July 14: Therapeutic 85...Value: 28

The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?

"I will shave with an electric razor from now on."

The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?

"I will take my blood pressure before taking my medicine."

Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques?

"Why did you get so angry when she ignored you?"

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate?

Drawing a trough level just prior to administration of the vancomycin

The nurse is reinforcing information to a client in preparation for discharge from the hospital when the client breaks down crying, saying "the health care provider thinks I am crazy because I was diagnosed with a functional disorder." Which statement would be the best reply to this client?

"Functional disorder is a diagnosis for a genuine medical issue that medical science does not yet fully understand."

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse?

"Have you thought of hurting yourself?"

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse?

"Hearing this diagnosis must have been difficult for you. What are your thoughts?"

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the supervisory registered nurse?

"I am feeling unsteady when I walk."

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse?

"I can see that you are very upset. Let's talk about what happened."

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful?

"I can stay and sit with you if you would like."

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the best response by the nurse?

"I don't see you that way; you are making progress toward a healthy weight."

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse?

"I know you are frightened, but I do not see a man in your room."

The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?

"I need a healthy diet and regular exercise to combat weight gain."

A nurse has reinforced teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching?

"I should use ibuprofen for pain relief."

The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?

"I take cimetidine rather than omeprazole for heartburn."

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse?

"I will help you get ready; then we can walk to the dining room together."

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which client statement regarding digoxin toxicity indicates that teaching reinforcement is needed?

"I will need to increase my potassium intake."

A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse?

"I've noticed that you seem frustrated lately."

The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse respond initially?

"It is frustrating to wait so long, and I am sorry for the delay."

The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful?

"It is normal for your child to regress while hospitalized."

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse?

"It sounds like you are angry. Tell me what's bothering you."

A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?

"Let's go back to your room and look for your headband together."

The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?

"Night fears are common at this age. Look under the bed with your child."

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do." What is the best response by the nurse?

"Our social worker can discuss long-term care options with you."

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship?

"People with cancer experience fear of dying; tell me about your concerns."

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?

"Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications."

The client had surgery for possible cancer. The positive biopsy result is back in the medical record, but the client has not been told that the biopsy showed malignancy. The client asks the nurse, "Am I going to die?" What is the best way for the nurse to initially handle the situation?

"Share with me your thoughts and feelings about the situation."

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate?

"Tell me about how you feel about your surgery." "Tell me about how you feel about your surgery."

A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the best response by the nurse?

"Tell me how you felt when your fiancé broke up with you."

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse?

"Tell me how you think your life would be different if you moved from here."

A client with multiple co-morbidities, including chronic obstructive pulmonary disease, diabetes, and chronic kidney disease, has just been told by the health care provider of the need to start dialysis. The client is in tears and says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now this." Which is the best response by the nurse?

"Tell me more about what has been overwhelming for you."

An adolescent client is brought to the emergency department by the parents after being found in the bathroom making cuts on an arm with a razor blade. There are a few minor cuts in various stages of healing on the client's forearms. Which of the following is the most appropriate statement to make to this client's parents?

"The cuts on your child's arm are superficial; there is no immediate danger."

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond?

"These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again."

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse?

"This has been very overwhelming for you. What are you feeling right now?"

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse?

"What have you and your future spouse discussed about your condition?"

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.... I can get out of anything. There could be trouble now." Which of the following is the best response to this client?

"What kind of trouble are you thinking about?"

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse?

"You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the best response by the nurse?

"You could not have anticipated the rape. You did not deserve or ask for it."

The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse?

"Your child should be able to more easily complete school assignments and other tasks."

The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse?

"Your child will have to remain here for observation until we know more."

A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse?

"Your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?"

A nurse is reinforcing teaching to a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply.

- "Antibiotics can affect my INR value." - "I will take warfarin at the same time daily."

The nurse reinforces instructions to a client discharged on warfarin, after being treated for a pulmonary embolism following surgery. Which statements made by the client indicate the need for further teaching? Select all that apply.

- "I will place small rugs on my wood floors to cushion a fall." - "I will take a baby aspirin if I have mild chest pain."

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply.

- Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) - Client on newly prescribed lisinopril and is at 8 weeks gestation - Client on nitroglycerin patch for heart failure and blood pressure is 84/56 mm Hg

The nurse on the mental health unit is collaborating with the registered nurse to develop the care plan for a newly admitted client with a diagnosis of schizophrenia with persecutory delusions. Which interventions should the nurse expect to include with regard to the delusional thinking? Select all that apply.

- Focus on reality and verbally reinforce it - Focus on the client's feelings secondary to the delusions

The nurse reinforces teaching for the parents of a 6-year-old diagnosed with nocturnal enuresis. What instructions will the nurse include? Select all that apply.

