NCLEX 1

"No, it isn't necessary because you aren't sexually active." Explanation: A 16-year-old girl who isn't sexually active doesn't need a Pap test. When a girl is sexually active or reaches age 18, she should have a Pap test.

A nurse is caring for a 16-year-old girl who isn't sexually active. The girl asks if she needs a Papanicolaou (Pap) test. How should the nurse respond?

providing education about documenting blood pressure readings Explanation: Implementation involves providing actual nursing care. Education is an intervention that occurs during the implementation phase. Goal setting and formulation of nursing diagnosis do not occur during the implementation phase of the nursing process.

A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process?

When the fetus is in the cephalic position (head down), fetal heart tones are best auscultated midway between the symphysis pubis and the umbilicus. When the fetus is in the breech position, fetal heart tones are best heard at or above the level of the umbilicus.

A nurse is caring for a client who is at 32 weeks of gestation and performs Leopold's maneuvers to confirm that the fetus is in the cephalic position. To identify fetal heart tones, identify where the nurse should place the Doppler transducer.

100 units of regular insulin in normal saline solution Explanation: Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of [800 mg/dl (44.4 mmol/L)]. Which solution is the most appropriate at the beginning of therapy?

application of powder to the skin under the cast Explanation: Powder should not be applied to the skin beneath the cast because powder can cause irritation and skin breakdown. The mother would need further teaching about avoiding this measure. Checking the smoothness of the cast edges, covering the cast around the perineum, and inspecting inside the cast are all appropriate actions for the child with a spica cast to help prevent skin breakdown.

After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching?

a low priority Explanation: In a situation when disaster triage is needed, the clients with the highest mortality rate are not given life-saving treatments. Care for the most clients where supplies can be used and staff can be used. The other choices are not correct.

In a disaster situation in the emergency department, the nurse is assessing a client who is critically ill, with a high likelihood of mortality. Which triage level would be appropriate?

"The client was catheterized, and 1,100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory." Explanation: A report about the client's condition should be as clear, pertinent, and concise as possible. It should be free of subjective information that could be interpreted differently by different caregivers. The report mentioning that a specimen was sent to the laboratory does not indicate how much urine had been drained from the client's bladder and how the urine appeared. The report describing the client as cooperative is subjective and provides only limited client data. The report that mentions that the client was in the emergency department for 3 hours does not mention the treatment provided.

The client with benign prostatic hypertrophy is being transferred from the emergency department to a surgery unit. Which information should be included in the report from the nurse in the emergency department to the nurse responsible for admitting the client?

"This drug has been found to decrease metastatic breast cancer." Explanation: Tamoxifen is an antiestrogen drug that has been found to be effective against metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.

The client with breast cancer is prescribed tamoxifen 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. What should the nurse tell the client?

providing a low-calorie diet Explanation: Because a client with a fever has an increased basal metabolism rate, the client needs additional calories in their diet, not fewer calories. Monitoring the client's temperature, increasing their fluid intake, and covering the client with a light blanket are therapeutic interventions for a fever.

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)?

banana dried fruit orange juice Explanation: Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake and peppers are low in potassium.

A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply.

need for a feeding tube Explanation: As muscular dystrophy progresses, the client becomes more susceptible to aspiration due to progressive decreasing ability to clear secretions and muscle weakness. A feeding tube will prevent problems with dysphagia resulting in aspiration. Avoiding crowds and hand hygiene might be a part of the overall teaching but are not a priority. All clients should be instructed regarding the need for an advance directive.

A 17-year-old adolescent with a history of muscular dystrophy is admitted with aspiration pneumonia. The client's medical history reveals that this is the third time in the past 6 months that the client has been diagnosed with pneumonia. Which topics should the nurse plan to address for teaching?

a high-backed chair with armrests Explanation: A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate.

The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend?

Normally, there is enough pressure around the lower esophageal sphincter (LES) to close it. Reflux occurs when LES pressure is deficient or when pressure in the stomach exceeds LES pressure.

A nurse is reviewing the causes of gastroesophageal reflux disease (GERD) with a client. What area of the GI tract causes the reduced pressure associated with GERD?

establishing a patent intravenous site Explanation: Tetany, because of decreased levels of calcium, indicates a rapidly worsening condition and should be immediately treated. The priority is establishing that there is a patent I.V. line in case emergency medications need to be ordered. Seizure precautions, including padding side rails and suctioning equipment, should be provided. Vital signs should be obtained but are not the priority.

A client is exhibiting manifestations of tetany. Which nursing intervention is a priority?

sigmoidoscopy Explanation: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

15 seconds Explanation: Suctioning the respiratory tract for prolonged periods depletes the client's oxygen supply and causes hypoxia. It is recommended that each suctioning period not exceed 15 seconds.

When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds?

"My medicine isn't for the everyday stress of life." Explanation: The statement, "My medicine isn't for the everyday stress of life," indicates an accurate understanding of the nurse's teaching about the use of lorazepam. Antianxiety agents like the benzodiazepines are used to treat anxiety that is unmanageable by other means and beyond the client's ability to cope. For the drug to be effective, it must be taken as prescribed. Lorazepam can cause physical and psychological dependence. Tolerance can occur, and doubling the dose of lorazepam may increase the risk of tolerance. Lorazepam is a central nervous system depressant. When it is taken in combination with alcohol, the depressant effect increases, posing a danger to the client.

