Nclex client Needs
A client is brought to the emergency department (ED) after ingesting an unknown quantity of antidepressant medication and sleeping pills. A family member tells the nurse that the client has recently experienced several significant losses. The client is stabilized in the ED and transferred to a psychiatric unit. What is the nurse's best response when the client sobs uncontrollably and refuses to come to breakfast? a) "I will bring you some medication to help settle your anxiety." b) "I know you are feeling sad now, but it will get better with time." c) "Your feelings are real. I'll bring your breakfast and sit with you if you want." d) "Come join the others. It will be good to get into the routine of the unit."
You selected: "Your feelings are real. I'll bring your breakfast and sit with you if you want." Explanation: Acknowledging the client's feelings is validating and builds rapport. The offer to bring breakfast and sit with the client is the most therapeutic response since the client is adjusting to the unit and requires considerable assessment. Encouraging someone who is in a poor emotional state to join others is not productive to the client or the milieu. Acknowledging the client's sadness is part of validating feelings; however, this response names the feelings for the client and provides platitudes that are not therapeutic. Finally, offering anti-anxiety medication simply because someone is tearful is not an acceptable intervention, and closes down what is a potentially a helpful opportunity for ventilation, validation, assessment, and intervention.
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? mL/h
You selected: 24 Correct Explanation: First, calculate how many units are in each milliliter of the medication. 25,000 units/500 mL = 50 units/1 mL. Next, calculate how many milliliters the client receives per hour. 1,200 units/1 hour divided by 50 units/1 mL = 1,200 units/1 hour X 1 mL/50 units = 24 mL/h. (less)
Which of the following behaviors by a neonate attempting an initial feeding should indicate to the nurse that the neonate may have tracheoesophageal fistula? a) Sucking attempts that are too poorly coordinated to be effective. b) Projectile vomiting that occurs after drinking 4 oz (118 ml). c) Coughing, choking, and cyanosis that occur after several swallows of formula. d) Sleeping that occurs after taking 10 ml of formula with an inability to be stimulated to take more.
You selected: Coughing, choking, and cyanosis that occur after several swallows of formula. Explanation: The newborn with tracheoesophageal fistula swallows normally, but the fluids quickly fill the blind pouch. The infant then coughs, chokes, and becomes cyanotic while the fluid returns through the nose and mouth. Poor rooting reflexes and sucking attempts are typical of infants with neurologic dysfunction or related to reflex depression secondary to medication given to the mother during labor. Projectile vomiting is typical of infants with neurologic dysfunctions. This reflex may also be depressed by medication given to the mother during labor. Falling asleep after taking little formula is characteristic of an infant who becomes exhausted with the exertion of feeding, commonly caused by a cardiac anomaly.
To which of the following unlicensed assistive personnel should the nurse assign a male Muslim client who needs complete morning care? a) Jill, who has four clients requiring partial morning care. b) Jim, who has five clients requiring partial morning care. c) Joe, who has one client requiring complete morning care. d) Mary, who has two other clients requiring complete morning care.
You selected: Joe, who has one client requiring complete morning care. Correct Explanation: The nurse should assign the Muslim male client who needs morning care to Joe. Muslim men cannot be cared for by female nurses. The nurse must also consider work load and Joe has the lightest amount. (less)
A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, she's been unable to eat enough and has lost weight. Which nonpharmacologic intervention should the nurse recommend? a) Drinking liquids with dry foods b) Keeping crackers at the bedside to eat before getting out of bed c) Drinking water with every meal d) Eating three large meals per day
You selected: Keeping crackers at the bedside to eat before getting out of bed Explanation: The nurse should advise the client to keep crackers at the bedside because eating dry crackers before getting out of bed and before the stomach becomes empty helps prevent nausea. Drinking water with every meal does not alleviate nausea. Eating six small meals per day, rather than three large meals, prevents nausea by preventing the stomach from becoming empty. Drinking liquids with dry food increases nausea. The client should be instructed to wait at least 30 minutes to consume liquids after eating dry food.
