Exam 3

ANS: C A major objective in caring for the client with leukemia is protection from infection. Frequent handwashing is of the utmost importance. If at all possible, the client should be in a private room. Masks are worn by anyone who has an upper respiratory tract infection. The client may be on a "minimal bacteria diet." Protein is not a factor in this diet.

1. The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client's care? a.Evaluate the amount of protein the client eats. b.Assess the client's roommate for symptoms of infection. c.Perform effective hand hygiene frequently. d.Wear a mask when entering the room

ANS: C Vitamin B12 deficiency impairs cerebral, olfactory, spinal cord, and peripheral nerve function. Severe chronic deficiency may cause permanent neurologic degeneration. The other options are not symptoms of vitamin B12deficiency.

A client who has a chronic vitamin B12 deficiency is admitted to the hospital. When obtaining the client's health history, which priority question does the nurse ask this client? a."Are you having any pain?" b."Are you having blood in your stools?" c."Do you notice any changes in your memory?" d."Do you bruise easily?

ANS: D Preterm infants have greater surface area in proportion to their weight. The others are indications of a more mature infant.

In comparison with the term infant, the preterm infant has a. Few blood vessels visible through the skin b. More subcutaneous fat c. Well-developed flexor muscles d. Greater surface area in proportion to weight

ANS: B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. Pupil reactivity is not part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness and intracranial pressure are not a part of the Glasgow Coma Scale.

The Glasgow Coma Scale consists of an assessment of a. Pupil reactivity and motor response b. Eye opening and verbal and motor responses c. Level of consciousness and verbal response d. ICP and level of consciousness

ANS: A The normal hemoglobin for a child this age is 10.55-12.7 g/dL, so this child is somewhat anemic. The nurse should assess for other manifestations of anemia, including normal activity level. The findings should be documented, but this is not the only action that the nurse should take. The provider needs to be notified, but it does not have to be done immediately, as this is not an emergency. After a full evaluation, the provider may or may not want to repeat the laboratory work in 6 months.

A 2-year-old child's hemoglobin is 8.2 g/dL. What action by the nurse is best? A. Ask the parents about activity level. B. Document findings in the chart. C. Notify the provider immediately. D. Schedule a re-draw of blood in 6 months

ANS: C Protecting the client from infection at home is just as important as it was during hospitalization for a client who has had stem cell transplantation. Hand hygiene is the best protection against infection. Salads, raw fruits, and live vaccinations (such as rubella) are contraindicated in a client who has a risk for infection. Energy management is important; therefore activities such as physical therapy may need to be postponed.

5.The nurse is teaching a client who is being discharged after stem cell transplantation. Which instruction does the nurse include in this client's discharge teaching?a.Eat a diet high in fruits and vegetables. b.Ask your provider to administer a rubella vaccination. c.Wash your hands frequently. d.Participate in physical therapy every day.

ANS: A, B. E Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury.Corticosteroids are administered to minimize the inflammation present with the injury.Spinal cord injury is a catastrophic event. Discussion regarding long-term care should be delayed until the child is stable.

A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes (select all that apply) a. Monitoring and maintaining systemic blood pressure b. Administering corticosteroids c. Minimizing environmental stimuli d. Discussing long-term care issues with the family e. Monitoring for respiratory complications

ANS: B All others are affected by facial surgery and oxygen mask.

A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's temperature? a. Tympanic membrane b. Right axillae c. Oral d. Temporal artery

ANS: A, B, D, G You need to determine the patient's usual temperature to evaluate the degree of temperature elevation. Heart rate and respiratory rate increase with temperature. The presence of diaphoresis may contribute to fluid volume deficit from hyperthermia.

A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2°C (100.8°F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all that apply.) a. Heart rate b. Presence of diaphoresis c. Smoking history d. Respiratory rate e. Recent bowel movement f. Blood pressure in right arm g. Patient's normal temperature h. Blood pressure in distal extremity

ANS: A A. Rapid rewarming is accomplished by immersing the part in well-agitated water at 37.8° C to 42.2° C (100° F to 108° F). B. The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage. C. Rapid rewarming results in less tissue necrosis than slow thawing. D. The frostbitten area should be rewarmed, as soon as possible, to avoid further tissue damage.

A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention should the nurse implement first?: a. Rapid rewarming of the fingers by placing in warm water b. Placing the hand in cool water c. Slow rewarming by wrapping in warm cloth d. Using an ice pack to keep cold until medical intervention is possible

ANS: D Anemia leads to decreased oxygenation of body tissues, including the brain. A lowered cerebral oxygen concentration can lead to dizziness and difficulty concentrating. Stating that all sick children have this problem is inaccurate and vague. The child may be tired, but this answer is also vague and does not really address the question. Describing the possibility of another medical problem is not warranted at this time.

A child has mild anemia and the parent asks why this makes the child have difficulty concentrating. What response by the nurse is best? A. "All sick children have trouble concentrating." B. "Her anemia makes her too tired to think." C. "She may have another problem with her brain." D. "The brain isn't getting enough oxygen."

ANS: B It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when the child's nurse: a. Places a hypothermia blanket at the bedside b. Adjusts the bed to the Trendelenburg position. c. Obtains electronic equipment for monitoring the vital signs. d. Secures a pump to administer the ordered intravenous fluids.

ANS: B Disoriented refers to lack of ability to recognize place or person. Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child's level of consciousness? a. Disoriented b. Obtunded c. Lethargic d. Stuporous

ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess."

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority.

A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.

ANS: C Clients need to know the early symptoms of crisis so that treatment can be started early to prevent pain, complications, and permanent tissue damage. The iron level is not low in sickle cell anemia. Hydroxyurea is used in the hospital during a sickle cell crisis. The use of oral contraceptives is controversial because they may enhance clot formation, predisposing the client to crisis.

A client is newly diagnosed with sickle cell anemia. Which information does the nurse include in the client's discharge instructions? a."Eat a diet high in iron." b."Take hydroxyurea (Droxia) every morning." c."Be aware of the early symptoms of crisis." d."Do not use any oral contraceptives."

ANS: A Bradycardia is a sign of spinal shock. This symptom is a result of the interruption of sympathetic nervous system stimulation associated with the cervical spinal neurons. A mean arterial pressure of 90 mm Hg and oxygen saturation of 95% indicate normal physiology and no concerning changes in airway or circulation. A pain level of 2 indicates pain that is well controlled at a value less than 4 on a 0 to 10 scale.

A client was admitted this morning with an incomplete cervical spinal cord injury and is placed in a halo fixator. Halo fixation is used to reduce motion of the cervical spine. Which assessment finding will the nurse report immediately to the health care provider? a. A new-onset heart rate of 48 beats/min b. Mean arterial pressure of 90 mm Hg c. Pain level of 2 on a 0-10 pain scale d. Oxygen saturation of 95% on room air

ANS: C All of these are treatments for sickle cell anemia. However, the client in severe pain is likely to be in sickle cell crisis. To prevent further sickling of the red blood cells, adequate hydration of at least 200 mL/hr is needed during a crisis. The other interventions should be implemented after the fluids are started.

