Coping and Cognition
A client develops acute otitis media and is ordered cefpodoxime proxetil 5 mg/kg P.O. every 12 hours. If the client weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose? 110 mg 50 mg 220 mg 100 mg
50 mg
The nurse gives a client an oral narcotic analgesic medication to treat postoperative pain. Which follow-up assessment most clearly indicates that the treatment was effective? Within 40 minutes the client breathes slowly with eyes closed. Within 10 minutes the client is moving down the hall. Within 20 minutes the client is reading with a relaxed posture. Within 30 minutes the client says that the pain is reduced.
Within 30 minutes the client says that the pain is reduced.
Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? anemia local joint pain weight loss osteoporosis
local joint pain
A client is resting in bed. The nurse visits the client to reassess the client's pain. The nurse notices that a visitor is in the room and is touching the client in various places on the client's body. The nurse understands that this type of practice is called: yoga. traditional Chinese medicine. herbal medicine. therapeutic touch.
therapeutic touch.
A nurse is preparing a 24-hour-old baby boy for circumcision. The hospital policy guidelines for circumcision support pain medication at least 1 hour prior to the start of the procedure. The provider did not order the pain medication. The provider arrives, and the nurse refuses to bring the baby for the circumcision stating that the pain medication was not ordered. Which is the rationale for refusing to bring the baby for the procedure? A nurse can refuse and request another provider to perform the procedure because of inadequate prep. A nurse is allowed to refuse orders only if another nurse can attest that the order is dangerous to the client. A nurse can refuse until the order requiring premedication is changed. A nurse has a right to refuse orders that might be harmful to the client.
A nurse has a right to refuse orders that might be harmful to the client.
A client with a history of combat-related post-traumatic stress is admitted for treatment of complicated pneumonia. The first night, he experiences nightmares and frightens everyone with his screaming. He declines offers of anxiolytics, replying that he just needs privacy to perform his Reiki treatment. The nurse's best response is: "Research is recommending medical marijuana." "Can you explain to me how you use Reiki?" "You need someone else to perform Reiki." "Reiki cannot help with post-traumatic stress."
"Can you explain to me how you use Reiki?"
The nurse gives a pamphlet that describes Kegel exercises to a client with stress incontinence. Which statement indicates that the client has understood the instructions contained in the pamphlet? "It will probably take a year before the exercises are effective." "I can do these exercises sitting up, lying down, or standing." "I should perform these exercises every evening." "I need to tighten my abdominal muscles to do these exercises correctly."
"I can do these exercises sitting up, lying down, or standing."
A client is being discharged from same-day surgery. Which statement indicates that the client does not understand postoperative instructions about transportation to home? "I can drive myself home after surgery." "My husband is taking the day off from work to drive me home." "I am taking a taxi home, and my daughter will meet me at home." "My son will be here at noon to take me home."
"I can drive myself home after surgery."
The nurse developed a plan of care for an adolescent who is receiving chemotherapy for lymphoma and has developed stomatitis. What statement made by the adolescent demonstrates understanding of the education provided from the plan of care? "I will rinse my mouth every 2-4 hours with baking soda and water." "I will use a hard bristle toothbrush to clean my teeth." "I will remove the white patches from my tongue and cheek with a toothbrush." "I will use an alcohol based mouthwash after brushing my teeth."
"I will rinse my mouth every 2-4 hours with baking soda and water."
When evaluating a pregnant client's knowledge of symptoms to report immediately, which statement indicates to the nurse that the client understands the information given to her? "If I feel tired after resting, I should report it immediately." "If I have blurred or double vision, I should call the clinic immediately." "Nausea should be reported immediately." "I'll report increased frequency of urination."
"If I have blurred or double vision, I should call the clinic immediately."
A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation? "My son will be fine, but I may be charged with reckless driving." "This accident will probably cost me my marriage." "If he dies, there will be nothing for me to do but join him." "I just did not see him run behind the car."
"If he dies, there will be nothing for me to do but join him."
A nurse is completing an admission assessment. The nurse asks the client about social support systems and the client asks the nurse to explain social support systems. Which statement describes a social support system? "It is a source of payment options to aid in the hospital bill of the client." "It is a group of friends and colleagues at home and in the community that help a client in times of need." "It is a group of health care providers who are available to assist with care needed for the client's family." "It is a health care system with a variety of educators available in the community."
