused by separation (e.g., divorce) or by death. Clients lamenting their loss of youth are demonstrating a type of perceived loss, which is intangible to others. Situational losses are experienced as a result of unpredictable events; a child going to college would be a maturational loss for the parent.

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: "Are you allergic to any medications?" "Can you tell me the medications you take on a daily basis?" "Do you have an advanced directive or a living will?" "What did your health care provider tell you about your need to be admitted?"

"What did your health care provider tell you about your need to be admitted?" Explanation: When obtaining a nursing history, use the open-ended question technique to allow the client a wide range of possible responses. The greatest advantage of this technique is that it prevents the client from giving a simple "yes" or "no" answer, which limits the client's response. The questions related to medication use, allergies, and an advanced directive are examples of closed communication, in which only one or a few words are required for an answer.

The nurse overhears a client, who is scheduled to begin chemotherapy, tell a family member that everything will eventually be okay and the cancer will be in remission. Which question will the nurse ask to begin a conversation about hope with the client? "What has the health care provider told you about your treatment?" "What provides you with strength to deal with this health situation?" "What is the most important thing in your life right now?" "What role does a higher power play in your life?"

"What provides you with strength to deal with this health situation?" Explanation: Hope is demonstrated by a positive outlook. It enables a person to consider a future and to work to actively bring that future into being. Asking the client, "What provides you strength?..." is an open-ended question and allows a conversation to begin about hope. Asking what the health care provider has told the client is seeking information, not initiating a conversation about hope. Asking about the most important thing in the client's life is beginning a discussion about meaning and purpose and not specifically about hope. Asking about the role of a higher power would begin a discussion on faith.

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 75 mL/hr for the first 15 minutes, then 200 mL/hr 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

A client is admitted to the oncology unit with a diagnosis of leukemia. Her sister comes to visit. The healthy sibling tells the nurse that her sister is sick because "I got mad at her and wished she would go away." Based on this information, the nurse would estimate the sister's age to be: 7 years 15 years 3 years 21 years

7 years Explanation: This is an example of magical thinking. Magical thinking is a common reaction to stress in a school-aged child.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 47-year-old who had a colon resection yesterday and is reporting pain a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

9a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med). Hypovolemia is a condition that occurs when your body loses fluid, like blood or water. - associated with FVD

Which client is most likely susceptible to the effects of disturbed sensory perception?' A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock An older adult client whose lung disease is being treated in the acute care for elders (ACE) unit of the hospital A client who has just been admitted to the emergency department with reports of chest pain A client who is having cataract surgery in an outpatient eye clinic

A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock Explanation: Clients in critical care settings are particularly susceptible to severe sensory alterations. A client who has been in a setting for a short time, such as an emergency or day surgery setting, is less likely to experience disturbed sensory perception. Older adults are often vulnerable to sensory disturbances, but the risks posed by an ICU setting likely supersede a geriatric medical unit.

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment Changing a client's advance directive after the prognosis has significantly worsened

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Explanation: Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are health care provider initiated. The care team cannot independently change a client's advance directive.

A freshman college student comes to the health clinic reporting insomnia and difficulty concentrating in class. The student has three red, scaly patches of skin on his arms and chest. The nurse believes the primary nursing diagnosis for this client is: Sleep Deprivation related to change in living arrangements. Impaired Skin Integrity related to psoriasis. Disturbed Thought Processes related to increased scholastic workload. Anxiety related to stress of achievement in school.

Anxiety related to stress of achievement in school. Explanation: This student, new to college, is demonstrating classic anxiety symptoms stemming from high stress levels. The best nursing diagnosis would be Anxiety. Sleep deprivation, impaired skin integrity, and disturbances of thought are applicable, but these diagnoses do not address the primary problem.

The nurse makes a home visit for a client whose 12-year-old child died 4 years ago. The nurse finds the child's room with all belongings still intact. The client also speaks as if the child is still alive. Which action would the nurse take in this situation? Recommend the client to participate in mourning rituals. Encourage the expression of feelings of sadness or resentment. Arrange for individual counseling for the client. Refer the client to a peer-led Internet-based support group for bereaved parents.

Arrange for individual counseling for the client. Explanation: Keeping the child's room intact and talking as if the child is still alive more than 3 years after the child's death are symptoms of dysfunctional grief. The nurse would refer clients experiencing dysfunctional or prolonged grief to individual counseling, psychotherapy, or to professionally led support groups. Participation in mourning rituals would have been helpful when the death occurred, not 4 years later. The client is stuck in feelings of sadness and resentment and needs professional help to work through these feelings. Peer-led Internet-based support groups fall into the self-help genre; a client with dysfunctional grieving 4 years after a death needs professional help.