A staff nurse on the mental health unit tells the nurse manager that kids with conduct disorders might as well be jailed because they all end up as adults with antisocial personality disorder anyway. What is the best reply by the nurse manager? a) "You sound really frustrated. Let's talk about the meaning of their behavior." b) "These children are more likely to have problems with depression and anxiety disorder as adults." c) "My experience hasn't been that negative. Let's see what the other staff members think; maybe I'm wrong." d) "You really sound burned out. Do you have a vacation coming up soon?"
"You sound really frustrated. Let's talk about the meaning of their behavior Explanation: The nurse manager needs to focus on the frustration that the nurse is expressing. Additionally, the nurse manager needs to correct any misinformation or misinterpretation that the staff nurse has. Saying that the nurse sounds burned out and asking about a vacation does not focus on the nurse's frustration or address the inaccuracy of the nurse's statement. There is no evidence to suggest that children with conduct disorder have more than the average adult's risk of depression or anxiety. Therefore, this response is inaccurate and inappropriate. Anecdotal information from personal experience does not supply the nurse with accurate, reliable information. (less)
A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin (Dilantin) to a client with a history of seizures. As the LPN walks into the room, she hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do? a) Take the medication from the nursing assistant and administer it. b) Remind the LPN that she must administer the medications herself. c) Allow the nursing assistant to administer this dose and tell the LPN later that it's her responsibility to administer the medication. d) Do nothing because the client has been taking the medication for a long time.
Remind the LPN that she must administer the medications herself. Explanation: The RN should intervene immediately by reminding the LPN that it's her responsibility to administer the medications. The RN should reinforce to the LPN that medication administration is beyond the scope of practice for a nursing assistant, and that allowing the nursing assistant to administer medications could lead to client injury. Although the client has been taking the medication for a long time, the responsibility for medication administration lies with the RN and LPN, not the nursing assistant. It's important for the nurse to intervene at the time of the incident to prevent injury. The registered nurse shouldn't administer the medication because she didn't prepare the medication for administration herself.
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide? a) "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." b) "Your condition isn't chronic, so you won't need to wear a medical identification bracelet." c) "Administer desmopressin while the suspension is cold." d) "You won't need to monitor your fluid intake and output after you start taking desmopressin."
You selected: "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." Explanation: The nurse should advise the client that desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and get adequate fluid replacement.
A client is expecting her second child in 6 months. During the psychosocial assessment, she says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response? a) "The facility requires these answers of all pregnant clients." b) "A second pregnancy may require more psychosocial adjustment." c) "Each pregnancy has a unique psychosocial meaning." d) "A client can develop couvade with any pregnancy."
"Each pregnancy has a unique psychosocial meaning." Explanation: With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother.
An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals blood pressure (BP) 160/78, heart rate (HR) 102 beats per minute, and respiration rate 32 breaths per minute with audible wheezing. Which of the following is the nurse's priority action? a) Administer 100% oxygen via mask b) Assess the site to remove the stinger c) Assist the client to lie down d) Assess the client's airway
Assess the client's airway Explanation: All of the answers may need to be done for this client, but the initial priority action for any client with an elevated respiratory rate and wheezing is to assess and maintain the airway.
Which parental characteristic is least likely to be a risk factor for child abuse? a) Being a member of a large family. b) Inadequate knowledge of normal growth and development patterns. c) Low self-esteem. d) History of substance abuse.
