EAQ 7: Nursing Attributes and Roles
Which choice is not part of a low-residue diet? 1 Apples 2 Spaghetti 3 Ice cream 4 Ripe bananas
1 Most raw fruits, such as apples, are high-residue foods that contribute to the development of bulk; the child's overdistended colon cannot tolerate an increase in residue. A low-residue diet prevents irritating the bowel further. Spaghetti is a low-residue food. Ice cream is a low-residue food. Although ripe bananas are raw fruit, they are not classified as high residue.
A client is diagnosed with celiac disease. Which foods would the nurse teach the client to avoid? Select all that apply. One, some, or all responses may be correct. 1 Corn 2 Cheese 3 Oatmeal 4 Rye bread 5 Fruit juice
3,4 Gluten is found in rye, oats, wheat, and barley, which should be avoided because gluten in these grains is irritating to the gastrointestinal mucosa in clients with celiac disease. Gluten is found in oatmeal and rye bread and should be avoided. Gluten is not found in corn. Gluten is not found in milk and dairy products. Gluten is not found in fruit.
Which nursing intervention is the priority action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation? 1 Treating pain 2 Assessing respirations 3 Initiating defibrillation 4 Monitoring blood pressure (BP)
3 The priority nursing action for a client who is admitted to the emergency department during cardiac arrest caused by ventricular fibrillation is initiating defibrillation. Treating pain, assessing respirations, and monitoring BP will not occur until this action has been initiated.
Which meal would the nurse select for a preschooler on a low-residue diet? 1 A frankfurter on a roll 2 Ripe peaches with ice cream 3 Peanut butter and jam on white bread 4 Scrambled eggs and toasted white bread
4 A low-residue diet should contain minimal roughage; eggs prepared any way but fried are permitted; refined bread and toast also are permitted. Although meat is permitted, spicy, fried, and tough meats are not. Most frankfurters have fillers that interfere with the goal of low residue. Raw fruits and nuts and jams are not permitted because they contain roughage.
Which action would the nurse take first when a client with acute bronchitis and emphysema reports feeling anxious and short of breath? 1 Obtain the oxygen saturation. 2 Provide oxygen at 2 L per minute. 3 Offer the prescribed rescue inhaler. 4 Suggest use of pursed-lip breathing.
1 More assessment is needed before further actions are taken; the nurse would check the client's oxygen saturation as the initial action. If oxygen saturation is low, then oxygen administration would be needed. The rescue inhaler may be needed if the client has wheezes or decreased breath sounds. Pursed-lip breathing may be helpful if anxiety is causing hyperventilation, but the first action would be to assure that the client is not hypoxemic.
Which clinical finding would the nurse expect when assessing a 3-week-old infant with hypertrophic pyloric stenosis who is severely dehydrated? 1 Weight loss of 5% 2 Severe allergic reactions 3 Depressed anterior fontanel 4 Urine specific gravity of 1.014
3 Depressed fontanels related to decreased cerebral spinal fluid are a classic sign of fluid volume deficiency in infants. A 5% weight loss indicates mild dehydration; a severely dehydrated infant will have a 15% weight deficit. Dehydration is unrelated to allergic reactions. This specific gravity is within the expected limits of 1.005 to 1.020.
The nurse develops a plan of care for a client with an ileostomy and would include which item? 1 Teach the client to eat foods high in residue. 2 Explain that drainage can be controlled with daily irrigations. 3 Expect the stoma to start draining on the third postoperative day. 4 Anticipate that any emotional stress can increase intestinal peristalsis.
4 Emotional stress of any kind can stimulate peristalsis and thereby increase the volume of drainage. The client should be encouraged to eat a regular diet if possible. Ileostomy drainage is liquefied and continuous, so irrigations are not indicated. The stoma will start to drain within the first 24 hours after surgery.
3 Involuntary muscle contractions after fractures cause muscle spasms. Thermotherapy reduces muscle spasms. Advise the client with muscle spasms to undergo thermotherapy treatment. Advise the client with foot drop to keep the foot in a neutral position. Advise the client with contractures to change positions frequently. Advise the client with muscle atrophy to practice an isometric muscle-strengthening exercise regimen.
