HESI MILESTONE 2 PRACTICE QUESTION

The nurse concludes that a client with glaucoma needs education when the client makes which statement?

"It is dangerous for me to use sedatives." Sedatives have no effect on intraocular pressure

The registered nurse is teaching a student nurse the points to be included while educating a client on cortisol replacement therapy about self-management. Which statement provided by the student nurse indicates the need for further teaching?

"I will advise the client to take the medication before meals."

The nurse and the treatment team establish a weekly weight gain goal for a client with anorexia nervosa. The client agrees to the goal, but continues to engage in vigorous exercise before the weight gain goal has been met. Which statement by the nurse is most effective in this situation?

"According to our agreement, no exercising is permitted until you have reached your goal." Rationale: Clients must be held accountable for behaviors that are not consistent with treatment plan goals. The nurse is correct to remind client about the previously established weight gain goals and to state that exercise should be limited (or not permitted) until the weekly goal has been achieved.

A student nurse working as an aide in a memory care facility asks the charge nurse if there is a neurobiological basis for the deterioration in cognitive function in Alzheimer's disease. Which explanation by the nurse is correct regarding the etiology of neurocognitive decline?

"Decreases in neurotransmitters affect parts of the brain responsible for memory." Rationale: Neurocognitive decline is associated with changes in neurotransmitter concentration. Alzheimer's disease has been linked with a decrease in the production and function of acetylcholine (ACh). Alzheimer's disease affects an area of the brain called the nucleus basalis, which contains cholinergic neurons. These neurons provide ACh to areas of the brain responsible for memory and learning.

During a meeting with the interdisciplinary treatment team, a client in the acute phase of schizophrenia states that she cannot return to live with her parents because they are trying to kill her. Which statement by the team leader represents a correct therapeutic response?

"That must be very frightening; tell us why you believe you are in danger." Rationale: The acute phase of illness is characterized by reality impairment and paranoia; it is not useful to debate or contradict a delusion while a client is in the acute phase. Attempting to see things from the client's perspective will build trust, which is the basis for an effective therapeutic relationship.

A client with stage 3 Alzheimer's disease is living with his son and daughter-in-law. The visiting nurse is educating the family about the progression of the illness, including "sundown syndrome," and is assisting with care planning and comfort measures. Which statement by the daughter-in-law reflects that the teaching has been effective?

"We will have locks placed at the top of all the outside doors." Rationale: Placing locks at the top of the doors is an important safety intervention. The term "sundown syndrome" refers to behaviors that become more pronounced in the evening. Clients with late stage dementia are prone to wandering, especially at night.

A 4-year-old child is referred to a mental health clinic for evaluation of hyperactivity and impulsive behaviors. At the first visit, nursing staff begin observing and assessing the child's behavior. Which developmental task should the child have achieved by this age?

-A sense of autonomy. -Satisfactory relationships with peers. -The ability to establish goals. -Separation from parents and the ability to socialize. Rationale: A 4-year-old child should have attained the developmental task of autonomy. According to Erikson's eight stages of development theory, the second stage is autonomy versus shame and doubt, which should occur between the ages of 1 and 1/2 to 3 years old. Unsuccessful resolution of the developmental task at this stage could lead to severe feelings of self-doubt and an internal independence/fear conflict.

When explaining "postpartum blues" to a client who is one day postpartum, which symptoms should the nurse include in the teaching plan?(Select all that apply)

-Mood swings -Tearfulness

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement theses actions? (Place the first action on top and the last on the bottom) Provide oxygen via mask reposition client call HCP Increase IV Fluids

-Reposition the client -Increase IV Fluids -provide oxygen via face mask -Call HCP To stabilize the fetus, intrauterine reconstitution is first priority, and to enhance fetal blood supply, the laboring client should be repositioned to replace the gravid uterus and to improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal circulating blood volume. Next, to optimize oxygenation of the circulatory blood volume, oxygen via face mask should be administered to mother. The HCP should provide other measures to relieve fetal stress.

A client is experiencing symptoms of alcohol withdrawal. During which interval is the client most likely to develop a seizure?