The nurse teaches the client with anxiety about the appropriate use of lorazepam. Which statement indicates that the client understands the nurse's teaching?

lactated Ringer's solution Explanation: Lactated Ringer's solution is recommended because it replaces the lost sodium and corrects the metabolic acidosis. If albumin is ordered, it's an adjunct therapy and not for primary fluid replacement. The stress from a burn injury affects the glucose metabolism. Dextrose shouldn't be given during the first 24 hours because it can put the client into pseudodiabetes. The client is hyperkalemic from the potassium shift from the intracellular spaces to the plasma, and additional potassium would be detrimental.

A team of nurses is preparing a trauma room for the arrival of a child with partial-thickness burns to both lower extremities and portions of the trunk. Which intravenous fluid should the nurse be prepared to administer to this client?

providing a variety of resources to help the parents quit smoking Explanation: Smoking is a main allergen that can initiate the inflammatory response in children with bronchial asthma. Few children with bronchial asthma will remain asymptomatic for the remainder of their lives. As many as one in two children who had childhood asthma and who are asymptomatic at 18 years of age are likely to have recurrent, symptomatic disease by age 26 years. Asthma usually persists as a low-grade, subclinical condition. Asthmatic episodes may be life threatening in all age groups.

A young child with a history of bronchial asthma is brought to the emergency department for the second time in a month with symptoms of audible expiratory wheezing and intercostal retractions. The parents voice frustration about repeated hospital visits. What information is most important for the nurse to address with the parents?

passage of flatus from the colostomy Explanation: A sign indicating that a client's colostomy is ready to function is the passage of flatus. The nurse will auscultate for the presence of bowel sounds. When this occurs, gastric suction is discontinued, and the client is started on fluids and food orally.Neither gastric drainage nor a decrease in nausea and vomiting is a criterion for determining whether or not the gastric suction should be discontinued.A soft, flat abdomen is an indication that abdominal distention has not developed. It is not an indicator for removal of the NG tube.

The client with an abdominal perineal resection and colostomy had a nasogastric (NG) tube inserted during surgery. The NG tube will most likely be removed when the client demonstrates:

"What is it that concerns you about having the school know about your daughter's condition?" Explanation: The nurse's first response should be to obtain more information about the mother's concerns. The nurse can then facilitate a dialogue that will help the mother weigh her concerns against the potential risks to the child's safety. It is true that the nurse would not discuss a client's medical condition with a school without permission, but this statement does facilitate discussion. It is also true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school. Dictating to the mother does not explain any rationale for the necessity of sharing the information.

The parent of a school-age client with diabetes tells the nurse that she does not want the school to know about her daughter's condition. Which is the nurse's best response?

60 to 100 mg/dl (3.3 to 5.6 mmol/L) before meals and bedtime snacks Explanation: The goal is to maintain blood plasma glucose levels at 70 to 100 mg/dL (3.5 to 5.6 mmol/L) before meals and bedtime snacks. Below 60 mg/dL (5.6 mmol/L) indicates hypoglycemia. A range of 110 to 140 mg/dL (6.2 to 7.8 mmol/L) suggests hyperglycemia. The target range 1 hour after meals is 100 to 120 mg/dL (5.6 to 6.7 mmol/L).

When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, the nurse would expect to include which desired target range for blood glucose levels?

shifting weight from side to side arm push-ups Explanation: The paraplegic client would have a loss of movement with the lower extremities and would be dependent on a wheelchair for mobility. For pressure relief with sitting in a wheelchair for long periods, the client should be encouraged to move side to side to shift pressure; push-ups, which involve pushing down on the armrests and lifting the buttocks off the seat; and shifting, with the client bending forward with the head down toward the knees and shifting in the chair. Arm curls and shoulder shrugs would help with the upper extremities, but there is no indication this client has strength or mobility issues with the arms.

The nurse is working in a rehabilitation facility with a paraplegic client who generally spends the day out of bed in a wheelchair. Which exercises will the nurse help the client perform to reduce the risk of skin breakdown? Select all that apply

restart the metoprolol. Explanation: The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta blocker. The beta blocker should be restarted due to the tachycardia, history of hypertension, and the desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated since the client's urine output and blood pressure are satisfactory and there is no indication of bleeding. The nurse should also determine the potassium level before starting the furosemide.

A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline, metoprolol, and furosemide. On postoperative day 1, the 1200 vital signs are: temperature 98.9° F (37.2° C); heart rate 132 bpm; respiratory rate 20 breaths/min; blood pressure 126/78 mm hg. Urine output is 50 to 70 mL/h. The hemoglobin and the hematocrit are stable. The medications have not been prescribed for administration after surgery. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse contacts the health care provider (HCP) and recommends to:

Contact the prescriber for clarification. Explanation: There are many problems with this medication prescription. The abbreviation QOD is ambiguous and open to various interpretations. The abbreviation D/C may be interpreted as "discontinue" or "discharge." The prescriber should have specifically stated when to start the lower dose because the nurse could reason beginning the medication that day, the next, or even the day after that. The only safe thing to do is call for clarification.

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome (see exhibit). What action should the nurse take?

occupational therapist Explanation: Occupational therapists can help evaluate sensory processing issues and fine motor difficulties. Many occupational therapists are also trained in coping strategies to help individuals feel more comfortable in their surroundings. Physical therapists primarily work on gross motor skills, often working closely with occupational therapy to develop effective exercise programs for autistic clients. A mental health provider will help the child and family manage emotional and mental health concerns. Speech language pathologists evaluate communication deficits and assist clients in developing functional communication skills.