The nurse assesses four clients with musculoskeletal injuries. Which client would the nurse advise thermotherapy? 1 Client A 2 Client B 3 Client C 4 Client D
2 Client B's levels are all elevated, indicating hyperthyroidism. In hyperthyroidism, thyroxine (T4) total should be greater than 11 mcg/dL (142 nmol/L), free thyroxine (FT4) should be greater than 2.7 ng/dL (35 pmol/L), and the triiodothyronine (T3) total should be greater than 204 ng/dL (3.14 nmol/L) for ages 20 to 50 years old or greater than 181 ng/dL (2.79 nmol/L) for ages greater than 50 years old. Clients A and C may have hypothyroidism. Client D's levels are normal.
The nurse is reviewing laboratory results from several clients. Based on the given data, which client is most likely to have a diagnosis of hyperthyroidism documented in the medical record? 1 Client A 2 Client B 3 Client C 4 Client D
When a client with chronic obstructive pulmonary disease has a new prescription for daily low-dose prednisone, which information will the nurse include when teaching the client? 1 Take the medication an hour before eating. 2 Report any dark stools to the health care provider. 3 Weight loss is a common side effect of the medication. 4 Take the medication as soon as you experience any dyspnea.
2 Because corticosteroids can cause peptic ulcers and gastrointestinal bleeding, the client will be instructed to call the health care provider for any symptoms of ulcer such as gastric pain or dark stools. Oral corticosteroids should be taken with food to help avoid gastric irritation and ulcer development. Corticosteroids cause fluid retention and increased appetite, leading to weight gain. Corticosteroids are used to prevent airway inflammation that can lead to dyspnea; they are not rapidly acting and must be taken regularly to be effective.
A client is admitted to the emergency department with reports of frequent loose, watery stools and anorexia during the past week. Blood pressure is 90/68 mm Hg and pulse is 124. Which prescribed action will the nurse take first? 1 Obtain blood and urine cultures. 2 Start infusion of normal saline. 3 Insert retention catheter. 4 Transfer the client to intensive care unit.
2 The client's history of watery stools and anorexia suggests hypovolemia as the cause of the hypotension and tachycardia; fluids should be rapidly infused to correct hypovolemia. Blood and urine cultures are needed to determine whether the client has a bacterial infection, but correction of the hypovolemia is a higher priority. A retention catheter may be needed for hourly intake and output measurements, but the nurse will first initiate actions to correct hypovolemia. Transfer to the intensive care unit is appropriate, but the nurse would not wait until after the transfer to initiate needed interventions to correct hypovolemia.
Which room assignment would the nurse make for a client exhibiting manic behavior? 1 With a client who is very quiet 2 Alone in a sparsely furnished room 3 Alone in a room at the end of the hall 4 With a client exhibiting similar behavior
2 The nurse would assign the client to a sparsely furnished room. Overactive individuals are stimulated by environmental factors; one responsibility of the nurse is to simplify their surroundings as much as possible. The quiet client may become the target of this client's overactivity so the nurse would not assign the room with a client who is very quiet. The client should be placed in a room near the nursing staff (not at the end of the hall) to prevent harm to self and others. Two overactive clients together will produce excessive stimuli for each other and would be nontherapeutic.
The critical care nurse with young children has a spouse who is not expected to return from work until 8 AM. The nurse is telephoned at 2 AM to come to work to assist with the care of multiple trauma victims. What should the nurse do first? 1 Wake the older child. 2 Call the spouse. 3 Shower and dress. 4 Collect the go bag.
2 When called to respond to work during a mass casualty event, some nurses may experience ethical and moral conflict between their family obligations and professional responsibilities. Each person has to make a choice about whether to be involved in helping during the emergency or when to become involved. The best action would be for the nurse to call the spouse to help with planning care for the children. Waking the older child might be premature. There is not enough information to determine if the children can be safely left in the home alone while the mother is at work. It might be premature for the nurse to shower and dress. Collecting the go bag is not necessary; the nurse and family are not experiencing a personal disaster.