"It is a group of friends and colleagues at home and in the community that help a client in times of need."
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan? "Follow good health habits to change the course of the disease." "Practice using the mechanical aids that you'll need when future disabilities arise." "Keep active, use stress reduction strategies, and avoid fatigue." "You'll need to accept the necessity for a quiet and inactive lifestyle."
"Keep active, use stress reduction strategies, and avoid fatigue."
A client with a moderate level of anxiety is pacing quickly in the hall and tells the nurse, "Help me. I can't take it anymore." What would be the nurse's best initial response? "I'll get some medicine to help you relax." "Try doing your relaxation exercises to calm down." "It would be best if you would lie down until you are calmer." "Let's go to a quieter area where we can talk if you want."
"Let's go to a quieter area where we can talk if you want."
A client with chronic pain comes to the clinic for an evaluation. During the visit, the client asks the nurse about possibly using acupuncture for pain relief. Which response by the nurse would be most appropriate? "This type of treatment is not effective in relieving pain." "You need to get your body into different positions which could increase your pain." "Restoring the energy balance in your body could help with pain relief." "Acupuncture is helpful for acute pain but not chronic pain."
"Restoring the energy balance in your body could help with pain relief."
A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury? "Bend over the object you're lifting." "Push or pull an object using your arms." "Stand close to the object you're lifting." "Narrow the stance when lifting."
"Stand close to the object you're lifting."
A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate? "Take a warm tub bath or shower before exercising. This may help with your discomfort." "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." "You're probably exercising too much. Decrease your exercise to every other day." "Tell the health care provider about your symptoms. Maybe your analgesic medication can be increased."
"Take a warm tub bath or shower before exercising. This may help with your discomfort."
A client is admitted for treatment of a flare-up of irritable bowel disease, exacerbated by severe anxiety. The client resists any discussion of taking medications and tells the nurse that a biofeedback device was suggested on the Internet. What is the best response of the nurse? "Your device is just another expensive electronic toy." "Biofeedback does not work for severe anxiety." "It does not work - you are back in the hospital." "Tell me more about the biofeedback device."
"Tell me more about the biofeedback device."
A client hospitalized with Crohn's disease is experiencing a migraine aura. The client requests that the client's chiropractor be allowed to visit even though it is after visiting hours. What is the nurse's best response? "Tell me what helps your migraines outside of the hospital." "Chiropractors are not real doctors and cannot practice here." "You can't have a visitor if you are having migraine pain." "I can bring you a PRN medication for your migraine."
"Tell me what helps your migraines outside of the hospital."
A nurse is caring for an adolescent after surgery. Which post-operative teaching statement is best to use for the adolescent? "The instructions that I give you will help you get back to your regular activities quickly." "It is important that you follow these instructions to prevent future complications." "Just believe me that you need to do each thing exactly as I instruct you." "Do everything just as instructed to avoid problems with your parents."
"The instructions that I give you will help you get back to your regular activities quickly."
After teaching the client how to use the patient-controlled analgesia (PCA) pump, the nurse determines that the client understands the use of the PCA when the client makes which statement? "I should wait until the pain is really bad before I push the button to get more pain medicine." "The machine will give me only the prescribed amount of pain medication even if I push the button too soon." "I have to be careful about pushing the button too many times or I will overdose." "It's OK for my family to press the button for me if I'm too tired to do it myself."
"The machine will give me only the prescribed amount of pain medication even if I push the button too soon."
During the interview at a crisis center, a newly widowed client reveals the wish "to join my spouse in heaven." The nurse determines that the client does not plan self-harm. What is the best response by the nurse? "What was the cause of your spouse's death?" "Are you feeling depressed?" "What family lives near by?" "What feelings have you been experiencing?"
"What feelings have you been experiencing?"
A client tells the nurse that "the hospital food is horrible." What should the nurse tell the client? "Would you like to speak with the dietitian about the food and meal selection?" "I don't like the hospital cafeteria food either." "The staff is doing the best it can to cook in such large quantities." "I'll report this to the health care provider (HCP)."
"Would you like to speak with the dietitian about the food and meal selection?"
