P. Adaptation Practice

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

Increased urine osmolarity Rationale: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

The nurse is managing care of a primigrada at full term who is in active labor. What should be included in developing the plan of care for this client?

Anesthesia/pain level assessment every 30 minutes. Rationale: The nurse should monitor anesthesia/pain levels every 30 minutes during active labor to ascertain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client. When in active labor, oxygen saturation is not monitored unless there is a specific need, such as heart disease. The client should not be on her back but wedged to the right or left side to take the pressure off the vena cava. When lying on the back, the fetus compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30 minutes to 1 hour.

After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death?

Relatives are especially grieved when a child does well at first but then declines rapidly. Rationale: It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child's death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily destroyed when a death is untimely if the family views the personnel as having done all that was possible. It is not more difficult for parents to accept the death of an older child than that of a younger child.

To follow standard precautions, the nurse should carry out which measure?

Wearing gloves when administering I.M. medication Rationale: To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with a client's blood, body fluid, mucous membranes, or nonintact skin (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.

After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?

Hydrocephalic infant. Rationale: Congenital anomalies such as hydrocephalus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth restriction, and poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of severe vasoconstriction. Intrauterine growth restriction is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction.

Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)?

Hyperactivity and speech disorders are common. Rationale: Central nervous system disorders are common in neonates with FAS. Speech and language disorders and hyperactivity are common manifestations of central nervous system dysfunction. Mild to severe intellectual disability and feeding problems also are common. Delayed growth and development is expected. These neonates feed poorly and commonly have persistent vomiting until age 6 to 7 months. These neonates do not have a 70% mortality rate, and there is no treatment for FAS.

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul-smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for:

Puerperal infection. Rationale: The client is exhibiting signs and symptoms of puerperal infection, which include profuse foul-smelling lochia, chills, fever, and a uterus that is larger than expected for the first postpartum day. Infection may spread through the lymphatic system; antibiotic therapy is necessary. During normal uterine involution, the lochia becomes less profuse and should not be foul-smelling. If the client had retained placental fragments, lochia rubra, not foul-smelling lochia serosa, would continue. Uterine atony refers to relaxation of the uterus and subsequent failure to contract properly. It may be a result of retained placental fragments.

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:

turn the client on his left side and place the bed in Trendelenburg's position. Rationale: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.

Which of the following assessments would be important for the nurse to make to determine whether or not a client is recovering as expected from spinal anesthesia?

Degree of response to pinpricks in the legs and toes. Rationale: Return of sensation in the toes and legs marks recovery from spinal anesthesia. Because the client receiving spinal anesthesia is conscious, he will not ordinarily be disoriented. The client's respiratory status is not affected by spinal anesthesia. Capillary refill time is an indicator of circulatory status, not neurologic status.

A client in the fourth stage of labor asks to use the bathroom for the first time since giving birth. The client has oxytocin infusing. Which response by the nurse is best?

"You may use the bathroom with my assistance." Rationale: The nurse should tell the client that she may use the bathroom with the nurse's assistance. The nurse should assist the client for the client's first trip to the bathroom after giving birth because it's common for a client to faint after birth. Telling the client she must wait until her vaginal bleeding stops is inappropriate; vaginal bleeding continues for about 6 weeks after childbirth. The nurse shouldn't tell the client she can get up whenever she needs to use the bathroom; doing so places the client at risk for injury.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN?

A 2-year-old child who nearly drowned 2 days earlier Rationale: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. His status could quickly become very critical.

Which of the following is characteristic of cardiogenic shock?

Decreased myocardial contractility. Rationale: Cardiogenic shock occurs when myocardial contractility decreases and cardiac output greatly decreases. The circulating blood volume is within normal limits or increased. Infarction is not always the cause of cardiogenic shock.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume Rationale: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?

Discuss the breach of practice with the physician. Rationale: The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.

Hemophilia A

Example of a disorder caused by an X-linked recessive gene.

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care?

Good Samaritan laws are designed to protect the caregiver in emergency situations.

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

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

When caring for a 12-month-old infant with dehydration and metabolic acidosis, the nurse expects to see:

tachypnea. Rationale: The nurse would expect to see tachypnea because the body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. Altered WBC and platelet counts aren't specific signs of metabolic imbalance.