The parent of an autistic child visits the clinic and tells the nurse that her child has been acting out in school, particularly in the cafeteria and during gym class. Understanding that the child may be having difficulty with sensory processing, the nurse should suggest that the health care provider refer the child to which professional?

hyperactivity and twitching Explanation: A neonate with cold stress must produce heat through increased metabolism, causing oxygen use to increase and glycogen stores to be quickly depleted leading to hypoglycemia. Hyperactivity and twitching are signs of hypoglycemia.Yellowish undercast to the skin color suggests jaundice related to excessive bilirubin levels, not cold stress.Increased abdominal girth suggests abdominal distention, possibly indicating necrotizing enterocolitis. It is unrelated to cold stress or possible hypoglycemia.Increased, not slowed, respirations are associated with neonatal cold stress and hypoglycemia.

What conditions would the nurse expect to find in in a preterm neonate suffering from cold stress?

chocolate smoked meats yogurt Explanation: When taking phenelzine, the client should not consume foods and beverages containing tyramine or tryptophan, or drugs containing pressor agents. Tyramine-containing foods/fluids include aged cheeses, tofu, beer, and smoked meats. Tryptophan-containing foods include chocolate, cottage cheese, milk, and yogurt. Strawberries and pasta are safe for this client to consume.

Which foods should the nurse teach the client not to consume when taking phenelzine? Select all that apply.

adequate nutrition Explanation: The client who has oral ulcerations related to the adverse effects of radiation is at risk for impaired nutrition. Adequate nutrition is important for healing of the ulcerations and therefore is the most important goal of those listed. The need for food and water is highest on Maslow's hierarchy, followed by the need for comfort (pain), anxiety, and self-esteem.

A client receiving radiation to the head and neck area as treatment for laryngeal cancer develops ulcerations and bleeding of the oral mucosa. What should the nurse consider as the primary goal for this client?

airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

A client with severe shortness of breath comes to the emergency department. The client tells the emergency department staff that they recently traveled to China for business. Based on the client's travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. Explanation: Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

Following a client's total hip replacement, what should the nurse do? Select all that apply.

inner-city areas Explanation: Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence.

In which areas of the United States and Canada is the incidence of tuberculosis highest?

broiled chicken, green beans, and cottage cheese Explanation: Carbohydrates are the first substance used by the body for energy. Proteins are needed to maintain muscle mass, repair tissue, and maintain osmotic pressure in the vascular system. Fats, in a small amount, are needed for energy production. Chicken, green beans, and cottage cheese are the best selection to provide a nutritionally well-balanced diet of carbohydrate, protein, and a small amount of fat. Cereal with milk and strawberries as well as toast, gelatin dessert, and cookies have a large amount of carbohydrates and not enough protein. Steak and french fries provide some carbohydrates and a good deal of protein; however, they also provide a large amount of fat.

The client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat?

cooked dry beans peanut butter yogurt Explanation: Yogurt, dry beans, and peanut butter all contain protein in amounts that make them good sources of protein for the child. Potatoes and apples are carbohydrates and do not provide a sufficient source of protein.

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply.

reduces compulsions to drink. Explanation: The mechanism of action of naltrexone isn't fully understood. The drug blocks opiate receptors and is believed to help diminish the compulsion to drink. Naltrexone doesn't prevent withdrawal symptoms, treat peripheral neuropathy, or manage symptoms of anxiety.

A client is being given naltrexone as part of an alcohol treatment program. When the client asks the nurse to explain the intended effects of the drug, the nurse should state that the drug:

enteric precautions must be continued. Explanation: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that

The pH of the aspirated fluid is measured. Explanation: Measuring the pH of the aspirated gastric fluid is the most accurate determination of the placement of the NG tube. A pH lower than 4 indicates that the tube is in the stomach. Whether or not the client is gagging or coughing is not an accurate way to determine if the tube is placed correctly. No fluids should be inserted into the tube until the placement has been determined. Inserting air into the tube and listening for the resulting whoosh can be used, but this is not as accurate as pH measurement.

After a nasogastric (NG) tube has been inserted, which finding helps the nurse determine that the tube is in the proper place?

glucocorticoids and androgens Explanation: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine.

The adrenal cortex is responsible for producing which substances?

postural or orthostatic hypotension Explanation: After the administration of certain antihypertensives or narcotics, the client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when assuming an upright position. Postural or orthostatic hypotension may then occur, causing a temporarily decreased blood supply to the brain. The client received analgesia, so pain should be controlled and the client's blood pressure should be within normal range or slightly lower. Pain should not be acute.

The nurse is aware that a client receiving morphine sulfate intravenously post-surgical repair of a hip fracture may exhibit which outcome when getting out of bed for the first time?

Ask about sleeping difficulties. Explanation: Clients taking paroxetine may experience insomnia and abnormal dreams. Clients do not tend to experience thyroid dysfunction when taking paroxetine. Paroxetine does not adversely affect the heart. Peripheral edema is not a known side effect of paroxetine.

The nurse is caring for a client who is receiving paroxetine for a major depressive disorder. What is the nurse's most important intervention?

Use a bed cradle to avoid the weight of bed linens on joints. Explanation: For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, which are not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.

Which action should the nurse perform to help alleviate a child's joint pain associated with rheumatic fever?

presence of fatigue and weakness Explanation: A hemoglobin of 10.2 is low; however the hematocrit is normal. RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Although chronic renal failure can cause fluid volume overload, the normal hematocrit level does not indicate fluid volume overload. Dyspnea and cyanosis is associated with fluid excess, not anemia. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, are not signs of anemia.