A client who has sickle cell anemia is admitted to the hospital. The client reports severe pain. Which action does the nurse take first? a.Administer one unit of packed red blood cells. b.Administer prescribed hydroxyurea (Droxia). c.Begin intravenous fluids at 250 mL/hr. d.Prepare for bone marrow transplantation.

ANS: C A hemolytic transfusion reaction is caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Manifestations include low back pain and chest pain, and the transfusion should be discontinued immediately. The other actions are not the priority.

A client who is receiving a unit of red blood cells begins to report chest and lower back pain. Which action does the nurse take first? a.Administer morphine sulfate 1 mg IV. b.Assess the level of the pain. c.Stop the transfusion. d.Reposition the client on the right side.

ANS: C Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure

A client with a neurological problem is experiencing hyperthermia. Which measure would be least appropriate for the nurse to use in trying to lower the client's body temperature? a. Giving tepid sponge baths. b. Applying a hypothermia blanket. c. Placing ice packs in the axilla and groin areas. d. Administering acetaminophen (Tylenol) per protocol.

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: C Iron levels can be low because intake of iron is too low, or because loss of iron through bleeding is excessive. A premenopausal woman may be having unusually heavy menses sufficient to cause excessive loss of blood and iron. Smoking and aspirin do not cause iron deficiency. A diet high in meat provides iron.

A female client is admitted with the medical diagnosis of anemia. The nurse assesses for which potential cause? a.Diet high in meat and fat b.Daily intake of aspirin c.Heavy menses d.Smoking history

ANS: A Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for manifestations of hypothermia, including: a. Stupor. b. Erythema. c. Increased anxiety. d. Rapid respirations.

ANS: C Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not accurate.

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How should the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures."

ANS: A The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.

A nurse assesses a client and notes the client's position as being stiff with arms bent toward the body, with clenched fists and legs held out straight. The wrists and fingers are bent and held on the chest. How should the nurse document this finding? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration

ANS: A The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive Romberg's sign.

A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: B, D, E Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia

ANS: B The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest

ANS: C, D Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, B, E The nurse should urgently communicate changes in a client's neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury.Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

ANS: C, E Appropriate interventions to relieve pressure on these area include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

ANS: D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client's recent memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client's immediate memory.

A nurse assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "Apple, chair, and pencil are the words you just stated." d. "I ate oatmeal with wheat toast and orange juice for breakfast."

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

ANS: D Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How should the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Give me more information about what worries you, so we can see if we can do something to make adjustments."

ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

ANS: B, D, F For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiberdiet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction

ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manage

ANS: A Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II impairment will not be able to see, so the UAP should tell the client where different food items are on the meal tray. The other options are not appropriate for a client with cranial nerve II impairment.

A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler's position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand."

ANS: A Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II impairment will not be able to see, so the UAP should tell the client where different food items are on the meal tray. The other options are not appropriate for a client with cranial nerve II impairment.

A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler's position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand."

ANS: B The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse should request a dietary consult. The other interventions do not address the information provided.

A nurse evaluates the following data in a client's chart:66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer - 4 cm ´ 2 cm ´ 1.5 cm Based on this information, which action should the nurse take? a.Perform a neuromuscular assessment. b.Request a dietary consult. c.Initiate Contact Precautions. d.Assess the client's vital signs

ANS: B A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding complications. The health care provider needs this information quickly to plan other therapy for the client's wound. The nurse should contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring is appropriate for a client who has a history of atrial fibrillation and should be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

A nurse evaluates the following data in a client's chart:78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuum-assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? a.Assess the client's vital signs and initiate continuous telemetry monitoring. b.Contact the provider and express concerns related to the wound treatment prescribed. c.Consult the wound care nurse to apply the VAC device. d.Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A The most common type of anemia worldwide is iron-deficiency anemia, which can be caused by ingesting non-iron-fortified formula if the child is not breastfed. This type of anemia is not genetic. Pallor, either of the skin or mucous membranes, would be seen in any type of anemia. Range of motion of the hips or shoulders is an important assessment in sickle cell disease, in which avascular necrosis can occur.

A nurse is assessing an infant for the most common type of anemia worldwide. What action by the nurse is most helpful? A. Assess if formula is iron-fortified. B. Determine family history of anemia. C. Look at mucous membranes for pallor. D. Perform range of motion on the hips.

ANS: A, B, C A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The client's kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the client's breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the client's safety during the procedure.

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the client's renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels.

ANS: C If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement? a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure.

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: B The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

ANS: C Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this client's discharge teaching? a. "Connect a light to flash when your doorbell rings." b. "Label your faucet knobs with hot and cold signs." c. "Ask a friend to drive you to your follow-up appointments." d. "Use a natural gas detector with an audible alarm."

ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client's problem.

A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the client's legs. d. Assess the client's feet for wounds each shift.

ANS: A, B, E A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: C Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the client's impaired sensory perception.

A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this client's plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the client's white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.

ANS: C The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear. The other interventions do not address the client's left temporal lobe damage.

A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the client's right side and speak into the right ear. d. Allow the client to use a white board to ask questions.

ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation.

A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet." b. "Bathe in warm water to increase your circulation." c. "Look at the placement of your feet when walking." d. "Walk barefoot to decrease pressure ulcers from your shoes."

ANS: B The fetus needs a higher hemoglobin level to compensate for the relatively low-oxygen environment of the uterus. The other answers are incorrect.

A nurse working in pediatrics learns that the normal hemoglobin value for an infant is high at birth, then decreases by 2 months of age before increasing again as the child grows. The nurse knows the reason for this shift is which of the following? A. Hemodilution from starting oral nutrition B. Lower available oxygen while in utero C. Rapid hemoglobin destruction at birth D. Slower hemoglobin production after birth

ANS: A Anemia is a symptom that can be caused by many disease states. It is not a disease that explains low hemoglobin. The other answers are incorrect.

A nursing student asks the instructor why he was marked off on his care plan when explaining a low hemoglobin level as being caused by "anemia." What response by the instructor is best? A. Anemia is a symptom, not a disease. B. Anemia only refers to a low red blood cell count C. Hemoglobin and anemia are unrelated. D. The hemoglobin must not be too low.

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM.

A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse.e. Subarachnoid hemorrhage is caused by high blood pressure

ANS: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

A older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check himself or herself? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying

ANS: D A temporal artery temperature verifies the forehead temperature in back of the left ear, which is the side not affected by the altered blood flow related to the stroke. Holding the thermometer or switching locations will not help the patient close her mouth during temperature assessment. The patient's right side has vascular changes related to the stroke.