Down Syndrome

trisomy 21, is an example of a disorder caused by chromosomal translocation.

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply.

• "When did the rash start?" • "Are you allergic to any medications, foods, or pollen?" • "What have you been using to treat the rash?" • "Have you recently traveled outside the country?" Rationale: When assessing a client who has a rash, the nurse should first find out when the rash began; this information can identify where the rash is in the disease process and assists with the correct diagnosis. The nurse should also ask about allergies because rashes related to allergies can occur when a person changes medications, eats new foods, or comes into contact with agents in the air, such as pollen. The nurse needs to find out how the client has been treating the rash because treating the rash with topical ointments or taking oral medications may make the rash worse. The nurse should ask about recent travel because travel outside the country exposes the client to foreign foods and environments, which can contribute to the onset of a rash. Although the client's age and smoking and drinking habits can be important to know, this information won't provide further insight to the rash or its cause.

A 4-year-old child has recently been diagnosed with acute lymphocytic leukemia (ALL). What information about ALL should the nurse provide when educating the client's parents? Select all that apply.

• ALL affects all blood-forming organs and systems throughout the body. • Adverse effects of treatment include sleepiness, alopecia, and stomatitis. • There's a 95% chance of obtaining remission with treatment.

Signs and symptoms of left-sided heart failure?

• Dyspnea • Crackles • Tachycardia • Oliguria

The nurse is teaching the parents of an 8-year-old child receiving treatment for cancer. What will the nurse include in the teaching? Select all that apply.

• Provide rest periods between activities • Expect periods when the child will refuse to eat • Call the healthcare provider with any concerns

Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he needs to follow at home?

"I should avoid alcohol and caffeine." Rationale: Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acid.

A 6-year-old boy is being treated in the emergency department for injuries inflicted by his stepfather. The client's mother says, "This never happened before. Jim got fired today. He got drunk and came home in a tirade. I'm so sorry that Jason got hurt, but I don't think it will ever happen again." Which of the following responses is most appropriate initially?

"I want to know more about your situation. Let's sit and talk." Rationale: The nurse needs to obtain more information before plans are developed. Therefore, asking to know more about the situation is most appropriate. The nurse has no way of predicting whether abuse will occur again. Therefore, it is inappropriate for the nurse to agree with the mother, stating that the abuse probably will not happen again. Filing charges and a formal report may be needed, but more information is needed first. These actions would not be done without the mother's understanding why.

The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, "I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client?

"It's okay to be scared. What is it about cancer that you're afraid of?"

Kawasaki disease

A condition that causes inflammation in the walls of some blood vessels in the body. One of the characteristics of children with KD is irritability. They are often inconsolable. Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart.

An adolescent child is admitted to the nursing unit after an attempted suicide. The nurse is discussing the attempted suicide with the parents. Which of the following statements by the parents indicate to the nurse that the parents need more teaching? Select all that apply.

• "Our child is just trying to get attention." • "Our child would not do this again." • "Our child will be fine in a couple of days." Rationale: Suicide should not be seen just as attention-seeking behavior. It has very serious consequences and should never be minimized. To believe that such an attempt might not happen again or that the adolescent will have resolved the problems that led to the attempt in a couple of days shows a lack of understanding of the seriousness of the situation.

n an outpatient addiction group, a recovering client says that before treatment, her husband drank on social occasions. "Now he drinks at home, from the time he comes home from work until he goes to bed. He says that he doesn't like me anymore and that I expect him to do more work on the house and yard. I used to ignore that stuff. I don't know what to do." The nurse would make the following comments in which order of priority from first to last?

"I hear how confused and frustrated you are." "It can happen that as one spouse becomes sober, the other spouse deteriorates." "What have you tried to do about your husband's behaviors?" "What do you think you could do to have your husband come in for an evaluation?"

After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which of the following statements indicates successful teaching?

"We'll wrap him in a blanket if he starts shivering." Rationale: Shivering, the body's defense against rapid temperature decrease, results in an increase in body temperature. Therefore the parents need to take measures to stop the shivering (and the resulting increase in body temperature) by increasing the room temperature or the temperature of the child's immediate environment (such as with blankets) until the shivering stops. Then, attempts are made to lower the temperature more slowly. Shivering does not necessarily correlate with being cold. Alcohol, a toxic substance, can be absorbed through the skin. Its use is to be avoided.