Being a member of a large family. Explanation: From documented cases of child abuse, a profile has emerged of a high-risk parent as a person who is isolated, impulsive, impatient, and single with low self-esteem, a history of substance abuse, a lack of knowledge about a child's normal growth and development, and multiple life stressors. Just because a parent comes from a large family, there is no increase in the incidence of the parent abusing their own children unless they possess the other risk factors. (less)
A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? a) Client's level of consciousness b) Client's nutritional status c) Client's risk for falls d) Client's vital signs and breath sounds
Client's level of consciousness Explanation: A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad. (less)
A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis should be the highest priority? a) Impaired physical mobility b) Disturbed body image c) Risk for injury related to unsteady gait d) Deficient fluid volume (hemorrhage)
Deficient fluid volume (hemorrhage) Explanation: Deficient fluid volume(hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage. Risk for injury related to unsteady gait isn't indicated in this situation. Disturbed body image isn't a concern because the adolescent doesn't have a visible injury. Although the adolescent may be placed on bed rest for 5 to 7 days, Impaired physical mobility isn't the priority nursing diagnosis. (less)
A client in severe respiratory distress is admitted to the hospital. When assessing the client, the nurse should: a) Delay assessment until client's respiratory distress is resolved. b) Focus assessment on the respiratory system and distress. c) Complete a comprehensive physical examination. d) Conduct a complete health history.
Focus assessment on the respiratory system and distress. Explanation: During an episode of acute respiratory distress, it is important that the nurse focus the assessment on the client's respiratory system and distress to quickly address the client's problem. Conducting a complete health history and a comprehensive physical examination can be deferred until the client's condition is stabilized. It is not appropriate to delay all assessments until the respiratory distress is resolved because the nurse must have data to guide treatment.
The nurse should assess the client with bladder cancer for which of the following? a) Painless hematuria. b) Urine retention. c) Dysuria. d) Suprapubic pain.
Painless hematuria. Explanation: Painless hematuria is the most common clinical finding in bladder cancer. Other symptoms include urinary frequency, dysuria, and urinary urgency, but these are not as common as hematuria. Suprapubic pain and urine retention do not occur in bladder cancer.
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? a) Risk for injury related to neurologic deficit b) Disturbed sensory perception (visual) related to neurologic trauma c) Feeding self-care deficit related to neurologic trauma d) Impaired verbal communication related to confusion
Risk for injury related to neurologic deficit Explanation: Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.
The nurse is caring for clients on an impatient psychiatric unit. Which client with obsessive-compulsive disorder is ready to be considered for discharge? a) The client who showers 3 instead of 10 times per day. b) The client who behaves in an outwardly normal manner. c) The client who willingly takes medication. d) The client who has obsessions but not compulsions.
The client who showers 3 instead of 10 times per day. Explanation: A decrease in compulsive behavior is an indication that anxiety has decreased and the client is better able to cope with his feelings of anxiety, thus decreasing the need to shower. The client who takes his medication may not have a decrease in obsessions or compulsive behavior. The client who has obsessions can experience interference in normal routine, social, and occupational functioning. The ability to behave in an outwardly normal manner does not indicate that the client's obsessions and compulsions have decreased. Obsessions and even some compulsions can be hidden from others. (less)
The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue? a) "I spend one weekend day a week resting in bed while my husband cares for the children." b) "I sleep for 8 to 10 hours every night so that I'll have the energy to care for my children during the day." c) "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." d) "I get up early in the morning and get all my household chores completed before my children wake up."
You selected: "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." Explanation: Regularly scheduled rest periods during the day along with 8 to 10 hours of sleep at night helps relieve the fatigue, pain, and stiffness associated with rheumatoid arthritis. Even with mild rheumatoid arthritis, the client may find it difficult to perform activities of daily living without some rest periods. Spending 1 day a week in bed to relieve fatigue does not adequately manage the disease. The client must recognize the need for rest before feeling exhausted because overexertion can cause exacerbations. In addition, prolonged periods of inactivity can increase joint stiffness and pain. Getting up early to do household chores before the children are awake does not allow for adequate rest. (less)
The parents of a 12-year-old girl ask why their non-sexually active daughter should receive the human papillomavirus (HPV) vaccine. The nurse should tell the parents: a) "The vaccine is most effective against cervical cancer if given before becoming sexually active." b) "Parents are never sure when their child might become sexually active." c) "If your daughter is sexually assaulted, she may be exposed to HPV." d) "HPV is most common is teens and women in their late twenties."