A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP?a. Direct the NAP to hold the thermometer in place with her gloved hand b. Direct the NAP to switch the thermometer probe to the left sublingual pocket c. Direct the NAP to obtain a right tympanic temperature d. Direct the NAP to use a temporal artery thermometer from right to left

ANS: C The pattern returns to acceptable levels at least once in 24 hours interspersed with fever spikes.

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of:38.7° C (101.6° F) (0400)36.6° C (97.9° F) (0800)36.9° C (98.4° F) (1200)37.6° C (99.6° F) (1600)38.3° C (100.9° F) (2000).How would you describe this pattern of temperature measurements? a. Usual range of circadian rhythm measurements b. Sustained fever pattern c. Intermittent fever pattern d. Resolving fever pattern

ANS: A Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.

A patient with hypothermia is brought to the emergency department. The nurse should explain to the family members that treatment will include: a. Core rewarming with warm fluids. b. Ambulation to increase metabolism. c. Frequent oral temperature assessment. d. Gastric tube feedings to increase fluids.

ANS: D The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, but seizure precautions should not be the first intervention. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.

A priority nursing intervention for a patient with hyperthermia would be a. Initiating seizure precautions. b. Limiting oral intake. c. Providing a blanket. d. Removing excess clothing

ANS: C Vitamin A does not have a relation to the prevention of spina bifida. Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy. The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy.

A recommendation to prevent neural tube defects is the supplementation of a. Vitamin A throughout pregnancy b. Multivitamin preparations as soon as pregnancy is suspected c. Folic acid for all women of childbearing age d. Folic acid during the first and second trimesters of pregnancy

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

ANS: A Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the client's respiratory rate, blood pressure, and level of consciousness.

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure

ANS: B Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures, and axillary temperatures are usually 0 C (0.9 F) lower than oral temperatures.

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done? a. Temperatures are the same regardless of the route used. b. Temperatures vary depending on the route used. c. Temperatures are cooler when taken rectally than when taken orally. d. Axillary temperatures are higher than oral temperatures.

ANS: A Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.

An 18-year-old male who fell through the ice on a pond near his farm was admitted to the ED with somnolence. Vital signs are BP 82 mm Hg systolic with Doppler, respirations 9/min, and core temperature of 90° F (32.2° C). The nurse should anticipate which intervention? a. Active core rewarming b. Immersion in a hot bath c. Rehydration and massage d. Passive external rewarming

ANS: B Current standard of care is immobilization and steroids for spinal cord injuries. Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: C The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: a. Decreased respiratory rate. b. Bradycardia followed by an increased heart rate. c. Mottled skin with acrocyanosis. d. Increased physical activity.

ANS: C Convection occurs when infants are exposed to cold air currents. A cold circumcision board and cool blankets would cause heat loss by conduction, while heat loss due to a bath would be due to evaporation.

Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b. Given a bath c. Placed in a drafty area of the room d. Wrapped in cool blankets

ANS: D The knee-chest position is not appropriate for a lumbar puncture. An infant can be placed in a sitting position with the infant facing the nurse and the head steadied against the nurse's body. A side-lying position with the head of the bed elevated is not appropriate for a lumbar puncture. The child should lie on her side with knees bent and chin tucked in to the knees.This position exposes the area of the back for the lumbar puncture.

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. "You will be on your knees with your head down on the table." b. "You will be able to sit up with your chin against your chest." c. "You will be on your side with the head of your bed slightly raised." d. "You will lie on your side and bend your knees so that they touch your chin."

ANS: A Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75%of this patient population. There are no non allergic latex products. At this time, desensitization is not an option. The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include a. Avoiding using any latex product b. Using only non allergenic latex products c. Administering medication for long-term desensitization d. Teaching family about long-term management of asthma

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

Nurses can prevent evaporative heat loss in the newborn by a. Drying the baby after birth and wrapping the baby in a dry blanket b. Keeping the baby out of drafts and away from air conditioners c. Placing the baby away from the outside wall and the windows d. Warming the stethoscope and nurse's hands before touching the baby

ANS: C Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Seizure medications are not routinely given to infants who do not have seizures.

Nursing care of the infant who has had a myelomeningocele repair should include a. Securely fastening the diaper b. Measurement of pupil size c. Measurement of head circumference d. Administration of seizure medications

ANS: C Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two.Evaporation is the transfer of heat energy when a liquid is changed to a gas.

Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement? a. Radiation b. Conduction c. Convection d. Evaporation

ANS: A An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.

Of the following patients, which one is the best candidate to have his temperature taken orally? a. A 27-year-old postoperative patient with an elevated temperature b. A teenage boy who has just returned from outside "for a smoke" c. An 87-year-old confused male suspected of hypothermia d. A 20-year-old male with a history of epilepsy

ANS: C, E Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

Of the following sites, which are used for obtaining a core temperature? (Select all that apply.) a. Oral b. Rectal c. Tympanic d. Axillary e. Pulmonary artery

ANS: B Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection of the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. he client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.

The client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? a. Advises the client to go to a calming environment b. Asks whether the client has increased cold sensitivity or weight gain c. Instructs the client to see his health care provider immediately d. Tells the client to check the pulse again and call back later

ANS: C Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may however be an issue. A client with hypothyroidism is not immune compromised or contagious. No environmental changes need to be made to the home.

The client is being discharged with hypothyroidism. Which environmental change may the client experience in the home? a. Frequent home care b. Handrails in the bath c. Increased thermostat setting d. Strict infection control measures

ANS: A Myelomeningocele is one of the most common causes of neuropathic(neurogenic) bladder dysfunction among children. Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

The most common problem of children born with a myelomeningocele is a. Neurogenic bladder b. Intellectual impairment c. Respiratory compromise d. Cranioschisis

ANS: A Cold stress may interfere with the production of surfactant, making respiratory distress syndrome worse. Preterm infants do not shiver to produce heat. Cold stress does interfere with ability to eat, but not with the ability to digest the nutrients. Decrease circulation is not the top priority in caring for an infant with cold stress.

The most important reason to protect the preterm infant from cold stress is that a. It could make respiratory distress syndrome worse b. Shivering to produce heat may use up too many calories c. A low temperature may make the infant less able to digest nutrients d. Cold decreases circulation to the extremities

ANS: D With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates: a. Increased respirations. b. Rapid pulse rate. c. Red, sweaty skin. d. Slow capillary refill.

ANS: C The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barré syndrome.

The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

ANS: C A smooth, beefy red tongue could signify glossitis, which is seen with vitamin B12 deficiency. Green leafy vegetables are high in vitamin B12. Iron supplements would be used with iron deficiency anemia. The red blood cell count is what is affected by vitamin B12 deficiency—not the white blood cell count. The beefy red tongue is caused by the vitamin deficiency, not by poor mouth care.

The nurse assesses that a client has a smooth, beefy red tongue. Which intervention does the nurse implement for this client? a.Administer prescribed oral iron supplements. b.Monitor the daily white blood cell count. c.Provide a diet high in green leafy vegetables. d.Perform more frequent mouth care.