12 to 48 hours after the last drink. Rationale: The risk for seizures is highest 12 to 48 hours after the last drink.

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? A. Diabetes mellitus. B. Hypothyroidism. C. Parkinson's disease. D. Recurring pneumonia.

A According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilized by the cells, leading to increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke.

The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia? A. Sweating, trembling, tachycardia. B. Polyuria, polydipsia, polyphagia. C. Nausea, vomiting, anorexia. D. Fruity breath, tachypnea, chest pain.

A Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? A. Report the findings to the surgeon. B. Irrigate the indwelling urinary catheter. C. Apply manual pressure to the bladder. D. Increase the IV flow rate for 15 minutes.

A After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon.

Small bowel obstruction is a condition characterized by which finding? A. Severe fluid and electrolyte imbalances. B. Metabolic acidosis. C. Ribbon-like stools. D. Intermittent lower abdominal cramping.

A Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances.

The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? A. Teach the client techniques of intermittent self-catheterization. B. Decrease fluid intake to prevent over distention of the bladder. C. Use incontinence briefs to maintain hygiene with urinary dribbling. D. Explain that anticholinergic drugs will decrease muscle spasticity.

A Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization to prevent bladder distention.

A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? A. Serum creatinine. B. Blood Urea Nitrogen (BUN). C. Sedimentation rate. D. Urine specific gravity.

A Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration.

Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.

A Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B. Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand the abdomen and make both hands move outward.

A Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen.

Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)? A. Hoarseness. B. Dry mouth. C. Mouth ulcers. D. Weight loss.

A Dyspepsia (indigestion) and regurgitation are the main symptoms of gastroesophageal reflux disease (GERD); however, hoarseness is one of the most common long-term symptoms of GERD due to the irritation of the reflux of gastric secretions.

Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? A. Horizontal white banding. B. Diffuse blue discoloration. C. Diffuse brown discoloration. D. Thin, dark red vertical lines.

A Fingernails and toenails can be affected by chronic kidney disease. This condition may cause horizontal white lines or bands (leukonychia) to appear on the nails.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Lower left quadrant pain and a low-grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea.

A Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever.

The registered nurse (RN) assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis? A. pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L. B. pH 7.45 , pCO 2 37 mmHg, HCO 3 24 mEq/L. C. pH 7.34, pCO 2 36 mmHg, HCO 3 21 mEq/L. D. pH 7.46, pCO 2 35 mmHg, HCO 3 28 mEq/L.

A Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L represents a client with respiratory acidosis which is characterized by: low pH, pCO2 higher than normal, and HCO3 within normal limits.

An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse should further assess the client for which condition? A. Pulmonary embolism. B. Heart failure. C. Tuberculosis. D. Bronchitis.

A Post-surgical clients are at an increased risk for deep vein thrombosis (DVT), which may result in pulmonary embolism if the clot breaks off and travels to the lungs. Signs and symptoms of pulmonary embolism include chest pain, dyspnea, anxiety, restlessness, and - in severe cases - cyanosis.

Which description of pain is consistent with a diagnosis of rheumatoid arthritis? A. Joint pain is worse in the morning and involves symmetric joints. B. Joint pain is better in the morning and worsens throughout the day. C. Joint pain is consistent throughout the day and is relieved by pain medication. D. Joint pain is worse during the day and involves unilateral joints.

A Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? A. Cyanosis of the fingertips. B. Bradycardia and bradypnea. C. Presence of S3 and S4 heart sounds. D. 3+ pitting edema of the lower extremities.

A Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A. Prevention of deformities. B. Avoidance of joint trauma. C. Relief of joint inflammation. D. Improvement in joint strength.

A Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.

A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." B. "Alopecia is a common side effect you will experience during long-term steroid therapy." C. "Your hair will grow back completely after your course of chemotherapy is completed." D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss."

A The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A. He visits his diabetic brother who just had surgery to amputate an infected foot. B. He is provided with the most current information about the dangers of untreated diabetes. C. He comments on the community service announcements about preventing complications associated with diabetes. D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.

A The loss of a limb due to diabetes by a family member should be the strongest event or "cue to action" and is most likely to increase the client's perceived seriousness of the disease.