A client is admitted to the hospital following an inadvertent overdose with oxycodone. He reveals that he has chronic back pain that resulted from an injury on a construction site. He states, "I know I took too much oxycodone at once, but I can't live with this pain without them. You can't take them away from me." Which response by the nurse is most appropriate? "Once you're tapered off the oxycodone, you will find that nonaddictive pain medicines will be enough to control your pain." "You're going to be switched from the oxycodone to methadone for long-term pain management." "The oxycodone will be stopped tomorrow, but you'll have lorazepam to help you with the withdrawal symptoms." "Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines."
"Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines."
The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply. A client who needs assistance with colostomy irrigation A client who has C3 to C5 spine injury A client who just had coronary artery bypass graft (CABG) A client who needs initial admission assessment A client who is receiving glargine subcutaneously
A client who needs assistance with colostomy irrigation A client who is receiving glargine subcutaneously
The nurse is developing a care plan for a client with cancer receiving hospice home care. Which would be the most appropriate action for managing the client's chronic pain? Administer analgesics regularly and additionally as needed for break-through pain. Administer analgesics when vital signs indicate increased pain severity. Sedate the client with tranquilizers. Avoid intravenous pain medication until the client is terminal.
Administer analgesics regularly and additionally as needed for break-through pain.
Two days after surgery to amputate the left lower leg, a client states that they have pain in the missing extremity. There is an existing prescription for PRN pain medication. Which action by the nurse is most appropriate? Do nothing because it isn't possible to have pain in a missing limb. Request a consult with a psychologist. Administer medication for the reported discomfort. Contact the health care provider.
Administer medication for the reported discomfort.
A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next? Ask the client what she did to make someone beat her so badly. Discuss with the client what she can do to deescalate the situation next time. Tell the client that it is difficult to believe that such injuries resulted from a fall. Ask the client specifically about the possibility of physical abuse.
Ask the client specifically about the possibility of physical abuse.
A nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What should the nurse do next? Give another 0.125 mg as soon as possible. Nothing; the dose will not make a significant difference. Hold the next dose to make sure the total amount balances. Assess the client and notify the client's physician.
Assess the client and notify the client's physician.
A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? Administer a neuroleptic medication before speaking with the client. Provide reassurance that the client is safe and the voices are not real. Assess the nature of the commands by asking what the voices are saying. Provide reassurance that the client is safe and promise the staff will protect the client.
Assess the nature of the commands by asking what the voices are saying.
A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL (51.1 g/L), and blood pressure is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the health care provider and family to plan to take which action next? Discontinue all measures. Notify the hospital attorney. Attempt to stabilize the client through the use of fluid replacement. Give enough blood to keep the client from dying.
Attempt to stabilize the client through the use of fluid replacement.
A nurse is reviewing the health care provider's (HCP's) admitting prescriptions for a post-menopausal woman scheduled for a dilatation and curettage. The nurse is unable to decipher the handwriting but thinks the medication prescription reads either metoprolol or topiramate. What should the nurse do next? Call the HCP to clarify the prescription. Ask the client if she has hypertension. Ask the client if she has migraines. Ask the pharmacist to interpret the prescription.
Call the HCP to clarify the prescription.
The nurse is providing care to a client with Alzheimer's-type dementia. Which nursing intervention is the priority? Maintain an environment with cheerful and pleasant surroundings. Structure a daily and precise routine that can be used after discharge. Establish a routine that reinforces memories and supports former habits. Control the environment by providing structure and consistent boundaries.
Control the environment by providing structure and consistent boundaries.
A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first? Discharge or admit all current clients in the emergency department. Place the fully clothed client in a shower for decontamination. Determine what decontamination measures took place in the field before approaching the client. Cut off the client's clothing and dispose of it in hazardous waste containers.
Determine what decontamination measures took place in the field before approaching the client.
The nurse is caring for a very anxious child whose pain has not been manageable. The parents stay in the child's room, crying and yelling at each other. Grandparents and other family members are also constantly in attendance. To effectively help the child with pain management, which action should be a priority for the nurse? Administer medication to help the child sleep during the night. Develop a visitation schedule with the family that allows the child to rest. Request that hospital security remove all visitors from the child's room. Tell the parents that their behavior is increasing the child's pain.
