Exam 2
The nurse is caring for a 17-year-old client who states, "My parents put so much pressure on me to go to college and become a lawyer, but that's not my dream. I just don't want to let them down, so I am going to apply anyway." The nurse knows the client is struggling with which phenomenon?
False self
What would alert the nurse to suspect that a client is developing ketoacidosis?
Fruity breath odor
The nurse is providing education to a client who has been prescribed therapy with an antidiabetic medication. During teaching, the nurse will caution the client against heavy intake of which herb?
Garlic
A nurse is caring for a patient who has developed a hypoglycemic reaction. Which intervention should the nurse perform if swallowing and gag reflexes are present in the patient?
Give oral fluids or candy.
A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take?
Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes.
A man is brought to the emergency department. He is nonresponsive, and his blood glucose level is 32 mg/dL. Which would the nurse expect to be ordered?
Glucagon
The nurse monitoring a client receiving insulin glulisine notices the client has become confused, diaphoretic, and nauseated. The nurse checks the client's blood glucose and it is 60 mg/dL (3.33 mmol/L). Which can a nurse give to treat a client with a hypoglycemic episode? (Select all that apply.)
Hard candy Orange or other fruit juice Glucose tablets
The nurse is preparing to administer 20 units of NPH insulin to a client. Before administering the medication, the nurse should implement which intervention?
Have a colleague confirm the dosage.
A nursing home recently has had a significant number of nosocomial infections. Which measure might be instituted to decrease this trend?
Have written, infection-prevention practices for all employees
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart?
stethoscope that remains in the client's room
A 65-year-old woman who recently retired from 40 years as a school teacher is scheduled for a physical examination. The nurse should be concerned about which comment?
"Every day, when I wake up, it's hard to find a reason to get out of bed."
The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states:
"I do not need to wash my hands if I am using gloves."
During a teaching session on the care of the client with diabetes, the nurse should make which statement to explain the differences in insulin?
"Insulins have different onsets and durations of action."
A parent of a 15-month-old brings his son to the clinic. During the nurse's assessment, the parent makes the following comments. Which comment will prompt the nurse to further investigate?
"My son is not crawling yet."
The nurse is reviewing discharge instructions for a client who was prescribed amoxicillin to be taken twice a day. Which statement by the client would require further teaching?
"Once I start feeling better, I should stop taking the antibiotic."
A client has been newly diagnosed with type 2 diabetes. What statement would be appropriate for the nurse to include in the teaching?
"Regular exercise makes your body better able to use the insulin it produces."
A client with type 1 diabetes has been prescribed 12 units of regular insulin and 34 units of NPH insulin in the morning. How should the nurse explain why two different types of insulin are required to control the client's blood glucose?
"The different onsets and peaks of the two types provide better overall glucose control."
factors that may delay growth and development
-genetics -illness -environment -nutrition -prenatal, individual and caregiver factors -culture
The client is scheduled to get a breakfast tray at 07:00. At what time should the client receive a prescribed dose of insulin lispro?
06:45
Erikson's stages of psychosocial development
1. trust vs. mistrust (infant- 18 months) Hope 2. autonomy vs. shame and doubt (18 months- 1 year) Will 3. initiative vs. guilt (3-5 years) Purpose 4. industry vs. inferiority (5-13 years) Competency 5. identity vs. role confusion (13-21) Fidelity 6. intimacy vs. isolation (21-39) Love 7. generativity vs. stagnation (40-65) Care 8. integrity vs. despair (65 & up) Wisdom
The nurse is caring for four clients. Which client presents the most susceptibility for infection?
46-year old with a foley catheter following anesthesia
The nurse is educating a newly diagnosed diabetic who must learn how to give himself insulin injections. The nurse tells the client that insulin is absorbed fastest from which area of injection?
Abdomen
A six-month-old child is scheduled for a routine exam in a pediatric clinic. The child's birth weight was 8lb. 3oz. The child now weighs 26lb. 4 oz. The nurse knows that the weight is:
Above the expected weight
When does self-concept develop?
Around 6-7 years of age
A nurse is assigned to administer glargine to a patient at a health care facility. What precaution should the nurse take when administering glargine?
Avoid mixing glargine with other insulin.
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
What do we know about infant physical growth/development?
Brain is growing Respiratory and thermoregulation Eyes begin to focus Develop muscle control Teeth erupt 4-6 months Sleep schedule changes Weight gain: 5 months-double their birth weight 1yr-triple Reflexes Crawl by 8 months
Factors Affecting Self-Concept?
Developmental considerations Culture Internal and external resources History of success and failure Crisis or life stressors Aging, Illness, Trauma
The nurse is interviewing a client who was diagnosed with type 2 diabetes four months ago. The client does not record glucometer readings. What laboratory test does the nurse anticipate the health care provider will order for this client?
HbA1c
The health care provider has ordered a change of prescription from rapid-acting insulin to an intermediate-acting type. Which adverse effect must the nurse closely monitor for in the client?
Hypoglycemia
A teenager refuses to wear the clothes his parents bought for him. He states he wants to look like the other kids at school and wear clothes like they wear. The nurse explains that this behavior is an example of teenage rebellion related to the internal conflict of:
Identity vs. role confusion
The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?