-"Attach an enuresis alarm to your child's underwear." -"Prepare a calendar with your child for logging wet and dry nights." -"Wake your child at a specified time each night to void."

A 28-year-old client is admitted to the labor and delivery unit for severe preeclampsia. She is started on IV magnesium sulfate. Which signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply.

-0/4 patellar reflex -Respirations are 10/min

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.

-Accepting a birthday gift of a gold bracelet from a client -Soliciting a wealthy client to invest in a company -Staying after work hours and drinking wine with a client

The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply.

-Administer the medication with food if nausea or diarrhea develops -Complete the medication course even if the child is better -Shake the medicine well before use

The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? Select all that apply.

-Apical heart rate of 88/min -Elevation of mood -Improved energy levels

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse plan to take? Select all that apply.

-Bathe the infant and apply lotion and powder -Encourage the parents to hold the infant -Perform handprints and footprints

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply.

-Belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest -Soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply.

-Guide suppository along the rectal wall -Hold buttocks together firmly after insertion -Position client supine with knees and feet raised -Use gloved fifth finger for insertion

Which positions are correct when caring for clients undergoing therapeutic procedures? Select all that apply.

-High-Fowler's for a paracentesis in cirrhosis -Sims for soap-suds enema administration -Supine position after lumbar puncture

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.

-Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) -Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) -Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

Which of the following are examples of medical battery? Select all that apply.

-The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline -The nurse inserts a needed urinary catheter even though a competent client refuses it

A client with atrial fibrillation has just been placed on warfarin therapy. The nurse preceptor overhears the student nurse reinforcing teaching to the client about potential food-drug interactions. Which statement made by the student nurse requires the nurse preceptor to intervene?

. "You will not be able to eat green leafy vegetables while taking warfarin."

The health care provider prescribes a therapeutic heparin protocol for a client who weighs 198 lb and has a pulmonary embolus. The nurse initiates the infusion with 25,000 units of heparin in 500 mL dextrose 5% in water at 18 units/kg/hr. At what rate per hour does the nurse set the intravenous (IV) pump? Record your answer as a whole number. Answer: (mL/hr)

32 mL/hr

The nurse caring for a client reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate?

Document the exchange in the chart

What is the most therapeutic intervention that the nurse should complete when caring for a 10-month-old?

Allow the child to sit on the primary caregiver's lap while auscultating breath sounds

The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take?

Ask the child to blow up a balloon

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse?

Assess the child's level of pain using a numeric rating scale

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?

Asymmetrical chest expansion and decreased breath sounds on the left

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider?

Continue at the current dosage

One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 µmol/L). Which action by the health care provider does the nurse anticipate?

Decrease phenytoin daily dose

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?

Diarrhea, vomiting, and mild tremor

The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action?

Encourage the client to talk about the trauma

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the best nursing action?

Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break

A nurse is reviewing the laboratory values of a 3-year-old with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? Click on the exhibit button for additional information.

Glomerular injury

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?

Have an ophthalmologic examination every 6 months

The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments?

Height/weight and blood pressure

The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect?

Improved mental status

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse?

Initiate one-on-one supervision of the client during feedings

The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel?

Lower the temperature in the room to make the environment cooler

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

Partial thromboplastin time of 110 seconds

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client?

Report excessive urination and increased thirst

The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect?

Respirations of 24/min

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most?

Seizure activity

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action?

Serve the client half of the meal initially and offer the other half later

A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to this client about which possible side effect?

Sexual dysfunction

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication?

Stop the feeding for 1 to 2 hours

A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response?

Suggest that the mother change the diaper as the nurse watches

A client recently diagnosed with heart failure is being discharged on the angiotensin-converting enzyme inhibitor lisinopril. Which information related to this new medication is important for the nurse to reinforce at discharge?

Teach client to rise slowly and sit on side of bed for several minutes before rising

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response?

The response devalues the client's feelings and gives false reassurance

A client with stable chronic obstructive pulmonary disease (COPD) has been prescribed extended-release oral theophylline for the past 2 years. The nurse reviews the serum laboratory results. Which value would the nurse report to the health care provider immediately?

Theophylline level 23.6 mcg/mL

The nurse helps the health care provider perform a thoracentesis at the bedside. In which of the following positions does the nurse place the client to facilitate needle insertion and promote comfort?

Upright leaning forward over the bedside table, with arms supported on pillows

A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question? Click on the exhibit button for additional information. Laboratory results Activated partial thromboplastin time (aPTT) 53 sec International normalized ratio (INR) 2.3 Medication administration record Allergies: None Medications Time Epoetin: 3,500 units subcutaneously, M-W-F 0800 Vitamin K: 10 mg subcutaneously, today 0800 Sodium polystyrene sulfonate: 15 g orally, today only 0800 Warfarin: 5 mg orally, daily 2000

Vitamin K