Nursing Concepts Exam 1

Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. 1 Slowed movement 2 Cartilage degeneration 3 Increased bone density 4 Increased range of motion 5 Increased bone prominence

1,2,5 The physiologic changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.

On an average, how many hours of sleep would the nurse state a preschooler needs during the night? Record your answer using a whole number. _____ hours

12 Preschoolers need an average of 12 hours of sleep a night for proper development of mental and physical health.

Until what age in years does a child need to drink whole milk for adequate neurologic development?

2 years Toddlers need to drink whole milk until the age of 2 years to ensure adequate intake of the fatty acids necessary for brain and neurologic development.

A client comes to the hospital because of intense feelings of unrest, inability to sleep, and frequent episodes of panic. The client tells the nurse, "I admitted myself because I think I'm going crazy." What does the nurse identify the client's remark to be? A plea for support A reflection of insight A symptom of depression A test of the nurse's trustworthiness

A plea for support Anxiety is a threat to the identity of the individual; the client is seeking assurance that the fear and panic being experienced will not mean loss of control. This is not evidence of insightfulness but instead is a plea for help in reducing the anxiety. The client is exhibiting not depression but instead severe anxiety and panic. The client is not seeking the nurse's trust; the client is asking for help.

An older adult has undergone chemotherapy. Which intervention would be beneficial for the client in preventing the risk of a potentially contagious common viral infection? 1 Administering famciclovir 2 Administering gabapentin 3 Administering the zoster vaccine 4 Administering vaccines for herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2)

Administering the zoster vaccine Herpes zoster or shingles is the most common viral infection that is potentially contagious to anyone who has not had varicella or who is immunosuppressed, such as clients on chemotherapy. Incidence increases with age mainly for adults 50 years old or older. Administering the zoster vaccine helps in preventing the risk of shingles. Famciclovir is an antiviral drug that helps in reducing the symptoms of the infection. Gabapentin is prescribed to clients suffering from neuralgia caused by shingles. Vaccines for HSV-1 and HSV-2 are not available.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A Caucasian female who is 39 weeks gestation. An African-American female who is breastfeeding. An Asian female diagnosed with hypoglycemia. A Hispanic female who has a BMI of 24.1.

An African-American female who is breastfeeding. Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

The nurse is caring for a patient who sustained a hip fracture and had an open reduction and internal fixation (ORIF) of a hip fracture. The patient is complaining of pain. Which should the nurse do next? Reposition the patient. Assess the level of pain. Administer of pain medications before getting the patient up. Maintain bed rest.

Assess the level of pain. The nurse should first assess the pain level further before determining which intervention is needed. Repositioning the patient is an intervention and should come after assessment. Administering pain medications is an intervention and should come after assessment. Bed rest is not an intervention for pain management.

A toddler who lacks toilet training is admitted to a hospital. What does the nurse need to do when collecting urine samples from the toddler? Select all that apply. Squeeze urine from the diaper. Place a hat under the toilet seat. Convince the child to void in the unfamiliar receptacle. Attach single-use bags over the child's urethral meatus. Use the terms for urination that the child can understand.

Attach single-use bags over the child's urethral meatus. Use the terms for urination that the child can understand. The nurse should use special collection devices for infants or toddlers who are not toilet trained. A single-use bag with self-adhering material over the child's urethral meatus can be used in toddlers to collect urine. The nurse needs to use terms for urination such as "pee pee" that the child is able to understand. Urine should not be collected by squeezing urine from the diaper because the results may be inaccurate. A young child is often reluctant to void in unfamiliar receptacles. A potty chair or specimen hat placed under the toilet seat is usually effective for young children rather than toddlers. A young child is often reluctant to void in unfamiliar receptacles. They should not forced to void.

A parent observes that the child is dressing on his or her own and is self-feeding. Which stage of life does the child belong to according to Erikson's theory of psychosocial development? Initiative versus guilt Trust versus mistrust Industry versus inferiority Autonomy verses sense of shame and doubt

Autonomy verses sense of shame and doubt According to Erikson's theory of psychosocial development, autonomy verses sense of shame and doubt stage is seen in children ages 1 to 3 years. By this age, the child is more accomplished in some basic self-care activities such as walking, feeding, and toileting. Therefore the child who is learning to dress himself or herself and self-feed is in the autonomy verses sense of shame and doubt stage. In the initiative versus guilt stage, the child likes to pretend and try out new roles. Fantasy and imagination allow them to explore their environment. In the trust versus mistrust stage, the infant requires a consistent caregiver who is available to meet his or her needs. From this basic trust in caregivers comes trust in himself or herself, in others, and in the world. Industry versus inferiority is seen in school-aged children (6-11 years). In this stage, children will apply themselves to learning socially productive skills and learning to play with peers.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) Body mass index (BMI) of 17 Waist-to-hip ratio of 1.0 Weight loss of 6% since last month's visit Prealbumin level of 16 mg/dL Hematocrit level of 50% Hemoglobin level of 8.2 g/dL

Body mass index (BMI) of 17 Weight loss of 6% since last month's visit Hemoglobin level of 8.2 g/dL A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.

To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address which organizational system exemplar? Care coordination Communication Diagnostic workup Fall prevention

Care coordination The most common safety issues at the blunt end include documentation/electronic records, team systems, environmental systems, error reporting/analysis systems, and regulatory systems. Each of the other options is classified as a point-of-care, sharp-end exemplar.

A nurse is caring for a 2½-year-old child who is expressing pain. What is the most reliable indicator of this child's pain? Crying and sobbing Changes in behavior Verbal exclamations of pain Changes in pulse and respiratory rate

Changes in behavior Although there are several indicators of pain in children, a change in behavior is the one that occurs most often. Crying is not a valid indicator of pain; there is more than one cause for crying, including pain, separation, fear, and unhappiness. Children often hide their pain; they may perceive it as punishment, or they may fear the treatment that will be given to relieve the pain. Vital signs often do not change, even if the child is in pain.

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. Chronic stress Severe anxiety Generalized pain Excessive caffeine Chronic depression Environmental noise/distractors

Chronic stress Excessive caffeine Environmental noise/distractors Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.

Acquisition of which skill is representative of adaptive development? Drawing with chalk on a blackboard Smiling in response to being stroked on the cheek Cooperating with playmates in picking up toys Crossing the street safely

Crossing the street safely Being able to cross the street safely is an example of adaptive development, which is defined as the acquisition of skills that enable independence at home and in the community. These include self-care skills, management of one's immediate environment and functional behaviors in the community.

Parents of a newborn tell the nurse they are exhausted when they wake up in the mornings. What should the nurse suspect as the most likely cause of the parent's fatigue? Possible thyroid disorder Disrupted sleep pattern Iron deficiency anemia Recent changes in diet

Disrupted sleep pattern A newborn does not have established, regular sleep patterns. Therefore, parents of newborns experience sleep pattern disturbances. While the nurse should assess for all possible causes of fatigue and obtain a history of any current concerns, sleep deprivation is the most common etiology in this situation.

A parent expresses concern that the adolescent child is not ingesting enough calcium because of an allergy to milk. What alternative foods or liquids should the nurse suggest? Select all that apply. Cottage cheese Green leafy vegetables Black or baked beans Yogurt Oranges Salmon and sardines

Green leafy vegetables Black or baked beans Oranges Salmon and sardines Green leafy vegetables, black and baked beans, oranges, and salmon and sardines are all good sources of calcium even though they do not contain milk or milk products. Cottage cheese and yogurt both contain milk and therefore must be eliminated.

A patient has impaired urinary elimination: retention. Which system is at risk for alteration in addition to the renal system? A. Gastrointestinal B. Immune C. Skeletal D. Gynecologic

Immune Systems are interrelated and alterations in one system contribute to alterations in other systems. Urinary retention, if untreated, causes urine to backflow out of the urinary bladder, up the ureters and into the kidneys themselves. This pressure can cause pyelonephritis and infection, which is an immune alteration.

What effect does inadequate fluid intake have on a patient's urinary system? A. Decreases the presence of bladder crystals. B. Decreases incidence of urinary incontinence. C. Increases the risk for urinary infections. D. Increases the ability to recognize bladder cues.

Increases the risk for urinary infections. The concept of urinary elimination interrelates with the concept of fluid and electrolyte balance. Inadequate fluid intake increases the risk for urinary infections because toxins cannot be eliminated from the body without adequate fluids.

The mother of a 2-year-old asks the nurse about her child's cognitive development. The best response of the nurse is that her child is beginning to think intuitively. is using magical thinking. can solve concrete problems. is using abstract thinking.

Is using magical thinking. The expected stage of development for a 2-year-old is one with magical thinking, where a child begins to engage in make-believe play. Intuitive reasoning occurs by the end of the preoperational period (at 2 to 7 years of age). The ability to solve concrete problems occurs with the period of concrete operations (at 7 to 11 years of age). The formal operational period (at 11+ years of age) is when individuals use thinking that is logical and can consider abstract ideas.

Which gross-motor skills would the nurse explain are developed in children between 3 to 5 years of age? Select all that apply. Jumping rope Walking stairs Drawing circles Stacking blocks Drawing triangles

Jumping rope Examples of the gross motor skills that a preschooler learns are jumping rope and walking up and down steps with ease. Fine-motor capabilities in a toddler include drawing circles and crosses accurately. By 3 years of age, the child draws simple stick people and is usually able to stack a tower of small blocks. Triangles and diamonds are usually mastered between ages 5 and 6 years of age.