The health care provider prescribes a contraction stress test (CST) for a client at 33 weeks' gestation whose nonstress test (NST) was nonreactive and whose biophysical profile (BPP) was inconclusive. Which maternal conditions would prompt the nurse to question the prescription? Select all that apply. One, some, or all responses may be correct. 1 Hypertension 2 Preterm labor 3 Placenta previa 4 Cervical insufficiency 5 Premature rupture of membranes
2,3,4,5 The CST may trigger a preterm birth in a client who is in preterm labor or has a history of preterm births. With a placenta previa, the contractions caused by the CST can stimulate bleeding. The CST is also contraindicated with cervical insufficiency, as these clients are already at a higher risk of preterm birth. The CST might also trigger a preterm birth in a woman whose membranes have ruptured prematurely. The CST is indicated to assess the influence of hypertension on the placental circulation and determine the response of the compromised fetus to labor.
When caring for a woman with a probable ruptured tubal pregnancy, which clinical manifestation requires immediate intervention? 1 Abdominal distention 2 Intermittent abdominal contractions 3 Dull, continuous upper-quadrant abdominal pain 4 Sudden onset of knifelike pain in one of the lower quadrants
4 One symptom of sudden rupture of a fallopian tube is pain on the affected side, usually sudden, excruciating, and radiating over the lower abdomen and to the shoulder; sometimes the pain is associated with nausea, vomiting, and diarrhea. Abdominal distention is not a classic sign of a ruptured fallopian tube. There are no contractions, because the pregnancy is not uterine. The pain is exquisite, sharp (not dull) and sudden in the lower abdomen when the fallopian tube ruptures.
The nurse is performing a physical assessment of a 15-month-old toddler. Which finding indicates that a disorder may be present? 1 The anterior fontanel is still palpable. 2 The liver is palpated 3 cm below the costal margin. 3 Abdominal movements are visible with respiration. 4 An apical pulse rate of 104 beats/min is auscultated.
2 A 15-month-old child's liver should be palpable 1 to 2 cm below the right costal margin. The anterior fontanel closes completely around 18 months of age. Abdominal or diaphragmatic breathing is expected in children younger than 7 years. A pulse rate of 104 beats/min is within the expected range (100-110 beats/min) for a 15-month-old child.
Which diet would the nurse anticipate for an infant with phenylketonuria? 1 Fat-free 2 Protein-enriched 3 Phenylalanine-free 4 Low-phenylalanine
4 Because phenylalanine is an essential amino acid, it must be provided in quantities sufficient for the promotion of growth, but low enough to maintain a safe blood level. Phenylalanine is derived from protein, not fat. An enriched-protein diet contains increased amount of proteins, including phenylalanine, which should be ingested in limited amounts. Because phenylalanine is an essential amino acid, it cannot be totally removed from the diet.
2 In prehypertension, the blood pressure will range from 120/80 to 139/89 mm Hg. The blood pressure is mainly influenced by heart rate and cardiac output. When the cardiac output and hematocrit are increased, the blood pressure also increases. Client B, with an increased cardiac output and an increased hematocrit, is at a higher risk for stage 1 hypertension. In client A, only the hematocrit is increased. Client C may be at risk of hypotension because the cardiac output is decreased. Client D has a normal hematocrit and blood pressure.
The nurse is reviewing the data of clients with prehypertension. Which client is at risk of stage 1 hypertension based on the given data? 1 Client A 2 Client B 3 Client C 4 Client D
Which finding in a client who has just arrived in the cardiac intensive care unit after having coronary artery bypass grafting (CABG) requires the most rapid action by the nurse? 1 The serum potassium level is 3.1 mEq/L (3.1 mmol/L). 2 The client is confused about the date and time of day. 3 The client reports incisional pain at level 8 (0 to 10 scale). 4 Chest tube collection chamber has 150 mL of bloody fluid.