A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be best?

"You sound concerned about what's happening."

A client with a Sengstaken-Blakemore tube has a sudden drop in SpO2 and increase in respiratory rate to 40 breaths/minute. The nurse should do which of the following in order from first to last?

Affirm airway obstruction by the tube. Deflate the tube by cutting with bedside scissors. Remove the tube. Apply oxygen via face mask.

SARS Isolation precautions

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

Wilms' Tumor

Also known as a nephroblastoma, is a tumor located on the kidney. It's most commonly found in children ages 2 to 4.

While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do ?

Assess the neurologic status of the toes. Rationale: Because the nurse suspects a possible fracture based on the child's presentation, assessing the neurologic and circulatory status of the toes, the tissues distal to the fracture, is important. Soft tissue contusions, which accompany femur fractures, can result in severe hemorrhage into the tissue and subsequent circulatory and neurologic impairment. Once this information has been obtained, vital signs can be assessed and the nurse can notify the primary health care provider and report the findings. In fractures, circulation impairment will occur distal to the injury.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?

Close all of the doors on the unit. Rationale: The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

Laboratory results for a child with a congenital heart defect with decreased pulmonary blood flow reveal an elevated hemoglobin (Hb) level, hematocrit (HCT), and red blood cell (RBC) count. These data suggest which condition?

Compensation for hypoxia Rationale: A congenital heart defect with decreased pulmonary blood flow alters blood flow through the heart and lungs, resulting in hypoxia. To compensate, the body increases the oxygen-carrying capacity of RBCs by increasing RBC production, which causes the Hb level and Hct to rise. In anemia, the Hb level and Hct typically decrease. Altered electrolyte levels and other laboratory values are better indicators of dehydration. An elevated Hb level and HCT aren't associated with jaundice.

When teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include?

Complaints of a stiff neck Rationale: The nurse should discuss complaints of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, fever that disappears for 24 hours then returns, and a history of febrile seizures should be addressed by the physician but can wait until office hours.

When making rounds on the pediatric neurology unit, the nurse manager notes that when giving IV medications many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After discussing the problem with the staff educator which intervention would be the most effective way to improve the nursing practice?

Create a poster presentation on the topic with a required post test. Rationale: A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the post test will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way may be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not alone assure that the information is read.

In an initial screening for lead poisoning a 2-year-old child is found to have a lead level just above 10 mcg/dL (0.48 µmol/L). The nurse should:

Educate parents on ways to reduce lead in the environment. Rationale: Treatment for children with minimally elevated lead levels should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach 45 mcg/dL (2.2 µmol/L). There is no such thing as a "normal" lead level because there is no beneficial action in the body.

When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?

It adds strength to the cast. Rationale: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client, because doing so may weaken the cast.

Acute Coronary Syndrome or MI or sudden onset of chest pain treatment

M-Morphine O-Oxygen N-Nitroglycerin A- ASPIRIN

A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan?

Meeting all of the client's physical needs Rationale: Because a client with catatonic schizophrenia can't meet his physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. Although this client is incapable of expressing concerns, the nurse should try to verbalize the message his nonverbal behavior conveys. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with him, not leave him alone all the time. Although aware of the environment, the client doesn't actively interact with it; the nurse's support and presence can be reassuring.

A nurse working in the emergency department enters the room of a client who is agitated and swears at the nurse. The client stands up and moves toward the nurse in an aggressive fashion. What is the most appropriate action by the nurse to address this situation?

Move toward the door and leave to call the crisis response team. Rationale: The nurse assesses and identifies that the nurse's safety is at risk because the client is agitated and moving aggressively toward the nurse. The nurse needs to leave and obtain help in the form of a crisis response team. The other options are incorrect because they do not provide for the safety of the nurse or the client.

A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

Rinne test Rationale: The Rinne test compares air conduction to bone conduction in both ears. The whispered voice test evaluates low-pitched sounds, and the watch tick test assesses high-pitched sounds. Both tests assess gross hearing. Weber's test evaluates bone conduction.

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals would be best?