Which phrase indicates that reporting of errors is valued and is free of reprisal or personal risk? Just culture High reliability Benign vigilance Blunt end surveillance

Just culture Just culture" refers to a system's explicit value of reporting errors without punishment. Reporting of mistakes or errors without reprisal or personal risk is essential to creating a culture of safety because adverse events must be reported so they can be analyzed for lessons learned and so that new procedures can be drafted to improve the system. A just culture promotes sharing and disclosure but does not negate accountability.

A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief but the client is still reporting pain. Which actions of the nurse would help the client to get relief? Select all that apply. Learning more about the client Looking for different distraction techniques Using known scientific and practice-based criteria Involving the client's family in creating a new plan for pain relief Bringing co-workers together to find a solution

Looking for different distraction techniques Involving the client's family in creating a new plan for pain relief Looking for a different distraction technique can help the client in pain relief. The nurse should also involve the client's family in adapting new approaches to pain relief. Learning more about the client will not help the nurse provide effective pain relief to the client. Scientific and practice-based criteria are used to perform assessments and evaluations. When some facts about the client are missing, then the nurse brings all the co-workers together to find the solution of the problem.

The nurse is caring for a 25-year-old woman who is requesting information to lose weight. What information will the nurse include in a weight-loss plan? Weigh yourself at the same time every morning and evening. Stick to a 600- to 800-calorie diet for the most rapid weight loss. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are not necessary for patients in the overweight category of obesity and need to be closely supervised. Patients should weigh weekly rather than daily.

What is the primary benefit to classifying errors as either active or latent? Decreased variability as to how health care agencies manage error Increased focus on the importance of individual vigilance More accurate identification of the part of the system needing improvement Enhanced attention to the need for transparency

More accurate identification of the part of the system needing improvement Determining whether errors are active or latent aids in understanding the cause of health care errors and hence in more accurately identifying the part of the system that needs improvement. Active errors are those made by providers of patient care-those responding to patient needs at the "sharp end." Latent errors are "blunt end"-those that are more organizational, contextual, and diffuse in nature, or those that are design-related.

The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? Nervous and weak Thirsty with a headache Flushed and short of breath Nausea and abdominal cramps

Nervous and weak Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.

The nurse is caring for a 50-year-old man who has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that is high in: Iron Protein Calories Carbohydrate

Protein These laboratory results are indicative of low protein levels. Protein intake is essential for cellular ability to manufacture other forms of proteins, such as carrier proteins, and to enable tissue growth and repair. Iron supplementation is indicated for anemia. This patient has a BMI of 31, which is obese. High calorie and high carbohydrates would lead to further weight gain.

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. Ptosis and blurred vision Agitation and hyperactivity Confusion and disorientation Increased sensitivity to pain Decreased auditory alertness

Ptosis and blurred vision Decreased auditory alertness Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? Push-ups to strengthen arm muscles Leg lifts to prevent hip contractures Balancing exercises to promote equilibrium Quadriceps-setting exercises to maintain muscle tone

Push-ups to strengthen arm muscles Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair. Equilibrium is not a problem. The client does not have neurologic control of the other activities.

A 10-year-old child in whom autism was diagnosed at the age of 3 years attends a school for developmentally disabled children and lives with parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. What is the priority nursing goal for this child? Controlling repetitive behaviors Being able to feed independently Remaining safe from self-inflicted injury Developing control of urinary elimination

Remaining safe from self-inflicted injury The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Children who need help with toileting are not necessarily incontinent, and it is not the priority.

A laboring client has asked the nurse to help her use a nonpharmacologic strategy for pain management. Name the sensory simulation strategy. Gentle massage of the abdomen Biofeedback-assisted relaxation techniques Application of a heat pack to the lower back Selecting a focal point and beginning breathing techniques

Selecting a focal point and beginning breathing techniques Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.

A new toy is shown to a baby, and after his or her attention is drawn, the parent hides the toy under the bed. Then the baby tries to find the toy, which is hidden. Which stage of cognitive development does the child belong, according to Jean Piaget? Sensorimotor Preoperational Formal operations Concrete Operations

Sensorimotor During the sensorimotor stage, the child learns that objects continue to exist even when they cannot be seen, heard, or touched. This is called object permanence. During the preoperational stage, the child learns to think with the use of symbols and mental images. In the formal operations stage, the child's egocentric thoughts would be prevalent and the child believes that his or her actions and appearance are constantly being scrutinized. In the concrete operations stage, the child is able to perform mental operations.

A client has a low hemoglobin level that is attributed to an iron deficiency. Which foods should the nurse recommend that the client increase in the diet? Select all that apply. Grapes Spinach Oranges Beef liver Cantaloupe

Spinach Beef Liver Spinach and beef liver contain high amounts of iron. Grapes, oranges, and cantaloupe are low in iron.

If a patient has a colostomy in the area known as the "ascending colon," what would the nurse expect of the stool in the colostomy device? A. Stool would be dark. B. Stool would be formed. C. Stool would be loose. D. Stool would have flecks of blood.

Stool would be loose. The correct answer is C because stool in the ascending colon is loose or watery. Stool should not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be loose, because the colon has not reabsorbed the water yet.

The nurse observes that a client has insomnia. Which intervention included in the care plan indicates a priority nursing intervention? Teaching about medication administration procedures Teaching the client about sleep and behavioral changes Teaching about dietary measures to be followed at night Teaching about nonpharmacologic measures including sleep techniques

Teaching the client about sleep and behavioral changes The nurse should first teach about sleep and behavioral changes to the client with insomnia. The nurse can teach about medication administration procedures, but this is not the priority. The nurse can teach dietary measures to be followed at night after teaching about sleep and behavioral changes. Teaching about nonpharmacologic procedures is also not the priority nursing intervention.

A nurse is teaching a group of parents about the developmental needs of adolescents. Which information is the nurse most likely to provide? Select all that apply. The adolescent has an increased need for calories. The adolescent's daily requirement of protein decreases. The adolescent needs to consume iron in the diet on a daily basis. The adolescent will show an increased inclination toward healthy food. The adolescent's need for nutrition is better guided by physiologic age than chronologic age.

The adolescent has an increased need for calories. The adolescent needs to consume iron in the diet on a daily basis. The adolescent's need for nutrition is better guided by physiologic age than chronologic age. The nurse will tell parents that during adolescence, energy needs increase to meet the greater metabolic demands of growth. Adolescent girls need a consistent source of iron to replace menstrual losses. Boys also need adequate iron for muscle development. The nurse should tell parents that physiologic age is a better guide to nutritional needs than chronologic age is. The daily requirement for protein also increases in adolescents. Fast food, particularly value-size or super-size meals, are popular among teens. These foods contain extra salt, fat, and kilocalories and contribute to nutrient deficiency and obesity.

The nurse assists an elderly client in squirting warm water over the perineum. Which outcome indicates effective nursing care? The client will not have nocturia. The client will not have a bladder infection. The client will not have a tendency to retain urine. The client will not have urinary stress incontinence.

The client will not have a tendency to retain urine. The renal system undergoes age-related changes in elderly clients. A tendency to retain urine is a physiologic change that can result in urine stasis. Assisting the client in squirting warm water over the perineum will help to initiate voiding in the client. Thus when the client does not have a tendency to retain urine, this finding is an effective outcome. Discouraging excessive fluid intake for two to four hours before the client goes to bed reduces nocturia. Providing thorough perineal care after each voiding will help to prevent bladder infections. Responding quickly to the client's indication of the need to void will help to reduce urinary stress incontinence.

What should the nurse include in dietary teaching for a client with a colostomy? Liquids should be limited to 1 L per day. Nondigestible fiber and fruits should be eliminated. A formed stool is an indicator of constipation. The diet should be adjusted to include foods that result in manageable stools.

The diet should be adjusted to include foods that result in manageable stools. Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and produce stools that are manageable depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Foods high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.

The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement? A. The patient must remain in the restraints all day. B. The patient needs to be toileted to maintain a regular toileting schedule. C. The patient needs to be provided with adult briefs for incontinence. D. The patient will use the call bell when he or she feels the urge to void.

The patient needs to be toileted to maintain a regular toileting schedule. The correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or she will not be able to use the call bell.

A patient with a history of cardiac problems talks with the nurse about bowel elimination. The nurse stresses to the patient not to strain during bowel movements. Straining can put pressure on the vagas nerve and cause bradycardia. The nurse is explaining which physiologic action? A. First-degree heart block B. Eupnea C. Valsalva maneuver D. Tachypnea

Valsalva maneuver The Valsalva maneuver happens when the cardiac patient strains to have a bowel movement. First-degree heart block is not brought on by straining. Eupnea means normal respirations and tachypnea means fast respirations; neither has any connection to straining during a bowel movement.

What suggestion should the nurse provide to the mother whose child has had constipation for three days? Select all that apply. Give laxatives to the child. Reduce the child's fluid intake. Include dairy products in the child's diet daily. Increase the child's physical activity. Include food with a high fiber content in the child's diet.

Give laxatives to the child. Increase the child's physical activity. Include food with a high fiber content in the child's diet. Constipation is infrequent and difficult passage of stools, and it can be managed by following certain measures. Laxatives may help with the easy passage of stools to relieve constipation. Bowel movements can also be promoted by increasing physical activity and adding fiber to the diet to add bulk to the stool to relieve constipation. Low fluid intake and consumption of dairy products can increase the risk for constipation.