ANS: C Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? a. Warming the crib pad b. Closing the doors to the room c. Drying the infant with a warm blanket d. Turning on the overhead radiant warmer

ANS: D After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? a. Withhold oral fluids for 8 hours. b. Sponge the child with cold water. c. Plan to administer salicylate (aspirin) in 4 hours. d. Remove excess clothing and blankets from the child.

ANS: B The red blood cells contain thousands of hemoglobin molecules. The most important feature of hemoglobin is its ability to combine loosely with oxygen. A low hemoglobin level can cause decreased oxygenation to the tissues, thus causing a compensatory increase in heart rate. The other options are close to normal range and are not indicative of not tolerating this activity.

The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity? a.Blood pressure of 120/90 mm Hg b.Heart rate of 110 beats/min c.Pulse oximetry reading of 95% d.Respiratory rate of 20 breaths/min

ANS: A A fibrinolytic lyses any clots in the body, thus causing an increased risk for bleeding. Fibrinolytic therapy does not place the client at risk for hypotension, thrombosis, or nausea and vomiting.

The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI). Which adverse effect does the nurse monitor for? a.Bleeding b.Orthostatic hypotension c.Deep vein thrombosis d.Nausea and vomiting

ANS: A Hemoglobin levels in men and women fall after middle age. Therefore, this client's hemoglobin value would be considered part of the aging process. Platelet counts and blood-clotting times are not age related; the client's platelet count and PT are elevated for some other reason. The WBC count shown is normal.

The nurse is assessing a 75-year-old male client. Which blood value indicates that the client is experiencing normal changes associated with aging? a.Hemoglobin, 13.0 g/dL b.Platelet count, 100,000/mm3 c.Prothrombin time (PT), 14 seconds d.White blood cell (WBC) count, 5000/mm3

ANS: A Factor VIII deficiency is also known as hemophilia A. With hemophilia, a client has a prolonged partial thromboplastin time (PTT) and is at risk for excessive bleeding from minor cuts. The other three distractors are not associated with a factor VIII deficiency

The nurse is assessing a client who has a factor VIII deficiency. Which clinical manifestation does the nurse expect to assess in this client? a.Excessive bleeding from a cut b.Chronic lower back pain c.Nausea and vomiting d.Temperature of 101° F

ANS: A Warfarin therapy increases the INR. Normal INR ranges between 0.7 and 1.8. Therapeutic warfarin levels, depending on the indication of the disorder, should maintain the INR between 1.5 and 3.0. When the effects of warfarin are no longer present, the INR returns to normal levels. Warfarin therapy does not affect white blood cell count, serum ferritin level, or reticulocyte count.

The nurse is assessing a client whose warfarin (Coumadin) therapy was discontinued 3 weeks ago. Which laboratory test result indicates that the client's warfarin therapy is no longer therapeutic? a.International normalized ratio (INR), 0.9 b.Reticulocyte count, 1% c.Serum ferritin level, 350 ng/mL d.Total white blood cell (WBC) count, 9000/mm3

ANS: D Circulatory overload can occur when a blood product is infused too quickly. Adults with a history of heart failure are at risk for this. Management of this complication can be achieved by infusing the blood products more slowly. The client is not having an allergic reaction to the blood; therefore the blood should not be stopped nor should diphenhydramine be administered.

The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first? a.Administer prescribed diphenhydramine (Benadryl). b.Continue to monitor the client's vital signs. c.Stop the infusion of packed red blood cells. d.Slow the infusion rate of the transfusion.

ANS: A Anemia is a reduction in the number of red blood cells (RBCs), the amount of hemoglobin, or the hematocrit level. Tissue oxygenation depends on RBCs. Typical symptoms of anemic clients include dyspnea, increased somnolence, tachycardia, and pallor. A client who is anemic tends to have lower blood pressure, increased heart rate, and skin that is pale and cool to touch.

The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client? a.Dyspnea with activity b.Hypertension c.Bradycardia d.Warm, flushed skin

ANS. D All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding.

The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client?a.Auscultation for bowel sounds b.Assessing for deep vein thrombosis c.Monitoring of blood pressure hourly d.Assessing for signs of bleeding

ANS: A Platelet aggregation is essential for blood clotting. An inability to clot blood when an injury occurs can result in bleeding, which would cause bruising. Aspirin is a drug that interferes with platelet aggregation and has the ability to "plug" an extrinsic event, such as trauma. Vitamin K found in green vegetables enhances clotting factors, which would improve the ability to stop bleeding associated with an extrinsic event. Acetaminophen (Tylenol) and exercise do not inhibit clotting factors.

The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding? a."Do you take aspirin?" b."How often do you exercise?" c."Are you a vegetarian?" d."How often do you take Tylenol?"

ANS: D A normal WBC count is 5000 to 10,000/mm3. A white blood cell count of 2000/mm3 is low and makes this client at risk for infection. Good handwashing technique is the best way to prevent the transmission of infection. The other laboratory results are all within normal limits.

The nurse is assessing the following laboratory results of a client before discharge. Which instruction does the nurse include in this client's discharge teaching plan?Test Results: Hemoglobin 15 g/dL Hematocrit 45% White blood cell (WBC) count 2000/mm3 Platelet count 250,000/mm3 a."Avoid contact sports." b."Do not take any aspirin." c."Eat a diet high in iron." d."Perform good hand hygiene."

ANS: D Permanent sterility can occur in male clients receiving radiation in the abdominal and pelvic regions. The client should be informed of this side effect and given the option to store sperm in a sperm bank before treatment. The other options do not appropriately address the client's concerns.

The nurse is caring for a 20-year-old man who has Hodgkin's lymphoma in the abdominal and pelvic regions. The client is scheduled for radiation therapy and states, "I want to have children someday, and this procedure will destroy my chances." How does the nurse respond? a."Adoption is always an option." b."Infertility is not seen with this type of radiation therapy." c."Sperm production will be permanently disrupted." d."You have the option to store sperm in a sperm bank."

ANS: C Keeping the room warm can be used as a complementary therapy to relieve the pain of a sickle cell crisis. Cold can act as a factor in causing a crisis. Analgesia is an important part of relieving pain. The analgesia routine should be followed on an around-the-clock basis and should consist of IV opioids for severe pain, followed by treatment with oral doses of opioids or NSAIDs. High-volume intravenous fluids should be administered to minimize pain during a sickle cell crisis.

The nurse is caring for a client during a sickle cell crisis. Which intervention does the nurse implement for the client? a.Administer acetaminophen (Tylenol) as needed. b.Administer intravenous fluids to keep the vein open. c.Keep the room temperature at 80° F. d.Transfuse red blood cells (RBCs).

ANS: A All these options could be done after a bone marrow aspiration and biopsy. However, the most important action when bleeding occurs is to apply external pressure to the site until hemostasis is ensured. The other measures could then be carried out.