A client with chronic renal failure (CRF) has a hemoglobin of 10.2 g/dl and hematocrit of 40%. Which choice would be a primary assessment?

parental reaction Explanation: Parents typically show a strong negative response to this deformity. They may mourn the loss of a perfect child. Helping the parents cope with their child's condition is a priority. Feeding can be challenging, and can result briefly in reduced fluid intake, but inadequate urinary output is unlikely to occur. Surgical repair is usually delayed until the child is 6 to 12 weeks of age. This deformity is not painful.

The nurse is planning care for a neonate with a cleft lip and palate. What is the nurse's priority action?

performing active range-of-motion exercises of the legs Explanation: Active range-of-motion exercises involve moving the client's joints through their full range of motion; they require some muscle strength and endurance. The client should have received passive range-of-motion exercises because admission to maintain joint flexibility and should have been taught isometric exercises to build strength and endurance for transfers and ambulation. Walking to the bathroom would be unsafe without the ability to first dangle the legs over the bedside and transfer from bed to chair.

A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation above, which procedures would the nurse implement next?

fingers on the left hand are swollen and cool Explanation: Swollen and cool fingers on the left hand are the most significant assessment findings. They represent altered circulation to the hand caused by the cast. A normal radial, not popliteal, pulse should be present in the left arm; the popliteal pulse is found on the leg. Skin irritation is an abnormal assessment finding but it isn't as significant as altered circulation. Minimal pain in the left arm is expected.

A nurse is caring for a client with a cast on their left arm after sustaining a fracture. Which assessment finding is most significant for this client?

Condoms should be stored in a cool, dry place to prevent damage. Leave a 1/2-inch space at the end of the condom. Never reuse a condom. The condom should be applied on an erect penis. Explanation: Condoms can be a reliable method of birth control offered with proper instruction. Condoms should be stored in a cool, dry place to prevent heat damage. A 1/2-inch space should be left at the tip of the condom to allow for collection of the ejaculate and to prevent tearing of the condom. A condom is applied after the penis is erect before insertion into the vagina. A condom should not be reused.

A 17-year-old client confides in the school nurse an interest in understanding safe sex practices. In instructing the client on how to correctly use a condom, which information would be stressed? Select all that apply.

Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation. Explanation: In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing an increased heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and antidiuretic hormone, causing sodium and water retention and arterial vasoconstriction.

A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?

an occurrence of the excess loss of fluid associated with osmotic diuresis Explanation: Due to the DKA and fluid shift, the client would present with the 3 Ps: polyuria, polyphagia, and polydipsia. Fatigue and weakness may be caused by muscle wasting from the catabolic state of insulin deficiency. The other choices are part of the problem but not the main manifestation of the disease process.

A client with diabetic ketoacidosis (DKA) has asked the unlicensed nursing assistant for another pitcher of water. It is the third such request over the past 4 hours. The nurse would recognize this request as which manifestation?

"Someone should supervise the client at all times." Explanation: The caregiver stating that someone should supervise the client at all times demonstrates effective teaching. Alzheimer's disease causes progressive psychological and physiological deterioration; someone needs to be in attendance at all times to ensure the client's safety. Allowing the client to do as much as possible and posting signs to orient the client to the surroundings are important strategies that help to provide optimal independence and create familiarity in the environment, but they don't specifically contribute to personal safety. Although ensuring that the client remains seated and holds onto safety bars while showering provides a measure of safety, the client shouldn't be allowed to shower without supervision.

A client with moderate Alzheimer's-related dementia is being prepared for discharge. What statement by the caregiver demonstrates that discharge teaching about client safety has been effective?

small, waxy nodule with pearly borders Explanation: A small waxy nodule with pearly borders may indicate a basal cell carcinoma. This finding requires further investigation and treatment. Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal age-related changes to skin.

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

"I must refrain from eating aged cheese or yeast products." Explanation: Cheese and yeast products contain tyramine, which the client should avoid to prevent a negative interaction with tranylcypromine, a monoamine oxidase (MAO) inhibitor. Sodium will not interact with tranylcypromine, and neither exercise nor sugar needs to be limited.

After a period of unsuccessful treatment with amitriptyline, a woman diagnosed with depression is switched to tranylcypromine. Which statement by the client indicates the client understands the side effects of tranylcypromine?

decreased cardiac output related to reduced myocardial contractility Explanation: Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although excess fluid volume, ineffective coping, and anxiety are important nursing diagnoses, the nurse can address them when the client has improved cardiac output and myocardial contractility.

The nurse is caring for a client with cardiomyopathy. Which diagnosis should the nurse make a priority to guide this client's care?

The student nurse irrigates the NG tube through the blue air vent port. Explanation: The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure?

elevating the head of the bed to 30 degrees Explanation: Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies

The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client?

It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, the intravenous piggyback would be initiated; the wound dressing could be changed while the IV is infusing. A client on a toileting schedule would be taken to the restroom as the last priority; this task that could also be delegated.

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours?

"When riding my bicycle, I will wear my helmet." "Hiking with my family is great exercise." "Soccer would not work with my health condition." Explanation: Swimming, hiking, and bicycle riding are all good choices for a child with hemophilia. The child should always wear a helmet while cycling. A child with hemophilia should avoid contact sports like football and soccer, even with protective equipment.

The school nurse is discussing sport and activity options with the family of a 13-year-old child with hemophilia. What statements by the child indicate that the education has been effective? Select all that apply.