You selected: "The vaccine is most effective against cervical cancer if given before becoming sexually active." Explanation: Vaccines are preventative in nature and ideally given before exposure. Focusing on the benefits of cancer prevention is most appropriate, as opposed to discussing with parents the potential that their child may become sexually active without their knowledge. It is true HPV is most common in adolescents and women in their late twenties, but parents still may not perceive that their child is at risk. Discussing the possibility of exposure through assault raises fears and does not focus on prevention.
A fourth heart sound (S4) indicates a: a) dilated aorta. b) normally functioning heart. c) decreased myocardial contractility. d) failure of the ventricle to eject all blood during systole.
failure of the ventricle to eject all blood during systole. Explanation: An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. She doesn't hear an S4 in a normally functioning heart.
A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) ice cream. b) ground beef patties. c) fresh orange slices. d) steamed broccoli.
ground beef patties. Rationale: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.
A client is admitted to the labor and birth department in preterm labor. She is estimated to be 30 weeks' gestation. To help manage preterm labor, the nurse should expect to administer: a) indomethacin. b) terbutaline (Brethine). c) magnesium sulfate. d) betamethasone (Betaderm, Diprolene).
indomethacin. Explanation: Terbutaline reduces frequency and intensity of uterine contractions (UCs) by stimulating B2 receptors in the uterine smooth muscle. It is the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia—a life-threatening form of gestational hypertension. Betamethasone, a synthetic corticosteroid, is administered to the mother to stimulate fetal pulmonary surfactant.
A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: a) monitor the child with a pulse oximeter in her office. b) contact the child's parent or guardian. c) return the child to class. d) prepare to ventilate the child.
prepare to ventilate the child. Explanation: The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child shouldn't be returned to class. When the child's condition allows, the nurse can notify the parents or guardian.
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? a) "I will take my dog for a walk every day." b) "I should try to drink twice as much water as I am now." c) "I need to use laxatives regularly to prevent constipation." d) "I will eat raw, green-leafy vegetables, unpeeled fruit, and whole grain bread."
"I need to use laxatives regularly to prevent constipation." Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.
A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation? a) Lochia alba b) Minimal afterpains when nursing c) A fundus palpable at the umbilicus d) A nonpalpable fundus in the abdomen
A fundus palpable at the umbilicus Explanation: A fundus palpable at the umbilicus 10 days postpartum is abnormal. The fundus is typically at this level 1 hour after delivery. By the 10th day postpartum, the uterus should no longer be palpable. Lochia alba is normal at 10 days postpartum. Minimal afterpains when nursing is a normal finding.
A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? a) At bedtime. b) At the time scheduled. c) All at one time. d) Two hours before mealtime.
At the time scheduled. Explanation: While the client is hospitalized for adjustment of medication, it is essential that the medications be administered exactly at the scheduled time, for accurate evaluation of effectiveness. For example, levodopa-carbidopa (Sinemet) is taken in divided doses over the day, not all at one time, for optimum effectiveness.
A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? a) Autonomy. b) Justice. c) Nonmaleficence. d) Fidelity.
Fidelity. Explanation: Fidelity is keeping one's promises and never abandoning a client entrusted to care without first providing for the client's needs. Autonomy respects the rights of clients or their surrogates to make healthcare decisions. Nonmaleficence is avoiding causing harm. Justice involves giving each his or her due and acting fairly.
An elderly client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client? a) Disturbed thought processes b) Impaired physical mobility c) Activity intolerance d) Hyperthermia
Hyperthermia Explanation: With age, the body's ability to regulate temperature diminishes and the number of sebaceous and sweat glands decreases. These changes put the elderly client at risk for Hyperthermia. Because hyperthermia can be life-threatening, this nursing diagnosis takes highest priority. If Activity intolerance, Disturbed thought processes, and Impaired physical mobility are relevant, the nurse should assign them lower priority when planning this client's care.
A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values? a) Increased serum amylase and lipase levels. b) Decreased glucose level. c) Increased calcium level. d) Decreased urine amylase level.