Increases the risk of infection by contaminating the wound
Which priority action should be implemented by the charge nurse when observing a new graduate nurse perform the procedure displayed in the image?
Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids
When administering insulin, what would be most appropriate?
Insert the needle at a 45-degree angle for injection.
Which would be least appropriate when administering insulin by subcutaneous injection?
Massaging the site after removing the needle
What is the primary goal of the observable action associated with the removal of contaminated gloves?
Prevent contamination of ungloved hand
A client diagnosed with diabetic ketoacidosis has been admitted to the intensive care unit. The client is prescribed an intravenous insulin drip, so the nurse knows that what type of insulin will be administered?
Regular.
Development of self?
Self awareness (infancy) Self recognition (18 months) Self definition (3 years) Self concept (6-7 years)
The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?
Stop and obtain appropriate PPE.
The student nurse asks the nursing instructor to explain why stress can increase the risk of infection. The instructor explains:
Stress causes the body to release cortisol, which can increase the risk of infection.
After teaching a group of students about the various methods for the delivery of insulin, the instructor determines that the teaching was successful when the students identify which method as most commonly used for administration?
Subcutaneous injection
The nurse in the emergency department receives a conscious client following a motor vehicle accident who has no known history of diabetes but whose blood glucose level is 325 mg/dL. What rationale does the nurse provide explaining this elevated blood glucose level?
The client's stress reaction likely caused an increase in blood sugar.
A nurse prefers to use an alcohol-based hand rub when providing care for clients. In which case is this practice contraindicated?
The nurse is caring for a client with a C. difficile infection.
Personal protective equipment (PPE) is used in health care facilities for primarily which reason?
To protect both the staff and clients from becoming infected by one another
The nurse is checking in a 50-year-old client for an annual physical. Which immunization does the nurse anticipate will be ordered for this patient?
Zoster recombinant (RZV)
Surgical asepsis is defined as:
absence of all microorganisms.
A nurse has seen several patients at a community health center. Which of the patients would be most at risk for developing an infection?
an older adult with several chronic illnesses
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?
diligent handwashing practices
After reviewing information about different insulin preparations, a nursing student demonstrates understanding of the information when the student identifies which medication as an example of a long-acting insulin?
insulin glargine
A client's current condition requires rapid reduction of blood sugar levels. Which type of insulin will have the most rapid onset of action?
insulin lispro
A nurse is preparing to administer a rapid-acting insulin. Which medication would the nurse most likely administer?
insulin lispro
Of all possible nursing interventions to break the chain of infection, which is the most effective?
practicing hand hygiene
The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a nosocomial infection?
urinary catheterization
A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?
wash the area with soap and water
The nurse is caring for a client who is taking insulin. The nurse suspects the client is experiencing hypoglycemia when the client displays what signs?
weakness, sweating, and decreased mentation.
Neonate: Birth to 28 days?
•APGAR •Done at 1 and 5 minutes After birth •Normal 7-10 •Assesses heart rate, respiratory effort, muscle tone, reflexes, and color
Interventions to Help Patients Maintain Sense of Self?
•Acknowledge patient status, role, and individuality •Speak to patients respectfully •Offer simple explanations for procedures •Move patient's body respectfully if necessary •Respect patient privacy •Acknowledge and allow expression of negative feelings •Help patients recognize strengths
Psychological conditions that foster healthy development of self in children:
•Emotional warmth & acceptance •Effective structure & discipline •Clearly defined standards and limits •Adequately defined family member roles •Established methods of parenting •Encouragement of competence and confidence •Helping children meet challenges •Appropriate role models •A stimulating and responsive environment
Interventions to Assist Patients to Develop a Positive Body Image?
•Express interest in and acceptance of the patient (Nonverbal and verbal) •Explore patient feelings about altered body image •Support patients through various stages of grief, loss, and mourning •Monitor own attitudes and feelings towards patients •↑ patient decision making ability (Help patients evaluate different courses of action) •Reinforce personal strengths of patients •Assess support persons response to patient situations and intervene if negative •Use play therapy with children so they can express feelings
Principles of growth and development?
•Growth and development are orderly and sequential, as well as continuous and complex. •Growth and development follow both regular and predictable trends. •Growth and development are both differentiated and integrated. •Different aspects of growth and development occur at different stages and at different rates, and can be modified. •The pace of growth and development is specific to each person.
growth in first trimester? (12 weeks)
•Kidney secretions begin •Some reflexes are present •Heartbeat can be heard •Sex of the fetus can be determined by outward appearance •Harmony Prenatal Test
growth in second trimester? (24 weeks)
•Liver and pancreas are functioning •Hair forms •Sleep-wake patterns are established •Lung surfactant is produced •Eyelids open
growth in third trimester? (40 weeks)
•Lung alveoli are formed •Subcutaneous fat is deposited •Testes have descended •Fetus actively kicks **Average neonate is 7.5 lb and 20 inches at birth
Prenatal risk factors for altered Growth/Development
•Maternal Nutrition •Maternal BMI •Maternal STIs •Domestic Violence •Teratogens