Which actions demonstrate fine motor skills? Select all that apply. Crawling Creeping Sitting erect Holding a rattle Picking up objects Holding a baby bottle

Holding a rattle Picking up objects Holding a baby bottle Holding a rattle, picking up objects, and holding a baby bottle are demonstrations of fine-motor skills. Gross-motor skills include crawling, creeping, and sitting erect.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? Decreased blood supply Impaired neural functioning Perforation of the bowel wall Obstruction of the bowel lumen

Impaired neural functioning Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.

The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? (Select all that apply.) Can feed herself and prepare meals but cannot drive to the store Lives on a fixed income and can balance her checkbook Experiences stress incontinence Cannot participate in activities at the senior center Lives alone and has no nearby relatives Has no transportation to the oncology clinic

Lives alone and has no nearby relatives Has no transportation to the oncology clinic Experiences stress incontinence The patient will not be able to get treatment if she has no transportation or no relatives that live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.

A pregnant woman was prescribed a drug for pregnancy-induced hypertension. Later, the client developed muscle weakness, edema, and nausea for which calcium gluconate was administered. What drug was administered to the client to treat pregnancy-induced hypertension? Nifedipine Terbutaline Indomethacin Magnesium sulfate

Magnesium sulfate Magnesium sulfate can be administered for pregnancy-induced hypertension; this medication may cause magnesium toxicity. Signs of this toxicity include muscle weakness, edema, and nausea. Calcium gluconate is co-administered along with magnesium sulfate to counteract this toxicity. Nifedipine, an antihypertensive agent, is listed as a category C drug, and can be safely used to treat pregnancy-induced hypertension. Terbutaline is a beta-adrenergic blocker used to manage preterm labor. Indomethacin is a nonsteroidal antiinflammatory drug used as a tocolytic for the management of preterm labor.

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem knows which information? Is disciplined according to established protocols. Must communicate the problem to the patient. Near misses in healthcare are used to improve care. Shares details to locate the individual at fault.

Near misses in healthcare are used to improve care. In an agency with a culture of safety, a nurse knows that near misses are used to improve care. Individual people are not punished for flawed systems, and there are no protocols for discipline. Consequences are individualized to improve the system and minimize the opportunity for future problems. Telling the patient is part of the transparency and the sharing and disclosure among stakeholders but is generally the responsibility of the risk management staff, not the staff nurse. Through a strategy such as root cause analysis, the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences, not to point a finger at a certain person.

A 65-year-old woman has fallen while sweeping her driveway, sustaining a tissue injury. She describes her condition as an aching, throbbing back. Which type of pain are these complaints most indicative of? Neuropathic pain Nociceptive pain Chronic pain Mixed pain syndrome

Nociceptive pain Nociceptive pain refers to the normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as dull or aching, and it is poorly localized. Neuropathic pain is described as shooting, tingling, burning, or numbness that is constant in the extremities, as in diabetic neuropathy. Chronic pain lasts longer than 30 days and is characterized by a disease affecting brain structure and function, such as chronic headaches or open wounds. Mixed pain syndromes are caused by different pathophysiologic mechanisms such as a combination of neuropathic and nociceptive pain; this occurs in syndromes such as sciatica, spinal cord injuries, and cervical or lumbar spinal stenosis.

Postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course, unless contraindicated? Antihistamine Local anesthetic Opioids Nonsteroidal anti-inflammatory drug (NSAID)

Nonsteroidal anti-inflammatory drug (NSAID) Unless contraindicated, all surgical patients should routinely be given acetaminophen and an NSAID in scheduled doses throughout the postoperative course. Opioid analgesics are added to the treatment plan to manage moderate-to-severe postoperative pain. A local anesthetic is sometimes administered epidurally or by continuous peripheral nerve block.

A patient complains to the nurse that he is unable to sleep well since he has been diagnosed with gastroesophageal reflux disease (GERD). What is the nurse's best response? "You should be able to rest if you eat a larger meal before bedtime." "You should sleep in a recliner in the lowest position every night to reduce symptoms." "A pillow wedge may help you sleep more comfortably while in bed." "Drinking at least 8-12 ounces at bedtime should help you sleep through the night."

"A pillow wedge may help you sleep more comfortably while in bed." Gastroesophageal reflux disease is a condition in which stomach acid rises up into the esophagus and causes irritation that is commonly referred to as "heartburn." Patients are often advised to sleep at a minimum 30 degree incline to reduce abdominal pressure and stomach acid entry into the esophagus. Patients diagnosed with GERD should consume small, frequent meals during the day. A large meal at night stimulates the secretion of stomach acid and increased intra-abdominal pressure. While sleeping in a recliner is commonly recommended to reduce stomach acid irritation, the recliner should not be placed in the lowest reclining position. This position defeats the purpose of sleeping at a slight inclination. Drinking a large amount of fluid at bedtime could lead to nocturia which interrupts sleep patterns.

The Parents of a six-month-old infant tell the nurse they are concerned because their infant is sleeping 14 hours a day? How should the nurse respond to this concern? "Your infant may have a thyroid disorder." "Your infant has disrupted sleep pattern." "Your infant will need additional testing." "There is no need for concern as this is normal.

"There is no need for concern as this is normal. This is a normal finding for infants. Infants sleep between 14-16 hours each day. Thyroid disorder is a common cause of sleep disturbance for adults. Disrupted sleep pattern would present with interruptions in the sleep/wake patterns. No further testing is necessary as this is a normal finding.

What nursing actions are appropriate for an adolescent girl undergoing a pelvic examination? Select all that apply. 1 Teach the adolescent about hygiene, body function, and sexuality. 2 Invite the adolescent's parent in the examination room. 3 Postpone giving details about an exam as it may arouse fear in the adolescent. 4 Encourage the discussion of safer sex practices. 5 Display drawings, models, and equipment to help educate the adolescent.

1,4,5 Adolescents are often apprehensive about a pelvic examination. During the pelvic examination, the nurse should give the adolescent information regarding hygiene, body functions, and sexuality. Drawings, models, and equipment should be displayed to better educate the adolescent. In addition, the nurse should discuss safer sex practices, sexually transmitted infection prevention, and the postponing of sexual activity until the adolescent feels emotionally ready. The adolescent's parents should not be invited without the adolescent's consent.

A child uses two- to four-word sentences. The nurse interprets this data as expected development for a child the age of 2 months. 1 year. 2 years. 3 years.

2 years. A child of 2 years is expected to say several single words and use simple phrases and two- to four-word sentences. A child of 2 months may begin to babble and imitate some sounds. A child of 1 year is paying increasing attention to speech, babbles with inflection, and usually says "dada" and "mama". A child of 3 years is expected to understand most sentences and use four- to five-word sentences.

Which nursing intervention helps to prevent medication errors in children? Select all that apply. 1 Encouraging the use of brand names 2 Promoting the use of abbreviations and acronyms 3 Minimizing the use of verbal and telephone orders 4 Carefully reading all labels for accuracy and checking expiration dates 5 Recording the client's weight before carrying out the medication order

3,4,5 All labels and warnings should be read carefully to avoid the administration of expired medications. The client's weight should be recorded to help decrease errors in dosage. The use of generic names should be encouraged to avoid medication errors. Brand names may cause confusion and may lead to medication errors. The use of abbreviations and acronyms should be avoided because of the risk of confusion. Minimizing the use of verbal and telephone orders will also help prevent medication errors in children. Verbal and telephone orders should be read back to the healthcare provider prescribing the medication(s), but this is not always done, so errors are made.

An exemplar of a social/emotional developmental delay is developmental dyspraxia. fragile X syndrome. mental retardation. separation anxiety disorder.

Separation anxiety disorder. Separation anxiety disorder is an exemplar of a social/emotional developmental delay. Developmental dyspraxia is an exemplar of an adaptive developmental delay. Fragile X syndrome is an exemplar of a physical developmental delay. Mental retardation is an exemplar of a cognitive developmental delay.

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene? "Clients with decreased sensory perception of touch should be carefully monitored for infection." "Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts." "Clients with slower processing time should be provided with sufficient time to respond to questions or directions." "Clients with decreased coordination should be instructed to hold handrails when ambulating."

"Clients with decreased sensory perception of touch should be carefully monitored for infection." Decreased sensory perception is a neurological change associated with aging. Clients with this change should be instructed to reduce the risks associated with falling. Therefore, the nurse should intervene to correct this misconception. All the other statements are correct and require no follow up. Clients with an increased risk for infections due to structural deterioration of microglia should be monitored for infections. Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts to facilitate retention of information. This would help the client to learn new information and recall it when needed. Clients with slower processing time should be provided with sufficient time to respond to questions or directions. Allowing adequate time for processing helps differentiate normal findings from neurologic deterioration. Clients with decreased coordination should be instructed to hold handrails when ambulating to provide support and prevent falls.

The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant? "Wash your hands frequently." "Do not skip any dose of your antibiotics." "Save the unfinished antibiotics for later use." "Stop taking the antibiotics when you feel better."

"Do not skip any dose of your antibiotics." Antibiotic-resistant infection develops when the hardiest bacteria survive and multiply. This may happen when a client stops taking an entire course of antibiotics, which leads to infections that are resistant to many antibiotics. Therefore a client should not skip any dose of an antibiotic. Hand washing is required to prevent infections; it is not related to antibiotic-resistant infections. Antibiotics should not be stopped even if the client has started feeling better; the full course of treatment should be taken. Non-compliance in taking the full course of prescribed antibiotics can lead to an antibiotic-resistant infection. It is dangerous to take the unfinished antibiotics at a later time; it may prove fatal if the antibiotics are outdated.