Spaghetti with tomato sauce, salad, and coffee. Rationale: Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak. Rationale: Constant bubbling in the water-seal chamber indicates a system air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.

A public health nurse is teaching a group of parents at a community health center about feeding and nutrition for toddlers. Which of the following is most important for the nurse to include in the teaching?

Toddlers often eat one food for many days in a row. Rationale: It is common and not harmful for toddlers to have food jags, eating one food for days on end. Using dessert as a reward makes vegetables and other foods seem less desirable. It is an unreasonable expectation to let a child choose his or her own food at this age.

The purpose of biofeedback is to enable a client to exert control over physiologic processes by:

Translating the signals of body processes into observable forms

When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be especially cautious about which of the following client behaviors?

Violent behavior. Rationale: The nurse must be especially cautious when providing care to a client who has taken PCP because of unpredictable, violent behavior. The client can appear to be in a calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients. However, the unpredictable, violent behavior presents a major issue of safety for clients and staff.

Most common site of aneurysm formation is in the

abdominal aorta, just below the renal arteries. Rationale: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:

assess the client for pain. Rationale: The nurse should assess the client for possible causes of the behavior, such as pain. A client should never be left alone while the nurse summons assistance. All staff members must receive annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy. In most settings, the nurse must have a physician's order before restraining a client.

A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should:

irrigate the NG tube gently with normal saline solution if ordered. Rationale: The nurse can gently irrigate the tube if ordered, but must be careful not to reposition it. Repositioning can cause bleeding. The nurse should apply suction continuously — not every hour. The nurse shouldn't clamp the NG tube postoperatively because secretions and gas will accumulate, stressing the suture line.

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:

pulmonary crackles. Rationale: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.

The nurse who uses self-disclosure should:

refocus on the client's experience as quickly as possible. Rationale: The nurse's self-disclosure should be brief and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion shouldn't dwell on the nurse's experience.

The nurse is teaching the parents of a child with myelomeningocele how to prevent urinary tract infections. What should the care plan include for this child? Select all that apply.

• Use the Crede's maneuver to empty the bladder. • Encourage frequent emptying of the bladder. • Assure adequate fluid intake.

A multigravid client will be using medroxyprogesterone acetate as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching?

"One possible adverse effect is absence of a menstrual period." Rationale: With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are common adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramuscular injections every 3 months. The first injection should occur within 5 days after menses.

Which characteristic is most common among suicidal clients?

Ambivalence Rationale: One of the characteristics most commonly shared by suicidal persons is ambivalence, an internal struggle between self-preserving and self-destructive forces. These doubts are expressed when a person threatens or attempts suicide and then tries to get help to save his life. When the possible consequences of suicide are discussed, such persons commonly describe life-related outcomes such as relief from an unhappy situation. Many people consider suicide an alternative to present circumstances, but they may not have considered the implications of no longer being alive. A psychotic person may or may not have suicidal tendencies. Remorse and anger may be associated with depression but aren't universally present in suicidal persons. Frustration isn't specifically associated with suicidal ideation.

When caring for a client with preeclampsia during labor, the nurse should:

restrict the amount of fluid administered. Rationale: The volume of fluids administered during labor to a client with preeclampsia should be restricted. Clients usually receive between 60 and 150 ml/hour.

A client with refractory angina pectoris is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab. Before beginning the infusion, the nurse should ensure the client has:

up-to-date partial thromboplastin time (PTT) result in his record. Rationale: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation and, thereby, reduces cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date PTT result available. The drug isn't contraindicated in clients with a seizure history. Abciximab isn't an opioid; therefore, an opioid antagonist doesn't need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn't a requirement for administering abciximab.

An 8-year-old child has just returned from the operating room after having a tonsillectomy. The nurse is preparing to do a postoperative assessment. The nurse should be alert for which signs and symptoms of bleeding? Select all that apply.

• Frequent clearing of the throat • Frequent swallowing • Bright red vomitus Rationale: A classic sign of bleeding after tonsillectomy is frequent swallowing; this sign occurs because blood drips down the back of the throat, tickling it. Other signs include frequent clearing of the throat and vomiting of bright red blood. Vomiting of dark blood may be seen if the child swallowed blood during surgery but doesn't indicate postoperative bleeding. Breathing through the mouth is common because of dried secretions in the nares. Sleeping for long intervals is normal after a client receives sedation and anesthesia. A pulse rate of 98 beats/minute is in the normal range for this age-group.

Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.

• Quality of breath sounds. • Occurence of chest pain. • Color of nail beds. Rationale: A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.

A parent is planning to enroll a 9-month-old infant in a day-care facility. The parent asks a nurse what to look for as indicators that the facility is adhering to good infection control measures. The nurse identifies which as an indication of meeting proper infection control standards? Select all that apply.

• Soiled diapers are discarded in covered receptacles. • Disposable papers are used on the diaper-changing surfaces. • Facilities for hand hygiene are located in every classroom.

Crackles heard on lung auscultation indicate which of the following?

Fluid-filled alveoli. Rationale: Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

Which nursing action is required before a client in labor receives an epidural anesthetic?

Give a fluid bolus of 500 ml. Rationale: One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent hypotension in the client who wishes to receive an epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.

The nurse teaches a client about using the crutches, instructing the client to support the weight primarily on which of the following body areas?

Hands. Rationale: When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.

Cri du chat

Example of a disorder caused by chromosomal deletion.

After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?

"The nerves at the end of the large colon are missing."

Phenylketonuria (PKU)

Autosomal recessive gene. PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine.

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

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

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises?

Deep breathing expands the alveoli and increases the lung surface available for ventilation. Rationale: Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

When teaching parents about fifth disease (erythema infectiosum) and its transmission, the nurse should provide which information?

Fifth disease is transmitted by respiratory secretions. Rationale: Fifth disease is transmitted by respiratory secretions. The transmission mode for roseola is unknown. Rubella is transmitted by respiratory secretions, stool, and urine. Intestinal parasitic conditions, such as giardiasis and pinworm infection, are transmitted by stool.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water. Rationale: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

Which of the following levels of the serum electrolytes potassium (K), chloride (Cl), and sodium (Na) should the nurse expect to find in an infant with persistent vomiting?

K+, 3.2; Cl-, 92; Na+, 120 Rationale: The serum electrolyte values in an infant with persistent vomiting reflect hypokalemia (potassium level of 3.2), hypochloremia (chloride level of 92), and hyponatremia (sodium level of 120). Chloride and sodium function together to maintain fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid. With persistent vomiting, hypokalemia (from movement of potassium into the extracellular fluid), hypochloremia (due to increased losses in gastric fluid), and hyponatremia (due to increased losses in gastric fluid) would result. In option B, the potassium level is almost normal (normal is 3.5 to 5.5), chloride is elevated (normal is 98 to 106), and sodium is normal (normal is 135 to 145). In option C, the potassium level is normal (normal is 3.5 to 5.5), chloride is decreased (normal is 98 to 106), and sodium is normal (normal is 135 to 145). In option D, the potassium level is normal (normal is 3.5 to 5.5), chloride is slightly elevated (normal is 98 to 106), and sodium is slightly decreased (normal is 135 to 145).

Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?

Lying on the abdomen with the head turned to the side. Rationale: Immediately after a surgical repair of a cleft palate, the child is placed on the abdomen with the head turned to the side to lessen the chance of aspiration by allowing secretions to drain out. Positioning the child on the back places the child at risk for aspiration should any regurgitation or vomiting occur, even in low Fowler's position with the head to the side or in reverse Trendelenburg position with the head tilted forward.

When assessing for pain in a toddler, which of the following methods should be the most appropriate?

Observe the child for restlessness. Rationale: Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. Numeric pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.

Which of the following positions would be best for a client's right arm when she returns to her room after a right modified radical mastectomy with multiple lymph node excisions?

On pillows, with her hand higher than her elbow and her elbow higher than her shoulder. Rationale: Lymph nodes can be removed from the axillary area when a modified radical mastectomy is done, and each of the nodes is biopsied. To facilitate drainage from the arm on the affected side, the client's arm should be elevated on pillows with her hand higher than her elbow and her elbow higher than her shoulder. A sentinel node biopsy procedure is associated with a decreased risk of lymphedema because fewer nodes are excised.

When providing oral hygiene for an unconscious client, the nurse must perform which action?