Increased serum amylase and lipase levels. Explanation: Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels. (less)
For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? a) The wound drainage is serous. b) The granulation tissue is at the wound edges. c) The skin around the wound is edematous. d) The tissue surrounding the wound is red and hot.
The granulation tissue is at the wound edges. Explanation: Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.
The nurse is planning care for a newly admitted client on the psychiatric unit. Which action by the nurse is most important? a) To set limits with the client for behavior b) To know how to solve the client's problems accurately c) To establish trust and rapport by using the client's name and maintaining eye contact d) To encourage the client to participate in recreational activities
To establish trust and rapport by using the client's name and maintaining eye contact Explanation: The nurse must establish trust and rapport with the client. The nurse should not offer advice. Instead, the nurse should help the client develop the coping mechanisms necessary to solve his or her own problems. Setting limits is important, but not as important as developing trust and rapport.
-Select all answer choices that apply. The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply. a) To ensure efficient and accurate communication. b) To make data entry into a computerized health record easier. c) To ensure client safety. d) To prevent medication errors. e) To make it easier for clients to understand the medication orders.
d) To prevent medication errors. a) To ensure efficient and accurate communication. c) To ensure client safety. Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication orders or to make data entry easier.
A nurse is providing care for a pregnant 16-year-old. The client says that she is concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: a) "The prenatal vitamins should ensure the baby gets all the necessary nutrients." b) "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." c) "Now isn't a good time to begin dieting because you are eating for two." d) "Let's explore your feelings further."
"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." Rationale: Depriving the developing fetus of nutrients can cause serious problems and the nurse should discuss this issue with the client. The client isn't eating for two; this belief is a misconception. Exploring feelings helps the client understand her concerns, but the nurse also needs to make the client aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or developing fetus needs; they work in conjunction with a balanced diet.
Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement? a) Continue previous contraceptive use even if you're experiencing amenorrhea. b) Amenorrhea is irreversible. c) This medication may result in heightened libido. d) Incidence of dysmenorrhea may increase while taking this drug.
Continue previous contraceptive use even if you're experiencing amenorrhea. Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics because amenorrhea doesn't indicate cessation of ovulation the client who experiences amenorrhea can still become pregnant. She should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and the depressant effect generally decreases libido.
Which of the following changes are associated with normal aging? a) The dermis becomes highly vascular and assists in the regulation of body temperature. b) The outer layer of skin is replaced with new cells every 3 days. c) Subcutaneous fat and extracellular water decrease. d) Collagen becomes elastic and strong.
You selected: Subcutaneous fat and extracellular water decrease. Correct Explanation: With age, there is a decreased amount of subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening. The outer layer of skin is almost completely replaced every 3 to 4 weeks. The vascular supply diminishes with age. Collagen thins and diminishes with age. (less)
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? a) Evaluation for signs and symptoms of increased intracranial pressure (ICP) b) Lung auscultation and measurement of vital capacity and tidal volume c) Evaluation of nutritional status and metabolic state d) Evaluation of pain and discomfort
Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.
A 17-year-old unmarried primigravida client at 10 weeks' gestation tells the nurse that her family doesn't have much money and her dad just got laid off from his job. Which of the following would be the nurse's most appropriate action? a) Ask the client if she has a job and the amount of income earned. b) Instruct the client in methods for low-cost, highly nutritious meal preparation. c) Refer the client to a social worker for enrollment in a food assistance program. d) Determine whether the client qualifies for local assistance programs.
Refer the client to a social worker for enrollment in a food assistance program. Explanation: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program. Instructing the client in low-cost, highly nutritious meal preparation will not meet the client's need for additional funds for food. Determining whether the client qualifies for assistance is part of the role of the social worker, not the nurse. Asking the client if she has a job and the amount of income earned is not within the role of the nurse. The social worker can determine whether the family income guidelines are met for assistance.
