Exam 3 New Content

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Impetigo ordinarily results in: a. No scarring b. Pigmented spots c. Slightly depressed scars d. Atrophic white scars

ANS: A A Impetigo tends to heal without scarring unless a secondary infection occurs. B Hyperpigmentation may occur; however, only in dark skinned children. C No scarring usually occurs. D No scarring usually occurs

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 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 caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

ANS: A A. Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. B. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other clients in the unit. C. Topical antimicrobials such as sulfadiazine do not enhance cell growth. D. Use of topical antimicrobials such as sulfadiazine does not minimize the need for a skin graft.

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 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.

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 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 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: 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.

13. 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 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.

7. 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: 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.

14. 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: 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.

After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a."At the next family reunion, I'm going to ask my relatives if they have psoriasis." b."I have to make sure I keep my lesions covered, so I do not spread this to others." c."I expect that these patches will get smaller when I lie out in the sun." d."I should continue to use the cortisone ointment as the patches shrink and dry out."

ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a.Beige freckles on the backs of both hands b.Irregular blue mole with white specks on the lower leg c.Large cluster of pustules in the right axilla d.Thick, reddened papules covered by white scales

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

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: 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.

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, 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.

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: 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.

Which type of seizures involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

ANS: C Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

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 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 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: 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 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 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.

Where do the lesions of atopic dermatitis most commonly occur in the infant? (Select all that apply.): a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk

ANS: A, C, E Correct: The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. Incorrect: These lesions are not typically on the back or the buttocks.

Which nursing assessment is applicable to the care of a child with herpetic gingivostomatitis? a. Comparison of range of motion for the upper and lower extremities b. Urine output, mucous membranes, and skin turgor c. Growth pattern since birth d. Bowel elimination pattern

ANS: B A An oral herpetic infection does not affect joint function. B The child with herpetic gingivostomatitis is at risk for deficient fluid volume. Painful lesions on the mouth make drinking unpleasant and undesirable, with subsequent dehydration becoming a real danger. C Herpetic gingivostomatitis is not a chronic disorder that would affect the child's long-term growth pattern. D Although constipation could be caused by dehydration, it is more important to assess urine output, skin turgor, and mucous membranes to identify dehydration before constipation is a problem.

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

22. 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 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.

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: 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.

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: 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.

What nursing assessment and care holds the highest priority in the initial care of a child with a major burn injury? a. Establishing and maintaining the child's airway b. Establishing and maintaining intravenous access c. Inserting a catheter to monitor hourly urine output d. Inserting a nasogastric tube into the stomach to supply adequate nutrition

ANS: A A Establishing and maintaining the child's airway is always the priority focus for assessment and care. B Establishing intravenous access is the second priority in this situation, after the airway has been established. C Inserting a catheter and monitoring hourly urine output is the third most important nursing intervention. D Nasogastric feedings are not begun initially on a child with major or severe burns. The initial assessment and care focus for a child with major burn injuries is the ABCs.

The client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? a. Assessing neurologic status at least every 2 to 4 hours b. Decreasing environmental stimuli c. Managing pain through drug and nondrug methods d. Strict monitoring of hourly intake and output

ANS: A The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure (ICP), such as decreased level of consciousness (LOC). Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. Assessing fluid balance while preventing overload is not the highest priority.

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: 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.

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: 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.

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: 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

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: 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.

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response? a. "This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." b. "This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling." c. "These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals." d. "These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit."

ANS: A Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea.

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

ANS: A The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a."Wash your hands before touching the client." b."Wear gloves when bathing the client." c."Assess skin for breakdown during the bath." d."Apply lotion to lesions while the skin is wet." e."Use a damp cloth to scrub the lesions"

ANS: A, B All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the client's skin. The other statements are not appropriate for the care of open skin lesions.

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level

ANS: A, C Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.

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: A, C The patient is experiencing heatstroke. 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.

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 should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply. a. Elevated white blood count (WBC) b. Decreased protein c. Decreased glucose d. Cloudy in color e. Increase in red blood cells (RBC)

ANS: A, C, D The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose. The protein is elevated and there should be no RBCs present. RBCs are present when the tap was traumatic.

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: 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.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

Parents of a child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect? a. Nephrotoxicity b. Neurotoxicity c. Ototoxicity d. Bone marrow depression

ANS: B A Antilice products are not known to be nephrotoxic. B Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. C Antilice products are not ototoxic. D Products that treat lice are not known to cause bone marrow depression.

Ringworm, frequently found in schoolchildren, is caused by a(n): a. Virus b. Fungus c. Allergic reaction d. Bacterial infection

ANS: B A These are not the causative organisms for ringworm. B Ringworm is caused by a group of closely related filamentous fungi, which invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin. C Ringworm is not an allergic response. D These are not the causative organisms for ringworm.

The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? a. "Sumatriptan should be taken as a last resort." b. "I must report any chest pain right away." c. "Birth control is not needed while taking sumatriptan." d. "St. John's wort can also be taken to help my symptoms."

ANS: B Chest pain must be reported immediately with the use of sumatriptan. Sumatriptan must be taken as soon as migraine symptoms appear. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans should not be taken with selective serotonin reuptake inhibitors (SSRIs) or St. John's wort, an herb used commonly for depression.

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 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.

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: 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.

After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a."I can help him shift his position every hour when he sits in the chair." b."If his tailbone is red and tender in the morning, I will massage it with baby oil." c."Applying lotion to his arms and legs every evening will decrease dryness." d."Drinking a nutritional supplement between meals will help maintain his weight."

ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home

The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? a. "I can still eat Chinese food." b. "I must not miss meals." c. "It is okay to drink a few wine coolers." d. "I need to use fake sugar in my coffee."

ANS: B Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. Monosodium glutamate (MSG)-containing foods such as Chinese food are a trigger for many people suffering from migraines and should be eliminated until the triggers are identified. Alcohol is a trigger for many people suffering from migraines and should be eliminated until the triggers are identified. Artificial sweeteners are a trigger for many people suffering from migraines and should be eliminated until the triggers are identified.

After a tonic-clonic seizure, it would not be unusual for a child to display a. Irritability and hunger b. Lethargy and confusion c. Nausea and vomiting d. Nervousness and excitability

ANS: B Neither irritability nor hunger is typical of the period after a tonic-clonic seizure. In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. Nausea and vomiting are not expected reactions in the postictal period. The child will more likely be confused and lethargic after a tonic-clonic seizure.

Which is the most effective way for the college student to minimize the risk for bacterial meningitis? a. Avoiding large crowds b. Getting the meningitis polysaccharide vaccine c. Taking a daily vitamin d. Taking prophylactic antibiotics

ANS: B People who live in highly populated areas, such as a college dorm, should get the meningitis polysaccharide vaccine (Menomune) to prevent infection. Avoiding large crowds is helpful but is not practical for the college student. Taking a daily vitamin is helpful but is not the best way to safeguard against bacterial meningitis. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

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: 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.

9. 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: 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 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: 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 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: 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 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: 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.

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

The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

ANS: B The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. Therapeutic massage, passive range of motion, and repositioning will not reduce muscle weakness.

1. The nurse is preparing to administer transfusion therapy to a client. Which interventions does the nurse implement before starting the infusion? (Select all that apply.) a. Confirm the client's room number with the blood tag. b. Check the client's ABO and Rh types with the blood tag. c. Place a 20-gauge needle or larger in the client's forearm. d. Obtain the client's pulse oximetry reading. e. Assess the client's temperature.

ANS: B, C, E Before giving any transfusion therapy, two nurses must examine the blood tag and the requisition slip to ensure that the ABO and Rh types are compatible. The client's room number is not an acceptable form of identification. A larger needle (at least a 20-gauge needle) should be used, and blood pressure, pulse, respirations, and temperature should be obtained. Obtaining an oxygen saturation reading is unnecessary.

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, 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 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: 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 is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a."Have you eaten a large amount of chocolate lately?" b."Have you been under a lot of stress lately?" c."Have you recently used a public shower?" d."Have you been out of the country recently?" e."Have you recently had any other health problems?" f."Have you changed any medications recently?"

ANS: B, E, F Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route? A. The drug will be effective more quickly than if given IM or subcutaneously. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client has delayed gastric emptying.

ANS: C Although providing some pain relief is a high priority and giving the drug by the IV route instead of the IM, subcutaneous, or oral routes does increase the rate of effect, the most important reason is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed while the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

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 manager

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 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: 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 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: 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 nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Assess religious and spiritual needs while in the hospital. b. Identify the client's ability to perform self-care activities. c. Evaluate the client's reaction to a change of environment. d. Ask the client about relationships with family members.

ANS: C As Alzheimer's disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client's reaction to environmental change.

Which statement is true of the ovulation phase? a. Progesterone levels are below normal. b. Body temperature is below baseline levels. c. Body temperature is at previous baseline levels or higher. d. Intense body heat and sweating occur.

ANS: C Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher. These temperature variations help to predict a woman's most fertile time to achieve pregnancy. Women who undergo menopause (cessation of menstruation) often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes)

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive UV exposure d. Instructing the patient to take their multivitamin prior to treatment

ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

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: 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.

2. 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: 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.

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: C, E Appropriate interventions to relieve pressure on these areas 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.

What procedure is contraindicated in the care of a child with a minor partial-thickness burn injury wound? a. Cleaning the affected area with mild soap and water b. Applying antimicrobial ointment to the burn wound c. Changing dressings daily d. Leaving all loose tissue or skin intact

ANS: D A Cleaning with mild soap and water are important to the healing process. B Antimicrobial ointment is used on the burn wound to fight infection. C Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed. D All loose skin and tissue should be debrided, because it can become a breeding ground for infectious organisms.

The pediatric nurse understands that cellulitis is most often caused by: a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococcus or Staphylococcus organisms

ANS: D A Herpes zoster is the virus associated with varicella and shingles. B Candida albicans is associated with candidiasis or thrush. C Human papillomavirus is associated with various types of human warts. D Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis

The skin condition commonly known as "warts" is the result of an infection by which organism? a. Bacteria b. Fungus c. Parasite d. Virus

ANS: D A Infection with these organisms does not result in warts. B Infection with these organisms does not result in warts. C Infection with these organisms does not result in warts. D Human warts are caused by the human papillomavirus.

The process of burn shock continues until what physiologic mechanism occurs? a. Heart rate returns to normal. b. Airway swelling decreases. c. Body temperature regulation returns to normal. d. Capillaries regain their seal.

ANS: D A The heart rate will be increased throughout the healing process because of increased metabolism. B Airway swelling subsides over a period of 2 to 5 days after injury. C Body temperature regulation will not be normal until healing is well under way. D Within minutes of the burn injury, the capillary seals are lost with a massive fluid leakage into the surrounding tissue, resulting in burn shock. The process of burn shock continues for approximately 24 to 48 hours, when capillary seals are restored.

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: 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.