The registered nurse is preparing to assess a client's renal system. Which statement by the nurse indicates effective technique? "I must first palpate the client if a tumor is suspected." "I must first listen for normal pulse at the client's wrist region." "I must first auscultate the client and then proceed to percussion and palpation." "I must first examine tender abdominal areas and then proceed to nontender areas."

"I must first auscultate the client and then proceed to percussion and palpation." Palpation and percussion can cause an increase in normal bowel sounds and hide abdominal vascular sounds. Therefore it is wise to perform auscultation prior to percussion and palpation during clinical assessment of the renal system. Palpation should be avoided if a client is suspected of having a tumor because it could harm the client. It is more important as part of clinical assessment of the renal system to listen for bruit by auscultating over the renal artery. Bruit indicates renal artery stenosis. The nontender areas should be examined prior to tender areas to avoid confusion regarding radiating pain from the tender area being percussed.

An older adult male is discharged after treatment for urinary tract infection. The family members are instructed regarding age-related changes and care to be taken. In the follow-up visit, which statement made by the client's family indicates decreased risk of urinary retention in the client? "I ensure he sips water just before bed." "I respond immediately when he indicates a need to void." "I provide privacy and assistance to him to void." "I encourage him to use the urinal at least every 2 hours."

"I provide privacy and assistance to him to void." The family must help the client while voiding and provide privacy to encourage voiding without embarrassment. These measures will promote voiding and prevent urinary retention in the client. Giving the client water to drink just before bed can increase the risk of nocturia. Immediate response to the client when he needs to void reduces the risk of urinary incontinence. Encouraging the client to use the urinal at least every 2 hours helps the client empty the bladder. Therefore voiding at regular intervals reduces the risk of overflow urinary incontinence.

A registered nurse (RN) is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicates a need for correction? "I should walk on scatter rugs at home." "I should drink 3000 mL of water every day." "I should eat fruits and vegetables six times a day." "I should exercise the joints above and below the cast daily."

"I should walk on scatter rugs at home." A client with injuries due to a fall must avoid having throw or scattered rugs at home to reduce the incidence of falls. The registered nurse (RN) should encourage the client to drink 3000 mL of water per day to promote optimal bladder and bowel function. The client should eat six small meals with foods rich in fiber, such as fruits and vegetables, to prevent constipation. The RN has to encourage the client to perform exercise above and below the cast daily for a speedy recovery.

The registered nurse is teaching a student nurse about the interventions to be followed by a client to prevent the spread of infection. Which statement made by the student nurse indicates the need for further learning? "I will advise the client to squeeze the pustules." "I will advise the client to bathe daily with an anti-bacterial soap." "I will advise the client to remove crusts before applying topical drugs." "I will advise the client to apply warm compresses to areas of cellulites."

"I will advise the client to squeeze the pustules." The client should not squeeze the pustule as it contains pus and squeezing may cause the spread of bacterial infections to unaffected areas. Taking daily baths with an anti-bacterial soap reduces and prevents the spread of infection. The crusts should be gently removed before applying topical drugs so that drugs can be easily absorbed. Applying warm compresses to areas of cellulites increases comfort.

Which dietary suggestion should the nurse provide while teaching a group of geriatric female clients who have reduced amounts of circulating estrogen? "Include fish in your diet." "Include fruits in your diet." "Include yogurt in your diet." "Include legumes in your diet"

"Include yogurt in your diet." Clients ages 65 years or older are referred to as geriatric. Females usually attain menopause at the age of 55 years. Due to reduced amounts of circulating estrogen in postmenopausal women, bone density decreases, thus increasing the risk of osteoporosis. Geriatric clients should be advised to consume foods rich in calcium such as yogurt, which helps support increases in bone mass. Fish is a good source of omega-3-fatty acids, which maintains a healthy heart. Fruits are rich in fiber, which prevents constipation. Fiber is good for a client's overall health. Legumes are a good source of protein and strengthen the body. However, these dietary suggestions for elderly female clients are less beneficial when compared to the consumption of yogurt.

Which statement by a mother in the pediatric clinic requires further assessment by the nurse? My 13 month old goes to bed around 7 pm and wakes up at 10 am." "My 2 year old sleeps about 9 hours at night and still takes a nap." "My 9 year old daughter sleep 10 hours a night, sometimes 11 hours." "My 16 year old finishes homework late at night but wakes up at 6 am every day."

"My 16 year old finishes homework late at night but wakes up at 6 am every day." General recommendations for sleep amounts vary with age as follows: Infants: 14-16 hours each day Toddlers: 9-10 hours at night plus 2-3 hours of daytime naps School-age children: 9-11 hours Teenagers: 9 hours Adults: 7-9 hours The teenager in this question does not appear to getting 9 hours of sleep. The nurse should further assess for any abnormal findings related to sleep pattern in this patient.

Which of the following statements made by a mother would raise concerns about a developmental delay? "My 3-month-old raises her head and chest when lying down." "My 7-month-old transfers blocks from one hand to the other." "My 7-month-old never seems to smile." "My 1-year-old seems shy or anxious with strangers."

"My 7-month-old never seems to smile." A 7-month-old who never seems to smile would be a concern. The lack of smiling could be related to a number of developmental issues, including vision and hearing. By the end of 3 months, a child begins to develop a social smile, and by the end of 7 months, a child enjoys social play. A 3-month-old is expected to raise her head and chest when lying down. A 7-month-old is expected to be able to transfer blocks from one hand to the other. By the end of 1 year, a child is often shy or anxious and may experience what is referred to as separation anxiety.

During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. Which guidance should the nurse provide regarding sleeping position? "Turn from side to side." "Try to sleep on your stomach." "Elevate the head of the bed on blocks." "Place two pillows under your knees for sleep."

"Turn from side to side." The side-lying position will relieve back pressure; it also promotes uterine perfusion and fetal oxygenation. At 32 weeks' gestation the abdomen is too distended for the pregnant woman to lie in the prone position. Elevating the head of the bed will not relieve back pressure; it is used to limit gastroesophageal reflux. Lying on the back is contraindicated because it puts pressure on the vena cava, resulting in hypotension and uteroplacental insufficiency. Pillows under the knees are contraindicated because they place pressure on the popliteal area, which compresses the venous circulation, increasing the risk of thrombophlebitis.

What instruction would the nurse be most likely to give a client with reduced sensory perception to prevent injury from scalding? "Apply moisturizers." "Use a bath thermometer." "Dress warmly in cold weather." "Avoid frequent bathing with hot water.

"Use a bath thermometer." A change in sensory perception may occur due to a physical change in the dermis. The client must be taught to use a bath thermometer to prevent scalds. Applying moisturizers is taught in case of decreased dermal blood flow to prevent dryness. The nurse advises the client to dress warmly in cold weather, when the client is at increased risk for hypothermia. The client is advised to avoid frequent bathing with hot water in case of increased susceptibility to dry skin.

A nurse is educating the mother of a seven-month-old child about an adequate diet plan for the child. Which statement made by the nurse should be included? "You should provide up to 4 to 6 cups of milk per day." "You should refrain from serving finger food and feed the child." "You should supplement milk with solid food items like vegetables and fruits." "It is preferably to provide low-fat or skimmed milk until the baby is 2 years old."

"You should supplement milk with solid food items like vegetables and fruits." When the child is 6 months old, the mother should start supplementing the child's intake of milk with solid food items to ensure a balanced diet for adequate growth. The intake of milk should be limited to 2 to 3 cups per day because the consumption of more than a quart of milk per day tends to decrease the child's appetite for essential solid foods and results in inadequate iron intake. Serving finger foods to toddlers allows them to eat by themselves and to satisfy their need for independence and control. Small, reasonable servings allow toddlers to eat all of their meals. Children below 2 years of age should not be given low-fat or skimmed milk because the fat is important for the physical and intellectual growth of the child.

During which health maintenance visit for a toddler-age client should the nurse assess the ability to throw a ball overhand without losing balance? 12 months 18 months 24 months 30 months

18 months A toddler-age client should be able to throw a ball overhand without losing balance by 18 months of age [1] [2]. Twelve months is too young to throw a ball without losing balance. Twenty-four months and 30 months are later than when the nurse anticipates this skill to occur.

A lactating woman receives treatment for a medical condition and is taking a prescription medication that cannot be withheld. What type of drugs can the client take to minimize the risk to the neonate? Select all that apply. 1 Drugs that have sustained release 2 Drugs that are excluded from milk 3 Drugs consumed immediately after breastfeeding 4 Drugs that are the least likely to affect the neonate 5 Drugs with the lowest effective dose for longer period

2,3,4 Drugs that do not enter the breast milk are preferred because they are safe for neonates. Drugs should be taken immediately after breastfeeding so that the concentrations of the drug will be low or nonexistent in the next feeding. Drugs that are least likely to affect the infant are preferred. Breast-feeding should be avoided if sustained drugs are taken because they remain for a longer time in plasma. Drugs with the lowest effective doses for a shorter period of time should be taken because they remain in the blood for a shorter period of time.

A nurse is counselling the parents of a 13-year-old child. Which of these behaviors will the nurse include in the discussion? Select all that apply 1 Animism 2 Egocentrism 3 Logical reasoning 4 Concrete thinking 5 Imaginary Audience

2,3,5 The nurse will explain about logical reasoning, egocentrism, and imaginary audience to the parents of a 13-year-old child. Logical reasoning, seen during the formal operations period, means that an individual is capable of reasoning according to the situations and possibilities. There is prevalence of egocentrism in adolescents where they have a belief that their actions and appearance are constantly being scrutinized by an imaginary audience. Animism, seen in the preoperational period, is when a child believes that inanimate objects have feelings and wishes. Animism is seen in the 5-6 year olds. Concrete thinking is when a child starts to think about an act before performing it and understands differences in perspectives of others. This is seen at the age of 7 to 11 years during the concrete operations period.