When integrating the concepts underlying the cognitive-behavioral model into a client's plan of care, the nurse should focus on which of the following areas? a) Reduction of bodily tensions and stress management. b) Analysis of fears and barriers to growth. c) Substitution of rational beliefs for self-defeating thinking and behaving. d) Insight into unconscious conflicts and processes.
Substitution of rational beliefs for self-defeating thinking and behaving. Explanation: Substituting rational beliefs is a major goal when using cognitive-behavioral models, which focus more on thinking and behaviors than feelings. Unconscious processes are the focus of psychoanalytic models. Analysis of fears and barriers to growth are the focus of developmental models. Tension and stress are targets of the stress models.
A client says he's stressed by his job but enjoys the challenge. What should the nurse suggest? a) Take stress-management classes. b) Change jobs. c) Spend more time with his family. d) Leave work at work.
Take stress management class. Rationale: The nurse should suggest stress-management classes, which would identify factors that contribute to stress in the client's life and teach him how to manage stress more effectively. The client may not have to leave a job he enjoys. The information provided by the client doesn't indicate that spending too little time with his family and taking his job home with him contribute to the client's stress.
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? a) Weakness in the extremities. b) Sudden bursts of energy. c) Muscle tremors. d) Double vision.
You selected: Sudden bursts of energy. Explanation: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.
A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true? a) The client can read the vision chart from a distance of 20′ with the right eye and from 40′ with the left eye. b) The client can read at a distance of 30′ (9 m) what a person with normal vision can read at a distance of 40′. c) The client can read the entire vision chart at a distance of 40′ (12 m). d) The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′.
The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. Rationale: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read
A nurse must assess skin turgor in an elderly client. When evaluating skin turgor, the nurse should remember that: a) inelastic skin turgor is a normal part of aging. b) dehydration causes the skin to appear edematous and spongy. c) normal skin turgor is moist and boggy. d) overhydration causes the skin to tent.
inelastic skin turgor is a normal part of aging. Explanation: Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.
- Select all answer choices that apply. A nurse is caring for a newborn with transient tachypnea of the newborn (TTN). Which of the following responses made by the newborn's mother demonstrates that she understands the newborn's condition? Select all that apply. a) "I will need to give supplemental oxygen to my baby for the next 6 months." b) "The healthcare provider will need chest X-rays to monitor respiratory distress." c) "My newborn is on oxygen because I was exposed to smoke during pregnancy." d) "I can feed my newborn even though the respiratory rate is fast." e) "Having a cesarean section increased the risk of transient tachypnea of the newborn."
• "Having a cesarean section increased the risk of transient tachypnea of the newborn." • "The healthcare provider will need chest X-rays to monitor respiratory distress." Explanation: TTN is caused by retention of extra amniotic fluid in the lung fields. Newborns who are born by cesarean section are more likely to have TTN because the mechanical squeezing of the newborn's rib cage does not occur with birth. The most distinguishing feature of TTN is the lung fields on a chest X-ray where there is hyperaeration of the alveoli. TTN usually lasts 48-72 hours and will need oxygen during this time period. TTN usually requires a low percentage of oxygenation (40% or less) along with supportive care such as IV fluid, antibiotics, and placement in a warmer. If the respiratory rate is consistently above 60 breaths/minute, the newborn takes nothing by mouth due to the risk of aspiration. Although smoking during pregnancy can lead to a smaller baby, smoking is not linked with TTN.
A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching? a) "I may stop taking this medication when I feel better." b) "I will see my ophthalmologist regularly for a check-up." c) "I will avoid friends and family members who are sick." d) "I will eat lots of chicken and dairy products."
"I may stop taking this medication when I feel better." Explanation: The client requires additional teaching because he states that he may stop taking corticosteroids when he feels better. Corticosteroids should be gradually tapered by the physician. Tapering the corticosteroid allows the adrenal gland to gradually resume functioning. Corticosteroids increase the risk of infection and may mask the early signs of infection, so the client should avoid people who are sick. Corticosteroids cause muscle wasting in the extremities, so the client should increase his protein intake by eating foods such as chicken and dairy products. Corticosteroids have been linked to glaucoma and corneal lesions, so the client should visit his ophthalmologist regularly. (less)
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: a) Check on the client at regular intervals to ascertain the need to use the bathroom. b) Put all four side rails up on the bed. c) Request that the client's roommate put the call light on when the client is attempting to get out of bed. d) Ask the unlicensed personnel to place restraints on the client's upper extremities.