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation? Ignore the boy's pain if he is not complaining about it. Ask the boy to draw a cartoon about the color or shape of his pain. Medicate the boy with analgesics to reduce the anxiety of experiencing pain. Distract the boy so he does not notice his pain.

Ask the boy to draw a cartoon about the color or shape of his pain. Explanation: Asking the boy to draw a cartoon about the color or shape of his pain is an excellent intervention by the nurse. The child could be in pain and not complaining, so ignoring the boy's pain is not correct. Distracting the boy so he does not notice his pain would not be appropriate. Medicating the boy with analgesics to reduce the anxiety of experiencing the pain is not correct. Addressing the anxiety does not address the pain.

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond? Assume a position at eye level with the client and continue with the interview. Stop the interview and ask, "How are you feeling?" Sit silently until the client looks up and makes eye contact. Touch the client's hand and say, "You seem upset, is there something bothering you?"

Assume a position at eye level with the client and continue with the interview. Explanation: When communicating with most clients, it is best to position oneself at the client's level and make frequent eye contact. Eye contact is perhaps among the most culturally variable nonverbal behaviors, and can be misunderstood as embarrassment, nervousness, or a problem with the client. Asian, Native American/First Nations, Indochinese, Arabian, and Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their eyes during the interview. Stopping the interview, staying silent, touching the client, and forcing eye contact will make the client uncomfortable and should be avoided.

A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating? Faith Hope Love Religion

Faith Explanation: Faith refers to a confident belief in something for which there is no proof or material evidence. It can involve a person, idea, or thing, and it is usually followed by action related to the ideals or values of that belief. Hope is a feeling of expectation and desire for a certain thing to happen. Love is an intense feeling of deep affection. Religion is a particular system of faith and worship.

What factor has been hypothesized by researchers regarding current thoughts on sleep? The current population requires less sleep. More sleep is obtained through napping. The population is healthier due to sleep. Chronic sleep deprivation is present.

Chronic sleep deprivation is present. Explanation: Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.

The nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure? Clients are better able to handle new experiences. Time is limited after the procedure because of the trend toward early discharge. Client education is the nurse's professional responsibility. Nurse practice acts dictate this specific practice.

Clients are better able to handle new experiences. Explanation: Education is a significant nursing responsibility that helps prepare clients for sensory experiences but not the only nurse can provide the information. An informed client is better able to handle fears, frustration, and confusion. Therefore, explain procedures before performing them or having the client experience them. Explanations also help prevent the client from feeling that his space and body are being invaded. The need for pre-procedure education is unrelated to early discharge. Education is a nursing responsibility, but the ultimate rationale is the direct benefit to the client. Nurse practice acts provide direction on nursing responsibility as identified by each state.

The school nurse is concerned about the week-long absence of Jerry, a third grader. The nurse visits the home and learns that Jerry has been diagnosed with appendicitis by a local clinic doctor. The parents, who are Christian Science church members, have had several church groups in to pray over Jerry. He is not improving and is getting worse. The nurse should do which of the following? Allow the parents their religious rights Insist that the parents take Jerry to the hospital Threaten the parents with a lawsuit Contact Child Protection Services

Contact Child Protection Services Explanation: Child Protective Services can intervene immediately, and have the child hospitalized and treated against the parents' wishes. Allowing the parents to make life/death decisions about their minor child could place the child in harm's way. Insisting the parents take the child to a hospital or threatening them will a lawsuit will only cause ill feelings toward you and will not likely change the parents' minds

When deciding what information the client needs to meet the learner objectives successfully, the nurse is formulating which part of the teaching plan? Content Teaching strategies Learning activities Learning domains

Content Explanation: The nurse is planning the content when the nurse decides what information the client needs to meet the learner objectives successfully. To ensure the teaching was effective, the nurse would include teaching strategies. The learning activities would be designed by the nurse to meet the needs of the client. Learning domains—including cognitive, affective, psychomotor—are the different types of learning. Psychomotor is physical or kinesthetic based. Cognitive is knowledge based. Affective is feeling or emotion based.

The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as: mild. moderate. severe. panic.