A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client? A. Assess neurovascular status. B. Change the client's position. C. Inspect the traction equipment. D. Review pain medication orders.

A The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority.

Which statement made by a client with chronic pancreatitis indicates that further education is needed? A. I will cut back on smoking cigarettes daily. B. I will avoid drinking caffeinated beverages. C. I will rest frequently and avoid vigorous exercise. D. I will eat a bland, low-fat, high-protein diet.

A To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinated beverages, resting frequently as needed, and eating a bland diet low fat and high in protein.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A. Jewish European ancestry. B. H. pylori bowel infection. C. Family history of irritable bowel syndrome. D. Age between 25 and 55 years.

A Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry.

The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? A. Potassium 6.0 mEq. B. Daily urine output of 400 ml. C. Peripheral neuropathy. D. Uremic fetor

A When assessing a client with chronic kidney disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority.

Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis?

Answer: Urine Osmolarity

A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.) A. Nausea and vomiting B. Loss of appetite C. Abdominal cramping D. Guarding with abdominal palpation E. Low urine output F. Cool, clammy skin

A, B, C, D The client is showing signs of peritonitis with a sudden spike in temperature. Low urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the health care provider must be notified immediately.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance.

A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. B. Tells the client to go to the quiet area of the unit. C. Is using a loud voice to talk to the client. D. Remains at a distance of 4 feet from the client.

A. Is attempting to physically restrain the patient.

A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client's acting out behavior.

A. Stay quietly with the patient

Which behaviors indicate that the treatment plan for a client in alcohol rehabilitation has been effective?

Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work. Rationale: The statement "one day at a time" reflects the Alcoholics Anonymous (AA) philosophy. AA promotes a 12-step program that has been successful in helping individuals who desire to stop drinking and abusing substances. Individuals learn about sobriety and responsibility through the support of other members.

A primary healthcare provider prescribes a low-sodium, high-potassium diet for client with Cushing Syndrome. Which explanation should the nurse provide to the client about the need to follow this diet?

Answer: "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

A client with GERD is being treated with dietary management. The client states, "I like to have a glass of juice everyday." Which juice will the nurse recommend?

Answer: Apple Juice

A woman who gave birth 48 hours ago is bottle feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

Apply cold compress to both breast for comfort

A newborn yellow abdomen and chest

Assess bilirubin level

The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client? A. Situational low self-esteem related to functional impairment and change in role function. B. Disabled family coping related to dissonant coping style of significant person. C. Interrupted family processes related to shift in health status of family member. D. Risk for ineffective therapeutic regimen management related to complexity of care.

B stroke affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing to the client's care. Her help is noted as being incongruent with attempts of self-care by the client thereby disabling family coping.

The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. The client has a carpal spasm when taking a blood pressure. C. On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7. D. The client states that she will continue to drink alcohol after going home.

B A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. The client begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.

B A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Dyspnea. B. Nocturia. C. Confusion. D. Stomatitis.

B As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contributes to nocturia.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Present knowledge related to the skill of injection. B. Intelligence and developmental level of the client. C. Willingness of the client to learn the injection sites. D. Financial resources available for the equipment.

C If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia

B Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias? A. The gram-negative infections occur in the lower lobe alveoli which are more sensitive to infection. B. Gram-negative organisms are more resistant to antibiotic therapy. C. Usually occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. Gram-negative pneumonias usually affect infants and small children.

B Gram-negative organisms are very resistant to drug therapy which makes recovery difficult. Antibiotic resistance has become a world-wide concern and the World Health Organization is keeping a very close surveillance on these occurrences.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia

B Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement? A. Give 20 mEq of potassium chloride. B. Initiate continuous cardiac monitoring. C. Arrange a consultation with the dietician. D. Teach about the side effects of diuretics.

B Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored.

Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate therapy? A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)

B Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished.

Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria

B Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake

B Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A. Myocardial infarction 2 months ago B. Anorexia and vomiting for the past 2 days C. Recently diagnosed type 2 diabetes mellitus D. Skeletal traction for a right hip fracture

B The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood count (CBC) but would not directly increase the BUN level.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.