Check on the client at regular intervals to ascertain the need to use the bathroom. Explanation: Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or unlicensed personnel should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written order from a physician before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety.
What would the nurse recognize as a common goal of discharge planning in all care settings? a) Prolonging hospitalization until the client can function independently b) Preventing the need for medical follow-up care c) Providing continuity of care for the client d) Providing the financial resources needed to ensure proper care
Providing continuity of care for the client Explanation: A common goal of discharge planning in all settings is providing continuity of care for the client. This action aids the client's transition to a new setting and can shorten facility stays. Providing financial assistance isn't a goal of discharge planning, although the nurse may make referrals to the appropriate department for financial assistance. Rather than preventing the need for follow-up visits, the nurse should encourage the client to return for these visits. (less)
Which of the following over-the-counter medications should the nurse tell the mother of a child with hemophilia to avoid using? a) Acetaminophen (Tylenol). b) Acetylsalicylic acid (ASA). c) Magnesium hydroxide (Milk of Magnesia). d) Multivitamin capsules.
You selected: Acetylsalicylic acid (ASA). Explanation: Acetylsalicylic acid inhibits platelet aggregation, prolongs bleeding time, and inhibits prothrombin synthesis. It is, therefore, contraindicated for a child with hemophilia. Magnesium hydroxide (Milk of Magnesia) has no effect on bleeding and is not contraindicated for a child with hemophilia. Acetaminophen (Tylenol) is the recommended alternative for analgesic and antipyretic purposes. Multivitamin capsules have no effect on bleeding and are not contraindicated for a child with hemophilia. (less)
Choice Multiple question - Select all answer choices that apply. A client who will have his last chemotherapy cycle in 11 days becomes neutropenic. The client understands his condition when he states which of the following. Select all that apply. a) "I love working in my garden; it gives me a lot of inner peace and tranquility." b) "I have this new blender and plan to make fruit or vegetable shakes for energy." c) "I will carry hand sanitizer with me and use it often." d) "I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.4° F (38° C )." e) "I need to avoid going to the movies or eating out while receiving my cancer treatment."
• "I need to avoid going to the movies or eating out while receiving my cancer treatment." • "I will carry hand sanitizer with me and use it often." • "I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.4° F (38° C )." Explanation: The client understands his neutropenic state when he states that he will monitor his temperature frequently and go to the emergency department if his temperature rises above 100.4° F (38° C). Washing hands frequently and using a personal hand sanitizer will help to prevent infection. Neutropenic clients should avoid crowds, eating fresh fruits and vegetables that can be blended into shakes, and working in the garden—all of which place the client at risk for infection. (less)
A client with borderline personality disorder tells a nurse, "You're the only nurse who really understands me. The others are mean." The client then asks the nurse for an extra dose of anti-anxiety medication because of increased anxiety. How should the nurse respond? a) "I don't want to hear you say negative things about the other nurses." b) "You will have to talk with your physician." c) "You know you can't have extra medication in your plan of care." d) "I'll have to discuss your request with the team. Let's talk about how you're feeling."
"I'll have to discuss your request with the team. Let's talk about how you're feeling." Explanation: Telling the client that it is important for him/her to talk about how he/she is feeling is an appropriate response, as it focuses on the emotional content of the client's message and helps the client identify his/her feelings. Focusing on the request for extra medication would allow the client to ignore the underlying emotional issues. Clients with borderline personality disorder commonly split the staff into "good guys" and "bad guys" to meet their needs; staff members must maintain consistency and a united front at all times. The nurse should not take the client's statements personally, as doing so would interfere with the nurse's ability to maintain a therapeutic relationship. (less)