On which basis is an alteration in functional ability categorized as a primary problem? Age at onset Sudden versus gradual onset Duration of the problem Absence as opposed to loss of function

Absence as opposed to loss of function Alterations in functional ability are categorized as a primary problem when the ability to perform a particular function never developed. They are categorized as secondary problems when the functional ability developed and was subsequently lost.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what? Providing instructions about restraints used during the procedure Administering a Fleet enema 1 hour before the procedure Encouraging increased intake of clear fluids Administering morphine 30 minutes before the procedure

Administering a Fleet enema 1 hour before the procedure To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A Fleet or tap water enema should be used. Restraints are not typically used during the procedure. The client will be kept nothing by mouth (NPO) for at least 8 hours before the procedure. Morphine is not typically used as a preoperative medication before a sigmoidoscopy.

A client undergoes a cesarean birth because of cephalopelvic disproportion. What care is needed for this client in addition to the routine nursing care given to all postpartum clients during the first 24 hours? Encouraging early ambulation Assessing the fundus gently but firmly Checking vital signs for evidence of shock Administering the prescribed pain medication

Administering the prescribed pain medication Because of increased pain and increased flatus, clients who have had cesarean births require more pain medication than do women who have vaginal births. Early ambulation is encouraged for all postpartum clients. Although this may be difficult because of the incision, palpating the fundus is a necessary part of postpartum care. Vital signs are checked routinely in all postpartum clients.

A client with end-stage renal disease is hospitalized. For which complications should the nurse monitor the client? Select all that apply. Anemia Dyspnea Jaundice Hyperexcitability Hypophosphatemia

Anemia Dyspnea Anemia results from decreased production of erythropoietin by the kidneys, which causes decreased erythropoiesis by bone marrow. Dyspnea is a result of fluid overload, which is associated with chronic kidney failure. Jaundice occurs with biliary obstruction or liver disorders, not with kidney failure. Lethargy occurs as a result of general depression of the central nervous system. Hyperphosphatemia occurs with kidney failure, not hypophosphatemia.

An 18-year-old adolescent reports irregularity in menses. Physical examination reveals decreased blood pressure. Her mother complains that her child often fears gaining weight and has a distorted self-image. What could be the reason for irregular menses? Bulimia Anorexia Orthorexia Binge disorder

Anorexia Anorexia is characterized by a lack of caloric intake motivated by a strong fear of becoming fat; this causes a decline in nutrition that may cause irregular menses. Bulimia is characterized by repeated episodes of binge eating followed by inappropriate compensatory behavior. Orthorexia is a disorder in which the individual avoids certain foods, believing them to be harmful. Binge disorder is excessive consumption of large amounts of high-calorie food.

A healthcare provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do? Slightly slit the top of the stockings to relieve pressure. Leave the anti-embolism stockings off to prevent tissue damage. Roll the top of the stockings to below the knees to limit popliteal pressure. Ask the healthcare provider if an elastic bandage can be used in place of the stockings.

Ask the healthcare provider if an elastic bandage can be used in place of the stockings. An elastic bandage can be adjusted to the varying proportions of the client's legs. Cutting the stockings to relieve pressure is inappropriate and will decrease the effectiveness of the stockings. Leaving the antiembolism stockings off to prevent tissue damage is unsafe; this permits venous stasis. Rolling the top of the stockings to below the knees to limit popliteal pressure will increase the pressure in the popliteal space, which increases venous stasis and the risk of thrombophlebitis.

he three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and which other element? Accountability Attitude Education Value

Attitude The Robert Wood Johnson Foundation funded the national initiative called Quality and Safety for Nurses (QSEN), which builds on the work of the Institute of Medicine (IOM), defines safety, and outlines the necessary elements of knowledge, skill, and attitude to demonstrate safety in one's practice. Accountability is a critical aspect of a culture of safety; recognizing and acknowledging one's actions is a trademark of professional behavior, but accountability is not considered one of the three major elements of QSEN.

Which of the following is a priority for a nurse to include in a teaching plan for a patient who desires self-management and alternative strategies? Body alignment and superficial heat and cooling Patient-controlled analgesia (PCA) pump Neurostimulation Peripheral nerve blocks

Body alignment and superficial heat and cooling Body alignment and thermal management are examples of nonpharmacologic measures to manage pain. They can be used individually or in combination with other nondrug therapies. Proper body alignment achieved through proper positioning can help prevent or relieve pain. Thermal measures such as the application of localized, superficial heat and cooling may relieve pain and provide comfort. PCA, neurostimulation, and peripheral nerve blocks are not totally self-managed or alternative therapies, because they are used under the direction of medical professionals.

The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which of the following activities are considered in the BADLs assessment? (Select all that apply.) Brushing teeth or dentures Dressing oneself in the mornings Washing, drying, and folding laundry Counting own pulse and taking heart pill Taking the bus to the park Calling family members

Brushing teeth or dentures Dressing oneself in the mornings BADLs include actions related to self care and mobility and also includes eating, personal hygiene, and grooming activities. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, using the telephone, taking medications, and using transportation.

A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How would the nurse evaluate the client for bladder distension? By catheterizing the client for residual urine By palpating the client's suprapubic area gently By asking the client whether she still feels the urge to urinate By determining whether the client is experiencing suprapubic pain

By palpating the client's suprapubic area gently Palpation will indicate whether bladder distention is present. The increased intra-abdominal space available after birth can result in bladder distention without discomfort. Assessment should be done before interventions. Trauma to the area makes surrounding organs atonic; the client may have a full bladder and not feel the urge to void.

The nurse is obtaining a history from a patient in pain. Which question asked by the nurse will give the most information about the patient's pain? How long have you had this pain? Can you describe your pain? How much medication do you take for the pain? How many times a day do you take medication for the pain?

Can you describe your pain? Because pain is a subjective experience, asking a question that addresses the patient's experience with the pain will elicit more information than the more specific information asked in the other three responses.

Which factors can alter both bowel and urinary elimination patterns in adult patients? (Select all that apply.) Cognitive disorders Antidepressant medications Sedentary lifestyle Impaired mobility Neurologic impairment

Cognitive disorders Impaired mobility Neurologic impairment Elimination is a concept that applies to both bowel and bladder function. Some factors such as cognitive disorders (difficulty sensing or communicating need); impaired mobility (inability to ambulate); and neurologic impairment (interruption of bowel and bladder innervation) affect both bowel and bladder function. Antidepressant mediations and sedentary lifestyle can affect bowel function by promoting constipation but are not ordinarily associated with urinary elimination alterations.

A nurse is teaching a childbirth preparation class. Which information regarding discomfort during labor should the nurse be certain to include in her teaching? Labor should be mostly pain free and uneventful. Breathing techniques will be taught to prevent the need for medication. Medication is given to women who experience painful labor contractions. Comfort measures are available when the discomfort of contractions becomes excessive.

Comfort measures are available when the discomfort of contractions becomes excessive. Classes in preparation for parenthood should help couples develop realistic expectations of the labor process, including associated discomfort and ways of dealing with it. Stating that labor should be mostly pain free and uneventful is false reassurance; contractions are uncomfortable, and there is no guarantee that the birthing process will be uneventful. Breathing techniques may not be enough for some women to limit the discomfort of contractions. The focus should not be on pain; comfort measures should be attempted first before medication is used.

Which of the following concepts would a nurse think has the strongest link to safety? (Select all that apply.) Cognition Communication Quality Regulation Teamwork

Communication Quality Regulation Teamwork Communication, quality, regulation, and teamwork are the concepts with the strongest links to safety and include processes that are essential for the nurse to consider related to safety. Safety refers to the prevention of injuries or freedom from accidents. Quality and safety are interrelated, overlapping concepts, and it is difficult to achieve outcomes in one without working on the other. Regulation refers to the mandates that have been credited with many of the improvements in health care systems, such as those from the Joint Commission, and to the oversight for the safety of the public provided by state boards of nursing. Teamwork and the ability of health care professionals to work together account for as much as 70% of health care errors. Cognition dependent on an optimally functioning brain could affect vigilance but would not be considered a concept that has one of the strongest links to safety.

Which is the best description of the scope of the concept of functional ability? Continuum from complete independence to complete dependence Ability to perform the normal range of basic and advanced activities of daily living Capacity to perform specific self-care behaviors Levels of function within the family and the community

Continuum from complete independence to complete dependence On the broadest level, the scope of functional ability occurs along a continuum ranging from complete independence to complete dependence. An individual with full functional ability can independently meet all necessary life activities without any sort of assistance or use of assistive devices.

The nurse is developing a teaching plan of general health for an adolescent who will be entering college. The nurse should discuss which modifiable factors that could affect the student's sleep pattern? (Select all that apply.) Coping strategies Study habits Diet Social concerns Age

Coping strategies Study habits Diet Social concerns Assessment of sleep is critical as a component of health and well-being assessment in every person. Changes in daily routine, stress, diet, social concerns, and anything that affects daily functioning, routine, or affect can be accompanied by a sleep problem of some type. Thorough assessment of sleep quality can be complex for a variety of reasons. Age is not a modifiable factor affecting sleep quality.

Which hormone levels peak during the client's sleep? Select all that apply. Cortisol Calcitonin Thyrotropin Progesterone Growth hormone

Cortisol Thyrotropin Growth hormone Cortisol, thyrotropin, and growth hormone levels peak during sleep. Calcitonin and progesterone hormone levels are not altered during sleep.