Correct response: severe. Explanation: Severe anxiety is manifested by difficulty communicating verbally, increased motor activity, tachycardia, and hyperventilating. Mild anxiety is present in everyday living and is manifested by restlessness and increased questioning. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, and slight increases in heart and respiration rates. Panic is manifested by difficulty with verbal communication, agitation, poor motor control, tachycardia, hyperventilation, palpitations, choking sensation, and chest pain or pressure.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? Create an area for sterile field and opening packages Place water-soluble lubricant on catheter tip prior to insertion Wash the perineal area with soap and water Ensure opening port of the catheter is closed

Create an area for sterile field and opening packages Explanation: Pathogens require a portal of entry to cause infection. Insertion of an indwelling urinary catheter is a sterile technique; any contamination could cause a portal of entry. Using water-soluble lubricant on catheter tip prior to insertion is correct but will not prevent an infection nor will closing the opening port. Likewise, washing the perineal area with soap and water will reduce microorganisms but will not prevent infection alone.

The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action? Document the finding. Clamp the tube. Strip the chest tubing of clots. Contact the rapid response team.

Document the finding. Explanation: Small stationary clots are a normal finding. The chest tubing should never be stripped of clots because this can create intrathoracic negative pressure. Clamping chest tubes is not recommended as it can create a tension pneumothorax. The rapid response team should be called if the chest tube becomes dislodged, an air leak occurs, or the client experiences dyspnea.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? Encourage hourly use of the incentive spirometer. Promote oral fluid intake between meals. Provide oral pain medication before ambulation. Reassess in 4 hours and document the findings.

Encourage hourly use of the incentive spirometer. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes: demonstrating or pantomiming ideas to clients with hearing impairments. cleaning the clients' ears daily with a cotton-tipped applicator. speaking loudly and directly to clients with hearing impairments. encouraging clients to use earphones adjusted to a loud volume for hearing

Explanation: For hearing-impaired clients, demonstrating or pantomiming may assist in communication. Clients should be instructed to avoid cleaning the ear with cotton-tipped applicators or sharp objects as this can cause damage to the inner ear. While speaking directly may enhance communication, speaking loudly will not benefit the client. Clients should be discouraged from using earphones that concentrate loud noise in the ear canal causing acoustic damage.

A nurse is completing the assessment of an 85-year-old client who is being admitted to a memory care home for progressing dementia. The client is unable to answer some of the questions or provide some of essential information that the nurse needs to create the best nursing care plan for this client. Which source will be the best for the nurse to consult to gain this missing information? Family member Past medical records Social media Neighbors

Family member Explanation: The nurse should consult with family members or significant others to gain this information. The best contact will be the individual who has been caring for the client most recently. Past medical records, social media, and neighbors will be limited in information about the client and most likely will be unable to provide the most accurate information.

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition? Hepatitis Appendicitis Diverticulitis Cellulitis

Hepatitis Explanation: Jaundice is a yellow color of the skin resulting from liver or gallbladder disease, some types of anemia, and hemolysis. Hepatitis, inflammation of the liver, is a potential cause of jaundice. Appendicitis and diverticulitis do not typically result in changes in skin color, but will manifest as severe abdominal pain. Cellulitis would not result in yellowing of the skin, but as red and swollen legs.

A client who is admitted to the ER with severe right-sided abdominal pain is diagnosed with appendicitis. The surgeon is called and proceeds to explain the procedure to the client and asks her to sign the consent. The client refuses and informs the doctor that her husband needs to be called to do this. Which of the following religions does this client likely practice? Hinduism Catholicism Islam Judaism

Islam Explanation: Some Muslim women are not allowed to make independent decisions; husbands may need to be present when consent is sought. The other religions, Hinduism, Catholicism, and Judaism, do not restrictions on women to make independent health care decisions.

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider? The nurse should use new tubing when attaching additional IV solutions. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container. It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Explanation: The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions.

What is a general task for a client adapting to acute and chronic illness? Maintain self-esteem Handle pain Carry out medical treatment Confront family problems

Maintain self-esteem Explanation: Adaptation to acute and chronic illness or to traumatic injury involves two sets of adaptive tasks:1. General tasks (as in the case of any situational stress) involve maintaining self-esteem and personal relationships while preparing for an uncertain future.2. Illness-related tasks include such stressors as losing independence and control, handling pain and disability, and carrying out the prescribed medical regimen.