The client will wear a dampened mask if dust is a problem The client reports no symptoms of peripheral tingling The client controls outdoor precipitating factors Explanation: Wearing a dampened mask if there is a dust problem, reporting no symptoms of peripheral tingling, and controlling outdoor precipitating factors are all expected client outcomes that would be included in a plan of care. Lungs should be absent of crackles or rhonchi. Cachexia is seen in clients with a chronic illness, such as AIDS, chronic obstructive pulmonary disease, or heart failure.

What are expected client outcomes the nurse would include in a plan of care for a client with allergic rhinitis? Select all that apply.

tactile agnosia. Explanation: The nurse should expect to find tactile agnosia (inability to identify objects by touch), a sign of a parietal lobe tumor. Short-term memory impairment occurs with a frontal lobe tumor. Seizures may result from a tumor of the frontal, temporal, or occipital lobe. Contralateral homonymous hemianopia suggests an occipital lobe tumor.

When caring for a client diagnosed with a brain tumor of the parietal lobe, the nurse expects to find

Avoid sunburn during the summer. Wear extra socks in the winter. Wear clean, loose, soft cotton socks. Explanation: A client with peripheral arterial occlusive disease is at high risk for injury. Thus, the client should be able to recognize the signs of potential thermal dangers to prevent skin breakdown. The individual should be instructed to wear clean, loose, soft cotton socks so that the feet are comfortable, air is allowed to circulate, and moisture is absorbed. In the winter or if the client has "cold feet," the client should be encouraged to wear an extra pair of socks and a larger shoe size. Getting a sunburn during the summer puts the client at risk for tissue injury and skin breakdown.Use of an electrical heating pad for warming places the client at risk for thermal injury and thus needs to be avoided.The client should be encouraged to walk to increase circulation. Walking distance should be increased incrementally.

Which instructions should the nurse give to a client with peripheral arterial occlusive disease? Select all that apply.

beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk Explanation: Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients.

Which meal would be appropriate for the child with osteomyelitis to choose?

respiratory depression Explanation: The client who has received general anesthesia with neuromuscular blocking agents must be carefully monitored when given clindamycin. A serious interaction could be enhanced, neuromuscular blockage, skeletal muscle weakness, or respiratory depression, if this combination is used during or immediately after surgery. Concurrent use should be avoided. The combined effect of the medications places the client at increased risk, and the nurse should assess the client closely for respiratory depression or paralysis. The nurse will be monitoring the client's heart rate, blood pressure, and urinary output but not specifically because of potential drug interactions and adverse effects of clindamycin.

Which sign should the nurse closely assess in a client who is reversing from general anesthesia and receiving clindamycin?

"There is a Certificate of Confidentiality which was issued; therefore, no information can be released." Explanation: The nurse can best respond by stating that a Certificate of Confidentiality was issued. This certificate protects researchers and institutions from disclosing information that identifies research subjects. The Certificate of Confidentiality helps the researcher promote client participation by guaranteeing confidentiality while the client is enrolled in the study. Providing information, asking the client's permission to release information, and asking the client to contact the naturopath does not ensure client confidentiality, which is guaranteed when a client enters a research study.

A client was recently enrolled in a clinical trial for lung cancer treatment. The client's naturopathic therapist contacts the nurse who is caring for the client and inquires about the client's status, treatment regimen, and possible adverse effects of the medication the client is taking. How can the nurse best respond?

Align self to prevent personal injury. Prepare the client to be in normal anatomical alignment. Keep the client in anatomical alignment during the move. Use large muscle groups to prevent sore muscles and joints. Explanation: The principles of body mechanics should be used when repositioning a client to prevent personal injury and prevent sore muscles and joints by using large muscle groups. These principles are also used to ensure that the client is in normal anatomical alignment before, during, and after the move. Raising the head of the bed would cause the client slide further down in the bed.

A client who is bedridden has slid down in the bed. Which principle of body mechanics should the nurse use when repositioning the client? Select all that apply.

Judaism Explanation: In Judaism, the Psalms and the last prayer of confession are said at the dying person's bedside. At death, the person's arms are not crossed; any clothing or bandages with the client's blood would be prepared for burial with the person. It is important that the whole person be buried together. Hinduism, Buddhism, and Islam do not follow these rituals.

A nurse cares for a terminally ill client. Family members have requested that at the time of the client's death, the client's arms not be crossed and that any clothing or bandages with the client's blood be prepared for burial with the person. The nurse recognizes that this family follows the rituals of which religion?

notify the physician about cloudy or foul-smelling urine. Explanation: The nurse should instruct the client to report the presence of foul-smelling or cloudy urine to the physician. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy.

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

iron-fortified infant formula. Explanation: For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of

Avoid criticizing the child, especially in front of other staff or visitors. Explanation: A 6-year-old child has a sense of inferiority and a precarious sense of self that can cause overreaction to criticism. Criticizing the child in front of others could jeopardize the child's trust in the nurse. By age 6, children can make noncritical choices about their care, so while the nurse does not have to defer to the parents for all decisions, giving the child control over interventions is too much responsibility. Privacy when interacting with peers is not appropriate at this age, because the child still requires supervision.

The nurse is working with a 6-year-old child on a hospital unit. What approach by the nurse is most appropriate given the child's developmental stage related to sense of self?

when the client resumes ambulating Explanation: A cesarean birth is an independent risk factor for thromboembolic event in pregnant women. Inflatable compression sleeves should be placed on the lower extremities of a client until risk of venous stasis is reduced through ambulation. While return of sensation must happen before the client can safely ambulate, this finding alone does not significantly decrease the risk of venous stasis. Platelets continue to be significantly elevated for at least 3 weeks after birth, which is well after a client would be discharged. It is unnecessary to continue wearing the compression sleeves after ambulation has returned.