Develop a visitation schedule with the family that allows the child to rest.
During a routine prenatal visit, a pregnant client reports heartburn. To minimize her discomfort, the nurse should include which suggestion in the care plan? Drink more citrus juice. Eat small, frequent meals. Take sodium bicarbonate. Limit fluid intake.
Eat small, frequent meals.
Which recommendation would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn? Eat smaller and more frequent meals during the day. Drink several cups of regular tea throughout the day. Decrease fluid intake to four glasses daily. Take a pinch of baking soda with water before meals.
Eat smaller and more frequent meals during the day.
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next? Report the incident to the team leader. Wait until the next shift and ask the nurse on that shift to contact the HCP. Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Ask the surgical resident to write a prescription for a stronger pain medication.
Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.
A charge nurse asks a newly graduated registered nurse (RN) who normally works on a medical-surgical nursing unit to take care of two clients in the coronary care unit. The nurse has not had experience with taking care of clients on monitors or using the medications that these clients are taking. What should the new nurse do? Ask the charge nurse if the assignment can be reduced to taking care of one client. Explain to the charge nurse about his or her level of experience and express concerns about this assignment. Tell the charge nurse that the assignment was to the medical-surgical unit and refuse to go to the coronary care unit. Accept the assignment and then plan to ask the nurses in the coronary care unit to administer the medications for these clients.
Explain to the charge nurse about his or her level of experience and express concerns about this assignment.
A client hospitalized for a round of chemotherapy reports being very distressed at being unable to sleep because of a series of roommates who have been actively withdrawing from opioids. The nurse responds that they must accept clients who are detoxing from prescribed and illicit drugs. Which action should the nurse take? Ask the client's physician for an order to avoid this type of roommate. Advise the client to ask the physician to transfer to another ward. Recommend the client request to sign out against medical advice. Explore difficulties, identify solutions, and negotiate short-term aids.
Explore difficulties, identify solutions, and negotiate short-term aids.
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? Apply an ice cube to the nipples. Offer the neonate a small amount of formula. Rub the nipples gently with lanolin cream. Express a small amount of breast milk.
Express a small amount of breast milk.
The nurse is assessing a client experiencing a sickle cell crisis who continues to rate the pain at 10 on a scale of 1 to 10. Which is true about pain? Tolerance of pain is the same in all people. Expression and perception of pain vary widely from person to person. Tolerance of pain is determined by a person's genetic makeup. Pain perception is the same in all people.
Expression and perception of pain vary widely from person to person.
A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first? Give the child a nonopioid analgesic for pain. Apply a warm compress to the injured shoulder. Keep the child in a comfortable position and apply ice to the injured shoulder. Ask the child to demonstrate full range of motion of the left arm.
Keep the child in a comfortable position and apply ice to the injured shoulder.
A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse? Provide privacy and emotional support. Avoid talking about the baby. Assess fetal heart tones via external monitor. Reassure the client that she'll get pregnant again soon.
Provide privacy and emotional support.
An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober? Provide the client with a quiet room to sleep in. Walk the client around the unit. Give the client black coffee to drink. Have the client take a cold shower.
Provide the client with a quiet room to sleep in.
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? Providing a solution of viscous lidocaine for use as a mouth rinse Recommending that the client discontinue chemotherapy Monitoring the client's platelet and leukocyte counts Checking regularly for signs and symptoms of stomatitis
Providing a solution of viscous lidocaine for use as a mouth rinse
A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. What would be the nurse's priority assessment? Client feelings about the injury Bladder distention Neurological deficit Pulse oximetry readings
Pulse oximetry readings
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first? Provide client education on medications and diet. Monitor daily weights and urine output. Limit visitation by family and friends. Reduce pain and myocardial oxygen demand.
Reduce pain and myocardial oxygen demand.
A client, who underwent femoral-popliteal (fem-pop) bypass surgery, is scheduled to return from the post-anesthesia care unit. Which staff member should receive this client? Registered nurse with one year of experience Charge nurse with 10 years of experience Nursing assistant with 15 years of experience Licensed practical nurse (LPN) with five years of experience
Registered nurse with one year of experience
A nurse and an unlicensed assistive personnel (UAP) are caring for clients in a labor and birth unit. Which task should the nurse assign to the UAP? Perform a fundal check on a 2-day postpartum client. Remove a fetal monitor, and assist a client to the bathroom. Teach a new mother how to bottle-feed her infant. Give ibuprofen 800 mg by mouth to a newly postpartum client.