2. 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: 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.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease? a. "His masklike face makes it difficult to communicate, so I will use a white board." b. "He should not socialize outside of the house due to uncontrollable drooling." c. "This disease is associated with anxiety causing increased perspiration." d. "He may have trouble chewing, so I will offer bite-sized portions."

ANS: D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client's masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

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: 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 patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate a. Candida albicans. b. group A beta-hemolytic streptococci. c. Staphylococcus aureus. d. Streptococcus pyogenes.

ANS: D Streptococcus pyogenes is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

ANS: D Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels. The other laboratory results are not associated with myasthenia gravis.

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 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

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: 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.

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: 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.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

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: 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%.

2. 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

And. 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.

3. 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.

NS: 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 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

NS: 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.

When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of: a. Asthma b. Nephrosis c. Lower respiratory tract infections d. Neurotoxicity

ANS: A A Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis, and up to 80% of children with atopic dermatitis have asthma or allergic rhinitis. B Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis. C There is no link between lower respiratory tract infections and atopic dermatitis. D Atopic dermatitis does not have a relationship to neurotoxicity.

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: 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.

When changing an infant's diaper, the nurse notices small bright red papules with satellite lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of: a. Primary candidiasis b. Irritant contact dermatitis c. Intertrigo d. Seborrheic dermatitis

ANS: A A Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. B A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. C Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. D Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp.

What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the child's mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed.

ANS: A A To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good handwashing is imperative in preventing the spread of impetigo. B The lesions should be washed gently with a warm soapy washcloth three times a day. The washcloth should not be shared with other members of the family. C Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the child's nails to prevent maceration of the lesions. D The child may return to school 24 hours after initiation of antibiotic treatment.

10. 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: 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.

What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss the teeth after every meal. b. The child will require monitoring of renal function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.

ANS: A A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

The client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

ANS: A A. Encouraging participation in wound care will offer the client some sense of control. B. Encouraging visitors may be a good distraction but will not help the client achieve a sense of control. C. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. It does nothing to help the client achieve a sense of control. D. Telling the client that his or her feelings are normal may be reassuring but does not address the issue of restoring a sense of control.

A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which physician request first? A. Give oxygen per non-rebreather mask at 100% FiO2. B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

ANS: A A. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. B. Although fluid hydration is important, the nurse's first priority is the client's airway. C. Pain control is important, but the nurse's first priority is the client's airway. D. Monitoring output is important, but the nurse's first priority is the client's airway.

The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white blisters B. Painless, brownish-yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

ANS: A A. Painful red and white blisters accompany a deep partial-thickness burn. B. Painless, brownish-yellow eschar accompanies a full-thickness burn. C. A painful reddened blister accompanies a superficial partial-thickness burn. D. Painless black skin with eschar accompanies a deep full-thickness burn.

To position the client's burned upper extremities appropriately, how will the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

ANS: A A. The neutral position is the correct placement of the elbow to prevent contracture development. B. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. C. The slightly flexed position increases the risk for contracture development. D. The slightly hyperextended position is not indicated and can be painful.

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? a. Absence b. Myoclonic c. Simple partial d. Tonic

ANS: A Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. Partial seizures are most often seen in adults. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.

A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial

ANS: A Absence seizures are very brief episodes of altered awareness. The child has a blank expression. Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms

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: 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.

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 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.

A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? a. Shingles on the client's back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea

ANS: A An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk of infection. A nurse would want to notify the health care provider if shingles were identified on the client's back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the client's needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.

19. 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: 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 client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next? a. Allow the client to remain undisturbed. b. Assess the client's vital signs. c. Remove the cloth because it can harbor microorganisms. d. Turn on the lights for a neurologic assessment.

ANS: A At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down and darkening the room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. Assessing the client' vital signs will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. Turning on the lights is not appropriate because light can cause the migraine to worsen.

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: 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.

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: 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.

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

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 nonallergic 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.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that the client may have bacterial meningitis? a. Cloudy, turbid CSF b. Decreased white blood cells c. Decreased protein d. Increased glucose

ANS: A Cloudy, turbid cerebrospinal fluid is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. Increased white blood cells and protein with decreased glucose are signs of of bacterial meningitis.

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: 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.

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: 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 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.

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: 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.

8. 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 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.

A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? a."You can use tap water instead of sterile saline to clean your wound." b."If you don't clean the wound properly, you could end up in the hospital." c."Sterile procedure is necessary to keep this wound from getting infected." d."Good hand hygiene is the only thing that really matters with wound care."

ANS: A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.

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: 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.

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis? a. CSF appears cloudy. b. CSF pressure is decreased. c. Few leukocytes are present. d. Glucose level is increased compared with blood.

ANS: A In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color. The CSF pressure is usually increased in acute bacterial meningitis. Many polymorphonuclear cells are present in CSF with acute bacterial meningitis. The CSF glucose level is usually decreased compared with the serum glucose level.

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

ANS: A Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

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

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.

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 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.

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: 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.

4. 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: 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.

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: 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.

The nurse should expect a child who has frequent tension type of headaches to describe headache pain as a. "There is a rubber-band squeezing my head." b. "It's a throbbing pain over my left eye." c. "My headaches are worse in the morning and get better later in the day." d. "I have a stomachache and a headache at the same time."

ANS: A The child who has tension type of headaches may describe the pain as a bandlike tightness or pressure, tight neck muscles, or soreness in the scalp. A common symptom of migraines is throbbing headache pain, typically on one side of the eye. A headache that is worse in the morning and improves throughout the course of the day is typical of ICP. Abdominal pain may accompany headache pain in migraines.