A school nurse is talking with an adolescent related to school and home situations. The adolescent states, "I can't focus when I study, can't eat or sleep, and I feel like I'm going to pass out sometimes." The nurse believes the adolescent is experiencing which disorder? Psychological alarm reaction Obsessive-compulsive disorder (OCD) Panic attacks Moderate anxiety response

Moderate anxiety response Explanation: Inability to concentrate, nausea, insomnia, dizziness, and hyperventilation are all symptoms of moderate-level anxiety. Alarm reaction is the initial physiologic response to a stressor described in Selye's general adaptation syndrome theory. OCD is a psychiatric pathology. Panic attacks go a step further in the anxiety cascade; the client is unable to function at this level.

The nurse is assessing a client for spirituality using the HOPE acronym. Which statement describes an element of this tool? H = sources of help O = organized religion P = persons important in the person's life E = external stressors affecting spirituality

O = organized religion Explanation: The HOPE assessment tool asses the client's spirituality. The acronym stands for: H—Sources of hope, meaning, comfort, strength, peace, love, and connection O—Organized religion P—Personal spirituality and practice E—Effects on medical care and end-of-life issue

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? Monitor the client closely and promote fluid intake. Contact the physician to come assess the client. Immediately administer a cleansing enema. Increase the rate of the client's intravenous infusion.

Monitor the client closely and promote fluid intake. Explanation: Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement. Reference:

While providing care to a client, a nurse encounters an ethical problem. The nurse knows the right thing to do, but the facility's policies interfere with the nurse's ability to follow through in doing the right thing. Which condition is the nurse experiencing? Ethical dilemma Moral distress Moral resiliency Ethical agency

Moral distress Explanation: Moral distress occurs when a nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action. In an ethical dilemma, two (or more) clear moral principles apply but support mutually inconsistent courses of action. The capacity to recover, adapt, and even thrive in the face of threats, misfortune, or challenging times is termed resilience. Moral resilience is the developed capacity to respond well to morally distressing experiences and to emerge strong. Ethical agency involves the ability to always do the ethically right thing because we know it is the right thing to do

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? Over the lower arm Brachial artery Over the client's thigh Radial artery

Over the client's thigh Explanation: The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable following a mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.

A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief? Personal moral Professional value Ethical principle Legal obligation

Personal moral Explanation: A personal moral is a standard of right and wrong that helps a person determine the correct or permissible action in a given situation. Professional values in nursing are a set of beliefs about the worth of things, about what matters, that provide the foundation for nursing practice and guide the nurse's interactions with clients, colleagues, and the public. Ethical principles are a set of specific concepts that guide a person's actions. A legal obligation is something that is required by law.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Make sure the bed brakes are unlocked. Put the chair at the foot of the bed. Place the bed in the highest position. Raise the head of the bed to a sitting position.

Raise the head of the bed to a sitting position. Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? Respiratory obstruction Cardiac distress Wound infection Dehydration

Respiratory obstruction Explanation: Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Cardiac distress, wound infection, and dehydration are all possible postoperative complications, but respiratory obstruction is most common.

A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system? General adaptation syndrome Local adaptation syndrome Reticular activating system Peripheral nervous system

Reticular activating system Explanation: The reticular activating system (RAS) is responsible for bringing together information from the cerebellum and other parts of the brain with information obtained from the sense organs. Awareness of the world depends on the RAS, which is located between the nerve centers of the medulla oblongata in the brain stem. Sensory, visceral, kinesthetic, and cognitive input stimulate the RAS.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? Risk for Falls related to immobility Risk for Injury related to substance use Risk for Poisoning related to poor eyesight and the inability to read medication labels Altered Sensory Perception related to decreased visual acuity

Risk for Poisoning related to poor eyesight and the inability to read medication labels Explanation: Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of the multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance use in this client.

Which statement is true of the nursing process? Scientific problem solving can occur within the nursing process. It is a valid alternative to using intuition to respond to nursing situations. It is more appropriate in medical surgical settings than community health care. Trial-and-error problem solving is an efficient use of the nurse's time.

Scientific problem solving can occur within the nursing process. Explanation: Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, scientific problem solving is the focus of the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing areas, from medical-surgical to community health settings.

A nurse is reviewing a journal article about the development of the self. Place the stages listed below in their correct sequence from first to last that reflect the nurse's understanding of this development. Self-awareness Self-concept Self-recognition Self-definition

Self-awareness Self-recognition Self-definition Self-concept Explanation: Stages in the development of the self include self-awareness (infancy), self-recognition (18 months), self-definition (3 years), and self-concept (6-7 years).