B The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

A client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed.

B The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D.

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition.

B The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B.

A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? A. Bilateral lower leg stasis dermatitis. B. Clubbing of fingers and toes. C. Intermittent claudication. D. Peripheral cyanosis.

C Clients who suffer from chronic venous insufficiency often develop stasis dermatitis in the lower extremities. Stasis dermatitis appear as brownish-red discoloration on the lower extremities at the ankles which can develop into stasis ulcers due to the pooling of the venous blood flow back to the heart.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? A. Stay out of direct sunlight. B. Restrict intake of high protein foods. C. Schedule extra rest periods. D. Go to the emergency room immediately.

C Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. The client should be encouraged to schedule extra rest periods to help reduce the symptoms.

The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment? A. serum digoxin level is 1.5. B. blood pressure is 104/68. C. serum potassium level is 3. D. apical pulse is 68/min.

C Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L).

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years.

C Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results

C The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?· A. Administer morphine sulfate · B. Start IV fluids C. Place the infant in a knee-chest position. D. Provide 100% oxygen by face mask

C. Place the infant in a knee-chest position

The nurse is caring for a client before, during and immediately after surgery. Which type of care is provided to the client?

Care that supports homeostatic regulation

A client is admitted due to alcohol intoxication and injuries sustained in a fall. The client appears anxious, agitated, and diaphoretic. Vital signs include a pulse of 140 and a blood pressure of 170/98. Delirium is suspected due to the client's claim that bugs are crawling on the bed. Which medication should the nurse expect will be administered to the client?

Chlordiazepoxide (Librium). Rationale: The information provided indicates that the client is experiencing alcohol withdrawal, and is therefore at an increased risk for seizures. Chlordiazepoxide (Librium) raises the seizure threshold to reduce the risk of convulsions.

A client with obsessive-compulsive personality disorder is admitted for laparascopic surgery of the gallbladder. What is the nurse likely to observe in the client prior to surgery?

Client keeps detailed notes of everything that is said by the nurse about the procedure and the postoperative instructions. Rationale: OCD is characterized by an occupation with control. Patients are very perfectionistic and rigid in their behavior and thought patterns. Taking detailed notes of everything being said is an attempt to regain control in a stressful situation.

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 bpm. What action should the nurse implement next?

Complete a sterile vaginal exam. A vaginal exam should be preformed after the rupture of membranes to determine the presence of a prolapsed cord.

A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.

D A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid.

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? A. An increase in abdominal girth. B. Hypertension and a bounding pulse. C. Decreased bowel sounds. D. Difficulty in handwriting.

D A daily record in handwriting may provide evidence of progression of hepatic encephalopathy leading to coma.

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action should the nurse take first? A. Increase the ventilator VT to 850 mL. B. Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the FiO2 to 0.70 and redraw ABGs. D. Add 5 cm positive end-expiratory pressure (PEEP).

D Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding? A. Wearing dentures. B. Use of aspirin prior to admit. C. Prescribed nitroglycerin for chest pain. D. Takes digitalis.

D Although it is important to obtain a complete medication history, the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. Elderly persons are particularly susceptible to digitalis intoxication which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue.

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? A. Vasodilators and hormones. B. Analgesics and sedatives. C. Anticoagulants and expectorants. D. Bronchodilators and steroids.

D Besides supplemental oxygen, a client with acute respiratory distress syndrome (ARDS) needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids.

A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstruction

D CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does, dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of kidney disease.

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? A. Fluid and electrolyte balance. B. Prevention of water toxicity. C. Reduced glucose in the urine. D. Adequate cellular nourishment.

D Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose into the cell for energy, so the outcome statement should include stabilization of adequate cellular nutrition which is done by providing the insulin supplement the client needs.

The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement? A. Administer 30 minutes before eating. B. Evaluate the effectiveness 1 hour after administration. C. Instruct the client to swallow the tablet whole. D. Question the healthcare provider's prescription.

D Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse.

A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication.

D Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication.

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A. Urine specific gravity of 1.03 B. Frothy, tea-colored urine C. Clay-colored stools D. Elevated serum amylase and lipase levels

D Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B and C are expected findings related to jaundice.