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 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 an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a.Place the client in a single room. b.Administer an antihistamine. c.Assess the client's airway. d.Apply gloves to minimize friction.

ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the client's infectious disorder

15. The nurse is preparing a client for surgery. The client states, "I am concerned I might be given blood products during surgery and this would be against my religious beliefs." How does the nurse respond? a. "We can use other means to replace blood loss besides blood products." b. "Your chance of needing a blood transfusion is small." c. "The operating team will do what is necessary to save your life." d. "You could have family members donate blood for you."

ANS: A The client's rights and wishes should be respected while accurate information is provided for reassurance. Directed donations from family members neither ensure safe blood products nor may be sanctioned by the client's religion.

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: 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.

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a.Recent wound assessment, including size and appearance b.Insurance information for billing and coding purposes c.Complete health history and physical assessment findings d.Resources available to the client for wound care supplies

ANS: A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action? A. Assess the client's blood pressure and urine output. B. Notify the physician or the Rapid Response Team. C. Document the report as the only action. D. Increase the IV infusion rate.

ANS: A The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to assess whether the fluid resuscitation at the current rate is adequate. The best ways to determine adequacy by noninvasive measures is by blood pressure measurement and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, it may need adjustment and the physician should be called.

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 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 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: 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.

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? a.Change the dressing every 6 hours. b.Assess the wound bed once a day. c.Change the dressing when it is saturated. d.Contact the provider when the dressing leaks

ANS: A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.

4. 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: 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 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: 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.

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 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 nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."

ANS: A Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the client's ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

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: 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

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 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 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: 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 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: 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 nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a.Client with a left heel ulcer with slight necrosis - Whirlpool treatments b.Client with an eschar-covered sacral ulcer - Surgical débridement c.Client with a sunburn and erythema - Soaking in warm water for 20 minutes d.Client with urticaria - Wet-to-dry dressing changes every 6 hours e.Client with a sacral ulcer with purulent drainage - Transparent film dressing

ANS: A, B Necrotic tissue should be removed so that healing can take place. Whirlpool treatment can gently remove the necrosis. A wound covered with eschar most likely needs surgical débridement. Warm water would not be recommended for a client with erythema. A wet-to-dry dressing and a transparent film dressing are not appropriate for urticaria or pressure ulcers, respectively.

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: 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 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: 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 client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply. a. Oropharyngeal airway b. Oxygen c. Nasogastric tube d. Suction setup e. Padded tongue blade

ANS: A, B, D An oropharyngeal airway, oxygen, and suction setup are provided to help manage hypoxia that occurs during repeated muscle contraction as well as the potential compromised airway from oral injury or emesis during a seizure. Do not force implements such as a tongue blade or nasogastric tube into a client's mouth or nose during a seizure because these devices are more likely to cause injury with no client benefit.

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client's care? (Select all that apply.) a. "Plan to bathe the client in the evening when the client is most alert." b. "Encourage the client to use a cane when ambulating." c. "Assess the client for symptoms related to pain and discomfort." d. "Remind the client to look at foot placement when walking." e. "Schedule additional time for teaching about prescribed therapies."

ANS: A, B, D The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse should assess the client for symptoms of pain and should provide sufficient time for older adults to process information, including new teaching. These are not items the nurse can delegate.

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, 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 nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos

ANS: A, B, E Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.

A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan?( Select all that apply.): a. Clean the diaper area gently after every diaper change with a mild soap. b. Use a protective ointment to clean dry intact skin. c. Use a steroid cream after each diaper change. d. Use rubber or plastic pants over the diaper. e. Wash cloth diapers in hot water with a mild soap and double rinse.

ANS: A, B, E Correct: Prompt, gentle cleaning with water and mild soap (e.g., Dove, Neutrogena Baby Soap) after each voiding or defecation rids the skin of ammonia and other irritants and decreases the chance of skin breakdown and infection. A bland, protective ointment (e.g., A&D, Balmex, Desitin, zinc oxide) can be applied to clean, dry, intact skin to help prevent diaper rash. If cloth diapers are laundered at home, the parents should wash them in hot water, using a mild soap and double rinsing. Incorrect: Occlusion increases the risk of systemic absorption of a steroid; thus steroid creams are rarely used for diaper dermatitis because the diaper functions as an occlusive dressing. Rubber or plastic pants increase skin breakdown by holding in moisture and should be used infrequently. A steroid cream is not recommended.

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: 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 cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a.Use a lift sheet when moving the client in bed. b.Avoid tape when applying dressings. c.Avoid whirlpool therapy. d.Use loose dressing on all wounds. e.Implement pressure-relieving devices.

ANS: A, B, E Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.

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: 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 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: 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 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: 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.

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste

ANS: A, C, D Wernicke's area (language area) is located in the temporal lobe and enables the processing of words into coherent thought as well as the understanding of written or spoken words. The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns. Personality changes are related to frontal lobe injury. Impaired taste is associated with injury to the parietal lobe.

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, 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 cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a.Cool, moist compresses b.Topical corticosteroids c.Heating pad d.Tepid bath with cornstarch e.Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse should implement cool, moist compresses and tepid baths with additives such as cornstarch. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

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: 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 depth of a burn injury may be classified as: a. Localized or systemic b. Superficial, superficial partial thickness, deep partial thickness, or full thickness c. Electrical, chemical, or thermal d. Minor, moderate, or major

ANS: B A These terms refer to the effect of the burn injury. For example, is there a reaction in the area of the burn (localized) or throughout the body (systemic)? B The vocabulary to classify the depth of a burn is superficial, partial thickness, or full thickness. C These terms refer to the cause of the burn injury. D These terms refer to the severity of the burn injury.