An adolescent client tells the nurse about asking oneself, "Do I like who I see in the mirror?" Which additional strategy can the nurse encourage the client to use to promote self-evaluation? Allowing life to unfold Taking a self-improvement class Meeting friends Setting goals

Setting goals Explanation: A client who asks oneself, "Do I like who I see in the mirror?" is engaging in self-evaluation. Self-evaluation is the conscious assessment of the self, leading to self-respect or self-worth. Setting goals will provide a client with a structured set of actions to attain. Allowing life to unfold does not provide structure for the client. Improving one's knowledge can be useful but does not factor into one's self-evaluation. Being more social may be a goal but is not a strategy for self-evaluation.

A nurse may attempt to help a client solve a situational crisis during what type of counseling session? Long-term counseling Motivational counseling Short-term counseling Professional counseling

Short-term counseling Explanation: Short-term counseling would help a client solve a situational crisis. A client experiencing a developmental crisis, for example, might need long-term counseling. Motivational counseling is an evidence-based counseling approach that involves discussing feelings and incentives with the client. Professional counseling is a general term.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness? Somnolence Coma Stupor Asleep

Somnolence Explanation: When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.

A college foreign exchange student is living with a family in England and is confused about the daily Catholic prayers and rituals of the family. The student longs for the comfort of her fundamentalist Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress? Spiritual alienation Spiritual guilt Spiritual anger Spiritual loss

Spiritual alienation Explanation: Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.

The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client? The client will stay in bed at all times. The client will learn how to communicate needs. The client will remain safe. The client will consistently follow instructions.

The client will remain safe. Explanation: Client goals are individualized but focus on achieving optimal sensory function. A nursing diagnosis for the client is Disturbed Sensory Perception. The priority goals for this client is ensuring the client remains safe. Developing an effective communication mechanism is a secondary goal. If the client is confused, he or she may or may not be able to communicate needs or follow instruction. A client may have toileting needs that may make it difficult to remain in the bed at all times. In this care, the nurse cannot assume that this intervention is appropriate.

Which does not coincide with Kübler-Ross's stages related to a dying client? Clients don't always follow the stages in order. Some client regress, then move forward again. The dying client usually exhibits anger first. The client may be in several stages at once.

The dying client usually exhibits anger first. Explanation: The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments? The health care provider The nurse The case manager The nursing supervisor

The nurse Explanation: The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional (e.g., the health care provider) whenever assessment data differs significantly from the baseline. The nursing supervisor would be alerted if the professional does not evaluate the client. The case manager would be alerted when the client was ready for discharge.

Regarding medication administration, what must occur at the change of shifts? The client's medications must be drawn up. The medications for the division are counted. The opioids for the division are counted. Only the LPNs on the division count medications.

The opioids for the division are counted. Explanation: Health care facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine).

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? They are loud, high-pitched sounds heard primarily over the trachea and larynx. They are medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the health care provider. The health care provider advises the nurse to prepare an incident report. What is the purpose of an incident report? To determine the nurse's fault in the incident To evaluate the quality of care provided and assess the potential risks for injury to the client To provide information to local, state, and federal agencies To evaluate the immediate care provided by the nurse to the client

To evaluate the quality of care provided and assess the potential risks for injury to the client Explanation: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. Incident reports determine how to prevent hazardous situations and serve as a reference in case of future litigation. Accurate and detailed documentation often helps to prove that the nurse acted reasonably or appropriately in the circumstances. It may not always serve as a method of determining the nurse's fault in the incident. The document does not evaluate the immediate care provided to the client but states the actions taken.

The nurse is taking care of a client who was hospitalized for an ulcerative colitis exacerbation. Recently, the client's parent died from colon cancer. Which question would be essential to ask this client at the start of the assessment of her loss reaction? What did your parent do for a living? What type of relationship did you have with your parent? Did your parent seek early treatment for the colon cancer? How old was your parent?

What type of relationship did you have with your parent? Explanation: When assessing a client for a reaction, both physically and psychologically, to loss, it is important to get a sense of what part the deceased person played in the client's life. If she was not close to her father, the impact might not be so great. On the other hand, if he was an important person in her life, her response might be greater. Other things to initially ask about include whether the loss was expected and whether or not the client feels a sense of responsibility for the loss.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: a bronchospasm. bronchitis. bronchiectasis. bronchiolitis.

a bronchospasm. Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler? a canister containing medication that is released when the container is compressed a propeller-driven device that spins and suspends a finely powdered medication a device that forces liquid drug through a narrow channel using pressurized air a device that forces medication through a narrow channel with the help of inert gas

a canister containing medication that is released when the container is compressed Explanation: A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed. A turbo-inhaler is a propeller-driven device that spins and suspends a finely powdered medication. An aerosol results after a liquid drug is forced through a narrow channel using pressurized air or an inert gas.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: the effects of anesthesia. the normal return of reflexes. a partial airway obstruction. the type of surgery.

a partial airway obstruction. Explanation: Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.

Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen? a woman who takes daily anticoagulants to treat atrial fibrillation a woman who takes daily thyroid supplements to treat her longstanding hypothyroidism a man who takes an angiotensin-converting enzyme (ACE) inhibitor because he has hypertension a man who regularly treats his rheumatoid arthritis with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs)

a woman who takes daily anticoagulants to treat atrial fibrillation Explanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. Thyroid supplements assist with thyroid function. Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels and lower blood pressure. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a drug class that reduce pain, decrease fever, prevent blood clots, and, in higher doses, decrease inflammation.

A home health nurse is visiting a family after the recent death of their matriarch. The nurse observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function? economical function physical function affective and coping functions socialization function

affective and coping functions Explanation: This family exhibits the function of affective and coping by observing the ritual of "Sitting Shiva." By observing this Jewish, seven-day period of mourning for first-degree relatives (husband, wife, parent, or child) the family provides emotional comfort to family members, helps to establish their identity, and maintains it in times of stress. Economical function provides financial aid to family members. Physical function provides a safe, comfortable environment necessary for growth and development. Through socialization the family teaches values, attitudes, and provides feedback, and with the function of reproduction the family produces and raises children.

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means? aggressive management of symptoms treatment of the disease process eliminating all forms of medical and nursing care providing counseling related to the stages of death and dying

aggressive management of symptoms Explanation: The goal of palliative care is to provide clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. There is no treatment goal for the life-threatening illness for palliative care. Aggressive management of symptoms includes medical and nursing care for the client. Providing counseling related to the stages of death and dying is pursued after aggressive management of symptoms.

The nurse is preparing to administer an injection to an adult client and states, "Try to stay as still as possible." Which stage of the General Adaptation Syndrome (GAS) is the nurse addressing by making this statement? pathological exhaustion resistance alarm

alarm Explanation: The alarm stage is correct, because this stage prepares the client for a "fight-or-flight" response to overcome the perceived danger, such as the injection of a needle. Stage of resistance is designed to restore homeostasis and is therefore incorrect. Stage of exhaustion occurs when more adaptive or resistive mechanisms are no longer to protect the client experiencing a stressor. Pathological response is not a phase of GAS.

A nurse is interviewing an asthmatic client who has a high respiratory rate and at times has difficulty breathing. The client is restless and at current can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document? altered gas exchange related to the disease condition altered verbal communication related to the breathing problem unable to speak due to ineffective airway clearance altered physical mobility related to tachypnea

altered verbal communication related to the breathing problem Explanation: The client has a high respiratory rate and difficulty breathing; the client therefore has trouble communicating. Altered verbal communication related to the breathing problem is the appropriate diagnosis. Although altered gas exchange may occur in an asthma attack, it does not relate to the current concern regarding the client's ability to communicate thus it is not the primary concern at this time. There is no evidence that the client is experiencing altered physical mobility due to the condition. Unable to speak due to ineffective airway clearance is not accurate, because the client is able to speak, although the speech is impaired.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult: an audiologist. an ophthalmologist. a clinical psychologist. an optometrist.

an audiologist. Explanation: A nurse who suspects a speech, language, or hearing problem should refer the client to a speech-language pathologist or audiologist. A speech-language pathologist is a professional educated in the study of human communication, its development, and its disorders. An audiologist is a professional educated in the study of normal and impaired hearing. An ophthalmologist is a medical doctor who specializes in the treatment of eye disorders. An optometrist has a practice doctorate and focuses on vision. A clinical psychologist is a behavioral health expert.

A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client? continuous drip bolus administration gravity infusion electronic infusion device

bolus administration Explanation: A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump.

The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? optic function auditory function cardiac function skeletal function

cardiac function Explanation: Potassium is essential for normal cardiac function. Optic, auditory, and skeletal function are dependent to other electrolytes.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? cardiac irregularities muscle weakness increased intracranial pressure (ICP) metabolic acidosis

cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? confusion decreased blood pressure decreased respiratory rate hyperactivity

confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. hypoxia means increased respiration due to shallow breathing to make up for lack of o2 going into cells.