The nurse is caring for a client who had a bone marrow aspiration. The client begins to bleed from the aspiration site. Which action does the nurse perform? a.Apply external pressure to the site. b.Elevate the extremities. c.Cover the site with a dressing. d.Immobilize the leg.

ANS: A Diets can alter cell quality and affect blood clotting. Diets low in iron can cause anemia and decrease the function of all red blood cells. The question does not say that the hemoglobin is low enough to affect the cardiac function. Family assessment may be important in finding out any genetic or family lifestyle causes of the low serum iron level. However, the first intervention that the nurse can provide is to have the client's dietary habits evaluated and changed so that iron levels can increase. Vitamin K is involved with clotting, not with iron stores.

The nurse is caring for a client who has a decreased serum iron level. Which intervention does the nurse prioritize for this client? a.Dietary consult b.Family assessment c.Cardiac assessment d.Administration of vitamin K

ANS: D White blood cells provide immunity and protect against invasion and infection. An elevated white blood cell count could indicate an infectious process, which could cause an elevation in body temperature. Tylenol would treat a fever but not the elevated white blood cell count. Steroids place the client at higher risk for infection but should not be stopped suddenly. The respiratory rate does not need to be assessed in this client.

The nurse is caring for a client who has an elevated white blood cell count. Which intervention does the nurse implement for this client? a.Administer the prescribed Tylenol. b.Hold the client's prescribed steroids. c.Assess the client's respiratory rate. d.Obtain the client's temperature

ANS: A With autoimmune thrombocytopenic purpura, the total number of circulating platelets is greatly reduced. As a result of the decreased platelet count, the client is at great risk for bleeding, and intramuscular injections should be avoided. Anticoagulants should not be given. A low platelet count is not treated with saline, and thrombocytopenia will not cause a change in body temperature.

The nurse is caring for a client who has autoimmune thrombocytopenic purpura. Which intervention does the nurse implement for this client? a.Avoid intramuscular injections. b.Administer prescribed anticoagulants. c.Infuse intravenous normal saline. d.Monitor for an increase in temperature.

ANS: C The client who is receiving chemotherapy drugs that suppress the bone marrow will be at risk for a decreased white blood cell (WBC) count and infection. The nurse will be most therapeutic by adhering to Standard Precautions to prevent infection, such as handwashing. The nurse will not expect the fibrinogen level to be affected by this therapy. Iron is not typically administered with chemotherapy because this is bone marrow suppression, so the administration of epoetin (Epogen) or filgrastim (Neupogen) is most effective. Monitoring the pulse oximetry is part of routine care and probably would not need to be done continuously

The nurse is caring for a client who is receiving chemotherapy for cancer. Which intervention does the nurse implement for this client? a.Assess the client's fibrinogen level. b.Administer the prescribed iron. c.Maintain strict Standard Precautions. d.Monitor the client's pulse oximetry.

ANS: B The PTT assesses the intrinsic clotting cascade. Heparin therapy is monitored by the PTT. Platelets are monitored by the platelet count laboratory value, bleeding time evaluates vascular and platelet activity during hemostasis, and fibrin degradation products help assess for fibrinolysis.

The nurse is caring for a client who is receiving heparin therapy. How does the nurse evaluate the therapeutic effect of the therapy? a.Evaluate platelets. b.Monitor the partial thromboplastin time (PTT). c.Assess bleeding time. d.Monitor fibrin degradation products.

ANS: C Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Mild temperature elevations enhance the body's immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should a. Call the physician and anticipate an order to treat the fever. b. Assume that the patient has an infection and order blood cultures. c. Wait an hour and recheck the patient's temperature. d. Be aware that temperatures this high are harmful and affect patient safety.

ANS: D Fever and hyperthermia are not the same things. An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is hyperthermia. Fever is an upward shift in the set point. Hyperthermia is not a shift in the set point.

The nurse is caring for a patient who has an elevated temperature. The nurse understands that a. Fever and hyperthermia are the same thing. b. Hyperthermia occurs when the body cannot reduce heat loss. c. Hyperthermia is an upward shift in the set point. d. Hyperthermia occurs when the body cannot reduce heat production.

ANS: B The average body temperature of older adults is approximately 96.8° F (36° C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature

The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is a. Suffering from hypothermia b. Expressing a normal temperature. c. Hyperthermic relative to his age. d. Demonstrating the increased metabolism that accompanies aging.

ANS: C The kidney releases more erythropoietin when tissue oxygenation levels are low. This growth factor then stimulates the bone marrow to increase red blood cell (RBC) production, which improves tissue oxygenation and prevents hypoxia. Hypoxia causes the body to increase its respiratory rate to overcome decreased oxygenation of the tissues. All these clients are important, but the woman with decreased erythropoietin takes priority because of her risk for hypoxia.

The nurse is caring for four clients with hematologic-type problems. Which client does the nurse prioritize to see first? a.18-year-old female with decreased protein levels b.36-year-old male with increased lymphocytes c.60-year-old female with decreased erythropoietin d.82-year-old male with an increased thromboxane level

ANS: B Aspirin and other salicylates interfere with platelet aggregation—the first step in the blood-clotting cascade—and decrease the ability of the blood to form a platelet plug. These effects last for longer than 1 week after just one dose of aspirin. The client may need to have the surgery rescheduled. Vitamin K, prescribed pain medication, and Tylenol cannot reduce the anticlotting effects of aspirin.

The nurse is completing the preoperative checklist on a client. The client states, "I take an aspirin every day for my heart." How does the nurse respond? a."I will call your doctor and request a prescription for pain medication." b."I need to call the surgeon and reschedule your surgery." c."I'll give you the prescribed Tylenol to minimize any headache before surgery." d."I need to administer vitamin K to prevent bleeding during the procedure."

ANS: A, C, D The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities.

The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.) a.Gums b.Lung sounds c.Urine d.Stool e.Hair

ANS: B The client with GBS often relates a history of acute illness, trauma, surgery, or immunization 1 to 3 weeks before the onset of neurologic symptoms. The other statements do not correlate with GBS.

The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis? a. "My neighbor also had Guillain-Barré syndrome." b. "I had a viral infection about 2 weeks ago." c. "I am an artist and work with oil paints." d. "I have a history of a cardiac dysrhythmia."

ANS: A A diet high in protein and iron helps keep the client's levels of iron within normal limits. Meat is a good source of protein and iron. A bleeding ulcer could cause anemia but would not cause iron deficiency. Sickle cell disease causes sickle cell anemia. Leukemia causes a decrease in white blood cells.

The nurse is obtaining the health history of a client who has iron deficiency anemia. Which factor in this client's history does the nurse correlate with this diagnosis? a.Eating a meat-free diet b.Family history of sickle cell disease c.History of leukemia d.History of bleeding ulcer

ANS: C The liver is the site for production of prothrombin and most of the blood-clotting factors. If the liver is damaged because of chronic alcoholism, it is unable to produce these clotting factors. Therefore, the PT could become elevated, which would reflect deficiency of some clotting factors. The WBC would not be elevated in this situation because no infection is present. Bleeding time would likely increase. The client's RBC count most likely would not be affected unless the client was bleeding, in which case it would decrease.

