Practice Session 1
A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit, and they obviously are upset by the crying. What explanation for the client's behavior does the nurse provide the family members? 1 Having difficulty controlling emotions 2 Demonstrating a premorbid personality 3 Mourning the loss of functional abilities 4 Conveying unhappiness about the situation
Correct Ans: 1 A common complication of a brain attack is an inability to control emotional affect; clients may be depressed or apathetic and have a lability of mood. There are no data to support the conclusion that the client is demonstrating a premorbid personality. There are no data to support the conclusion that the client is mourning the loss of functional abilities. There are no data to support the conclusion that the client is conveying unhappiness about the situation.
A healthcare provider prescribes 0.2 mg of cyanocobalamin (vitamin B12) intramuscularly for a client with pernicious anemia. A vial of the drug labeled 100 mcg = 1 mL is available. How much solution should the nurse administer? Record your answer using a whole number. ___ mL
Correct Ans: 2 mL
A client is diagnosed with varicose veins, and the nurse teaches the client about the pathophysiology associated with this disorder. The client asks, "What can I do to help myself?" How should the nurse respond? 1 "Limit walking to as little as possible." 2 "Reduce fluid intake to 1 L of liquid a day." 3 "Apply moisturizing lotion on your legs several times a day." 4 "Put on compression hose before getting out of bed in the morning."
Correct Ans: 4 As valves become incompetent, they allow blood to pool in the veins, which increases hydrostatic pressure and leads to further valve destruction. Compression hose provide external pressure, thereby facilitating venous return and minimizing blood pooling in the veins. The legs are less congested after sleeping, and therefore the hose should be put on before getting out of bed in the morning and before the legs are in the dependent position. The client should engage in exercise such as walking or swimming because muscle contraction encourages venous return to the heart. Prolonged sitting, standing, or crossing the legs should be avoided because they reduce venous return. Limiting fluid intake will not alter the leakage of fluid or blood into the interstitial space; this occurs in response to the increased hydrostatic pressure in the veins. Although applying moisturizing lotion may make the skin more supple, it will not treat enlarged and tortuous veins.
A school-aged child has a cast applied to a fractured wrist. What action should the nurse take to hasten drying of the cast? 1 Use a blow dryer. 2 Expose the casted extremity. 3 Cover the cast with a light sheet. 4 Open a window to promote ventilation.
I put 1 Ans: 2 Exposing the cast is the safest way to dry it evenly; a fan may be used if the humidity is high. Besides the danger of a burn injury to the child, the cast may dry on the outside and remain damp within with use of a blow dryer. Covering the cast impedes circulation of air, which will delay drying. Opening a window is not necessary if the cast is exposed to air.
An 11-year-old boy who has stepped on a rusty nail is given tetanus immune globulin in the emergency department. The nurse knows that the immune globulin injection will confer what type of immunity? 1 Longer-lasting active immunity 2 Temporary passive acquired immunity 3 Passive immunity throughout the child's life 4 Active natural immunity throughout the child's life
I put 1 Ans: 2 Temporary passive immunity is provided by tetanus immune globulin, which is administered immediately after an injury like the one the child sustained. If the child has not had a tetanus toxoid booster, it is given at another site at the same time. Longer-lasting active immunity is conferred by tetanus toxoid, which is a modified toxin that stimulates the body to form antibodies that last as long as 10 years. Passive immunity, even the natural type derived from the mother, is temporary. Only by having the disease is lifelong natural immunity made possible.
The nurse observes that a client who is on intravenous medication is experiencing an anaphylactic reaction. What is the priority nursing intervention in this situation? 1 Elevate lower extremities of the client. 2 Start normal saline infusion immediately. 3 Report to the primary healthcare provider immediately. 4 Stop intravenous medication and administer epinephrine (adrenaline).
Correct Ans: 4 Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the nurse should immediately stop the intravenous medication and administer epinephrine (adrenaline). The nurse can elevate the client's lower extremities, but only after administering epinephrine (adrenaline). The nurse can start a normal saline infusion and report to the primary healthcare provider, but only after stopping the intravenous medication and administering epinephrine (adrenaline).
A spouse spends most of the day with a client who is receiving chemotherapy for inoperable bone cancer. The spouse asks the nurse, "What can I do to help?" How can the nurse best support the client's spouse? 1 Assist the couple to maintain open communication. 2 Offer the couple a description of the disease process. 3 Instruct the spouse about the action of the medications. 4 Meet privately with the spouse to explore personal feelings.