A client is having a stress response related to a recent accident while boating. What does the nurse identify will be excreted from the adrenal cortex in response to this reaction? cortisol insulin epinephrine thyroxine

cortisol Explanation: Cortisol is the main glucocorticoid hormone from the adrenal cortex. Cortisol affects glucose metabolism, which is necessary for increased energy expenditure.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? decreased blood volume and intracellular dehydration increased blood volume and intracellular dehydration increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration

decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration. intracelluar dehydration = water from ECF moving into ICF.

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing? denial anger bargaining acceptance

denial Explanation: By making this statement, the client denies the seriousness of the malignant tumor diagnosis. Denial is often the first emotion the client will experience, as initially it helps in coping with the reality of impending death. There is nothing in the client's statement to indicate anger or acceptance. Bargaining would be indicated by the client negotiating with a higher power to extend life or delay the inevitable.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? oxygen analyzer nasal strip nasal cannula flow meter

flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. What type of assessment will the nurse perform? time-lapsed assessment emergency assessment focused assessment funtional assessment

focused assessment Explanation: The nurse will perform a focused assessment. This type of assessment allows the nurse to gather data about a specific problem that has already been identified, such as this client's cancer and subsequent colostomy. The nurse would perform a emergency assessment when a client presents with a physiologic or psychological crisis. This type of assessment allows the nurse to identify life-threatening problems. The nurse would perform a time-lapsed assessment to compare a client's current status to the baseline data obtained earlier. This type of assessment is used most often in residential settings and for those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses. The functional assessment is a comprehensive evaluation of a client's physical strengths and weaknesses in areas such as the performance of activities of daily living, cognitive abilities, and social functioning.

The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population? Schedule eye examinations every 4 years. good management of illness such as hypertension Continue driving a car to maintain memory skills. Avoid places full of people to prevent spread of infection.

good management of illness such as hypertension Explanation: Client education to promote sensory health and function focuses on ways to prevent sensory loss and to maintain general health. Education topics include the importance of frequent eye examinations (yearly) and close control of chronic illnesses such as hypertension and diabetes. Age related changes in eyesight and motor function may affect the ability to drive. Avoiding places full of people can prevent infection but may cause sensory overload in older adults.

Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line

handwashing after removing gloves Explanation: Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary catheter, placement of intravenous catheters or drawing blood).

A client who has a history of sexual abuse is demonstrating repression. What client behavior does the nurse expect? blaming others for the sexual abuse having no memory of the sexual abuse refusing to believe that the sexual abuse occurred behaving like a young child

having no memory of the sexual abuse Explanation: Repression is forgetting about the stressor or removing the experience from the subconscious. Blaming others is a sign of displacing anger. Refusal to believe is a sign of denial. Childish behavior is demonstrative of regression.

During the orgasmic phase of the sexual response, the woman may experience: vaginal relaxation. bradycardia. hypoventilation. hypertension.

hypertension. Explanation: The orgasm in the woman produces contractions, and the woman experiences an increased respiratory rate, heart rate, and blood pressure.

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? hyperphosphatemia hyperchloremia hypokalemia hypomagnesemia

hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection? subcutaneous intramuscular intradermal intravenous

intradermal Explanation: The nurse will use the intradermal route, which is injecting the drug between the layers of the skin. The subcutaneous route is reserved for drugs to be injected beneath the skin but above the muscle. The intramuscular route is reserved for drugs to be injected in the muscle. The intravenous route is reserved for drugs to be instilled into veins.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? left side-lying prone right side-lying supine

left side-lying Explanation: When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position. Prone is lying flat, especially face downward. Visualization of the rectum is acceptable but insertion of the enema is difficult. The supine position means lying horizontally with the face and torso facing up, and this is not helpful for inserting an enema as a nurse cannot visualize the rectum. The right side-lying position is used for positioning of a client, not for an enema.

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? tell the family they are causing too much stress limit the family visits to once daily explain that family visits and support are important do not intervene and allow the client to work out the family issue

limit the family visits to once daily Explanation: When a person is experiencing a stressor, it is important for the nurse to reduce or eliminate the stress. In this case, it is appropriate to limit the family visiting time to allow the client to recover without experiencing a stress response. Telling the family they are causing the stress is not therapeutic. Telling the client that the family should be there invalidates the client's feelings. Doing nothing is not an appropriate response to decrease or remove the stressor.