A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration. Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? A. Warfarin B. Ibuprofen C. Nitroglycerin D. Digoxin

D Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms described.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A. Losing weight. B. Decreasing caffeine intake C. Avoiding large meals. D. Raising the head of the bed on blocks.

D Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non-pharmacological effective recommendation for a client experiencing severe gastroesophageal reflux during sleep.

A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale

D Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level.

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A. Avoid high carbohydrate foods. B. Decrease intake of fat soluble vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake.

D Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A. Vitamin K1, 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 mL/day D. Nembutal sodium at bedtime for rest

D Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

D Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain? A. Irritable bowel syndrome. B. Diverticulitis. C. Crohn's disease. D. Ulcerative colitis.

D The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration.

The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? A. Place a chair at a right angle to the bedside. B. Encourage deep breathing prior to standing. C. Help the client to sit and dangle legs on the side of the bed. D. Allow the client to sit with the bed in a high Fowler's position.

D The first step in assisting a client out of bed for the first time after surgery is to raise the head of the bed to a high Fowler's position, which allows venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall.

A client has a history of GERD. Why should the nurse monitor the client for clinical manifestation of heart disease?

Esophageal pain may imitate the symptoms of a heart attack

An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? A. Abdominal distention. B. Undue fatigue. C. Cyanosis of the lips. D. Confusion and tachycardia.

D The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch. Cyanosis is a very late sign.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia

D The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

The post-operative client states to the nurse, "I hate the feeling of those compression stockings as they inflate and deflate all the time. It keeps me awake." What is the nurse's best response? A. "They are for your own good." B. "Your health care provider ordered them. You have no choice but to wear them." C. "They are to help prevent blood clots. Do you want that to happen, do you?" D. "Tell me what you know about the intermittent compression stockings."

D The purpose of the intermittent compression stockings is to decrease the risk of blood clots forming in the legs. By assessing the client's knowledge about the devise, the nurse can determine if the client is aware of the potential for blood clots and the sequela that clots have. By answering "They are for your own good," the nurse dismisses the client's concerns. Having no choice about treatment does not acknowledge client autonomy. The "Do you want that to happen to you" is a statement using coercion by fear.

A female client with obsessive-compulsive disorder complains that she feels "driven" to check the locks on her front door. Which response is best for the nurse to provide? A. Have you had a bad experience related to unlocked doors? B. What are your thoughts when you are checking the locks? C. Feelings of being driven to do something are related to anxiety. D. Repeating the same behavior helps you diminish your anxiety.

D. Repeating the same behavior helps you to diminish your anxiety

An older client who is hospitalized with pneumonia becomes disoriented and confused 2 days after admission. Which factor should the registered nurse (RN) identify to differentiate that the client is experiencing delirium, not dementia? A. impaired memory B. clear awareness of surrounding C. unrelated to specific cause D. acute onset of symptoms

D. acute onset of symptoms Rationale: Delirium has an acute onset (D) characterized by a reduced level of consciousness, not (B), disturbed sleep-wake patterns, disorientation and perceptual problems, and is often associated with drug cumulative effects, a medical condition, or hospitalization, not (C). Dementia has a slow, insidious onset of symptoms, which include impaired memory (A) with loss of abstract thinking, judgment, language and motor skills and is often not reversible.

A HCP informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruption placentae. What findings should the nurse expect the client to demonstrate?

Dark, red vaginal bleeding. Increased uterine irritability. A rigid abdomen.

A nurse is planning to teach a school-aged child with newly diagnosed type 1 diabetes about self-care. After an assessment of what the child knows about diabetes, what is the next nursing intervention?

Developing a sequence of goals with the child and parents.

A client with long-term alcohol addiction is admitted to the emergency department. Which medications should the nurse anticipate the healthcare provider will prescribe for this client?

Diazepam. Multivitamins. Thiamine (vitamin B1). Rationale: Alcohol withdrawal delirium usually peaks 48-72 hours since last consumption of alcohol. The diazepam has sedative and anticonvulsant properties. Thiamine and multivitamins are usually given to help with nutritional and malabsorption deficiencies common in clients with alcohol addiction.