Correct Ans: 1 Clients and their families need to maintain honest, open interpersonal communication so that concerns can be shared and future problems addressed. Although an understanding of the disease is important, details will not assist the significant other in maintaining an active, caring role. The spouse may want to know about the action of the medications, but it will not help meet the needs of both the spouse and the client. Although the nurse may meet privately with the spouse to explore feelings, this does not address the spouse's immediate concern.
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? 1 "It must be frustrating to deal with your child's behavior." 2 "Have you considered any alternatives to using medication?" 3 "Perhaps you're looking for an easy solution to the problem." 4 "Let me teach you about the side effects of medications used for ADHD."
Correct Ans: 1 Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.
There has been a fire in a healthcare facility. How should the nurse respond to the situation? Select all that apply. 1 The nurse should move bedridden clients from the affected area. 2 The nurse should direct ambulatory clients to walk to a safe location. 3 The nurse should keep all clients hooked up to oxygen. 4 The nurse should seek to contain the fire by closing the doors and the windows. 5 The nurse should ask other hospital workers only to help push the clients in wheelchairs.
Correct Ans: 1, 2, 4 In the case of a fire in a healthcare facility, the nurse should move bedridden clients from the affected area with the help of wheelchairs or stretchers. The nurse should also direct ambulatory clients to walk to a safe location. The nurse can help to contain the fire by closing the doors and the windows and using an ABC extinguisher. The nurse should only discontinue oxygen for clients who can breathe on their own. The nurse should ask the ambulatory clients, not just other hospital workers, to help push clients in wheelchairs if possible.
An infant who has undergone cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administration of the prescribed antibiotic? 1 Give the antibiotic between feedings. 2 Ensure that the antibiotic is administered as prescribed. 3 Shake the bottle thoroughly before giving the antibiotic. 4 Keep the antibiotic in the refrigerator after the bottle has been opened.
Correct Ans: 2 Ensuring that the antibiotic is administered as prescribed is a priority because inadequate antibiotic therapy may predispose the infant to the development of bacterial endocarditis. Giving the antibiotic between feedings, shaking the bottle, and storing the medication in the refrigerator are not priority instructions because instructions often vary depending on the antibiotic.
A nurse in a summer day camp that has access to a local beach has cared for several children with impetigo. What is the best nursing intervention to prevent complications? 1 Use of an oil-based soap for bathing 2 Administration of a systemic oral antibiotic and a topical antibiotic may be used as well 3 Removal of crusts with an antimicrobial liquid 4 Application of an antibiotic ointment to the lesions
Correct Ans: 2 Glomerulonephritis may occur as a result of impetigo, a streptococcal infection. Systemic antibiotics are necessary to eradicate the streptococcal organism that caused the primary infection. Ointments such as mupirocin (Bactroban) may be prescribed for topical application as well. Bathing the child with a special soap will not prevent glomerulonephritis. Although removing the crusts is part of the local therapy for impetigo, using an antimicrobial liquid will not prevent glomerulonephritis; nor will applying an antibiotic ointment.
A breastfeeding parent asks the nurse if the use of herbal medicines will increase breast milk supply. What is the best response from the nurse? 1 "It may be safe if taken with lots of water." 2 "You should speak to your healthcare provider about this." 3 "It may cause iron deficiency anemia in the infant." 4 "It does not effectively increase breast milk supply."
Correct Ans: 2 The use of herbs may increase breast milk supply, but research is limited, so the mother should consult with her healthcare provider. The herbs are safe for the mother with or without water. However, the priority in this case is to inform the parent of the adverse effects that can result in the infant. Early introduction of solids may increase the risk for iron deficiency anemia in the infant. The herbs increase breast milk supply.
A client visiting the prenatal clinic for the first time tells the nurse that she has heard conflicting stories regarding sex during pregnancy and asks about continuing sexual activity. How should the nurse respond? 1 "You should discontinue intercourse after the second trimester." 2 "This information can be given only by your obstetrician or nurse-midwife." 3 "With an uncomplicated pregnancy, there are no limitations on sexual activity." 4 "Sexual activity should be avoided during the first and last six weeks of pregnancy."