1 Hypokalemia is a common complication after CABG and immediate infusion of potassium to correct hypokalemia is needed to prevent postoperative dysrhythmias. Confusion in the immediate postoperative period is common after cardiopulmonary bypass and will be monitored by the nurse, but does not require any other action at this time. Incisional pain is common after CABG and the nurse will administer prescribed pain medications, but pain is not a life-threatening complication. Chest tube drainage of 100 to 200 mL is not unusual in the first hours after CABG; the nurse will monitor the chest tube drainage hourly, but no other action is needed.
Which priority teaching point would the nurse include when educating parents how to facilitate the developmental task of trust for their newborn? 1 Wrapping the newborn in a blanket 2 Breast-feeding the newborn on demand 3 Feeding the newborn on a rigid schedule 4 Allowing the newborn to self-soothe and cry self to sleep
2 Breast-feeding on demand is the priority teaching point for parents of a newborn that will facilitate the development task of trust. Wrapping the newborn in a blanket is an age-appropriate nursing intervention; however, it is not one that will facilitate trust. Feeding the newborn on a rigid schedule and allowing the newborn to cry self to sleep do not facilitate trust, but mistrust.
Place the clients in order, from the one with the highest risk for life-threatening physiological withdrawal to the one with the lowest risk. 1. An adolescent who is withdrawing from cocaine 2. An older adult who is withdrawing from alcohol 3. A middle-aged adult who is withdrawing from marijuana 4. A young adult who is withdrawing from a long-acting benzodiazepine
2,4,1,3 The order is as follows: older adult withdrawing from alcohol; young adult withdrawing from benzodiazepine; adolescent withdrawing from cocaine; and middle-aged adult withdrawing from marijuana. Older adults possess fewer physiological reserves and are at the highest risk for life-threatening withdrawal, especially from a drug, such as alcohol. Long-acting benzodiazepines, although potentially lethal in withdrawal, will be less of a problem in a young adult because young adults have greater physiological reserves than do older adults. Cocaine is not lethal during withdrawal unless clients intentionally hurt themselves. Marijuana has minimal physiological withdrawal symptoms because of its long half-life.
Which nursing intervention is the most important when caring for a 3-year-old child with nephrotic syndrome? 1 Regulating diet 2 Encouraging fluids 3 Preventing infection 4 Encouraging ambulation
3 Infection is a constant threat because of a poor general state of nutrition, a tendency toward skin breakdown in edematous areas, corticosteroid therapy, and lowered immunoglobulin levels. Although the intake of foods with high nutritional value should be encouraged, this is not the priority. Fluid monitoring is important in determining whether a fluid restriction is indicated. Ambulation is to be encouraged, but preventing infection is the highest priority.
Which is the appropriate nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? 1 Document the fetal heart rate every 5 minutes. 2 Call the anesthesia department to alert the staff there of an imminent birth. 3 Assist the client's coach in helping her with the use of breathing techniques. 4 Suggest that the client accept the as-needed (PRN) medication for pain that has been prescribed.
3 The client is in the early part of the first stage of labor, and it is important to help the partner with the role of coach. It is not necessary to check the fetal heart rate every 5 minutes until the second stage of labor. The first stage of labor is not as stressful for the fetus as the second stage of labor. Birth is not imminent at this time; the client is only dilated 4 cm. Suggesting that there is discomfort may increase anxiety and produce greater discomfort.
Which source of stress would the nurse expect in both 3-year-olds and 4-year-olds? 1 Nap or bedtime 2 Insecurity 3 Questions 4 Fears
4 Fears are a source of stress in children of both age groups. The fears for a 3-year-old may be precipitated by imagination. This child may also fear dogs or other animals. A 4-year-old picks up fears from adults. This child may fear a dark room or anything perceived as "creepy." Insecurity is a source of stress in 4-year-olds. A child in this age group may develop nervous habits, such as nail biting, facial tics, thumb-sucking, and so on. This is not seen in 3-year-olds. Questions and nap or bedtime are sources of stress in 3-year-olds. A 3-year-old continually asks "Why?" and is upset if trusted adults do not respond or do not know the answer. This child may also fear bad dreams, the dark, or missing out on some fun while asleep. These are not sources of stress in 4-year-olds.