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a.Place a small pillow between bony surfaces. b.Elevate the head of the bed to 45 degrees. c.Limit fluids and proteins in the diet. d.Use a lift sheet to assist with re-positioning. e.Re-position the client who is in a chair every 2 hours. f.Keep the client's heels off the bed surfaces. g.Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

What should the nurse teach an adolescent who is taking tretinoin (Retin-A) to treat acne? a. The medication should be taken with meals. b. Apply sunscreen before going outdoors. c. Wash with benzoyl peroxide before application. d. The effect of the medication should be evident within 1 week.

ANS: B A Tretinoin is a topical medication. Application is not affected by meals. B Tretinoin causes photosensitivity, and sunscreen should be applied before sun exposure. C If applied together, benzoyl peroxide and tretinoin have reduced effectiveness and a potentially irritant effect. D Optimal results from tretinoin are not achieved for 3 to 5 months.

The primary treatment for warts is: a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy

ANS: B A Vaccination is prophylaxis for warts and is not a treatment. B Topical treatments include chemical cautery, which is especially useful for the treatment of warts. Local destructive therapy individualized according to location, type, and number. Surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used. C These are not effective in the treatment of warts. D These are not effective in the treatment of warts.

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: 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 assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a."Do you have a bedpan at home?" b."How are you coping with providing this care?" c."What are you doing to prevent pediculosis?" d."Are you sharing a bed with your husband?"

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wife's feelings and provide support for coping with changes. Asking about the client's toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregiver's support and coping mechanisms and ability to continue to care for her husband.

Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

ANS: B A. Clients typically have some type of respiratory distress. However, the client is talking without difficulty, which shows that the client has minimal respiratory distress. B. The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. C. Extensive burns to the hands and face, not the extremities, would be a greater risk. D. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

ANS: B A. Regardless of when the last tetanus injection is given, it is still given on admission to prevent Clostridium tetani. B. Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital. C. This is not the primary reason the client received a tetanus toxoid injection. D. Tetanus toxoid injection does not prevent Pseudomonas infection.

The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much as in the beginning."

ANS: B A. This statement indicates that the client is coping effectively. B. This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. C. This statement indicates that the client is coping effectively. D. This statement indicates that the client is coping effectively.

The client is in the resuscitation phase of burn injury. Which route will the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

ANS: B A. When administered to the client in the resuscitation phase of burn injury via the intramuscular route, drugs remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. B. During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. C. Because the skin is too damaged, the sublingual route is not the indicated route for administering drugs to the client in the resuscitation phase of burn injury. D. Because the skin is too damaged, the topical route is not the indicated route for administering drugs to the client in the resuscitation phase of burn injury.

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: 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.

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this client's teaching? a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." b. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines."

ANS: B Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.

9. 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 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.

25. 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: 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.

A nurse assesses a client who has psoriasis. Which action should the nurse take first? a.Don gloves and an isolation gown. b.Shake the client's hand and introduce self. c.Assess for signs and symptoms of infections. d.Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.

23. 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: 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.

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: 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 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: 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.

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: 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.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

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 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 nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

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: 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 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: 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.

What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if standing and go for help. b. Turn the child's body on the side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the child's wrists.

ANS: B The child should be placed on a soft surface if he is not in bed; however, it is inappropriate to leave the child during the seizure. Positioning the child on his side will prevent aspiration. Nothing should be inserted into the child's mouth during a seizure to prevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed.

ANS: B The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the the head, neck, and upper body). The drooling indicates oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation now.

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 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.

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the client's head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.

ANS: B The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a.Low-fat diet with whole grains and cereals and vitamin supplements b.High-protein diet with vitamins and mineral supplements c.Vegetarian diet with nutritional supplements and fish oil capsules d.Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.

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 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.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? a. Adult who is lethargic after a generalized tonic-clonic seizure b. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes c. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions d. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

ANS: B This client is experiencing status epilepticus, which is a medical emergency and requires immediate intervention. The others are not medical emergencies and do not require immediate attention.

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: 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.

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 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.

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: 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.

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: 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.

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: 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.

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

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: 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.

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: 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.

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

ANS: B Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug. The other medications are not appropriate for complications of this test.

The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

ANS: B The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex and caloric reflex test would not be appropriate for this client.

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: 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

A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

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: 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 that falsely raise or lower temperature.

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: 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.

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: 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.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a.Prepare a room for reverse isolation. b.Assess staff for a history of or vaccination for chickenpox. c.Check the admission orders for analgesia. d.Choose a roommate who also is immune suppressed. e.Ensure that gloves are available in the room.

ANS: B, C, E Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.

What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply. a. It must be given with D5 1/2NS. b. The child will require monitoring of therapeutic serum levels while taking this medication. c. Dilantin should be given with food because it causes gastrointestinal distress. d. It must be given in normal saline. e. It must be filtered.

ANS: B, D, E The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D5 1/2NS. The IV dose must be filtered. The IV dose must be given in normal saline, not D5 1/2NS. Dilantin has not been found to cause gastrointestinal upset, and since it is being given by the IV route, this is not a concern. The medication can be taken without food.

A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this client's plan of care? (Select all that apply.) a. "Increase your intake of caffeinated beverages." b. "Incorporate physical exercise into your daily routine." c. "Avoid all alcoholic beverages." d. "Participate in a smoking cessation program." e. "Increase your intake of fruits and vegetables."