Correct Ans: 3 Although there are no limitations on sexual activity, as the pregnancy progresses the client and her partner may need some guidance in altering positions to make sexual activity more comfortable. Intercourse may be continued throughout the entire pregnancy if there are no complications. Information on sex may be given by a professional nurse; it is not necessary to refer this client to another care provider. Avoiding sexual activity during the first and last six weeks of pregnancy is unnecessary if the cervical plug is still in place and the membranes are intact.
A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? 1 Give aspirin for pain; if swelling at the injection site develops, call the healthcare provider. 2 Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed. 3 Give acetaminophen for fever; call the healthcare provider if the child exhibits marked drowsiness or seizures. 4 Apply ice to the injection site if soreness develops; call the healthcare provider if the child comes down with a fever.
Correct Ans: 3 Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the healthcare provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the healthcare provider.
Prednisone, an adrenal steroid, is prescribed for a client with an exacerbation of colitis. When administering the first dose of the medication, what information does the nurse provide to the client? 1 Prednisone protects the client from getting an infection. 2 The medication may cause weight loss by decreasing appetite. 3 Prednisone is not curative, but does cause a suppression of the inflammatory process. 4 The medication is relatively slow in precipitating a response, but is effective in reducing symptoms.
Correct Ans: 3 Prednisone inhibits phagocytosis and suppresses other clinical phenomena of inflammation; this is a symptomatic treatment that is not curative. Prednisone suppresses the immune response, which increases the potential for infection. The appetite is increased with prednisone; weight gain may result from the increased appetite or from fluid retention. Generally the response to prednisone is rapid.
A nurse is conducting the sixth and final session of crisis intervention with a client in a community health center. Evaluation demonstrates that the client has not yet resolved her crisis issues. What is the most acceptable intervention by the nurse? 1 Discharging the client on time whether or not the crisis has been fully resolved 2 Agreeing to continue the treatment until the client feels that the crisis has been resolved 3 Providing the client with additional information and referral regarding other community resources 4 Focusing on the client's underlying personality conflicts in preparation for referral to long-term therapy
Correct Ans: 3 The client needs continued assistance to facilitate resolution of unresolved conflicts and problems. Discharging the client on time whether or not the crisis has been fully resolved is unethical; referral for ongoing therapy is warranted in this situation. If immediate issues have not been resolved during crisis intervention, further therapy is an appropriate option. Focusing on underlying personality conflicts is not the objective of crisis intervention and should be left to the therapist who undertakes long-term therapy with the client.
A confused, hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse? 1 "May I examine your arms?" 2 "When did this feeling first start?" 3 "That's a rather unusual sensation." 4 "It can be frightening to feel that way."
Correct Ans: 4 Depersonalization communication is the result of a high anxiety level; projecting empathy to the client will facilitate exploration of concerns. The response "May I examine your arms?" does not acknowledge the frightening experience for the client and supports the client's hallucination. When the feeling started is irrelevant; the nurse must address what the client is experiencing now. The response "That's a rather unusual sensation" belittles the client's feelings and may make establishment of a therapeutic relationship difficult.
A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. Which is a priority nursing action? 1 Tell the client that chest tubes will be present after the procedure. 2 Explain that the procedure will allow visualization of lungs and chest cavity. 3 Inform the client that some pleural fluid will be removed during this procedure. 4 Advise the client to avoid eating or drinking anything for several hours before the test.
Correct Ans: 4 To prevent aspiration during the procedure, clients are required to be nothing by mouth before the procedure. Chest tubes are not required unless the lungs are punctured accidentally. A mediastinoscopy permits visualization of the anterior mediastinum or hilum extrapleurally; bronchoscopy permits visualization of the larynx, trachea, and bronchi. Fluid is removed from the pleural space during a thoracentesis.
The parent of a 14-month-old toddler asks the nurse how to proceed with bowel training. What is the best response by the nurse? 1 Place the child on the toilet every 2 hours. 2 Start by having the child sit on a potty chair. 3 Avoid bowel training until the child is 2 years old. 4 Begin before the child's diet consists mainly of solid foods.
I put 3 Ans: 2 A potty chair is sized for a child and allows the child to display its contents with pride. A potty chair also allows the child to place the feet on the floor for an effective Valsalva maneuver to aid bowel evacuation. Sitting on a toilet seat can be frightening for a toddler. Timing of bowel training should coincide with the gastrocolic reflex. Bowel training should be started whenever the child shows readiness. A diet consisting mainly of solid foods will make stools bulkier and easier to control.
