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A nurse is caring for an older client with a diagnosis of myasthenia gravis and has reinforced self-care instructions. Which statement by the client indicates that further teaching is necessary? "I rest each afternoon after my walk." 2."I cough and deep breathe many times during the day." 3."If I get abdominal cramps and diarrhea, I should call my doctor." 4."I can change the time of my medication on the mornings that I feel strong

"I can change the time of my medication on the mornings that I feel strong." Rationale: The client with myasthenia gravis should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If not given on time, the client may become too weak to swallow. Options 1, 2, and 3 include the necessary information that the client needs to understand to maintain health with this neurological degenerative disease.

A nurse is assisting with providing a teaching session to a community group regarding the risks and causes of bladder cancer. The nurse determines that additional teaching is needed if a member of the community group states which of the following regarding this type of cancer? 1. It most often occurs in women. 2.It is generally seen in clients who are older than 40 years old. 3.Environmental health hazards have been found to be a cause of this disease. 4.Using cigarettes, artificial sweeteners, and coffee drinking can increase the risk for this cancer.

1. It most often occurs in women. Rationale: The incidence of bladder cancer is three times greater among men than among women, and it affects the white population twice as often as the black population. Options 2, 3, and 4 are associated with the incidence of bladder cancer.

A nurse is checking lochia discharge in a woman in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. The nurse determines that this finding: 1.is normal 2. Indicates that the client is hemorrhaging 3. Indicates the need to increase oral fluids 4. Indicates the need to contact the health care provider

1. is normal Rationale: Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 2, 3, and 4 are incorrect.

A nursing student is assisting in caring for a client with a lung tumor; the client will be having a pneumonectomy. The nursing instructor reviews the postoperative plan of care developed by the student and suggests deleting which of the following from the plan? 1.Monitoring the closed chest tube drainage system 2.Encouraging coughing and deep breathing 3.Checking the surgical dressing for drainage 4.Avoiding complete lateral positioning

1.Monitoring the closed chest tube drainage system Rationale: Closed chest drainage usually is not used following pneumonectomy. The serous fluid that accumulates in the empty thoracic cavity eventually consolidates. The consolidation prevents shifts of the mediastinum, heart, and remaining lung. Complete lateral positioning is avoided because the mediastinum is no longer held in place on both sides by lung tissue and extreme turning may cause mediastinal shift and compression of the remaining lung. Options 2 and 3 are general postoperative measures.

Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that the action of the medication is to: 1.Stimulate the uterus to contract, thus reducing possible blood loss. 2. Stimulate the production of progesterone for breast-feeding. 3. Stimulate the production of estrogen post-delivery. 4. Minimize the possibility of uterine infection.

1.Stimulate the uterus to contract, thus reducing possible blood loss. Rationale: The action of oxytocin is to stimulate the uterus to contract, to control uterine atony, and therefore reduce hemorrhage. Options 2, 3, and 4 are not actions of this medication.

A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem should initially direct nursing care at this time? 1.The client is blaming herself. 2. The client lacks knowledge regarding diabetes treatment. 3. The client is concerned about her appearance. 4. The client is experiencing fetal distress.

1.The client is blaming herself. Rationale: The client is putting the blame for the diabetes on herself. She is expressing fear and grief. There is no data in the question that indicates that the client lacks knowledge about diabetes treatment, is concerned about appearance, or is experiencing fetal distress.

A nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client: 1. Lying down 2. In a sitting position 3. On the right side 4. On the left side

2, in a sitting position Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. The blood pressure should be obtained in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 3, and 4 are incorrect, and these positions may cause physiological stress that will affect the blood pressure.

The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following? 1.A low-calorie diet to ensure the absence of weight gain 2. A diet that is high in fluids and fiber to decrease constipation 3. A diet that is low in fluids and fiber to decrease blood volume 4. Unlimited sodium intake to increase the circulating blood volume

2. A diet that is high in fluids and fiber to decrease constipation Rationale: Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system. The absence of weight gain is not recommended during pregnancy. Diets that are low in fluid and fiber cause a decrease in blood volume, which in turn deprives the fetus of nutrients. Too much sodium could cause an overload to the circulating blood volume and contribute to the cardiac condition.

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply. 1.Place bassinets 1 foot apart in the nursery. 2. Adhere to standard precautions during delivery and in the nursery. 3. Place an identification bracelet on the infant only after the initial bath is completed in the nursery. 4. Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5. Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room.

2. Adhere to standard precautions during delivery and in the nursery. 4. Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5. Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room. Rationale: Newborn safety and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines are always followed to prevent transmission of bacteria and other illnesses to infants. Safety precautions to prevent infant abduction include footprinting the infant along with fingerprinting the mother on the identification card as well as placing bracelet identification on the mother and infant immediately following delivery. Educating parents to only release their infant to those wearing proper identification is key in preventing infant abductions in the inpatient situation. Bassinets are to be 3 feet apart, not 1 foot apart.

A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. Which action should the nurse initially include in the plan of care? 1.Maintain complete bedrest, encourage fluids, and reduce stimuli. 2. Maintain complete bedrest, monitor IV fluid intake, and monitor the fetal heart rate. 3. Maintain complete bedrest, assist with the vaginal exam, and restrict food and fluids. 4. Maintain complete bedrest, monitor intravenous (IV) fluid intake, and monitor for uterine contractions.