The nurse is performing an admission assessment on a 46-year-old client, who states, "I have been drinking a 12-pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history? a.Decreased white blood cell (WBC) count b.Decreased bleeding time c.Elevated prothrombin time (PT) d.Elevated red blood cell (RBC) count

ANS: B The normal platelet count ranges between 150,000 and 400,000/mm3. This client is at extreme risk for bleeding. Although it is necessary to notify the provider, the nurse would first protect the client by instituting Bleeding Precautions. The other interventions are not related to the low platelet count.

The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client's plan of care? a.Oxygen by nasal cannula b.Bleeding Precautions c.Isolation Precautions d.Vital signs every 4 hours

ANS: B With leukemia, energy management is needed to help conserve the client's energy. Care should be scheduled when the client has the most energy. This client may not have the most energy in the morning. If the benefit of an activity such as physical or occupational therapy is less than its worsening of fatigue, it may be postponed. The nurse should limit the number of visitors and interruptions by visitors, as appropriate.

The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue? a.Arrange for a family member to stay with the client. b.Plan care for times when the client has the most energy. c.Schedule for daily physicals and occupational therapy. d.Plan all activities to occur in the morning to allow for afternoon naps.

ANS: A The spleen is the major site of B-lymphocyte maturation and antibody production. Those who undergo splenectomies for any reason have a decreased antibody-mediated immune response and are particularly susceptible to viral infections. Eating raw fruits and vegetables places the client at risk for bacterial infections. The body responds to environmental allergens with an unspecific inflammatory process. The client is not at risk for bleeding or injury due to contact sports.

The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client's teaching plan? a."Avoid crowds and people who are sick." b."Do not eat raw fruits or vegetables." c."Avoid environmental allergens." d."Do not play contact sports."

ANS: A Clients with AML have a low platelet count and are at risk for bleeding. Contact sports can cause bleeding and should be avoided by those with a low platelet count. Anal intercourse should be avoided, but it is not necessary to refrain from all types of intercourse. Ice should be placed on bruised areas instead of heat, and aspirin should not be used by those with a low platelet count.

The nurse is planning discharge teaching for a client who has acute myelogenous leukemia (AML). Which instruction does the nurse include in this client's discharge plan? a.avoid contact sports. b.Refrain from intercourse. c.Apply heat to any bruised areas. d.Use aspirin for headaches.

ANS: C Clients may have pain during this procedure. The type and amount of anesthesia or sedation depend on the physician's preference, the client's preference, and previous experience with bone marrow aspiration. The procedure takes from 5 to 15 minutes. Guided imagery can relieve pain but works well only with some clients.

The nurse is preparing a client for a bone biopsy and aspiration. The client asks, "Will this be painful?" How does the nurse respond? a."The procedure is always done under general anesthesia." b."The biopsy lasts for only 2 minutes." c."There is a chance that you may have pain." d."You can relieve pain with guided imagery."

ANS: D Red urine can occur as a result of red blood cell breakage within infused stem cells. The cells are transfused during the time frame of an ordinary blood transfusion, numbness and tingling may have been seen during pheresis (not transfusion), and nausea and vomiting may occur during administration of chemotherapy before the stem cell transfusion.

The nurse is preparing a client with leukemia for a peripheral stem cell transfusion. Which information does the nurse provide the client? a."Nausea and vomiting are common after the transfusion." b."The transfusion will take about 6 hours." c."You may have numbness in your fingers and toes." d."Your urine may be red for a short time.

ANS: A, D, E The Standard Precautions approach is based on the premise that a medical history and a physical examination cannot reliably identify all those infected by pathogens. Consequently, health care workers should consider all human blood and body fluids as potentially infectious and must use appropriate protective measures to prevent possible exposure. Specimens should be labeled appropriately and transported in a sealed bag displaying the biohazard symbol. The nurse should use Standard Precautions when handling the specimen. The nurse should also confirm the identification of the client and the specimen. The nurse does not need sterile gloves, and the specimen should not be iced.

The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which actions does the nurse implement during this procedure? (Select all that apply.) a. Use Standard Precautions. b. Wear sterile gloves when handling the specimen. c. Place the specimen on ice. d. Send the specimen in a sealed bag displaying a biohazard symbol. e. Confirm the specimen label with the client's identification band.

ANS: C Electrolyte imbalance is possible as a result of transfusions, especially with red blood cells or whole blood. Potassium is the main electrolyte inside cells. During transfusion, some cells are damaged and release potassium. Low fibrinogen levels would require transfusion of cryoprecipitate. The client would be a candidate for red blood cell transfusion if his hematocrit level were low, so this would not be a concern for preparation of the red blood cells. The serum ferritin level is normal and is not a matter of concern.

The nurse is preparing to transfuse a third unit of red blood cells to a client. Which laboratory result is the nurse most concerned about? a.Fibrinogen level less than 100 mg/dL b.Hematocrit of 30% c.Potassium level of 5.5 mg/dL d.Serum ferritin level of 250 ng/mL

ANS: B Many genetic and environmental factors are involved in the development of leukemia. Exposure to radiation increases the risk for development of leukemia, particularly acute myelogenous leukemia (AML). Although alcohol consumption, high-cholesterol diet, and smoking are not healthy behaviors, they do not increase the risk for leukemia.

The nurse is providing health promotion education to a client who has a family history of leukemia. Which factor does the nurse teach this client to avoid? a.Alcohol consumption b.Exposure to ionizing radiation c.High-cholesterol diet d.Smoking cigarettes

ANS: C Treatment for iron deficiency anemia involves increasing oral intake of iron from food sources. Foods high in iron include red meat, organ meat, kidney beans, leafy green vegetables, and raisins.

The nurse is teaching a client who has iron deficiency anemia. Which food choice indicates that the client correctly understands the teaching? a.Chicken b.Oranges c.Steak d.Tomatoes

ANS: D Myelodysplastic syndrome is a group of disorders that includes anemia, neutropenia, and thrombocytopenia. Because of low platelets, the client is at risk for bleeding. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding. The other instructions are not appropriate for this syndrome.

The nurse is teaching a client who has myelodysplastic syndrome. Which instruction does the nurse include in this client's teaching? a."Rise slowly when getting out of bed." b."Drink at least 3 liters of liquids per day." c."Wear gloves and socks outdoors in cool weather." d."Use a soft-bristled toothbrush."

ANS: D Abdominal pain and a palpable spleen could indicate blood trapping in the spleen. Over time, the spleen may become nonfunctional, which makes the client at risk for infection. An annual influenza vaccination helps prevent infection. A client with sickle cell disease should not become dehydrated or engage in strenuous physical activity because this could precipitate a crisis. Eating smaller meals has no impact on sickle cell disease or infection.