Remove a fetal monitor, and assist a client to the bathroom.
Which safeguard should the nurse take to ensure accuracy of a telephone order? Repeat the order to the prescriber. Insist that the nursing supervisor monitor the call. Wait for the physician to sign the order before administering the drug. Repeat the order to the nursing supervisor.
Repeat the order to the prescriber.
A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? Report the incident to risk management. Anticipate suspension from the facility due to the error. Report the incident to the nursing regulatory agency. Complete an adverse drug reaction (ADR) report.
Report the incident to risk management.
A nurse manager is auditing the nursing unit's adherence to infection control practices. Which observation causes the nurse manager to be most concerned that the clients on the unit are at risk for infection? A nurse does not wear a mask when entering the room of a client on contact precautions. A client receives a prophylactic antibiotic 20 minutes late. A nurse does not use sterile scissors to cut the tape for a wound dressing. Several nurses fail to perform hand hygiene between clients.
Several nurses fail to perform hand hygiene between clients.
A community nurse is making a home visit to an elderly, depressed client. During the assessment, the client experiences periods of silence. What would be the appropriate nursing response during these periods of silence? Change the subject by introducing a new topic of interest for the nurse. Inform the client that the day is too busy to sit there in silence. Leave the client's home because the conversation is obviously finished. Sit quietly and allow the client to think.
Sit quietly and allow the client to think.
When caring for a client with acute osteomyelitis in the right tibia, which measure is most appropriate to implement when repositioning the client's leg? Support the leg above and below the affected area when positioning. Hold the leg by the ankle when repositioning to avoid touching the tibia. Apply warm, moist compresses to the leg before repositioning. Have the client move the leg by himself to decrease pain.
Support the leg above and below the affected area when positioning.
A client is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the pain of rheumatoid arthritis. What information should the nurse give to the client about taking these medications? Take antacids 1 hour after taking NSAIDs. Take NSAIDs at least three times per day. Exercise the joints at least 1 hour after taking the medication. Take NSAIDs with food.
Take NSAIDs with food.
The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain. Get used to some pain, and use a little less medication than needed to keep from being addicted. Take analgesics only when pain returns.
Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.
The client with first-time bacterial cystitis is being treated with an antibiotic to be taken for 7 days. What should the nurse instruct the client to do? Take the entire prescription as ordered. Use condoms if having sex. Limit fluids to 1,000 mL/day. Notify the health care provider (HCP) when the urine is clear.
Take the entire prescription as ordered.
A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding the application of the complementary oil? Tea tree oil has antibacterial properties. Antiperspirant will aid with vasoconstriction. Fish oil has antiviral properties. Baby oil can assist with smooth skin.
Tea tree oil has antibacterial properties.
The nurse is trying to establish a trusting relationship with a client experiencing pain. When the client asks for pain medication, the nurse notes that it is not time to give the medication. What is the best action by the nurse to facilitate a trusting relationship? Tell the client a personal story about difficulty managing pain. Tell the client how unfortunate the situation is and offer distraction. Tell the client that a more experienced nurse will administer the pain medication. Tell the client when the medication is due and return promptly at that time.
Tell the client when the medication is due and return promptly at that time.
The use of a patient-controlled analgesia (PCA) pump is effective in which situation? The client does not become dependent on opioids postoperatively. There is decreased cost by decreasing use of intramuscular (IM) injections. The client achieves a therapeutic level of analgesia. The family can assist the client in managing the pain.
The client achieves a therapeutic level of analgesia.
A nurse is performing a psychosocial assessment on a first-time mother and her neonate. Which behavior indicates a need for further evaluation? The mother holds the neonate close to her. The mother makes little eye contact with the neonate. The mother speaks to the neonate in a soft tone. The mother pays more attention to the neonate than to the nurse.
The mother makes little eye contact with the neonate.
Which finding requires further intervention in a mother who's breast-feeding? The neonate's lips smack. The neonate makes swallowing noises when breast-feeding. The mother is comfortable positioning the neonate. The neonate latches easily to the breast.