A client who had abdominal surgery is receiving patient-controlled analgesia intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client, with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? Monitor the client's pain level for another hour. Determine the integrity of the intravenous delivery system. Reprogram the pump to deliver a bolus dose every 8 minutes. Arrange for the client to be evaluated by the healthcare provider.

Determine the integrity of the intravenous delivery system. Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a healthcare provider's prescription. The healthcare provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.

An advertisement at a local church reads, "New Mothers: Join us Friday evening at 7 for an informal discussion about your baby. Find out when you can expect the first smile, the first word, the first step." Which of the following is an appropriate description of the topic? Developmental level Developmental delay Developmental milestones Developmental age

Developmental milestones Developmental milestones are a set of functional skills or age-specific tasks that most children can complete at a certain age range. These milestones provide a basis for developmental assessment because they serve as major markers in tracking the emergence of motor, social, cognitive, and language skills. Thus the topic of a discussion about when to expect a baby to exhibit abilities such as saying the first word or taking the first step can appropriately be referred to as developmental milestones.

A client is admitted to the emergency department with profuse vomiting. The client reports that the vomitus was bright red in color. What does the nurse identify as the priority intervention? Begin gastric lavage Obtain stool for occult blood Ascertain the client's eating habits Draw blood for typing and crossmatching

Draw blood for typing and crossmatching Immediate blood replacement is indicated. A type and crossmatch will ensure that the correct blood type will be administered to the client, preventing a transfusion reaction. Beginning gastric lavage is not the priority, although it may be done later. Obtaining a stool for an occult blood test is not the priority, although it may be done later. Ascertaining the client's eating habits is not the priority, although it may be done later when completing an admission history and physical.

The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? A. Eat foods high in fiber. B. Drink 6 to 8 glasses of noncaffeinated fluids daily. C. Exercise in the morning and evening. D. Visit the urologist once yearly.

Drink 6 to 8 glasses of noncaffeinated fluids daily. Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.

The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? (Select all that apply.) Drink 6 to 8 glasses of noncaffeinated fluids daily. Exercise daily. Increase fiber in the diet. Void when the urge is felt. Eat fruit twice daily.

Drink 6 to 8 glasses of noncaffeinated fluids daily. Void when the urge is felt. Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract infection.

Which factors differentiate developmental disability from developmental anomaly? Select all that apply. Severity Time of onset Level of care demand Developmental area involved Duration

Duration Time of onset A developmental anomaly is any congenital defect whereas a developmental disability is any type of pathologic condition that occurs before the age of 22 and persists throughout the life of the individual. Thus the factors that differentiate the two are time of onset and duration.

A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do? Request that the client's food be pureed. Feed the client to conserve the client's energy. Have a family member assist the client with each meal. Encourage the client to participate in the feeding process.

Encourage the client to participate in the feeding process As part of the rehabilitative process after a brain attack, clients should be encouraged to participate in their own care to the extent that they are able and to extend their abilities by establishing short-term goals. A client with a brain attack may or may not have dysphagia; altering the consistency of food without the need to do so may make it less palatable. Making the client feel helpless discourages independence. Having a family member assist the client with each meal is unrealistic; family members may not be available because of other responsibilities.

The nurse should teach a patient about the dangers of excessive drowsiness when prescribed a combination of which medications? (Select all that apply.) Gabapentin (Neurontin) Fluoxetine (Prozac) Diphenhydramine (Benadryl) Lorazepam (Ativan) Zolpidem (Ambien) Pseudoephedrine (Sudafed)

Gabapentin (Neurontin) Fluoxetine (Prozac) Diphenhydramine (Benadryl) Lorazepam (Ativan) Zolpidem (Ambien) Common pharmacologic agents used for sleep disorders, to aid in sleeping, include: Neurontin (anticonvulsant), Prozac (antidepressant), Benadryl (antihistamine), Ativan (benzodiazepine), and Ambien (benzodiazepine receptor-like agent). Sudafed is commonly prescribed for congestion and is more likely to act as a stimulant.

During percussion of the client's bladder, the primary healthcare provider hears sounds as high up as the umbilicus. While caring for this client, the nurse provides privacy, assistance, and voiding stimulants as needed. What other action should the nurse perform while caring for this client? Administer potentially nephrotoxic agents Evaluate the client's history for steroid therapy Evaluate the client's history for anticholinergic therapy Administer nonsteroidal antiinflammatory drugs (NSAIDs)

Evaluate the client's history for anticholinergic therapy Distention of the bladder occurs due to urine retention. A distended bladder can be percussed as high as the umbilicus. The other intervention that the nurse should perform is to evaluate the client's history for anticholinergic therapy because anticholinergic drugs promote urine retention. The nurse should provide privacy, assistance, and voiding stimulants, such as warm water over the perineum as needed. The nurse should carefully administer potentially nephrotoxic agents if the client has decreased glomerular filtration rate (GFR). The nurse should evaluate the client's history for steroid therapy if there is an increase in blood urea nitrogen (BUN) levels. The nurse should not administer nonsteroidal antiinflammatory drugs (NSAIDs) for urinary retention.

A nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). What does the nurse conclude that these findings indicate? Hypoglycemia Seizure activity Expected adaptations Respiratory distress syndrome

Expected adaptations During periods of active or irregular sleep, healthy newborns have some twitching movements and irregular respirations; the heart rate, respirations, and blood glucose level are within expected limits. Hypoglycemia in newborns is characterized by a blood glucose level below 30 mg/dL (1.7 mmol/L). Twitching is a common finding in healthy neonates and does not indicate seizure activity; it often occurs with crying or stimulation. There are no signs of respiratory distress syndrome. The newborn respiratory rate ranges between 30 and 60 breaths/min; irregular breathing is expected.

Which clinical indicators does the nurse identify that suggest a client is experiencing urinary retention and overflow after a cerebrovascular accident (also known as a "brain attack")? Select all that apply. Edema Oliguria Frequent voidings Suprapubic distention Continual incontinence

Frequent voidings Suprapubic distention With retention, the total amount of urine produced is unaffected. Atony permits the bladder to fill without being able to empty. As pressure builds within the bladder, the urge to void occurs, and just enough urine is eliminated to relieve the pressure and the urge to void. The cycle is repeated as pressure again builds. Thus small amounts are voided without emptying the bladder. As urine is retained and the bladder enlarges, it causes suprapubic distention. Edema is a sign of fluid volume excess, not urinary retention. Oliguria (urinary output less than 500 mL/day) is a sign of kidney failure. Continual incontinence does not occur with urinary retention.

In which way is the relationship between sexuality and functional ability most similar to or most different from that between culture and functional ability? Functional ability is a significant determinant of sexuality. There is a strong reciprocal relationship between sexuality and functional ability. Neither sexuality nor culture influences functional ability but rather are affected by it. Both sexuality and culture are major determinants of functional ability.

Functional ability is a significant determinant of sexuality. Sexuality has a primarily unidirectional relationship with functional ability in that functional ability is a significant determinant of sexuality. Culture also has a unidirectional relationship with functional ability but it is in the opposite direction, with culture being a major determinant of functional ability.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? Moving the client's bedside table closer to the bed Encouraging the client to take an available sedative Instructing the client to call the nurse before going to the bathroom Assisting the client to telephone home to say goodnight to the spouse

Instructing the client to call the nurse before going to the bathroom Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to go to the bathroom unassisted. Although moving the bedside table closer to the bed is helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it does not reduce the incidence of falls.

In which way is the concept of family dynamics unique among the concepts with significant relationships to development? It both affects and is affected by developmental status. It potentially affects all five areas of development. Its effect on development is reversible to a degree. Its effect on development varies with age.

It both affects and is affected by developmental status. In addition to family dynamics, concepts that represent major influencing factors on development are nutrition, genetics, culture, sensory perception, cognition, functional ability, mobility, reproduction, and sexuality. The concept of family dynamics is unique among these because of its strongly reciprocal relationship with development. Family dynamics both affects development and is affected by it. Nutrition, genetics, and culture are primarily determinants of development, whereas development is a major determinant of sensory perception, cognition, functional ability, mobility, reproduction, and sexuality.

Which nursing interventions would help to prevent medication errors in pediatrics? Select all that apply. Knowing information about the drug Avoiding verbal telephone orders Using abbreviations and acronyms Checking the drug label and client's information three times before giving the drug Using authoritative resources as references

Knowing information about the drug Avoiding verbal telephone orders Checking the drug label and client's information three times before giving the drug Using authoritative resources as references The nurse should know all about the information of the drug (such as the action, dosage, route, uses, and adverse effects) to avoid medication errors. The nurse should avoid the use of verbal telephone orders because of the high risk of miscommunication. The nurse should check the drug label and the client's information three times before administering the drug. The nurse should use the authoritative resources such as the drug handbooks as a reference. The nurse should avoid the use of abbreviations and acronyms because they lead to confusion.

A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do? 1 Shorten the stride of the unaffected extremity. 2 Advance the cane and the affected extremity simultaneously. 3 Lean the body toward the side with the cane when ambulating. 4 Hold the cane on the same side as the affected extremity and increase the base of support.

Lean the body toward the side with the cane when ambulating. Advancing the cane and the affected extremity simultaneously supports stability. The body is supported partially on the affected limb and partially on the cane as the unaffected limb moves forward. Shortening the stride of the unaffected extremity will produce an awkward gait and instability; normal ambulation should be approximated. Leaning the body toward the cane when ambulating will change the center of gravity and cause instability. The cane is held on the unaffected, not the affected, side and advanced at the same time as the affected extremity to increase the base of support and provide stability.

