Physiological Health Problems (10)

A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction?

A. "I should put a steam vaporizer in her room." Rationale: Steam from running water in a closed bathroom and cool mist from a bedside humidifier or a freezer are effective in reducing mucosal edema. A cool mist humidifier is recommended over a steam vaporizer, which presents a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling.

A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which of these statements by the mother indicate a need for further instructions? Select all that apply.

A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him." Rationale: Hemophilia is the term given to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Identifying the specific coagulation deficiency is important because it allows definitive treatment with the specific replacement agent to be implemented; aggressive replacement therapy is initiated to prevent the chronic crippling effects of joint bleeding. The child does not outgrow the disorder, and lifetime management is needed. The nurse must stress the importance of immunizations, dental hygiene, and routine well-child care for the child with hemophilia. The remaining statements represent appropriate care measures.

A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which of the following serum potassium readings does the nurse associate this finding?

A. 3.1 mEq/L. Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia, the most common electrolyte imbalance, which is potentially life threatening. ECG changes in hypokalemia include peaked P waves, flat T waves, a depressed ST segment, and prominent U waves. Readings of 4.5 mEq/L and 4.2 mEq/L are normal potassium levels; 5.4 mEq/L indicates hyperkalemia.

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which of the following interventions does the nurse prepare the client?

A. An ultrasound examination. Rationale: A manual pelvic examination or any action that would stimulate uterine activity is contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placental previa is made with the use of ultrasound. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia, but internal fetal monitoring is contraindicated. Oxytocin would stimulate uterine contractions and is therefore contraindicated.

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which of the following questions does the nurse plan to include?

A. Call the physician if the infant is lethargic. Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which causes the infant to make a high-pitched cry or induces changes in level of consciousness, such as lethargy. The infant should not be positioned on the side of the shunt, because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urine output is not expected. The anterior fontanel normally bulges when the infant cries.

A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately:

A. Contacts the client's physician. Rationale: Preeclampsia is dangerous to the woman and fetus because it can progress rapidly, and the earliest manifestations may go unnoticed by the woman. Some symptoms, such as epigastric pain and upset stomach, are particularly ominous because they indicate distention of the hepatic capsule and often mean that a seizure is imminent. Therefore telling the client to avoid lying flat position, instructing the client to eat a small portion of food every 2 to 3 hours, and administering an antacid and telling the client to take a dose every 6 hours are all incorrect. Additionally, the nurse would not administer an antacid to the pregnant client without a prescription to do so.

A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child?

A. Lethargy. Rationale: Clinical manifestations of iron-deficiency anemia vary with the degree of anemia but usually include extreme pallor with porcelainlike skin, tachycardia, lethargy, and irritability.

A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse tells the client:

A. To plan to drain the reservoir every 2 to 3 hours initially. Rationale: An Indiana pouch is a continent internal ileal reservoir, and the nurse instructs the client in the technique of catheterization. Initially the client drains the reservoir every 2 to 3 hours. Each week thereafter, the interval is increased by 1 hour until finally catheterization is completed every 4 to 6 hours during the day. The catheter is never forced into the reservoir. If resistance is met, the client is instructed to pause and apply only gentle pressure while slightly rotating the catheter. A 16F to 20F catheter is used; 26F is too large and could damage the reservoir. Mucus is expected, and the client is instructed to irrigate the reservoir with 50 to 60 mL of normal saline solution to prevent excessive mucus buildup.

A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition?

A. Trace protein in the urine. Rationale: Preeclampsia is considered mild when the systolic blood pressure is 140 mm Hg or greater but less than 160 mm Hg and the diastolic blood pressure is 90 mm Hg or greater but less than 110 mm Hg, proteinuria is 1+ on a random dipstick, and symptoms such as headache, visual disturbances, and abdominal pain are absent. In addition, signs of kidney or liver involvement are absent. An increased BUN level indicates kidney damage, a result of the preeclampsia.

A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented?

A. Uterine tenderness. Rationale: In abruptio placentae, abdominal pain and uterine tenderness are present. Uterine tenderness accompanies placental abruption, especially with a central abruption in which blood becomes trapped behind the placenta. The abdomen will feel hard and boardlike on palpation because the blood penetrates the myometrium, resulting in uterine irritability. Excessive uterine activity with poor relaxation between contractions is present. Fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. Painless bright-red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. Constipation is not associated with this disorder.

A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which of the following findings would the nurse expect to note?

A.Hypertension. Rationale: Hypertension is a common finding in glomerulonephritis. Gross hematuria resulting in dark-brown or smoky tea-colored urine is also a classic symptom of glomerulonephritis. The blood urea nitrogen and creatinine levels are increased only when there is an 80% decrease in glomerular filtration rate and renal insufficiency is severe. A high potassium level results from inadequate glomerular filtration.

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states:

B. "I should sleep flat on my right side." Rationale: A side-lying position with head of the bed elevated is most likely to prevent reflux while sleeping. A flat position will increase reflux. The client is instructed to avoid eating in the 3 hours before bedtime because a full stomach may also cause reflux. Antacids and histamine antagonists may be prescribed for the client.