The neonate's lips smack.
Assessment of suicidal risk in children and adolescents requires the nurse to know what information? Children rarely commit suicide unless one of their parents has already committed suicide, especially in the past year. Children do have a suicidal risk that coincides with some significant event such as a recent gun purchase in the family. Adolescents typically do not choose suicide unless they live in certain geographical regions of the United States or Canada. The risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord being most at risk.
The risk of suicide increases during adolescence, with those who have recently suffered a loss, abuse, or family discord being most at risk.
A client in the hospital for gout reports an excruciating migraine but declines analgesic medications when offered. Later the nurse observes a visitor performing what appears to be a type of physical manipulation of the client's head and neck. The client reports that the visitor is a therapist. The best action for the nurse to take is to: alert staff that this client is receiving illicit treatment. notify the physician to restrict the client's visitors. call security to escort the visitor out of the hospital. advise the client how the client might receive adjunct services.
advise the client how the client might receive adjunct services.
A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated? reassuring the client that such pain is normal after vaginal birth preparing a warm sitz bath for the client administering additional pain medications assessing the perineum
assessing the perineum
A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time? checking vital signs and assessing for nonverbal indications of pain documenting that the client is resting quietly and denies pain calling a family member to obtain information about the client giving the client the ordered as-needed pain medication
checking vital signs and assessing for nonverbal indications of pain
The nurse is caring for a group of clients. The client with which condition is most likely to benefit from acupressure treatment? venous lower leg ulcer small bowel obstruction chronic lower back pain pneumonia with shortness of breath
chronic lower back pain
A client with pancreatic cancer has been receiving morphine via a subcutaneous pump for 2 weeks. The client is requiring an increased dose of the morphine to manage the pain. How should the nurse document this finding? tolerating the medication well showing addiction to morphine developing a tolerance for the medication experiencing physical dependence
developing a tolerance for the medication
A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? massaging the toes placing the child on his right side applying ice to the foot elevating the foot of the bed
elevating the foot of the bed
A nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits? encouraging the client use relaxation exercises telling the client to play ping pong in the day room administering sleeping pills suggesting that the client talk with other clients until ready to sleep
encouraging the client use relaxation exercises
A client reports nausea unrelieved by a recent antiemetic dose. The client asks for another treatment for the nausea. What is an alternative therapy to treat nausea? kava red clover ginger raspberry
ginger
A client has been taking prescribed aspirin in large doses and reports having stomach irritation, sometimes with vomiting. Which food or beverage noted from the client's diet history should the nurse suggest the client avoid? glass of wine scrambled eggs sweetened tea dry toast
glass of wine
After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client: has experienced increased pain due to a muscle spasm. requires repositioning to achieve better alignment of the leg. would benefit from additional muscle-strengthening exercises. has experienced a dislocation of the hip prosthesis.
has experienced a dislocation of the hip prosthesis.
Which nursing measure would most likely relieve postoperative gas pains after abdominal hysterectomy? helping the client walk providing extra warmth offering the client a hot beverage applying a snugly fitting abdominal binder
helping the client walk
A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching? herbal remedies acupuncture meditation music therapy
herbal remedies
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide factor replacement and implements which intervention? institutes rest, ice, compression, and elevation begins physical therapy with active range of motion administers an aspirin-containing compound initiates skin traction immobilization
institutes rest, ice, compression, and elevation
A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, the client has been unable to eat enough and has lost weight. Which nonpharmacologic intervention should the nurse recommend? keeping crackers at the bedside to eat before getting out of bed drinking water with every meal eating three large meals per day drinking liquids with dry foods
keeping crackers at the bedside to eat before getting out of bed
The best way for a nurse to assess pain in an 18-month-old client is to ask the client, "Are you feeling any pain?" check the client's pupils. tell the caregivers to call if the client has pain. observe for behavioral changes.
observe for behavioral changes.
For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep? serving the client a cup of coffee and a snack in the evening increasing the client's activity 2 hours before bedtime encouraging the client to be less active during the day playing soft or soothing music
playing soft or soothing music
A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to: realign fracture fragments. prevent neurologic damage. control internal bleeding. maintain skin integrity.
realign fracture fragments.