2. Maintain complete bedrest, monitor IV fluid intake, and monitor the fetal heart rate. Initial nursing actions for care of a pregnant client with bleeding include maintaining complete bedrest (to reduce the chance for further bleeding), initiating and monitoring an IV (anticipating the need for fluid replacement), and monitoring the fetal heart rate (assessing the status of fetus). Food and fluid may or may not be restricted. Reducing stimuli is not a priority consideration. A vaginal exam is not appropriate because it may stimulate uterine contractions and increase bleeding.

A nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the health care provider any early signs of vaginal discharge or perineal tenderness. What is the primary expected outcome for this intervention? 1Relieves anxiety for the pregnant client 2. Eliminates the need for further unnecessary screenings 3. Assists in identifying infections that may need to be treated 4. Minimizes the financial cost of caring for an HIV-positive client

3. Assists in identifying infections that may need to be treated The HIV-positive client may be further at risk for superimposed infections during pregnancy. Among these include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. The remaining options are benefits that can be experienced when complications such as infections are identified early.

A nurse is caring for a client who was admitted to the maternity unit at 8:00 AM with contractions occurring every 2 minutes, lasting 1½ minutes, and is dilated 4 cm with a cervical effacement of 60%. At 10:30 AM, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which of the following? 1. Abruptio placentae 2. Placenta previa 3. Ruptured uterus 4. Preterm labor

3. ruptured uterus Rationale: The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock caused by bleeding in the abdomen. The manifestations identified in the question are not characteristic of abruptio placentae, placenta previa, or preterm labor.

A nurse is reinforcing discharge instructions to a client who has had ocular surgery of the left eye. Which statement by the client indicates a need for further instructions? 1."I need to wear an eye shield at night." 2."I need to sleep on the back or the right side." 3."I need to call the doctor if I develop any fever." 4."I need to wear sunglasses during the day."

3."I need to call the doctor if I develop any fever." Rationale: The client is generally taught to report a temperature of 101° F or greater. The client should also report chills, pain unrelieved by medication, bleeding, foul-smelling drainage, or redness at the surgical site. The client should protect the eye by wearing sunglasses during the day and an eye shield at night. The client should lie on the back or the nonoperative side, unless otherwise instructed by the surgeon.

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client would best indicate to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use? 1."I know I'm ready to be discharged; I feel like I can say no and leave a group of friends if they are drinking. No problem." 2."I'll keep all my appointments and go to all my AA groups. I'll do everything I'm supposed to. Nothing will go wrong that way." 3."I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." 4."This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and friends will all help me like the people in this group have. They'll all help me; I know they will. They won't let me go back to my old ways."

3."I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." rationale: In option 3, the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in the statement. Option 1 indicates client denial. In option 4, the client is relying heavily on others. In option 2, the client is concrete and procedure oriented; again, the client denies that "nothing will go wrong that way" if the client follows all the directions.

A nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate (Methergine). The nurse determines the medication is effective when the client says: 1."At least now I can sleep." 2."I feel less nauseated." 3."My afterpains are really strong." 4."The pain is less intense."

3."My afterpains are really strong Rationale: Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 4 are not related to this medication.

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? 1.Reports not going to work for this past week 2.Complains of not being able to "do anything" anymore 3.Arrives at the clinic neat and appropriate in appearance 4.Reports sleeping 12 hours per night and 3 to 4 hours during the day

3.Arrives at the clinic neat and appropriate in appearance Rationale: Depressed individuals will sleep for long periods, are not able to go to work, and feel as if they cannot "do anything." Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints as well as demonstrate an improvement in their appearance.

A nurse is reviewing medications with the client receiving colchicine for the treatment of gout. The nurse determines that the medication is effective if the client reports a decrease in: 1.Blood glucose 2.Blood pressure 3.Joint inflammation 4.Headaches

3.Joint inflammation rationale: Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Colchicine has no effect on the client's blood glucose or blood pressure; it is not used to treat a headache.

nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will: 1.Sit in soft, deep chairs. 2.Exercise in the evening to combat fatigue. 3.Rock back and forth to start movement with bradykinesia. 4.Buy clothes with many buttons to maintain finger dexterity.

3.Rock back and forth to start movement with bradykinesia. Rationale: The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs because getting up from them can be difficult. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.

After a precipitate delivery, a nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which of the following first to help the woman process what has happened? 1. Encourage the mother to breast-feed soon after birth. 2. Consider the cultural characteristics of the woman. 3. Write a complete account of the parent's reaction on the birth record. 4. Support the mother no matter what her reaction to the newborn is.

4. Support the mother no matter what her reaction to the newborn is. Rationale: There may be many reactions to the birth of a baby. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or may be following her cultural norms. The mother may want to process what has happened and will need time to assimilate all that occurred. The new mother requires support, and the nurse needs to provide a nurturing and accepting attitude.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs: 1.General anesthesia 2.To be left totally alone 3.To push with her contractions 4.To regain her breathing pattern

4.To regain her breathing pattern Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated. The client may be terrified of being left alone during this phase of labor.