After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings through a nasogastric tube. A family member asks why this is necessary. What is the nurse's best response? 1 "Tube feedings prevent aspiration of food into the lungs." 2 "Tube feedings promote healing by reducing the risk for infection." 3 "Let me show you how to do a gavage. It will make you less anxious." 4 "You seem concerned about the gavage. You probably will not have to do this at home."
I put 1 Ans: 2 The response "Tube feedings promote healing by reducing the risk for infection" permits the esophageal suture line to heal before contact is made with food, which increases the risk for infection. Aspiration is still possible with nasogastric tube feedings. An explanation is not provided by the response "Let me show you how to do a gavage. It will make you less anxious." Also, it may increase anxiety. The response "You seem concerned about the gavage. You probably will not have to do this at home" does not answer the question and may provide false reassurance.
A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual? 1 It demonstrates respect for the client's autonomy. 2 This behavior is viewed as a result of anger turned inward. 3 Denying this activity may precipitate an increased level of anxiety. 4 Successful performance of independent activities enhances self-esteem.
I put 1 Ans: 3 The repeated thought or act defends the client against severe anxiety; the client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level. Compulsive behaviors are not autonomous choices. The client is compelled to perform the activity to reduce anxiety. Anxiety reduction, not anger, is the motivation for performing the ritual. Rituals are not activities that enhance self-esteem; they control anxiety. The client may be ashamed of the rituals that cannot be stopped.
After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response? 1 "It's premature separation of a normally implanted placenta." 2 "Your placenta isn't implanted securely in place on the uterine wall." 3 "You have premature aging of a placenta that is implanted in your uterine fundus." 4 "The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."
I put 1 Ans: 4 Implantation of the placenta in the lower uterine segment is the accepted definition of placenta previa. Premature separation of a normally implanted placenta is known as abruptio placentae; it occurs because the placenta is attached insecurely to the uterine wall. Premature aging of a placenta may not lead to placenta previa but will put the fetus in jeopardy.
The nurse reviews the medical record of a client who is eligible to receive end-of-life care. What are the criteria for a client to receive this type of care? Select all that apply. 1 When the client is nearing death 2 When the expected death of the client is within 6 months 3 When the client seeks no aggressive disease management 4 When a family member has signed an informed consent form 5 When the client has been issued a "do not resuscitate" order
I put 1, 2, 3, 5 Ans: 2, 3, 5 Clients who do not seek aggressive disease management and are expected to die in a span of 6 months are eligible for end-of-life care. The client may require end-of-life care when he or she has signed a "do not resuscitate" order. A client who is nearing death may not receive end-of-life care; instead, the client receives comfort care. An informed consent form signed by a family member is not necessary for the client to receive end-of-life care.
For how long should a nurse maintain isolation of a child with bacterial meningitis? 1 For 12 hours after admission 2 Until the cultures are negative 3 Until antibiotic therapy is completed 4 For 48 hours after antibiotic therapy begins
I put 2 Ans: 4 Most children are no longer contagious after 24 to 48 hours of intravenous antibiotics. Twelve hours after admission is inadequate, even if antibiotics are started immediately. Keeping the child isolated until cultures are negative or antibiotic therapy is complete is an excessively long period and is unnecessary.
A school-aged child is admitted to the pediatric unit with the diagnosis of a brain tumor. During breakfast the child vomits. What are the priority nursing interventions? Select all that apply. 1 Refeeding breakfast 2 Notifying the practitioner 3 Requesting a reevaluation 4 Administering the prescribed antiemetic 5 Increasing the intravenous infusion rate
I put 2, 3, 4 Ans: 2, 3 When a child displays signs of increasing intracranial pressure, the healthcare provider must be notified and should conduct a repeat assessment. Refeeding breakfast is unsafe; the child should not be fed until the practitioner has reassessed the child. If the cause of the vomiting is increased intracranial pressure, antiemetics will not be effective. There is no indication that an intravenous line is in place, and increasing the flow rate is a dependent function of the nurse. Also, additional fluids may further increase intracranial pressure.