The nurse places inflatable compression sleeves on the legs of a client undergoing a cesarean birth under regional anesthetic. When does the nurse tell the client that the sleeves will be removed?

Straighten the client's pillow behind the back. Explanation: The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his or her name and checking the armband, so that the medication can be administered.

The nurse walks into a client's room to administer the 0900 medications and notices that the client is in an awkward position in bed. What should the nurse do first?

"Your child needs all of the medicine so that the infection clears." Explanation: Commonly, when a child appears better, the parents stop the medication. Unfortunately, the infection remains. Therefore, the nurse needs to explain that all of the medication must be administered to clear up the infection. Explaining why the medicine should be continued is more helpful to parents than saying it needs to be given. Telling the parent that stopping the medication will make the next ear infection harder to treat does not focus on the present issue.

The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that he has stopped the medicine since the child is better and is saving the rest of the medication to use the next time the child gets sick. What should the nurse tell the parent?

pneumonitis Explanation: Chemical pneumonitis is the most common complication of ingestion of hydrocarbons, such as in kerosene. The pneumonitis is caused by irritation from the hydrocarbons aspirated into the lungs. Uremia is the result of renal insufficiency, which causes nitrogenous waste products to build up in the blood rather than being excreted. Hepatitis is caused by a viral infection. Carditis in a preschooler may be the result of rheumatic fever.

While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which complication?

Obtain another pump from central supply. Explanation: Because safety is imperative for both the nurse and the client, the nurse should obtain another pump from central supply. Using the pump as is could lead to electric shock. The nurse should never use damaged equipment, even after performing a temporary repair. The nurse should pull the pump out of service by labelling it as damaged equipment as directed by facility policy and by reporting it to the appropriate department for repair, but this should be done after the client's treatment needs are addressed.

While preparing to start a stat I.V. infusion, a nurse notices a broken ground wire on the infusion pump's plug. What would the nurse do first?

acetaminophen 500mg Explanation: The nurse should question an order to administer acetaminophen by intraosseous infusion because the drug can only be administered orally or rectally. Any medication that can be administered via I.V. can be administered by intraosseous infusion. Therefore, sodium bicarbonate, dopamine, and calcium chloride can all be administered by way of intraosseous infusion.

A nurse is caring for a client with an intraosseous infusion. Which order should the nurse question?

washing hands before/upon entering room Explanation: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation does not significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. The client does not need to wear a mask when in their room. Instead of limiting the number of visitors to the client, the nurse should keep persons with known infections out of the client's room.

A school-age child is admitted to the medical facility with a diagnosis of acute lymphocytic leukemia (ALL). Which nursing interventions are most appropriate?

Ask the client to sit for a few minutes to discuss missing the afternoon session. Explanation: The client is demonstrating a behavior that should be further assessed. The nurse should take the time to assess the client's thoughts, feelings, and behaviors. While the client may truly just need the rest, the client may be upset, or employing a pattern of behavior that is part of the problem. Regardless, the nurse should investigate this and also assess for safety. Asking a closed question, such as "Are you angry?" would not assist this assessment, nor would it be therapeutic to focus on rules of the program or the client's interest or enjoyment of the food.

A client with a history of suicidal thoughts and depression has just attended an outpatient day therapy group session. The nurse hears from the client that they plan to forgo lunch and the afternoon session, stating, "I just need to go home and have a nap." What would be the day therapy nurse's best response?

Clean both sites independently. Explanation: The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. What information should the nurse give the spouse about cleaning the wound?

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. Explanation: The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?

transurethral resection of the prostate (TURP) Explanation: TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for clients with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; each requires an incision.

A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal?

"It is not a procedure you should do at home." Explanation: Clients who need ear irrigations should not perform these at home. The procedure is one that should be performed by a healthcare professional only due to the risk of damage to the ear if performed incorrectly. Supplies are not routinely furnished by the hospital, and could be obtained from a medical supply company; however, this is not relevant because the client should not irrigate the ear.

A client with cerumen impaction presents to the emergency department. The client asks about supplies to perform ear irrigations at home. What is the nurse's best response?

Invite the client to play a game of ping-pong with the nurse. Explanation: The nurse should invite the client who is anxious to participate in an activity that involves gross motor movements. Doing so helps to direct energy toward a therapeutic activity. Appropriate activities include walking, riding a stationary bicycle, or playing volleyball. Assigning the client to an educational group is not helpful because the anxious client would be unable to sit in a group setting and concentrate on what was occurring in the group. Watching television may be too stimulating for the client, possibly increasing anxiety. Additionally, the client may be too anxious to sit and focus. Waiting for the client to approach the nurse is not helpful or appropriate. The nurse is responsible for initiating contact with the client.

A client with symptoms of amphetamine psychosis that are improving is anxious and still experiencing some delusions. When developing the client's plan of care, which measure should the nurse include?

Notify the physician of the fingerstick glucose level, inquire about insulin therapy, and ask whether the dexamethasone should be administered. Explanation: Dexamethasone is commonly ordered to help reduce edema caused by brain tumors. Elevation in glucose level is a common adverse reaction to the drug. The nurse should notify the physician of the elevated fingerstick glucose level and ask about insulin therapy and whether the drug should be administered. The nurse shouldn't wait until the physician makes rounds to report the elevated glucose level; a delay in treatment could cause further elevation in the glucose level. The glucose level should be treated despite the client's past medical history.