ANS: B, D, E Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.

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: 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-fiber diet, 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.

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a.Turn the mattress overlay to the opposite side. b.Do nothing because this is an expected occurrence. c.Apply a different pressure-relieving device. d.Reinforce the overlay with extra cushions.

ANS: C "Bottoming out," as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

Treatment for herpes simplex virus (types 1 or 2) includes: a. Corticosteroids b. Oral griseofulvin c. Oral antiviral agent d. Topical and/or systemic antibiotic

ANS: C A Corticosteroids are not effective for viral infections. B Griseofulvin is an antifungal agent and not effective for viral infections. C Oral antiviral agents are effective for viral infections such as herpes simplex. D Antibiotics are not effective in viral diseases.

An important nursing consideration when caring for a child with impetigo contagiosa is to: a. Apply topical corticosteroids to decrease inflammation. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. c. Carefully wash hands and maintain cleanliness when caring for an infected child. d. Examine child under a Wood lamp for possible spread of lesions.

ANS: C A Corticosteroids are not indicated in bacterial infections. B Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. C A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough handwashing before and after contact with the affected child. D A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis.

To assess the child with severe burns for adequate perfusion, the nurse monitors: a. Distal pulses b. Skin turgor c. Urine output d. Mucous membranes

ANS: C A Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion. B Skin turgor is often difficult to assess on burn patients because the skin is not intact. C Urine output reflects the adequacy of end-organ perfusion. D Mucous membranes do not reflect end-organ perfusion.

The primary clinical manifestation of scabies is: a. Edema b. Redness c. Pruritus d. Maceration

ANS: C A Edema is not observed in scabies. B Redness is not observed in scabies. C Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. In the previously sensitized person, the response occurs within 48 hours. D Maceration is not observed in scabies.

What best describes a full-thickness (third-degree) burn? a. Erythema and pain b. Skin showing erythema followed by blister formation c. Destruction of all layers of skin evident with extension into subcutaneous tissue d. Destruction injury involving underlying structures such as muscle, fascia, and bone

ANS: C A Erythema and pain are characteristic of a first-degree burn or superficial burn. B Erythema with blister formation is characteristic of a second-degree or partial-thickness burn. C A third-degree or full-thickness burn is a serious injury that involves the entire epidermis and dermis and extends into the subcutaneous tissues. D A fourth-degree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a.Client with blood cultures pending b.Client who has thin, serous wound drainage c.Client with a white blood cell count of 23,000/mm3 d.Client whose wound has decreased in size

ANS: C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.

27. 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 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.

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 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.

12. 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 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 is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor? A. Blood glucose B. C-reactive protein C. Serum and urine creatinine D. Platelet count

ANS: C A. 2 Topical gentamicin sulfate does not affect blood sugar. B. C-reactive protein is used as a marker of inflammation. C. Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment. D. Topical gentamicin sulfate does not alter platelet counts.

The nurse is evaluating the effectiveness of fluid resuscitation for the client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

ANS: C A. A BUN of 36 mg/dL is above normal. B. A creatinine of 2.8 mg/dL is above normal. C. Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr. D. A urine specific gravity of 1.042 is above normal.

In assessing the client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Acute Pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

ANS: C A. Acute Pain is relevant in the resuscitation phase of burn injury. B. Potential for inadequate oxygenation is relevant in the resuscitation phase of burn injury. C. In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. D. Potential for infection is relevant in the acute phase of burn injury.

Which assessment will the nurse prioritize for the client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

ANS: C A. Assessing bowel sounds is not the priority during the acute phase of burn injury. B. Assessing muscle strength is not the priority during the acute phase of burn injury. C. The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. D. Assessing urine output is not the priority during the acute phase of burn injury.

The client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Body temperature assessment B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

ANS: C A. Assessment of body temperature is not the priority for this client. B. Although emotional support is important, this is not the priority during the resuscitation phase for this client. C. The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. D. Although sterile dressing changes are important, this is not the priority for this client.

Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

ANS: C A. Pale, boggy, dry, or crusted granulation tissue is indicative of infection. B. Increasing wound drainage is indicative of infection. C. Indicators of wound healing include the presence of granulation, re-epithelization, and scar tissue formation. D. Sloughing of grafts is indicative of infection.

The nurse is caring for the client with burns. Which question will the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

ANS: C A. Yes or no questions are not very effective in extrapolating helpful information. B. The client and family in this situation probably are overwhelmed and may not know how they will manage. This question does not assess coping strategies. C. This question assesses whether the client's and the family's coping strategies may be effective. D. Asking the client and the family if they would like to see a counselor does not assess their coping strategies.

What is an appropriate nursing intervention for the child with a tension headache? a. Assess for an aura. b. Maintain complete bed rest. c. Administer pharmacologic headache relief measures. d. Assess for nausea and vomiting.

ANS: C An aura is associated with migraines but not with tension headaches. Complete bed rest is not required. Administration of pharmacologic techniques is appropriate to assist in the management of a tension headache. Nausea and vomiting are associated with a migraine but not with tension headaches.

A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client's teaching? a. "Place a warm compress on your forehead at the onset of the headache." b. "Wear dark sunglasses when you are in brightly lit spaces." c. "Lie down in a darkened room when you experience a headache." d. "Set your alarm to ensure you do not sleep longer than 6 hours at one time."

ANS: C At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a.A 44-year-old prescribed IV antibiotics for pneumonia b.A 26-year-old who is bedridden with a fractured leg c.A 65-year-old with hemi-paralysis and incontinence d.A 78-year-old requiring assistance to ambulate with a walker

ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.