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? relief from pain relief from constipation increased ability to sleep reduced muscle spasticity
reduced muscle spasticity
A client in a double hip spica cast is constipated. The surgeon cuts a window into the front of the cast. Which outcome is intended? The window in the cast will allow: the surgeon to manipulate the fracture site. the nurses to reposition the client. relief from pressure due to abdominal distention. The window will allow the nurse to palpate the superior mesenteric artery.
relief from pressure due to abdominal distention.
The client with a fractured tibia has been taking methocarbamol. Which finding indicates that the drug is having the intended effect? decrease in nervousness lack of infection relief of muscle spasms reduction in itching
relief of muscle spasms
A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it produces which outcome? reduces the urine bacterial count. induces sleep. relieves muscular spasticity. stimulates the client's appetite.
relieves muscular spasticity.
The nurse is working on a pediatrics unit. Which intervention for a 6-year-old who still wets the bed would be best assigned to the unlicensed assistive personnel (UAP)? reminding the child to use the bathroom before going to bed administering a prescribed dose of a tricyclic antidepressant discussing research related to hypnotics with the mother reaching the mother about moisture alarm devices
reminding the child to use the bathroom before going to bed
The nurse is planning care for a group of clients who requested the use of yoga. The client with which condition is not a candidate for yoga? arthritis spinal fusion diabetes anxiety
spinal fusion
The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse explain is the expected outcome of these exercises? strengthening the abdominal muscles reducing the risk of hemorrhoids strengthening the perineal muscles alleviating lower back discomfort
strengthening the perineal muscles
The mother tells the nurse she will be afraid to allow her child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fitness is important for children with hemophilia, which activity should the nurse suggest as ideal? swimming basketball gymnastics snow skiing
swimming
When determining how to administer analgesics to a client who has been receiving opiates for pain relief administered by injection, the nurse should consider using patient-controlled analgesia since it is more effective because: the nurse interrupts the client less frequently and the client can get more sleep. a different opioid can be used. the client will control the amount of pain medication administered. two opioids can be administered simultaneously.
the client will control the amount of pain medication administered.
A client with chronic cancer pain has been receiving opiates for 4 months. She rated the pain as an 8 on a 10-point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to 8 again. What is the most likely explanation for the increasing pain? withdrawal from the opioid tolerance to the opioid development of an addiction to the opioids placebo effect has decreased
tolerance to the opioid
A nurse in a physician's office has noted on several occasions that one of the physicians frequently obtains controlled drug prescription forms for prescription writing. The physician reports that their spouse has chronic back pain and requires pain medication. One day the nurse enters the physician's office and sees the physician take a pill out of a bottle, and mentions the physician suffers from migraines and it really helps when the physician takes the spouse's pain medication. What type of nurse-physician ethical situation is illustrated in this scenario? disagreements about the proposed medical regimen unprofessional, incompetent, unethical, or illegal physician practice claims of loyalty conflicts regarding the scope of the nurse's role
unprofessional, incompetent, unethical, or illegal physician practice
When developing a teaching plan for women about human immunodeficiency virus (HIV) transmission, the nurse should instruct the group that to reduce the risk of transmission they should: avoid prolonged sex. avoid inhalant drugs. use latex condoms with sexual intercourse. douche before and after sexual intercourse.
use latex condoms with sexual intercourse.
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? "Apply an antibacterial dressing to the incision daily." "Be aware that your urine will be cherry-red for 5 to 7 days." "Increase your fluid intake to 2 to 3 L per day." "Take your temperature every 4 hours."
"Increase your fluid intake to 2 to 3 L per day."
A physician orders a soap suds enema, 500 ml. What does this amount equal in liters? 0.5 L 1 L 2 L 0.75 L
0.5 L
What is the nurse's priority intervention for a toddler who has just had a hip spica cast applied? Instruct the parents how to get their child home in the car. Reduce the risk of constipation by avoiding pain medications. Assess sensation, circulation, and motion of the child's feet and toes. Limit fluids to reduce urine output and risk of getting the cast wet.
Assess sensation, circulation, and motion of the child's feet and toes.