A nurse is administering dexamethasone 4 mg I.V. to a client diagnosed with a brain tumor. The nursing assistant informs the nurse that the client's fingerstick glucose level is 240 mg/dl (13.32 mmol/L). A sliding insulin scale hasn't been ordered. How should the nurse intervene?

500 Explanation: The recommended energy intake for a lactating client is 500 calories more than her nonpregnant intake.

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

replacement with biosynthetic growth hormone Explanation: The definitive treatment of growth hormone deficiency is the replacement of growth hormone (somatotropin) with biosynthetic somatotropin. This treatment is successful in 80% of affected children. Desmopressin acetate is used to treat diabetes insipidus. A deficiency of antidiuretic hormone causes diabetes insipidus, and isn't related to hypopituitarism. Testosterone or estrogen may be given during adolescence for normal sexual maturation, but neither is the definitive treatment for hypopituitarism.

A nurse is caring for a school-age client who is in the second percentile of height and weight for age as a result of an endocrine disorder. Which pharmacological intervention should the nurse anticipate?

"Your child is taking a very powerful medication and needs careful monitoring." Explanation: The caregiver's behavior does not indicate comprehension of the seriousness of the child's condition; the caregiver must be educated about the child's situation and how the paranoia and auditory hallucinations are managed. The nurse is in a key position to provide such education by explaining the client's medication and the need for careful monitoring. Telling the caregiver to talk with the health care provider dismisses the caregiver's concerns and deflects an opportunity to develop a therapeutic relationship. Stating the child is a danger to other people might unnecessarily alarm the caregiver and does not provide sufficient information about the child's condition. There is no indication that any legal restrictions or orders are in place.

A nurse is caring for an adolescent with paranoia who attempted to stab a family member. The client reports hearing voices but stabilizes after receiving haloperidol. The client's caregiver states, "There have been troubles in the past, but my child is a good person. Can I take my child home now?" Which response by the nurse is most appropriate?

middle-aged adult with hematuria and ecchymosis of the penis 1 hour after a bicycling accident Explanation: Prioritization is based on evidence that a client's condition is unstable or deteriorating over time. The client with perineal injury following a bicycle accident is exhibiting immediate signs of a straddle injury that could result in a urethral rupture. This is an emergency that could require surgery. The client with a hip injury may also require surgery but is of lower priority because of the duration. The other two clients are both stable; therefore, they are less urgent.

A nurse is triaging clients in the emergency department. Which client is the highest priority to receive treatment?

enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin

performing a preoperative surgical scrub for at least 3 to 5 minutes. Explanation: The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

I have a fever." Explanation: Fever is generally not thought to be a sign of impaired renal function related to long-term use of gentamicin. The client should report signs of decreasing urinary function, such as decreased output, unusual appearance of the urine, or edema.

The nurse is instructing the client who is taking gentamicin to monitor renal function. The nurse determines that the client needs additional instruction when the client makes which statement? "I should call you if:

"Wait until the child has the developmental abilities of a 3 year old." Explanation: It is important to help families develop realistic toilet training regimens. For example, training should not begin until the child attains the developmental abilities of a 3 year old. It would not prove successful to have the child wear diapers for several years, to leave the decision regarding when to start up to the child, or to start toilet training immediately. Toilet training does not have to be completed by a certain age. It needs to be completed when the child's neurological development is developed enough to understand the urge to empty the bladder or evacuate the bowel. The mother will have to be patient with the child in any normal potty training situation but especially if the child has delays.

The parent of a 2.5-year-old child with a developmental delay asks the nurse what this means in relation to toilet training. Which of the following is the best response by the nurse?

activity intolerance related to inadequate oxygenation anxiety related to breathlessness ineffective breathing pattern related to hypoxia risk for decreased cardiac output related to failure of the left ventricle Explanation: When planning care, the nurse would select nursing diagnoses that anticipate pulmonary compromise secondary to reduction of air, blood, and gas exchange because these are ensuing complications that can develop from a pulmonary embolism, particularly in a client with a history of heart failure. The prudent nurse would analyze the client's condition and anticipate the need for safe, supportive nursing interventions related to the client's activity intolerance, anxiety, ineffective breathing, and risk for decreased oxygen output. The client history does not indicate that this client has difficulty sleeping, and although nutrition is important to consider, it is not a priority.

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply.

Palpation of the liver in the right upper quadrant would provide essential information on the organ's status. Palpation in a systematic manner identifies masses, enlargement, and degree of tenderness. The nurse can best palpate the liver by standing on the client's right side and placing the nurse's right hand on the client's abdomen, along the right midclavicular line. The nurse would point the fingers of the right hand toward the client's head, just under the right rib margin.

A client presents to the emergency department with liver failure and obvious jaundice. When palpating a client's abdomen, which area would provide the most essential information?

Ensure the parents know opioids can cause further respiratory depression. Explanation: The infant is actively dying and on comfort measures only, so the nurse's priority is the infant's and the parent's comfort. The nurse helps prepare the parents by making them aware of the effects of the opioid to ensure they are giving an informed request for this treatment. Once the parents indicate understanding, the nurse can provide the treatment. The respiratory rate is significantly lower than normal for a premature infant, which could be due in part to previous administration of opioids, so the parents should be made aware of this. However, the infant is showing some evidence of pain (grimacing), and the opioid is prescribed to treat this pain, so the nurse does not need to contact the healthcare provider. The nurse should not stimulate the infant, because doing so could cause more discomfort.