The nurse is teaching a client who has sickle cell disease and was admitted for splenomegaly and abdominal pain. Which instruction does the nurse include in the client's discharge teaching? a."Avoid drinking large amounts of fluids." b."Eat six small meals daily instead of large meals." c."Engage in aerobic exercise 3 days a week." d."Receive a yearly influenza vaccination."

ANS: B The most important instruction is to have the client monitor the area for external or internal bleeding. Activities such as contact sports should be avoided, and an ice pack can be used to limit bruising.

The nurse is teaching a client who has undergone a bone marrow biopsy. Which instruction does the nurse give the client? a."Wear protective gear when playing contact sports." b."Monitor the biopsy site for bruising." c."Remain in bed for at least 12 hours." d."Use a heating pad for pain at the biopsy site."

ANS: B Platelets recover more slowly than other blood cells after bone marrow transplantation. Thus the client is still thrombocytopenic at home and remains at risk for excessive bleeding after any trauma or injury. Injured tissue makes a client at risk for infection, and trauma could result in injury to the transplant (but not rejection). However, these are not the best responses to give the client. A steroid regimen may make a client more at risk for bruising, but the most accurate response pertains to platelet recovery.

The nurse is teaching a client who is being discharged to home after bone marrow transplantation. The client asks, "Why is it so important to protect myself from injury?" How does the nurse respond? a."Injuries put you at high risk for infection." b."Platelet recovery is slow, which makes you at risk for bleeding." c."Severe trauma could result in rejection of the transplant." d."The medications you are taking will make you bruise easily."

ANS: A, B, D, E The client on warfarin will need to know which foods are high in vitamin K because vitamin K intake must be consistent to avoid interfering with the anticoagulant properties of warfarin. Clients should not take aspirin or NSAIDs for minor pain owing to their anticoagulant properties. Clients must use safety razors and soft toothbrushes to avoid bleeding episodes. The client on warfarin needs regular blood tests for prothrombin time (PT) and international normalized ratio (INR). Daily exercise and weight management are not specifically important to this client.

The nurse is teaching a client who is receiving sodium warfarin (Coumadin). Which topics does the nurse include in the teaching plan? (Select all that apply.) a.Foods high in vitamin K b.Using acetaminophen (Tylenol) for minor pain c.Daily exercise and weight management d.Use of a safety razor and soft toothbrush e..Blood testing regimen

ANS: C, D Engraftment, or the successful take of transplanted cells, takes anywhere from 8 to 28 days, depending on the type of cell transplantation. For donated marrow or stem cells to work, the client will require large doses of chemotherapy before transplantation. The client will not require radiation after the transplant. Transplanted marrow is delivered intravenously. It is not placed into any bone. The client is at risk for infection until the bone marrow begins to produce white blood cells. Therefore visitors should be limited to prevent infection to the client.

The nurse is teaching a client who is scheduled to undergo allogeneic bone marrow transplantation. Which statements indicate that the client correctly understands the teaching? (Select all that apply.) a."The surgeon will insert the marrow into my femur bone." b."Until the marrow transplant takes, I can have visitors." c."The transplant does not start working immediately." d."I will need chemotherapy before my transplant." e."Radiation treatments will begin 2 days after transplantation."

ANS: B Decreased platelet counts increase the risk for prolonged bleeding, even with slight injury. Fluid intake will not affect the platelet count. The client can blow his or her nose if necessary but should be instructed to do so gently. Aspirin should be avoided because it can cause an even greater risk of bleeding.

The nurse is teaching a client who was recently diagnosed with thrombocytopenia. Which instruction does the nurse include in this client's discharge teaching? a."Drink at least 3 liters of fluid each day." b."Use a soft-bristled toothbrush." c."Avoid blowing your nose." d."Use only aspirin when having pain."

ANS: C Organ meats and leafy green vegetables have the highest content of vitamin B12. The other selections do not indicate understanding of the teaching on diet.

The nurse is teaching a client with vitamin B12 deficiency anemia to eat a diet high in this vitamin. Which meal selected by the client indicates that the client correctly understands the prescribed diet? a.Baked chicken breast, mashed potatoes, glass of milk b.Eggplant parmesan, cottage cheese, iced tea c.Fried liver and onions, orange juice, spinach salad d.Fettuccine alfredo, green salad, glass of red wine

ANS: C Clients with sickle cell disease are anemic but are not iron deficient. Transfusions are prescribed cautiously to prevent iron overload with repeated transfusions. Iron overload damages the heart, liver, and endocrine organs. Monitor the client's serum ferritin, serum iron (Fe), and total iron-binding capacity (TIBC) during transfusion therapy. The other laboratory values should not result in discontinuation of the transfusion by the nurse.

The nurse is transfusing red blood cells to a client who has sickle cell disease. Which laboratory result indicates that the nurse should discontinue the transfusion?a.Hematocrit level (Hct), 32% b.Hemoglobin S, 88% c.Serum iron level, 300 mcg/dL d.Total white blood cell count, 12,000/mm3

ANS: B Body temperature normally changes 0.5° C to 1° C (0.9° F to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.

The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the physician immediately to report a possible infection. b. Realize that this is a normal temperature variation c. Provide another blanket to conserve body temperature. d. Provide medication to lower the temperature further

ANS: B Clients with an AB-negative blood type can receive O-negative blood because they do not have antibodies against this type of blood. The transfusion can proceed. The nurse monitors the client's vital signs as if he or she were receiving type AB-negative packed red blood cells. The blood bank would not need to be called. Blood would not need to be stopped because the blood is compatible with the client's blood type. Benadryl would be given only if the client had an allergic reaction.

The nurse observes that a client, whose blood type is AB-negative, is receiving a transfusion with type O-negative packed red blood cells. Which action does the nurse take first? a.Report the problem to the blood bank. b.Assess and record the client's vital signs. c.Stop the transfusion and keep the IV open. d. administer prescribed diphenhydramine

ANS: C Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue, and because foot calluses may appear yellow, neither of these areas should be used to assess for jaundice. The client's pulse and lung sounds have no correlation with an assessment of jaundice.

The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next? a.Assess the client's pulses b.Examine the soles of the client's feet. c.Inspect the client's hard palate. d.Auscultate the client's lung sounds.

ANS: B In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract.

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

ANS: A A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS.

The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

ANS: B Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. "I need to see a lawyer because I do not expect to recover from this disease." b. "I will have to take things slowly for several months after I leave the hospital." c. "I expect to be able to return to work in construction soon after I get discharged." d. "I wonder if my family will be able to manage my care now that I am paralyzed."

ANS: C Infants are wet with amniotic fluid and blood at birth,which accelerates evaporative heat loss. Rubbing the infant does stimulate crying, but it is not the main reason for drying the infant. Drying the infant after birth does not remove all of the maternal blood.