The nurse is making assignments for the unlicensed assistive personnel (UAP). Which tasks can be safely assigned to UAP? Select all that apply. Assisting a client with a chest tube during ambulation Bathing a client with Alzheimer's disease Turning a client who is poorly nourished Feeding a client with swallowing difficulty Teaching a client how to use a cane
Bathing a client with Alzheimer's disease Turning a client who is poorly nourished
The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider's (HCP's) prescription, the nurse notes that the prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take? Contact the HCP to verify the prescription. Administer 15 mg of the drug. Administer the medication as prescribed. Ask another nurse to review the prescription.
Contact the HCP to verify the prescription.
When developing the postoperative plan of care for a child who is scheduled to have a tympanostomy tube inserted into the right ear, which intervention should the nurse identify to facilitate drainage? Apply a gauze dressing to the left ear. Position the child to lie on the right side. Apply an ice pack to the left ear. Apply warm compresses to the right ear.
Position the child to lie on the right side.
A client is receiving cyclobenzaprine for management of a herniated lumbar disk. Which finding indicates the drug is providing the intended relief? The client can take deep breaths. The client is sedated. The client's muscles are not in spasm. The client is not anxious.
The client's muscles are not in spasm.
A client reports being allergic to amoxicillin even though the medication administration record and armband do not indicate medication allergies. What should the nurse do about administering the drug to the client? Call the family to verify the client's statement. Withhold the medication. Administer another, similarly acting antibiotic. Administer the prescribed medication.
Withhold the medication.
A client is describing to a nurse a special type of therapy using needles inserted in specific areas along channels in the skin. What type of therapy is the client describing? biofeedback yoga herbal therapy acupuncture
acupuncture
A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? Try to persuade the client to take the medication as ordered by the doctor. Document the client's choice and re-assess pain in 1 hour. Ask the client's spouse to hold the client's hands while the nurse puts the pill under the tongue. Emphasize the rationale for taking the medication now as ordered.
Document the client's choice and re-assess pain in 1 hour.
A young client is admitted with a diagnosis of somatic symptom disorder, but declines analgesic medications. The nurse learns that the client finds relief in regular hypnotherapy practice. The best response of the nurse should be: "Explain how you find the procedure helpful." "You have to believe in hypnosis for it to work." "Hypnosis does not help with severe pain." "Hypnosis is all entertainment and theater."
"Explain how you find the procedure helpful."
Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? Place client in supine position. Stop the feeding. Aspirate stomach contents. Reposition the nasogastric tube.
Stop the feeding.
The client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn pain. The client rates the pain as a 7 on the numeric scale of 0/10. How many tablets of oxycodone/acetaminophen should the nurse administer? 2 6 4 8
2
The client reports that the nasal packing is uncomfortable and asks when it will be removed. The nurse should tell the client the nasal packing is usually removed: the day of surgery. 24 to 48 hours after surgery. after nasal edema subsides. after pain has diminished.
24 to 48 hours after surgery.
The nurse has a five client assignment on a medical surgical unit. Place in order the priority which the nurse will assess the clients. All options must be used. 1Client admitted with fever with last temperature of 100.2 degrees Fahrenheit. 2Client admitted with arm cellulitis after a cat bite. 4Client admitted with renal failure receiving a unit of packed red blood cells for the past 30 minutes. 3Client admitted with uncontrolled hypertension with last blood pressure of 160/95 mmHg. 5Client admitted with end stage bladder cancer receiving oral morphine for pain control every two hours.
4.Client admitted with renal failure receiving a unit of packed red blood cells for the past 30 minutes. 3.Client admitted with uncontrolled hypertension with last blood pressure of 160/95 mmHg. 1.Client admitted with fever with last temperature of 100.2 degrees Fahrenheit. 5.Client admitted with end stage bladder cancer receiving oral morphine for pain control every two hours. 2.Client admitted with arm cellulitis after a cat bite.
A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next?
Administer the acetaminophen with codeine.
When the nurse is assessing a client who reports a back injury, what should the nurse ask the client about first? personal history of illness mechanism of injury previous hospitalizations family history of back problems
mechanism of injury
A client experiencing alcohol withdrawal reports being upset about going through detoxification. Which goal is the priority for this client? making a personal inventory of strengths working with the nurse to remain safe committing to a drug-free lifestyle drinking plenty of fluids on a daily basis
working with the nurse to remain safe