The laboratory values shown here are returned on a male client being treated for bipolar disorder, type 2 diabetes, and peripheral vascular disease who is currently reporting chest pain. What is the priority nursing intervention? Lab values: INR 2.6, CK 120 units/L, Lithium 2.5 mEq/L, A1C 8.2% 1 Implementing seizure precautions immediately 2 Moving the crash cart outside the client's room 3 Assessing the client's respiratory and circulatory status 4 Performing a stat fingerstick to check the blood sugar level
I put 3 Ans: 1 The normal range of therapeutic lithium levels is 0.6 to 1.4 mEq/L (0.6 to 1.4 mmol/L). A lithium level of 2.0 (2.0 mmol/L) or greater indicates intoxication and may present with symptoms including seizure activity. The normal hemoglobin A1c range for adults is 4% to 6%, with a level greater than 8% indicating poor diabetic control. This value is in the abnormal range, but another lab value takes priority. The creatine kinase level in men ranges from 55 to 170 units/L. There is no indication that the client has experienced or is about to experience a heart attack. A normal international normalized ratio (INR) is between 0.7 and 1.8; in an individual undergoing warfarin therapy it ranges between 2.0 and 3.0. This value is within the therapeutic range for a client being treated for peripheral vascular disease.
An older client is found lying in the hospital hallway gasping for breath after a large hospital fire. The nurse observes that the client has probably sustained an unwitnessed fall, shows evidence of having a neck trauma, and is unable to speak. Which nursing interventions are most important for the nurse to perform at that moment? Select all that apply. 1 Placing a nasogastric tube 2 Performing jaw-thrust maneuver 3 Calling out for additional code blue assistance 4 Preparing to assist with endotracheal intubation 5 Monitoring respiratory rate and oxygen saturation
I put 3, 4, 5 Ans: 2, 3, 4 Researchers have shown that the jaw-thrust maneuver helps to open the airway of a neck trauma client without further traumatizing the neck. The nurse should also call out for additional code blue assistance from emergency medical services (EMS) in the hospital - or the community, if the hospital is not functional. The nurse should also anticipate assisting with endotracheal intubation when EMS arrives. Endotracheal intubation can provide proper breathing for this client and may need to be performed in the hallway before they are able to transport the client to the emergency room, if it is operational. A nasogastric tube should not be placed in the client with neck trauma because it could enter the brain and insertion is more difficult without having the client bend the neck forward and further traumatizing the neck. Monitoring the respiratory rate and oxygen saturation is required as soon as possible after performing the jaw-thrust maneuver, but it may not be immediately available in this disaster situation.
What instruction would the nurse be most likely to give a client with reduced sensory perception to prevent injury from scalding? 1 "Apply moisturizers." 2 "Use a bath thermometer." 3 "Dress warmly in cold weather." 4 "Avoid frequent bathing with hot water."
I put 4 Ans: 2 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.
Which statement demonstrates that a psychiatric nurse has fostered the most therapeutic nurse-client relationship? 1 "My clients and I are partners in the planning that helps meet their physical and mental health needs." 2 "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." 3 "Mental health is best achieved and maintained when the nurses and the clients exhibit respect and caring for each other." 4 "Without a mutually satisfying relationship between nurse and client, the process needed to maximize mental and physical wellness is greatly hindered."
I put Option 2 Ans: Option 1 Today's nurse-client relationship is one that demonstrates the nurse's clinical competence while recognizing the client's right to self-determination in decisions affecting both physical and mental health. Although the development of a true therapeutic relationship is a goal, when that is not achievable because of the client's mental health status, appropriate nursing care is still achievable. Although the demonstration of mutual respect and caring are basic elements, other factors also have an impact on the formation of a therapeutic nurse-client partnership. A truly therapeutic nurse-client relationship provides satisfaction for both nurse and client; that may not be achievable because of the client's mental health status. The nursing process can still provide care that strives to meet client outcomes that are reflective of their potential for both physical and mental wellness.
A nursing student is giving examples of healthcare settings and services. Which scenario is a perfect example of tertiary care? 1 Preparing a client for an X-ray who has sustained a leg fracture in an accident 2 Teaching community members about the importance of using seat belts in cars 3 Caring for a postoperative client in the intensive care unit who is suffering from respiratory distress 4 Advising a client with stage 1 Parkinson's disease to include exercise in his or her daily routine
I put Option 4 Ans: 3 Tertiary care consists of intensive care and subacute care. Caring for a postoperative client in an intensive care unit who is suffering from respiratory distress is a perfect example of tertiary care. Preparing a client with a leg fracture for an X-ray is an example of secondary acute care. Teaching community members about the importance of using seat belts in cars is an example of secondary acute care. Advising a client in stage 1 of Parkinson's disease about the importance of exercise in his or her daily routine is an example of primary care.