The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. Which statement by the client indicates that teaching was effective? 1 "I should eliminate excessive blinking." 2 "I should not move my extraocular muscles." 3 "I should elevate the head of my bed at night." 4 "I should avoid using a sleeping mask at night."
4 The mask may irritate or scratch the eyes if the mask moves during sleep. Blinking of the eyes will bathe the eyes and prevent corneal ulceration. Not moving extraocular muscles will not relieve edema or prevent ulceration of the eyes. Although elevating the head of the bed at night will help reduce periorbital edema, it will not prevent ulceration of the cornea.
The nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. Which is the best response by the nurse? 1 "That client is not on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 "The client has requested that no information be given out. You'll need to call the client directly." 4 "It is against the hospital's policy to provide you with any information."
4 The response "It is against the hospital's policy to provide you with any information" is a factual statement, without indicating whether or not the client is in the hospital. The response "That client is not on our unit. Thank you for calling" is a lie and would be avoided. HIPAA (Canada: FOIPOP) laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly" implies that the client is admitted to the facility; this violates the client's request that no information would be shared with others.
1 The nursing safety priority for client A with lymph node dissection is monitoring for manifestations of fluid overload. The nursing safety priority for client B with laparoscopic cholecystectomy is to assess the oxygen saturation level frequently until the effects of the anesthesia have passed. The nursing safety priority for client C with surgical intervention for hemorrhoids is ensuring the presence of someone near the client during the first postoperative bowel movement because it is very painful. The nursing safety priority for client D with liver transplantation is monitoring for clinical manifestations of rejection such as tachycardia and fever.
Which of the four clients in the postoperative unit should be monitored for fluid volume overload as nursing safety priority? 1 Client A 2 Client B 3 Client C 4 Client D
Which statements about newborn laboratory values are correct? Select all that apply. One, some, or all responses may be correct. 1 Leukocytosis is normal at birth. 2 Platelets are much lower in newborns compared with adults. 3 Term newborns can have a hemoglobin of 14 to 24 g/dL at birth. 4 Levels of factors II, VII, IX, and X found in the liver are higher during the first few days of life. 5 At birth, average levels of red blood cells, hemoglobin, and hematocrit are higher than in adults.
1,3,5 Leukocytosis is common in the newborn infant. Term newborns can have a hemoglobin of 14 to 24 g/dL at birth; values will decrease to 12 to 20 g/dL by 2 weeks of life. At birth, average levels of red blood cells, hemoglobin, and hematocrit are higher than in adults because the fetus needs red blood cells for the transport of oxygen in utero. Platelets are not lower in newborns, and levels are mostly the same as they are in adults. Levels of factors II, VII, IX, and X are lower during the first few days of life because newborn infants are not able to synthesize vitamin K until feedings have begun.
The nurse is conducting a health maintenance visit for a 5-year-old client who will begin kindergarten in the fall. Which teaching statement would the nurse include for this child, who is considered slow to warm up? 1 "Your child should adapt without any issues." 2 "You should expect minimal stress from your child." 3 "Your child would benefit from a practice run before riding the bus on the first day of school." 4 "You should encourage your child to try new things, allowing for adequate time for adaptation."
4 Slow-to-warm-up children often exhibit discomfort when placed in new situations, such as the start of kindergarten. The nurse would encourage this child's parents to encourage their child to try new things while allowing adequate time for adaptation. The easy, not slow-to-warm-up, child is expected to adapt to kindergarten without any issues and experience minimal stress. The difficult, not slow-to-warm-up, child would benefit from a practice run to riding the school bus on the first day of school.
Which statement by the client would alert the nurse the client is experiencing a somatic delusion? 1 "I am Jesus Christ." 2 "I know I'm dead." 3 "This food has been poisoned." 4 "My stomach has disintegrated."
4 The statement, "My stomach has disintegrated," indicates a somatic delusion. A somatic delusion is a false belief that one has a disease or a physical defect. A delusion about being a person of importance is a grandiose delusion ("I am Jesus Christ"). A delusion about death is a nihilistic delusion ("I know I'm dead"). A delusion that others are out to cause personal harm is a paranoid delusion ("This food has been poisoned").