Place the client in a side-lying position. Rationale: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.

Which of the following actions should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth?

Providing warm, humidified oxygen in a warm environment. Rationale: Symptoms of transient tachypnea include respirations as high as 150 breaths/minute, retractions, flaring, and cyanosis. Treatment is supportive and includes provision of warm, humidified oxygen in a warm environment. The nurse should continuously monitor the neonate's respirations, color, and behaviors to allow for early detection and prompt intervention should problems arise. Feedings are given by gavage rather than bottle to decrease respiratory stress. Obtaining extracorporeal membrane oxygenation equipment is not necessary but may be used for the neonate diagnosed with meconium aspiration syndrome.

he nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first:

Take the client's blood pressure. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:

The client should not have her hip externally rotated when she is positioned for the procedure. Rationale: The nurse should notify the surgery department and document the past surgery in the chart in the preoperative notes so that the client's hip is not externally rotated and the hip dislocated while she is in the lithotomy position. The prosthesis should not be a problem as long as the perioperative nurse places the grounding pad away from the prosthesis site. The perioperative nurse will inform the rest of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of the client. The surgeon can hand-write an addendum to the history and initial and date the entry. The history and physical information can then be retyped at a later date.

Which measure should the nurse teach the client with adult macular degeneration (AMD) as a safety precaution?

Turn the head from side to side when walking. Rationale: To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. A patch does not address the problem of hemianopsia. Appropriate client positioning and placement of personal items will increase the client's ability to cope with the problem but will not affect safety.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?

Using a picture board. Rationale: Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

A client has an ileal conduit. Which of the following solutions will be useful to help control odor in the urine collecting bag after it has been cleaned?

Vinegar. Rationale: A distilled vinegar solution acts as a good deodorizing agent after an appliance has been cleaned well with soap and water. If the client prefers, a commercial deodorizer may be used. Salt solution does not deodorize. Ammonia and bleaching agents may damage the appliance.

The Women's Clinic nurse is instructing a client on the proper use of an applicator to instill vagina cream. Which of the following instructions is applicable when teaching a client about vaginal medication insertion?

Direct the tip of the applicator toward the sacrum. Rationale: The normal position of the vagina slants up and back toward the sacrum. Directing the tip of the applicator toward the sacrum allows it to follow the normal slant of the vagina and minimizes tissue trauma. The applicator should be inserted about 2" (5 cm). The medication can be administered by placing continuous pressure until the tip of the plunger until it hits the applicator, taking 10 to 15 seconds. This eliminates the medication from the applicator placing it in the vagina. Should the applicator need to be reused, the applicator may be washed thoroughly and placed on a towel to dry.

A child with hemophilia is brought to the clinic with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, what should the nurse do?

Elevate the right knee. Rationale: The goal is to decrease the bleeding. This can be aided by decreasing circulation to the area. Elevating the part and applying cold decreases circulation to the area. The child will also receive cryoprecipitate. Aspirin is contraindicated for a child with a bleeding disorder because it increases capillary fragility. The dependent position will increase bleeding and swelling, and the goal is to decrease bleeding. Lack of clotting factors, not lack of platelets, is the problem in children with hemophilia.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

Encouraging increased fluid intake Rationale: During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.

During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. Which nursing diagnosis is most appropriate for this client?

Imbalanced nutrition: Less than body requirements related to limited food intake. Rationale: A substance abuser may spend more money on drugs than on food and other basic needs, leading to a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to limited food intake. Activity intolerance might be a relevant nursing diagnosis if the client were having trouble sleeping or getting adequate rest; however, activity intolerance wouldn't be related to decreased tissue oxygenation in this case. If the client were an I.V. drug abuser, a diagnosis of Risk for infection related to I.V. drug use might be appropriate. Because the question doesn't specify how the client is using cocaine, a diagnosis of Impaired gas exchange related to respiratory effects of substance abuse is inappropriate.

When formulating outcomes for the post-term neonate at discharge, which of the following would be most appropriate?