An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavily while sleeping. The client is found to have enlarged tonsils. Which condition may the client have? Laryngeal trauma Vocal cord paralysis Obstructive sleep apnea Subcutaneous emphysema

Obstructive sleep apnea Obstructive sleep apnea (OSA) is a condition in which the client may feel tired upon waking in the morning and may feel sleepy during the daytime. These clients may also snore heavily while sleeping. Smoking and enlarged tonsils increase the risk of sleep apnea. Laryngeal trauma occurs secondary to a crushing or direct blow injury, fracture, or prolonged endotracheal intubation. Vocal cord paralysis occurs in clients with neurologic disorders or with conditions that damage either the vagus nerve or the laryngeal nerves. Subcutaneous emphysema is a manifestation of laryngeal trauma, a condition in which there is the presence of air in the subcutaneous tissue.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs, such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation

Pain history, including location, intensity, and quality of pain Pain pattern, including precipitating and alleviating factors Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain, and its assessment helps the nurse anticipate and meet the needs of the client. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Assessment of the precipitating factors helps the nurse prevent the pain and determine its cause. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience, and therefore the nurse has to ask the client directly instead of accepting the statement of the family members.

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply. Palpating for tenderness Observing nonverbal cues Inspecting any areas of discomfort Noticing if the pain localized or radiated Noticing if the client gives nonverbal signs of pain

Palpating for tenderness Inspecting any areas of discomfort To understand the severity of a client's pain, the registered nurse asks the client to rate the pain on a scale from 0 to 10. The nursing student may palpate for tenderness while assessing the severity of pain and inspecting the area of discomfort. Nonverbal cues are used to understand the nature of pain. Physical assessments of the nature of pain may involve the nurse noticing whether the pain is radiated or localized. The client should also be checked for any nonverbal signs of pain.

At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client? Planning nursing care activities that provide time for the client to rest and sleep Preparing for the probability of hemorrhage by massaging the client's uterus frequently Arranging an individual session in which the client can learn about successful breastfeeding Anticipating safety needs by instructing the client to remain in bed and call for assistance whenever ambulating

Planning nursing care activities that provide time for the client to rest and sleep After laboring all night the client is tired and needs uninterrupted rest. Massaging the fundus frequently is unnecessary unless the uterus becomes boggy. Providing a lesson on breastfeeding is premature. The client is not ready to learn because she needs to rest and sleep after a long labor. It is necessary for the client to call for assistance only the first time she ambulates; otherwise the client may ambulate ad libitum.

The student nurse is studing for an exam. The student nurse understands that which of the following is the one of the most important tests to identify sleep disorders? Actigraphy Sleep Journals Polysomnogram (PSG) Detailed sleep history

Polysomnogram (PSG) One of the most important tests to identify sleep disorders is the Polysomnogram (PSG). PSGs can be used to evaluate a variety of sleep disorders, including difficulty falling asleep, difficulty staying awake, and sleep-related breathing disorders. Actigraphy has been found to be a valid measure in a variety of populations, although it is not a definitive diagnostic tool. Sleep journals and sleep history are subjective assessments and are not as accurate as the PSG. Subjective assessment of sleep is fraught with difficulties because an individual who is sleeping is not aware of what is happening during sleep.

The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which of the following activities are considered in the IADLs assessment? (Select all that apply.) Feeding oneself Preparing a meal Balancing a checkbook Walking Toileting Grocery shopping

Preparing a meal Balancing a checkbook Grocery shopping IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care. IADLs are more complex skills that are essential to living in a community.

Who would the nurse explain would go through the initiative versus guilt stage of Erikson's theory? Toddlers Preschoolers Old aged people Middle aged people

Preschoolers Preschoolers between the ages of 3 to 6 years of age are in the initiative versus guilt stage. During this stage, children like to pretend and play new roles. Toddlers will go through the autonomy versus guilt stage. By this stage, a growing child is more accomplished in some basic self-care activities, including walking, feeding, and toileting. The integrity versus despair stage of Erikson's theory relates to the elderly. Middle-aged people go through the generativity versus self-absorption and stagnation stage. Here, adults start focusing on future generations.

A defining characteristic of high reliability organizations (HROs) is sensitivity to operations. Which of the following is a manifestation of this characteristic? Near misses are treated as opportunities for improvement. Process anomalies and outliers are quickly identified. Ongoing efforts are to simplify solutions to problems. Decision making is strongly hierarchical.

Process anomalies and outliers are quickly identified. HROs exhibit sensitivity to operations, which means that they maintain a "situational awareness" in which process anomalies and outliers are quickly identified. This sensitivity to operations both reduces the number of errors and facilitates prompt recognition to avoid larger consequences from errors. HROs are preoccupied with failure and focused on predicting and eliminating errors instead of reacting to them. This is a second defining characteristic of HROs which involves near misses being treated as opportunities for improvement. HROs recognize the complexity of their work and have a reluctance to simplify. They also deemphasize hierarchy and defer to the person with the most knowledge.

A teenager about to drive a car for the first time says, "I don't want to drive in the empty parking lot; I want to drive to the mall." His father replies "You have to crawl before you can walk." Which attributes of development are most clearly reflected in the father's response? Growth and differentiation Maturation and refinement Progression and sequence Organization and duration

Progression and sequence The attributes of development most clearly reflected in the statement "You have to crawl before you can walk" are progression and sequence. Development is a gradual, qualitative change in which an individual's abilities expand and increase in complexity according to a dynamic, predictable sequence that begins at birth and ends at death. Developmental level refers to an individual's position in the sequence of development. Developmental age is used to describe developmental progress.

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what? Promote gluconeogenesis. Produce an antiinflammatory effect. Promote cell growth and bone union. Decrease pain medication requirements.

Promote cell growth and bone union. There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. Intake of a high protein diet during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain

Which of the following interventions are priorities in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? (Select all that apply.) Promoting rest and sleep Promoting a diet rich in protein Promoting exercise and ambulation Assisting the patient with ADLs Limiting visitors and social contacts

Promoting exercise and ambulation Promoting rest and sleep It is important to promote independence in ADLs early in the plan of care to increase independence in general. Promoting rest and sleep will promote well-being. Ambulation and exercise promote well-being and increase healing by circulating oxygen to the brain. Protein promotes healing in postsurgical patients but is not a main focus in stroke patients. Assisting the patient does not promote independence. Limiting visitors will isolate the patient, which can lead to depression.

A 30-year-old patient presents to the clinic complaining of difficulty sleeping and is diagnosed with disrupted sleep pattern. The nurse is reconciling the patient's medications. Which of the following medications would the nurse suspect is the cause of the patient's disrupted sleep pattern? Gabapentin (Neurontin) Diphenhydramine (Benadryl) Pseudoephedrine (Sudafed) Zolpidem (Ambien)

Pseudoephedrine (Sudafed) Sudafed is commonly prescribed for congestion and acts as a stimulant and is the most likely is the cause of this patient's disrupted sleep pattern. Gabapentin (Neurontin), Diphenhydramine (Benadryl), and Zolpidem (Ambien) are all common pharmacologic agents used to aid in sleeping. These are not likely to cause disrupted sleep pattern.

A nurse is counseling a pregnant client who maintains a vegetarian diet. What should the nurse plan to do to ensure optimal nutrition during the pregnancy? Refer the client to a dietitian to help plan her daily menu. Encourage the client to join a group that teaches nutrition. Explain that she needs to include meat in her diet at least once a day. Advise the client that it is unhealthy to continue a vegetarian diet during pregnancy.

Refer the client to a dietitian to help plan her daily menu. The dietitian can give the client specific information that would help her plan nutritious meals. Specific foods, such as nuts and soy products, may be substituted for meat or animal-related products. The client may know healthy nutrition; she needs help to adapt the vegetarian diet to meet pregnancy needs. Explaining that she needs to include meat in her diet at least once a day or advising the client that it is unhealthy to continue a vegetarian diet during pregnancy ignores the client's beliefs and lifestyle; a nutritious vegetarian diet is available during pregnancy.

When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." How does the nurse interpret the client's behavior? Needs the instructions to be repeated Requires an intervention immediately Does not understand the numeric scale Is using humor to get the nurse's attention

Requires an intervention immediately The client reported a number as instructed but chose a number beyond the stated intensity scale. When numbers above 10 are identified, clients are communicating that the pain is excessive; immediate nursing action is indicated. It is not likely that the client misunderstood the instructions or does not understand the numeric scale; the client reported a number as instructed but chose a number beyond the stated intensity scale. The client has the nurse's attention; the use of humor is not commonly associated with clients in pain.

Appropriate approaches used by the long-term care nurse to provide education for a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) Schedule a visit by another resident who is diabetic. Demonstrate food choices using food photographs. Avoid discussion of the patient's favorite foods. Remind the patient that a lot of damage has already occurred. Encourage the patient's family to participate in teaching sessions. Ask the patient about past experiences with lifestyle changes.

Schedule a visit by another resident who is diabetic. Demonstrate food choices using food photographs. Encourage the patient's family to participate in teaching sessions. Ask the patient about past experiences with lifestyle changes. Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

A nursing instructor asks a nursing student about the sleep pattern of teenagers. Which statements made by the student indicate adequate learning? Select all that apply. Teenagers often have reduced hours of sleep. Teenagers often suffer from restless leg syndrome. Teenagers get roughly 7.5 hours of sleep each night. Twenty percent of a teen's sleep cycle is rapid eye movement (REM) sleep. Teenagers resist sleeping because they are unaware of fatigue.