The nurse thoroughly dries the infant immediately after birth primarily to a. Stimulate crying and lung expansion. b. Remove maternal blood from the skin surface. c. Reduce heat loss from evaporation. d. Increase blood supply to the hands and feet.

ANS: B Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient's temperature through the use of a. Radiation. b. Conduction. c. Convection. d. Evaporation

ANS: A, C The patient is experiencing heat stroke. Treatment focuses first on stabilizing the patient's ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate (select all that apply)? a. Administer 100% O2 b. Immerse in an ice bath. c. Administer cool IV fluids. d. Cover the patient to prevent chilling. e. Administer acetaminophen (Tylenol).

ANS: C The rectal route is argued to be more reliable when oral temperature cannot be obtained. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating

The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes? a. Oral b. Axillary c. Rectal d. Temporal

ANS: A During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable

The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is a. Place the patient on oxygen. b. Restrict fluid intake c. Increase patient activity. d. Increase patient's metabolic rate.

ANS: B The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patient's agitation state may not allow for long periods of attention.

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature a. Orally. b. Tympanically. c. Rectally. d. By the axillary method.

ANS: A If the posterior hypothalamus senses that the body's temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production

The posterior hypothalamus helps control temperature by: a. Causing vasoconstriction. b. Shunting blood to the skin and extremities. c. Increasing sweat production. d. Causing vasodilation

ANS: D The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? a. Document the findings. b. Retake the temperature in 15 minutes. c. Notify the health care provider (HCP). d. Increase hydration by encouraging oral fluids.

ANS: thermogenesis Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production by as much as 100%.

The shivering mechanism of heat production is rarely functioning in the newborn. Nonshivering _____________ is accomplished primarily by metabolism of brown fat, which is unique to the newborn, and by increased metabolic activity in the brain, heart, and liver.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients d. Apply sunscreen 30 minutes prior to exposure.

ANS: C The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? a. Dyspnea. b. Precordial pain. c. Increased pulse rate d. Elevated blood pressure

ANS: B Tremulous movements are characteristic of rigid/tremor/atonic cerebral palsy. Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The child's muscles are very tight and any stimuli may cause a sudden jerking movement. Slow, writhing, uncontrolled, involuntary movements occur with athetoid or dyskinetic cerebral palsy. Clumsy movements, loss of coordination, equilibrium, and kinesthetic sense occur in ataxic cerebral palsy.

What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements

ANS: C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.

What is a result of hypothermia in the newborn? a. Shivering to generate heat b. Decreased oxygen demands c. Increased glucose demands d. Decreased metabolic rate

ANS: A Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. Bulging fontanels is a manifestation of increased ICP in infants. A 10-year-old child would have a closed fontanel. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length. By 10 years of age, cranial sutures have fused so that head circumference will not increase in the presence of increased ICP.

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference

ANS: D The exact cause of most cases of neural tube defects is unknown. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects. The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined.

What is the most appropriate nursing response to the father of a newborn infant with myelomeningocele who asks about the cause of this condition? a. "One of the parents carries a defective gene that causes myelomeningocele." b. "A deficiency in folic acid in the father is the most likely cause." c. "Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele." d. "There may be no definitive cause identified."

ANS: B Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. Airway is always the number one priority. Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure.Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention, but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This is not the priority nursing intervention

What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)? a. Immunosuppressive medications b. Respiratory assessment c. Passive range-of-motion exercises d. Anticoagulant therapy

ANS: B Stabilizing the child's neck does not address the child's symptoms. Any indication of ICP should be promptly reported to the physician. This intervention may facilitate the child's comfort. It would not be the nurse's first action. The child's episode of vomiting does not necessitate a fluid restriction.

What should be the nurse's first action when a child with a head injury complains of double vision and a headache, and then vomits? a. Immobilize the child's neck .b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

ANS: A The combination of signs is strongly suggestive of hydrocephalus. SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reye's syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of a. Hydrocephalus b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Cerebral palsy d. Reye's syndrome

ANS: D The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults? a. It is accurate even when the forehead is covered with hair. b. It is not affected by skin moisture. c. It reflects rapid changes in radiant temperature. d. There is no risk of injury to patient or nurse

ANS: D A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment. The normal temperature range gradually drops as individuals approach older adulthood.

When focusing on temperature regulation of newborns and infants, the nurse understands that a. Temperatures are basically the same for infants and older adults. b. Infants have well-developed temperature-regulating mechanisms. c. The normal temperature range gradually increases as the person ages. d. Newborns need to wear a cap to prevent heat loss.

ANS: A Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever "breaks," the patient becomes afebrile.

When heat loss mechanisms of the body are unable to keep pace with excess heat production,the result is known as a. Pyrexia. b. The plateau phase. c. The set point. d. Becoming afebrile.

ANS: B The skill of temperature measurement can be delegated. The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature and to consider specific factors thatfalsely raise or lower temperature.

When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel? a. Temperature measurement b. Assessment of changes in body temperature c. Selection of appropriate route and device d. Consideration of factors that falsely raise temperature

ANS: D Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with ICP. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure. The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema.

Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status

ANS: A Padding the scale prevents heat loss from the infant to a cold surface by conduction. Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. Hourly assessments are not necessary for a normal newborn with a stable temperature.

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Place a blanket over the scale before weighing the infant. b. Maintain room temperature at 70° F. c. Undress the infant completely for assessments so they can be finished quickly. d. Take the rectal temperature every hour to detect early changes.

ANS: C Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.

Which of the following patients is most at risk for tachycardia? a. A healthy professional tennis player b. A patient admitted with hypothermia c. A patient with a fever of 39.4° C (103° F) d. A 90-year-old male taking beta blockers

ANS: B Chronic alcohol abuse is strongly associated with malnutrition of many dietary essentials, including iron, folic acid, and vitamin B12. Antacids, heart failure, and diabetes affect nutrition at varying levels, but anemia is most closely related to the malnutrition seen with chronic alcohol abuse.

Which risk factor does the nurse assess for to determine a client's cause of anemia? a.Antacid therapy b.Chronic alcoholism c.Congestive heart failure d.Type 2 diabetes

ANS: B Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Obtundation describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

ANS: D Sliding a disposable plastic probe cover over the thermometer probe stem will prevent the transmission of microorganisms between patients. Squeezing a liberal portion of lubricant on the tissue helps lubricate the rectal mucosa and minimizes trauma. Application of clean gloves between cleaning the anal region and measuring rectal temperature is important to maintain standard precautions. Inserting the thermometer probe gently into the anus in a direction of umbilicus 2.5 to 3.5 cm helps ensure adequate exposure against blood vessels in the rectal wall.

While assessing the rectal temperature of a patient, the nurse slides a plastic disposable probe cover over the thermometer probe stem until the cover locks in place. What is the reason behind this intervention? a. Lubricating rectal mucosa during insertion b. Maintaining standard precautions when exposed c. Ensuring adequate exposure against blood vessels d. Preventing transmission of microorganisms between patients