A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will:

B. Breastfeed the newborn every 2 to 3 hours. Rationale: Breastfeeding should be initiated within 2 hours of birth and performed every 2 to 3 hours thereafter. Supplementation with water should be avoided because the newborn may take less milk, which is more effective than water in removing bilirubin from the intestines. The infant should not be fed less frequently. It is not necessary to stop breastfeeding and to bottle feed only.

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply.

B. Decreased urine output D. Increased respiratory rate. Rationale: A client with dehydration has an increased depth and rate of respirations. The diminished fluid volume is perceived by the body as a decreased oxygen level (hypoxia), and increased respiration is an attempt to maintain oxygen delivery. Other assessment findings in insufficient fluid volume are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry mucous membranes, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. Increased blood pressure, decreased pulse, and increased urine output occur with fluid-volume overload.

An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will:

B. Have her child use a straw to make drinking easier. Rationale: Introduction of a straw, fork, or any other pointed object into the mouth could result in accidental contact with the surgical site and disrupt its integrity. Citrus fruits are avoided because they could irritate the throat. Acetaminophen is used for pain relief. A foul mouth odor is normal and can be relieved by drinking fluids.

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?

B. Semi-Fowler. Rationale: After cataract extraction surgery, the client should be placed in the semi-Fowler position or on the unaffected side to prevent edema at the surgical site. Supine, on the affected side, and prone are all incorrect because they will result in increased edema at the site.

A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside?

B. Sterile dressing. Rationale: The newborn with spina bifida is at risk for infection before the closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin at the site. A flashlight may be needed to closely assess the status of the gibbus but is not a priority item. A cardiac monitor is not necessary. Blood pressure is difficult to assess during the newborn period and is not the best indicator of infection. The blood pressure cuff would not be a priority item.

A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to:

B. Take the prescribed insulin dose even if he is unable to eat. Rationale: Insulin should never be independently stopped or decreased, and the client is instructed to take prescribed insulin even if he or she is vomiting or unable to eat. Acute illness may cause a counterregulatory hormone response, resulting in hyperglycemia. During times of illness, the client should monitor the blood glucose level and notify the physician if it exceeds 250 mg/dL. Adequate fluids and carbohydrates are essential during illness. The client should eat 10 to 15 g of carbohydrate every 1 to 2 hours and drink a small quantity of fluid every 15 to 30 minutes to help prevent dehydration and ketoacidosis. The client should notify the physician of a fever over 100° F.

A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother:

B.To bring the newborn to the clinic. Rationale: Symptoms of cord infection include moistness, oozing, discharge, swelling, and a reddened base. If symptoms of infection occur, the newborn must be seen by the healthcare provider. Telling the mother to increase the number of times that the cord is cleansed each day or to place an ice pack on the umbilical cord site and stating that this is a normal occurrence are inappropriate nursing interventions.

A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment?

C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema. Rationale: The client who should be seen first is the one with SOB and a history of pulmonary edema. In light of such a history, SOB could indicate that fluid-volume overload has once again developed. The client with a fever and who is diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid through the skin, but this client is not the priority.

A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am-7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume?

C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr. Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the greatest risk for excessive fluid volume because of the diminished cardiovascular and renal function that occur with aging. Other causes of excessive fluid volume include renal failure, heart failure, liver disorders, excessive use of hypotonic IV fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. A client who is receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at risk for deficient fluid volume.

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first:

C. Attaches the child to a pulse oximeter. Rationale: To adequately determine whether the child is getting enough oxygen, the nurse attaches the child to a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately attached to a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. Next the nurse performs an assessment, including the child's temperature and weight, and asks the parents about the child. An antibiotic may be prescribed, but the child's airway status must be assessed first.

A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child's condition:

C. Indicates deterioration in neurological function. Rationale: In decorticate posturing, the upper extremities are flexed and the lower extremities are extended. In decerebrate posturing, the upper and lower extremities are extended and the upper arms and wrists and the knees and feet are internally rotated. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification. The remaining options are inaccurate interpretations.

A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately:

C. Places the client in the knee-chest position. Rationale: When cord prolapse occurs, prompt action is taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Such positions include knee-chest, Trendelenburg, and the hips elevated on pillows with the client in a side-lying position. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it, because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by way of facemask is administered to the mother to increase fetal oxygenation. A tocolytic medication is administered to inhibit contractions on the order of the physician, and the client is quickly prepared for delivery, but these are not the actions that would be taken immediately.

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately:

C. Places the infant in the knee-chest position. Rationale: If a hypercyanotic episode occurs, the infant is calmed and placed in the knee-chest position, and the physician is notified. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to achieve this position and relieve chronic hypoxia. Oxygen is also administered to the infant.

A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which of the following interventions does the nurse include in the plan?

C. Providing a high-calorie, high-protein diet. Rationale: Graves disease is characterized by a hypermetabolic state, and the client benefits most from an environment that is restful both physically and mentally. Therefore the client is encouraged to rest. As compensation for the hypermetabolic state, the client needs a diet that is high in calories and high in protein. Individuals with Graves disease experience heat intolerance and diaphoresis and require a cool environment.

A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn?