A couple has sent their youngest child to college in another state and both are experiencing "empty nest syndrome." This is an example of: maturational loss. situational loss. physical loss. anticipatory loss.

maturational loss. Explanation: Maturational loss is experienced as a result of natural developmental processes, such as sending children off to kindergarten or away to college. A situational loss occurs as a result of an unpredictable event. Physical loss is a loss such as a body part (amputation). Anticipatory loss involves a display of loss, and grief behaviors for a loss that has yet to take place

The nurse is assessing a client in the community. To obtain a relative estimate of the client's skeletal mass, the nurse will take which measurement? midarm circumference body mass index (BMI) triceps skinfold measurement abdominal circumference

midarm circumference Explanation: Midarm circumference helps determine skeletal muscle mass. This technique, combined with other body measurements, helps assess a client's nutritional status. The measurement is based on the assumption that muscle is usually located in anatomic areas such as the biceps. Body mass index (BMI) provides numeric data to compare a person's size in relation to established norms for the adult population. It is calculated using height and weight. Triceps skinfold measurement adds additional data for estimating the amount of subcutaneous fat deposits. The skinfold thickness measurement relates to total body fat. Abdominal circumference is an indirect measurement of fatty (adipose) tissue that is distributed in and about the viscera of the abdomen.

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs together near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed.

near the client's hip, with legs shoulder width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) Explanation: In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) Explanation: In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

In Stage 4 sleep, the: blood pressure is elevated pulse rate is slow respirations are irregular temperature increases

pulse rate is slow Explanation: During slow-wave sleep, the muscles are relaxed, but muscle tone is maintained; respirations are even; and blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle all decrease.

A decrease in arterial blood pressure will result in the release of: protein. thrombus. renin. insulin.

renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is: reviewing the client's sleep diary for the past 2 weeks. identifying specific foods that negatively impact sleep. having the client recall the number of sleep hours each night for the past week. asking the client's bed partner to describe the sleep problem.

reviewing the client's sleep diary for the past 2 weeks. Explanation: A sleep diary kept for 2 weeks will provide a more detailed history of the client's sleep-wakefulness pattern than having the client identify foods that impact sleep, or having the client recall the number of hours of sleep each day for the past week. Client recall may be inaccurate. The client should describe the sleep problem, not the client's bed partner.

A nurse is assessing a client who has recently lost her husband. During the interview the nurse realizes that the client is unable to cope with the loss. The client finds it difficult to organize daily tasks or solve problems effectively. Which suggestion would be most appropriate for the nurse to suggest as a crisis intervention? perform meditation to relax tense and relax muscle groups systematically seek assistance from family and friends keep the home environment noise free

seek assistance from family and friends Explanation: The nurse should suggest that the client seek assistance from family and friends as a crisis intervention. Adequate support during a crisis and its resolution can help clients realistically perceive the problem and reinstitute coping strategies. Performing meditation, tensing and relaxing muscle groups systematically for progressive relaxation, and keeping the home environment noise free are methods to calm and relax the client that may not necessarily help in crisis intervention.

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea? Immediately administer an antiemetic. contact the primary care provider sit with the client and ask them about their feelings explain that the physical symptoms are all in their head

sit with the client and ask them about their feelings Explanation: Somatization is manifesting an emotional stress through a physical disorder. Treating the nausea with an antiemetic will not get at the root cause of the emotional issue. Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic. Sitting with the client to explore what is really going on is most appropriate nursing response.

The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV

stage IV Explanation: Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess? sternum thigh hand abdomen

sternum Explanation: The older adult client will most likely demonstrate a decrease in skin turgor when dehydrated and the best option for assessment is the sternum. The hand may normally tent when the skin is pulled up since older adult clients lose elasticity in that area first. The thigh and abdomen do not give the best information related to skin turgor when assessed due to the lack of elasticity in these areas of the older adult client.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: staring into the neonate's eyes and smiling. softly humming a song near the neonate. swaddling the child and gently stroking its head. offering the neonate infant formula.

swaddling the child and gently stroking its head. Explanation: Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or long-term care facility care. Vision, taste, and hearing are not as fully developed as touch in the neonate.

A client with a diagnosis of colon cancer has required the creation of an ostomy following bowel surgery. Which factor is most likely to influence the client's adjustment to this change? the coping mechanisms that the client possesses the prognosis of the client's cancer after the surgery the specific location of the ostomy the client's knowledge of a peer who also has an ostomy

the coping mechanisms that the client possesses Explanation: While having a peer with a similar challenge is likely to facilitate adjustment to a change such as this, the most significant consideration is likely the client's own coping mechanisms. This factor supersedes the client's prognosis or the location of the ostomy.