Maintenance of normal body temperature. Rationale: Hypothermia and temperature instability are primary problems in the post-term neonate, so maintaining a normal temperature pattern is the most appropriate goal. Post-term neonates have little subcutaneous fat, predisposing them to cold stress. Establishment of a deep respiratory pattern is inappropriate because all neonates tend to breathe in a shallow manner. A weight gain of 4 ounces (112 g) may not be feasible because most neonates lose 5% to 15% of their birth weight during the first few days of life. All infants should be assessed for hyperbilirubinemia. Although polycythemia is common in post-term infants and may take a while to resolve, hyperbilirubinemia is not more common in the post-term neonate than it is in neonates born at term.

The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique?

Nasogastric (NG) tube placement Rationale: The GI system isn't a sterile system; therefore, NG tube placement doesn't require sterile technique. I.V. insertion requires sterile technique because intentional penetration of the skin occurs. The urinary system is sterile, so the nurse must maintain sterility during catheter placement. Burns have a high risk for infection; the nurse must maintain sterile technique to decrease this risk.

The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?

Pneumonia Rationale: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis.

Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis?

Raise the arm on the affected side over the head. Rationale: A client who has undergone chest surgery should be taught to raise the arm on the affected side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power. Turning from side to side, raising and lowering the head, and flexing and extending the elbow on the affected side do not exercise the shoulder joint.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which of the following clients?

62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics. The client has fallen at home but is able to ambulate with a cane. During his hospitalization, he has gotten out of bed without calling for assistance. Rationale: Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client A is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client B risks include IV access and secondary diagnosis (35 points). Client D is at risk due to his IV access only (20 points).

Twenty-four hours after birth, a neonate hasn't passed meconium. The nurse suspects which condition?

Hirschsprung's disease Rationale: Failure to pass meconium is an important diagnostic indicator for Hirschsprung's disease. Hirschsprung's disease is a potentially life-threatening congenital large-bowel disorder characterized by the absence or marked reduction of parasympathetic ganglion cells in a segment of the colorectal wall; narrowing impairs intestinal motility and causes severe, intractable constipation leading to partial or complete colonic obstruction. Celiac disease, intussusception, and abdominal wall defects aren't associated with failure to pass meconium.

The nurse assesses the neurologic system of a newborn. Which of the following behaviors would the nurse interpret as a normal reflex response?

Makes a walking movement when held upright with one foot touching the table Rationale: Newborns who are held in a vertical position with their feet touching a hard surface will take a few quick, alternating steps. This stepping reflex is more pronounced at birth and typically disappears between 4 and 8 weeks of age. When the palm of a newborn's hand is stimulated, he/she will typically grasp the object. When the cheek is touched, the newborn typically will turn the head toward the stimulation. A newborn's toes will expand slightly when the sole of the foot is touched.

When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?

Padding for the side rails. Rationale: The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

A 20-year-old client diagnosed with schizophrenia is recovering from his first psychotic break. Before discharge from the hospital, the client becomes depressed and states, "I don't want this illness. I'm about to begin my junior year in college." Which of the following issues would be most important for the nurses to address at this time?

Potential for medication non-compliance. Rationale: Though disturbed thoughts and sensory perceptions would be a concern to the nurse, as well as communication issues, the primary issue for this client in terms of his comments would be the potential for medication noncompliance and relapse. Most college students want to be like their peers and perceive themselves as capable and well. These beliefs can lead a young client with schizophrenia to stop taking medication which leads to relapse.

The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:

Promote interactions with one friend instead of groups. Rationale: Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism report being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.

The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they:

Strengthen the muscles while keeping the joints stationary. Rationale: An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process. Isometric exercise costs little in terms of time and money but these are not necessarily primary reasons for using it. Isometric exercises may help improve a client's morale by promoting self-care but this is not the reason for doing them. Isometric exercise will not help prevent joint stiffness; the joint is kept stationary.

A nurse is assisting with the removal a of central venous access device (CVAD). The nurse should instruct the client to:

Take a deep breath and hold it. Rationale: The client should be asked to perform the Valsalva maneuver (take a deep breath and hold it) during insertion and removal of a CVAD. This increases central venous pressure during the procedure and helps prevents air embolism. Trendelenburg is the preferred position for CVAD insertion and removal. If it is not possible, supine position is sufficient for CVAD removal. It is not recommended to position the client on the left or the right side. The client should hold the breath, not exhale, which lowers central venous pressure.