A newly admitted client diagnosed with schizophrenia who is physically healthy believes that they are in the process of dying and their body is actively decaying and falling apart. Which intervention for this client should the nurse implement?

Discuss what they are feeling and acknowledge their fear and anxiety. Rationale: The client's delusion of dying and their body decaying is their reality. The nurse should identify and focus on the client's feelings and discuss those and try to divert the client's preoccupation of the delusion.

The Total bilirubin of a 36-hour, breastfeeding newborn is 14mg/dL. Based on this finding, Which intervention should the nurse implement?

Encourage the mother to breastfeed frequently.

A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What is the primary long-term goal this nurse and client should agree on?

Maintaining normoglycemia

A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide?

Maternal blood pressure

A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration?

Metabolic acidosis

A client with an anxiety disorder is having trouble completing work because emails need to be reread several times before sending to ensure nothing inappropriate is written. Which disorder is this client most likely experiencing?

Obsessive-compulsive disorder (OCD). Rationale: client with OCD present with a combination of repetitive thoughts and specific fears (obsession), as well as stereotyped, ritualized behavior (compulsions) that are used to reduce that fear.

A client is undergoing treatment for schizophrenia. Which outcome provides evidence that the client's negative symptoms are improving?

Participates in music therapy and states that he enjoys playing the drums. Rationale: An inability to experience pleasure and a desire to remain isolated are examples of negative symptoms exhibited by clients with schizophrenia. By participating in therapy and expressing enjoyment, the client shows a decrease in negative symptoms and evidence that the treatment is being effective.

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention?

Performing postural drainage

A client with stage 2 Alzheimer's disease is being cared for at home by the spouse. The client's spouse tells the nurse about the emotional difficulties involved in providing fulltime care at home. Which self-care activity is most important for the nurse to recommend to the spouse?

Periodic times of respite from caregiving. Rationale: Caregiver role strain may be attributed to many different factors. The nurse must become familiar with this diagnosis in order to accurately assess the caregiver and offer effective interventions. One important recommendation is to have the caregiver incorporate periodic breaks as part of the daily routine to relieve stress. The nurse should contact the client's manager and provide the client's caregiver a list of agencies offering "Respite Care".

A mother reports feeding her infant immediately before arriving in the emergency department. After completing the assessment, the nurse reports which finding immediately to the primary healthcare provider because it likely indicated pyloric stenosis?

Peristaltic waves that transverse the epigastrium.

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?

Place the client in a slight Trendelenburg position. The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?

Postpartum blues During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.

The emergency department nurse is providing care for a rape victim. Which action represents an essential element of care for this client?

Providing nonjudgmental care. Rationale: The nurse's attitude can have an important therapeutic effect on the victim of rape. Displays of shock, horror, disgust, or disbelief can increase anxiety and shame. When providing care for a rape victim, it is essential to maintain a nonjudgemental attitude, and to let the client talk while listening attentively.

A client with schizophrenia suddenly becomes very anxious and says that an evil alien is trying to get him. What should the nurse do at this time?

Relocate the client to the assigned room and suggest doing a puzzle together. Rationale: the nurse should distract an anxious client with a non-threatening activity in a low stimuli environment. Solving a puzzle together in the client's room will help reduce anxiety.

The nurse is counseling a client who is dealing with complicated grief over the death of a spouse. Which statement reflects the most desirable outcome for the client?

The client will attend a surviving spousal support groups. Rationale: A major outcome of grief counseling is to assist the client in sharing their loss and to accept support from others. It is critical for the spouse to share the feelings of loss and grief in a supportive interpersonal environment. Complicated grief is a consistent state of sadness associated with a great loss. It is suspected that there may be a relationship between complicated grief and adjustment disorder. Most people go through the stages of grief at their own pace. Individuals dealing with complicated grief have difficulty progressing through the stages and it may take over a year or more to resolve their sense of lost.

Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis?

Urine osmolarity

risk factor for abruptio placentae

hypertension

A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?

obtain written consent for an emergency cesarean section