C. Short palpebral fissures and a flat midface. Rationale: Fetal alcohol syndrome (FAS) is characterized by recognizable facial anomalies, prenatal and postnatal growth restriction, and central nervous system impairment. The common facial anomalies include short palpebral fissures (the openings between the eyelids), a flat midface, an indistinct philtrum (median groove on the external surface of the upper lip), and a thin upper lip.

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to:

C. Turn the head to scan the lost visual field. Rationale: Homonymous hemianopsia is loss of half of the visual field. The nurse instructs the client to scan the environment to overcome the visual deficit. The nurse encourages the use of personal eyeglasses to improve overall vision, but it is not necessary to wear the glasses 24 hours a day. The client should keep objects in the intact field of vision whenever possible. An eye patch is of no use because the client does not have double vision.

An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client?

C. With the knees drawn up to the chest. Rationale: Helping the client assume the fetal position (legs drawn up to the chest) will ease the abdominal pain of pancreatitis. Other helpful positions include sitting up, leaning forward, and flexing the legs (especially the left leg). Prone, supine with the legs straight, and side-lying with the head of the bed flat are incorrect.

A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease?

D. "Has he had a sore throat in the last few months?" Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. The nurse first determines whether the child had a sore throat or an unexplained fever within the past 2 months. Asking the parents whether the child has had any loss of appetite, complained of backache recently, or been excessively tired or lethargic will elicit information unrelated to rheumatic fever.

The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately:

D. Begins cardiopulmonary resuscitation (CPR). Rationale: Ventricular fibrillation is the result of chaos in the ventricles. Impulses from many irritable foci fire in a totally disorganized manner, preventing ventricular contraction. There are no recognizable deflections. The goals of treatment are to terminate the ventricular fibrillation promptly and to convert it to an organized rhythm by means of defibrillation. The nurse would immediately begin CPR and continue it until a defibrillator arrived. Because the nurse has already noted that the client is unconscious, assessing the client's neurological status is incorrect. Increasing the flow rate of the oxygen and increasing the flow rate of the client's IV infusion will not provide the support needed in this emergency. CPR guidelines recommend CAB - circulation, airway, and breathing. If the nurse checks for a pulse, it should be a carotid pulse, not a radial pulse.

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which of the following occurrences does the nurse expect the mother to report?

D. Bloody mucus stools and diarrhea. Rationale: In the child with intussusception, bloody mucus stools, commonly described as "currant jelly" stools, and diarrhea may occur. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees to the chest. This pain progresses to a more severe constant pain. Vomiting may be present, but it is not projectile in nature. Pale, hard stools and scleral jaundice are not manifestations of this disorder.

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which of the following assessment findings indicates to the nurse that the client may be experiencing hypotonic contractions?

D. Contractions that can be indented easily with fingertip pressure at their peak. Rationale: Hypotonic contractions, coordinated but too weak to be effective, usually occur during the active phase of labor, when progress normally quickens. Contractions are infrequent and brief and can easily be indented on the abdomen with fingertip pressure at their peak. These contractions cause minimal discomfort because the contractions are weak. Fetal hypoxia is not usually seen with hypotonic contractions.

A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to:

D. Eat small frequent meals that are low in fat and protein and high in carbohydrates. Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce metabolic demand on the liver and increase its blood supply, but strict bed rest is unnecessary. The client should avoid taking medications, including acetaminophen (which is hepatotoxic), unless they are prescribed by the healthcare provider. The client must avoid all alcohol consumption. The client should consume small frequent meals that are low in fat and protein and high in carbohydrates to reduce the workload of the liver.

A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which of the following findings does the nurse monitor the neonate most closely?

D. Respiratory distress syndrome. Rationale: The major neonatal complications of preexisting diabetes mellitus in the mother are hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome. The infant of a diabetic mother is more likely to have delayed production of pulmonary surfactant, which is needed to keep the alveoli open after birth.

A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved?

D. Weight loss of 4 lb in 24 hours. Rationale: One sign that excessive fluid volume is resolving is loss of body weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb (1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is retaining fluid. Assessment findings associated with excessive fluid volume include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased blood pressure and bounding pulse, increased central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. These symptoms must be reversed if the fluid-volume excess is to be resolved.

A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication?

D.Ensure that the medication is diluted in an appropriate amount of normal saline solution. Rationale: Potassium chloride administered IV must always be diluted in IV fluid. Undiluted potassium chloride given IV can cause cardiac arrest. The intramuscular and subcutaneous routes of administration are not recommended because the medication cannot be adequately diluted for these routes; toxicity could result if the medication is not adequately diluted. Potassium chloride is never administered as a bolus (IV push) injection; an IV push would result in sudden severe hyperkalemia, which could precipitate cardiac arrest. Saline dilution is recommended, but dextrose is avoided because it increases intracellular potassium shifting. Although urine output is monitored carefully during administration, it is not necessary to insert a Foley catheter unless this is specifically prescribed. The physician is notified if the urinary output is less than 30 mL/hr. Potassium chloride should be administered with the use of a controlled IV infusion device to avoid bolus infusion and increased risk of cardiac arrest. A central IV line is not necessary; potassium chloride may be administered through a peripheral IV line.