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 door bell 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: 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.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been requested for treatment of epilepsy. The nurse plans to instruct the client to avoid which beverage? a. Apple juice b. Grape juice c. Grapefruit juice d. Milk

ANS: C Citrus fruits, such as grapefruit juice, can interact with the metabolism of antiepileptic drugs. This interference can raise the blood level of the drug and cause the patient to develop drug toxicity.

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: 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.

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: 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.

20. 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: 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.

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: 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.

The client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What will the nurse do first? a. Administer phenytoin (Dilantin) b. Draw blood c. Assess the need for additional support d. Start an intravenous (IV) line

ANS: C Convulsive status epilepticus must be treated promptly and aggressively. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already under way. Drawing blood is not the priority in this situation. Starting an IV is not the priority in this situation.

The nurse is assessing a client's susceptibility to rejecting a transplanted kidney. Which result does the nurse recognize as increasing the client's chances of rejection? a. Decreased T-lymphocyte helper b. Decreased white blood cell count c. Increased cytotoxic-cytolytic T cell d. Increased neutrophil count

ANS: C Cytotoxic-cytolytic T cells function to attack and destroy non-self-cells, specifically virally infected cells and cells from transplanted grafts and organs. A high level of these cells would increase the chances of rejection. Decreased white blood cells would indicate immune suppression. Neutrophils are increased during an infection.

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 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 assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

ANS: C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.

28. 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: 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 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: 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).

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 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.

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

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: 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.

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: 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 nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a."Do you spend a great deal of time in the sun?" b."Have you or any family members ever had skin cancer?" c."Which method of contraception are you using?" d."Do you drink alcoholic beverages?"

ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.

3. 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: 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.

18. 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: 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 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: 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 admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? a. Stroke b. Tension headache c. Classic migraine d. Cluster headache

ANS: C Migraine symptoms include frontotemporal pain and can sometimes be preceded by an aura, which can be manifested by visual disturbances. Cluster headaches occur in the oculotemporal area without an aura and a tension headache can feel like a band around the forehead.

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: 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.

The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or food additives may trigger a migraine headache? a. Salt b. Sugar c. Tyramine d. Glutamine

ANS: C Only tyramine has been consistently linked to the onset and severity of migraines. Its action is related to altering the vasoreactivity of cerebral blood vessels. Salt intake may cause fluid retention and a headache, but it is not associated with migraines. Sugar has not been demonstrated to cause migraines. Glutamine is used as a nutrition supplement and has no association with migraines.

10. 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 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.

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: 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.

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: 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.

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: 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.

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.

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: 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.

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 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.

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: 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 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: 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.

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

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: 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.

6. The nurse prepares to administer a blood transfusion to a client. Which means of identification does the nurse use to ensure that the blood is administered to the correct client? a. Ask the client whether his or her name is the one on the blood product tag. b. Ask the client's spouse if the client is supposed to have a transfusion. c. Compare the name and ID number on the blood product tag with the name and ID number on the client's ID band. d. Compare the unit and room number of the client with the unit and room number listed on the blood product tag.

ANS: C The safest way to determine whether the blood product is to be given to the correct client is to check the client's hospital ID band and compare the information on it with that on the blood product tag. The room and unit numbers are never considered as means of positive identification. Asking the client who he or she is might result in an error if the client is confused. Similarly, a visitor cannot be assumed to know whether this is the client to have the blood transfusion.

What is the best response to a father who tells the nurse that his son "daydreams" at home and his teacher has observed this behavior at school? a. "Your son must have an active imagination." b. "Can you tell me exactly how many times this occurs in one day?" c. "Tell me about your son's activity when you notice the daydreams." d. "He is probably overtired and needs more rest."

ANS: C This response does not address the child's symptoms or the father's concern. This behavior is consistent with absence seizures, which can occur one after the other several times a day. Determining an exact number of absence seizures is not as useful as learning about behavior before the seizure that might have precipitated seizure activity. The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained. This response ignores both the child's symptoms and the father's concern about the daydreaming behavior.

11. 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: 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.

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: 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.

A nurse is teaching the daughter of a client who has Alzheimer's disease. The daughter asks, "Will the medication my mother is taking improve her dementia?" How should the nurse respond? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer's disease but will not cure it." c. "It will not improve her dementia but can help control emotional responses." d. "It is used to improve short-term memory but will not improve problem solving."

ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.

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 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 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: 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.

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 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.

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

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: 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

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 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 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: 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 nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? (Select all that apply.): a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.

ANS: C, D, E Correct: An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix crème rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. Incorrect: The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in antilice shampoo or hot water (greater than 60° C [140° F]) for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting.

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.

What should the parents of an infant with thrush (oral candidiasis) be taught about medication administration? a. Give nystatin suspension with a syringe without a needle. b. Apply nystatin cream to the affected area twice a day. c. Give nystatin before the infant is fed. d. Swab nystatin suspension onto the oral mucous membranes after feedings.

ANS: D A Medication may not reach the affected areas when it is squirted into the infant's mouth. Rubbing the suspension onto the gum ensures contact with the affected areas. B Nystatin cream is used for diaper rash caused by Candida. C To prolong contact with the affected areas, the medication should be administered after a feeding. D It is important to apply the nystatin suspension to the affected areas, which is best accomplished by rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared.

When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis? a. Any pain the child is experiencing b. Enlarged, mobile, and nontender lymph nodes c. Child's urinalysis results d. Recent infections or signs of infection

ANS: D A Pain is important, but the history of recent infections is more relevant to the diagnosis. B Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen with red "streaking" of the surrounding area. C An abnormal urinalysis result is not usually associated with cellulitis. D Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated.