A premature infant in the neonatal intensive care unit is actively dying and on comfort care measures only. The infant is grimacing with a respiratory rate of 20 breaths/minute. The parents ask the nurse to administer an opioid analgesic. What should the nurse do first?

Maintain a tidy environment around the child. Explanation: Visually impaired children explore their environment by feel. A tidy and organized environment can support this and promote the child's safety. It is a priority to make sure all items that could potentially injure the child are removed from the environment. This includes meal trays and supplies for procedures.

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?

Provide anticipatory guidance for parents. Help the parents understand their child's behavior. Identify deviations from normal growth and development patterns. Explanation: Goals for promoting healthy development in preschoolers include anticipatory guidance, helping parents understand their child's behavior, identifying deviations from the norm, and assessing parent-child interaction. No one can assess or determine the child's future development, and trying to do so can limit the potential the child may achieve. Although learning to interact with others is important, sending the child to a day care center is not essential to promote healthy development. The nurse can encourage the parents to provide opportunities for the child to play with others.

Which nursing interventions are appropriate when creating a plan of care to promote the development of a preschooler? Select all that apply.

Alternatively patch one eye every 2 hours. Explanation: Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

progressive weakness of the extremities inability to ambulate independently urinary incontinence Explanation: Multiple sclerosis is a chronic, progressive disease that results in the destruction of the myelin sheath. This eventually affects the proper transmission of nerve impulses and results in weakness of the extremities with exacerbations and remissions where the client may be wheelchair dependent. In later stages, urinary incontinence is present due to the lack of tone to the bladder. Increased appetite and loss of cognition are not symptoms of multiple sclerosis. The appetite may decrease due to weakness of muscles that involve chewing. Cognition is not affected. The client continues to be alert and oriented despite the other widespread neurological impairments.

A client is admitted to the hospital with an exacerbation of multiple sclerosis after an MRI revealed progressive demyelination. The nurse should assess for which symptom? Select all that apply.

Dim the lights in the room. Explanation: The nurse is helping the client manage pain and comfort level. The nurse has completed the assessment of the client and should now dim the lights and create a quiet environment. Such nonpharmacologic measures as adjusting the light level in the room facilitate pain management. Decreasing stimulation from the environment, such as brightness to the optic nerve, promotes the client's ability to relax skeletal muscles and fall asleep. It is too soon to reassess vital signs. Checking that the family is comfortable is important but is not the next thing to do for this client. Increasing the oxygen flow rate is not indicated, and, if needed, should have been done before repositioning the client.

A client who had a colectomy 8½ hours ago and has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?

a paraplegic client admitted with dehydration and ordered bedrest an older adult client with a diagnosis of left hip fracture a client with diverticulitis who is occasionally incontinent a client with sickle cell disease who is reporting pain Explanation: The client who is paraplegic with dehydration and on bedrest has the most risk factors for skin breakdown because of limited motion and is ordered bedrest. The older adult client with a hip fracture will require help with mobility and has risk factors due to mobility and age. The client with occasional incontinence has a risk factor due to wetness and how long the wet garment remains on. While the client with sickle cell disease is in pain which may affect mobility, there are no other factors that would indicate a risk for skin breakdown.

The nurse is planning the order of client assessments at the beginning of the shift based on the risk for skin breakdown each client presents. The nurse should assess the clients in which order? All options must be used.

The parents may be at different stages in dealing with their child's impending death. The dying child may become clingy and act like a toddler. The death of a child may have long-term disruptive effects on the family. The child doesn't fully understand the concept of death. Explanation: When dealing with a dying child, parents may be at different stages of grief at different times. The child may regress in behaviors. The stress of a child's death commonly results in divorce of parents and behavioral problems in siblings. Preschoolers see illness and death as a form of punishment. Talking about death openly helps to correct this thinking and relieve guilt. They fear separation from parents and might worry about who will provide care for them. Preschoolers have only a rudimentary concept of time; thinking about the future is typical of an adolescent facing death, not a preschooler.

A nurse is caring for a 5-year-old client who is in the terminal stages of cancer. Which statements, regarding this child's cancer, are true? Select all that apply.

Drink plenty of water before, during, and after a workout. Take precaution to prevent overheating. Avoid jerky, high-impact motions. Modify any positions that put strain on the abdomen. Explanation: Clients should keep well hydrated with any form of exercise. Dehydration can lead to dizziness and put the client at risk for falls. Later in pregnancy, dehydration can contribute to preterm labor. Becoming overheated can lead to dehydration. In the first trimester heat can act as a teratogen. Ligaments become more relaxed during pregnancy, making joints more mobile. High impact, quick movements can lead to injury. Many yoga poses put pressure on the abdomen and would need to be modified as a pregnancy progresses. It is unnecessary to restrict participation to a prenatal yoga class only; however, the client should be advised to notify the instructor that she is pregnant and discuss if participating in that particular class is appropriate.

A prenatal client wants to begin a yoga-based exercise class to keep her healthy during pregnancy. What information should the nurse include in the plan of care? Select all that apply.

increased insulin levels Explanation: Metformin works by decreasing the production of glucose in the liver and improving insulin sensitivity. These two mechanisms reduce insulin and blood glucose level. Reducing insulin levels reduces androgens and helps to restore menstruation.

An adolescent client with polycystic ovarian syndrome (PCOS) has been placed on metformin. The nurse determines the client needs more teaching about metformin if she states the medication helps achieve which outcome?