Teenagers often have reduced hours of sleep. Teenagers get roughly 7.5 hours of sleep each night The typical adolescent is subject to a number of changes, such as school demands, after-school social activities, and part-time jobs, that reduce the time spent sleeping. On average, teenagers get about 7.5 hours of sleep per night; preschoolers sleep an average 12 hours a night. Restless leg syndrome is common in young adults, not teenagers. Young adults, not adolescents, have 20% of their sleep time in REM sleep. Preschoolers often resist sleeping because they are unaware of fatigue or have a need to be independent.

A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube? Select all that apply. The infant cries without noise. Aspiration produces a small quantity of light-yellow or light-green liquid. The tube is inserted to a depth from the ear to the tip of the nose to the sternum. A whooshing sound is auscultated in the epigastric area when air is introduced into the tube. Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic.

Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic. Aspiration produces a small quantity of light-yellow or light-green liquid. Aspirated fluid that is either light green or yellow indicates gastric contents. The Nitrazine strip test provides reliable proof that the tube is in the stomach. The tube is in the trachea, not the esophagus; when a tube crosses through the larynx, the infant is unable to vocalize. Although the tube being inserted to a depth from the ear to the tip of the nose to the sternum is the correct measurement of the length of tube to be inserted, it is not a guarantee that the tube is in the stomach. The "whoosh test" is no longer used to verify placement of the tube because evidence has shown that it is not reliable.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? The client weighs 151 lbs (68.5 Kg). The client's pain is 7 on a scale of 1 to 10. The client's fasting blood sugar is 95 mg/dL. The client's blood pressure is 140/90 mm/Hg.

The client's pain is 7 on a scale of 1 to 10. Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client's health status. The client's weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.

Instruments such as the Functional Activities Questionnaire (FAQ) for postoperative patients who are at home, the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening (MDS) for nursing home patients, the Functional Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). The nurse needs to remember that a disadvantage of these instruments includes: The measurement of efficacy and reliability of the instruments used to assess activities of daily living (ADLs). The variations in assessments and responses may be subjective because of self-reporting of functional activities. The instruments do not show a true measure of ability because of a lack of interactivity during the assessments. The information contained in the instruments is insufficient to make a determination about functional status in these populations.

The variations in assessments and responses may be subjective because of self-reporting of functional activities. A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) instruments is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.

Which older adult populations should have a comprehensive assessment of functional ability? Select all that apply. Those with multiple coexistent health problems Those older than age 75 Those with a change in mental status Those with a demonstrated loss of ability to perform one or more instrumental activities of daily living Those who live alone

Those with a demonstrated loss of ability to perform one or more instrumental activities of daily living Those with a change in mental status Those with multiple coexistent health problems Comprehensive functional assessment, which is a time-intensive, interprofessional effort requiring use of multiple assessment tools, is indicated under specific circumstances. In older adults it is indicated when an individual has demonstrated a loss of functional ability, has experienced a change in mental status, has multiple health conditions, or is frail.

A nurse is teaching a group of parents about the sleep patterns of their children, who range in age from 18 to 36 months. What information is the nurse likely to provide? Select all that apply. Total sleep averages 12 hours a day. Toddlers normally take several naps during the day. It is uncommon for toddlers to awaken during the night. In the waking period, the toddler may engage in sleepwalking. During this period, the toddler may be unwilling to go to bed at night.

Total sleep averages 12 hours a day. During this period, the toddler may be unwilling to go to bed at night. The nurse tells the parents that toddlers sleep an average of 12 hours a day. During this period, toddlers may be unwilling to go to bed at night because they need autonomy or because they fear separation from their parents. The infant normally takes several naps during the day, but sleeps an average of 8 to 10 hours during the night. It is common for toddlers to awaken during the night. In the waking period, preschoolers (rather than toddlers) exhibit brief crying, walking around, unintelligible speech, sleepwalking, or bed-wetting.

A student nurse receives an order for diazepam to be given intravenously. Diazepam tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? Communication error Diagnostic error Preventive error Treatment error

Treatment error The nurse avoided a treatment error; she was prevented from giving the wrong type of medication. Diazepam (Valium) for intravenous administration is clear and comes prepared in a vial labeled for intravenous administration. According to Leape, treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in an avoidable delay in treatment or in responding to an abnormal test. A communication error results from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, a failure to employ indicated tests, the use of outmoded tests, or a failure to act on results of monitoring or testing. Preventive errors occur when there is a failure to provide prophylactic treatment when monitoring is inadequate, or when follow-up of treatment is inadequate.

The nurse is caring for a patient who will be discharged with a pain management plan following a fracture to the forearm. Which of the following should the nurse instruct the patient to do first when in pain? Try not to take your medications until you pain level is at an 8. Take your pain medications when your pain level is at a 3. Try repositioning your arm and applying ice before taking medications. Keep the hand immobile to prevent pain.

Try repositioning your arm and applying ice before taking medications. Nonpharmacological measures may prevent the need for medications and may be all that is necessary for proper management. A pain level of an 8 is difficult to manage. Patients should consider taking pain medications when their pain level is under 5 to gain better control over the pain. Elevating the shoulder would be uncomfortable for the patient and this position may increase pain.

An person of Northern heritage is at an increased risk for which of the following: (Select all that apply.) Vitamin c deficiency Type 1 diabetes Celiac disease Type 2 diabetes Hypertension Metabolic syndrome

Type 1 diabetes Celiac disease Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, Hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? Urinate small amount, stop flow, fill half of cup Collect the last urine sample voided in the night Keep the urine sample in dry warm area if delay is anticipated Send the urine sample to the laboratory within 6 hours of collection

Urinate small amount, stop flow, fill half of cup The nurse instructs the client to always collect the midstream urine to send as a test specimen. The client should be instructed to cleanse the perineum with the wipe provided, urinate a small amount, and then stop the flow. The client should then position the specimen cup a few inches from the urethra and resume urination, filling the cup at least half way. The client is asked to collect the first sample voided in the morning because the urine is highly concentrated in the morning. Keeping the urine sample in the refrigerator helps reduce bacterial growth due to alkaline environment. The cells in the urine sample begin to break down in alkalinity, and therefore the client is instructed to send the sample to the laboratory as soon as collected.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? Asking the client's parent Using Wong's "Pain Faces" Observing the client's body language Explaining the use of a 0 to 10 pain scale

Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

Stephanie is a 70-year-old retired schoolteacher who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Which of the following options should you suggest for her plan of care, considering her expressed wishes? Using a stationary exercise bicycle and free weights and attending a spinning class Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Drinking chamomile tea and applying icy/hot gel Receiving acupuncture and attending church services

Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Mind-body therapies are designed to enhance the mind's capacity to affect bodily functions and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Although getting exercise, drinking chamomile tea and applying gels, and receiving acupuncture and attending church services may be beneficial, they are not classified as mind-body therapies in combination as specified in these answer choices.

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? Vitamin B12 Vitamin C Vitamin D Omega-3 fatty acids

Vitamin B12 Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

Gastrointestinal elimination serves which primary physiologic purpose? Electrolyte homeostasis Gastrointestinal integrity Peristaltic activity Waste product excretion

Waste product excretion The definition of elimination is the excretion of waste products, which is also the primary physiologic purpose of elimination. The concept of gastrointestinal elimination refers to the physiologic elimination of waste products by the bowel. Electrolyte homeostasis, maintenance of gastrointestinal integrity (intact bowel), and peristaltic activity facilitate waste product excretion.

Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. Pain should be re-assessed at which minimum interval? With each new report of pain Before and after administration of narcotic analgesics Every 10 minutes Every shift

With each new report of pain Before and after administration of narcotic analgesics Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. At a minimum, pain should be reassessed with each new report of pain and before and after administration of analgesics.

The geriatric nurse practitioner preparing to assess an 84-year-old whose daughter is concerned about her ability to live alone would complete a developmental assessment. functional assessment. life experiences survey. recent life changes questionnaire.

functional assessment. The nurse would complete a functional assessment of an individual's ability to carry out activities of daily living (ADLs) such as basic activities of daily living (BADLs) or instrumental activities of daily living (IADLs). The focus of the assessment to address the daughter's concern should be function, not overall development. The life experiences survey is aimed at identifying those in need of guidance relative to stress and coping, as is the recent life changes questionnaire.

A young adult patient complains to the nurse that they are falling asleep at various times during the day without any indication that they are tired. The nurse suspects which of the following conditions? narcolepsy disrupted sleep pattern obstructive sleep apnea somnambulism

narcolepsy Narcolepsy is characterized by overwhelming daytime sleepiness; individuals with this condition often find it difficult to stay awake for long periods of time, and they may experience brief periods of falling asleep throughout the day. Disrupted sleep pattern would present as nighttime interruptions in the sleep/wake patterns. OSA is a condition characterized by interruption of sleep due to temporary airway obstruction by the soft palate, base of the tongue, or both. Somnambulism is a term used to define sleep walking and occurs most frequently among children.

The nurse is advising a patient about weight management and the importance of maintaining a healthy weight. Which of the following should the nurse include in the teaching plan? sleep hygiene instruction sleep medication instruction reducing sleeping time increasing sleep time

sleep hygiene instruction Good sleep hygiene and sleep are essential to effective weight management and anything that diminishes the amount or quality of sleep can have significant consequences on a person's weight. Weight gain is a common side effect of medications for sleep. Good sleep hygiene includes getting the same amount of sleep every night. Reducing or increasing sleep will lead to imbalances and can lead to weight gain.