Which statement made by a parent indicates an understanding about the management of a child with cellulitis? a. "I am supposed to continue the antibiotic until the redness and swelling disappear." b. "I have been putting ice on my son's arm to relieve the swelling." c. "I should call the doctor if the redness disappears." d. "I have been putting a warm soak on my son's arm every 4 hours."

ANS: D A The parent should not discontinue antibiotics when signs of infection disappear. To ensure complete healing, the parent should understand that the entire course of antibiotics should be given as prescribed. B A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to the affected area and inhibit the healing process. C The disappearance of redness indicates healing and is not a reason to seek medical advice. D Warm soaks applied every 4 hours while the child is awake increase circulation to the infected area, relieve pain, and promote healing.

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a.Draw blood for albumin, prealbumin, and total protein. b.Prepare for and assist with obtaining a wound culture. c.Place the client in bed and instruct the client to elevate the foot. d.Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

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 Result 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 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 client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What will the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

ANS: D A. A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output. They actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. B. Fluid boluses are avoided because they increase capillary pressure and worsen edema. C. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital. D. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. "Do you want some pain medication before I begin?" B. "The only things I am removing are blocks of bacteria growth, not skin." C. "Don't worry, I have worked the burn unit for years and know what I am doing." D. "This tissue is no longer living and as long as it is present, real healing cannot start."

ANS: D A. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity B. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity C. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity D. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity

The client is in the acute phase of burn injury. In which situation will the nurse decide to coordinate with the dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

ANS: D A. It is fine for the client with a burn injury to have food brought in from the outside. B. The hospital kitchen can be consulted to see what other food options may be available to the client. C. It is not therapeutic for the client with burn injury to lose weight. D. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red. B. The client reports that the area hurts when touched. C. The area does not blanch when firm pressure is applied. D. Thrombosed blood vessels are visible beneath the skin surface.

ANS: D A. Red areas can be associated with nearly any depth of burn injury. Reference: p. 515, Physiological Integrity B. The presence of pain is not a good indicator of burn depth. Although full-thickness injuries have much less pain than partial-thickness injuries, pain may still be present. Reference: p. 515, Physiological Integrity C. Deep partial-thickness injuries may or may not blanch with firm pressure. Reference: p. 515, Physiological Integrity D. The presence of thrombosed blood vessels beneath the skin surface is a strong indication of a full-thickness injury. Partial-thickness injuries can directly damage more superficial blood vessels but do not cause thrombosis of deeper vessels. Reference: p. 515, Physiological Integrity

When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 100 mL/hr

ANS: D A. This client requires specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. B. This client requires specialized knowledge about assessment and interventions in burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. C. This client requires specialized knowledge about interventions in burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. D. An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.

2. 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: 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 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: 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.

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: 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.

26. 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: 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.

A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)

ANS: D Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally. Fosphenytoin or Phenobarbital can be given intravenously as a second round of medication if seizures continue. Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 liters of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

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 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 clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a.Viral infection - Clindamycin (Cleocin) b.Bacterial infection - Acyclovir (Zovirax) c.Yeast infection - Linezolid (Zyvox) d.Fungal infection - Ketoconazole (Nizoral)

ANS: D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

24. 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 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.

16. 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: 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.

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.

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

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

17. 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: 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.

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: 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.

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

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.

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a."Use lots of moisturizer several times a day to minimize dryness." b."Take a cold shower instead of soaking in the bathtub." c."Use antimicrobial soap to avoid infection of cracked skin." d."After you bathe, put lotion on before your skin is totally dry."

ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.

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: 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.

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: 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.

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: 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.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my epilepsy medications, I will not drink any alcoholic beverages." c. "I will tell my doctor about my prescription and over-the-counter medications." d. "If I am nauseated, I will not take my epilepsy medication."

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

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: 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.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? a. Documents the length and time of the seizure b. Forces a tongue blade in the mouth c. Restrains the client d. Positions the client on the side

ANS: D Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness. Documenting the length and time of seizures is important, but not while the seizure is occurring. Forcing a tongue blade in the mouth and restraining the client can cause damage.

Which statement by an adolescent indicates an understanding about factors that can trigger migraine headaches? a. "I should avoid loud noises because this is a common migraine trigger." b. "Exercise can cause a migraine. I guess I won't have to take gym anymore." c. "I think I'll get a migraine if I go to bed at 9 PM on week nights." d. "I am learning to relax because I get headaches when I am worried about stuff."

ANS: D Visual stimuli, not auditory stimuli, are known to be a common trigger for migraines. Exercise is not a trigger for migraines. The adolescent needs regular physical exercise. Altered sleep patterns and fatigue is a common migraine trigger for migraine headaches. Going to bed at 9 PM should allow an adolescent plenty of sleep to prevent fatigue. Stress can trigger migraines. Relaxation therapy can help the adolescent control stress and headaches. Other precipitating factors in addition to stress include poor diet, food sensitivities, and flashing lights.

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: 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 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: 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.

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: 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.

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"

ANS: D ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this client's plan of care? a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

ANS: D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the client's blood. Pursed-lip breathing increases exhalation of carbon dioxide.

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: 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 instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to a. bathe and dry the skin vigorously to stimulate circulation. b. keep the head of the bed elevated 30 degrees. c. limit intake of fluid and offer frequent snacks. d. turn the patient at least every 2 hours.

ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

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

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.

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