Prep U Safety, Med Emergencies, and Psychosocial Well-Being

When preparing to give a client an ordered drug, a nurse realizes that the drug is one she has never administered before. No drug references on the nursing unit contain information about the drug in question. What should the nurse do?

Contact a pharmacist to obtain information about the drug. Explanation: When print resources aren't available, pharmacists are the best resources for drug information, which they can provide quickly and reliably. Pharmacists have more up-to-date and accurate drug information than physicians or other nurses do. The nurse should refuse to give a drug only if she can't find any information about it.

A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply.

decreased cardiac output hypotension tracheal deviation to the opposite side Explanation: Tension pneumothorax results when air in the pleural space is under higher pressure than air in the adjacent lung. The site of the rupture of the pleural space acts as a one-way valve, allowing the air to enter on inspiration but not to escape on expiration. The air presses against the mediastinum, causing a tracheal shift to the unaffected side and decreased venous return (reflected by decreased cardiac output and hypotension). Neck veins bulge with tension pneumothorax. This also leads to compensatory tachycardia and tachypnea.

The parents of a 15-year-old female with a history of disordered eating are concerned about her loss of 24 lb (10.9 kg) during the previous month. The nurse tells the parents that she'll give their daughter a comprehensive examination and make appropriate referrals. Which initial referrals should the nurse make? Select all that apply.

nutritional consult psychiatric evaluation Explanation: A nurse must assess a client with disordered eating and create a care plan to stabilize body weight and prevent further weight loss. The nutritional consult helps determine nutritional needs to maintain body weight. A psychiatric evaluation establishes the baseline for a care plan to address the client's emotional needs, process the client's feelings and experiences, develop effective coping skills, and develop a realistic body image and positive self-image. After the adolescent's body weight stabilizes, she should have a dental assessment to identify dental problems resulting from malnutrition or purging. Although females with disordered eating may have amenorrhea, this adolescent shouldn't have a gynecologic examination unless a medical condition warrants one at a later time. She doesn't need a toxicology evaluation unless a severe substance-abuse problem is identified.

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

"Check breathing and heart rate." Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. After that, rescuers attempt to identify what was ingested, how much, and when. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach.

A 45-year-old man is being treated for bladder cancer. Which therapy would have the least complications?

Intravesical chemotherapy Explanation: Intravesical chemotherapy, where the cytotoxic drug is instilled directly into the bladder, avoids the side effects of systemic therapy. Radiation will cause other tissue damage and cystectomy may cause impotence.

The nurse is caring for a client whose spouse has just passed away. The nurse knows that according to the Kubler-Ross Model of Grief, there are five stages of grief that most grieving people progress through in order, although not everyone experiences all stages or in this order. Place the stages of grief in the order that is most commonly observed, and that the nurse would expect to see in this grieving client.

Denial Anger Bargaining Depression Acceptance Explanation: Elisabeth Kubler-Ross described the five stages of grief as a model that many grieving clients progress through. Although not all clients will experience all five stages or in this chronological order, and some may go back and forth between the stages, the nurse should understand the five stages of grief and be able to put them in the chronological order that the majority of clients will experience which is denial, anger, bargaining, depression and acceptance.

A client comes to the emergency department after taking an overdose of amitriptyline hydrochloride. Immediate care for this client should include

administering activated charcoal every 4 hours for 24 hours. Explanation: After administering appropriate stomach lavage, the nurse should give the client activated charcoal every 4 hours for 24 hours. The charcoal binds with amitriptyline and inactivates it. The nurse shouldn't induce vomiting because the client's mental status may rapidly deteriorate and pose the risk of aspiration. Large boluses of enteral saline can force the drug into the small intestine, where it will be absorbed. The nurse should use a large tube for gastric lavage so she can remove intact pills.

A preschool-aged child with suspected epiglottitis is emitting no sounds during inhalation attempts and begins drooling. What is the nurse's priority action?

assisting with tracheotomy Explanation: The child is showing signs of total airway obstruction, so the nurse should immediately prepare to assist with emergency tracheotomy. Supplemental oxygen is required with epiglottitis, but administration by mask or other external device will not be successful once obstruction progresses to this point. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management.

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms

may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. Explanation: Administration of amphotericin B may cause fever, chills, and body aches. The administration of diphenhydramine and acetaminophen approximately 30 minutes before the administration of amphotericin B may prevent these side effects. Renal toxicity due to amphotericin B is dose limiting. Monitoring serum creatinine and blood urea nitrogen levels may alert the nurse to the development of renal insufficiency and the need to address the clients' renal status. Vascular changes are associated with C. immitis and Aspergillus. Manifestations of vascular change may include arteritis or cerebral infarction. Blood and CSF cultures help diagnosis fungal encephalitis.

A nurse manager attempts to achieve performance improvement in the emergency department of a busy inner-city hospital. Which nursing actions follow Haase and Miller's recommended steps in performance improvement? Select all that apply.

The nurse discovers that there is a problem with the triage system that is in place in the emergency department. The nurse calls a meeting of the emergency department interdisciplinary team to effect change in the triage process. The nurse organizes a task force to implement change in the triage process of a busy emergency department. The nurse meets with the emergency department staff to assess changes made to the triage process. Explanation: Nurses committed to healthier clients, quality care, reduced costs, and the personal satisfaction of knowing that they are actually making a difference (versus merely wishing things were different) value performance improvement. The four steps, according to Haase & Miller, that are crucial in improving performance include:1. Discover a problem.2. Plan a strategy using indicators.3. Implement a change.4. Assess the change; if the outcome is not met, plan a new strategy.

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?

aortic insufficiency Explanation: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP.

The nurse suspects a client is a victim of intimate partner violence (IPV). Which statement by the client supports the nurse's suspicion?

"My spouse refuses to let me go out to find a job." Explanation: Financial abuse would be indicated by the partner preventing one's spouse from going out to find a job. Constant complaints about a job, being abusive to animals, and road rage are not indicative of IPV to the client.

An adolescent who is depressed states, "Nothing ever seems to be right in my life." Which would be the most appropriate response by the nurse?

"You are feeling sad right now. It's a hard time." Explanation: Some degree of depression is present in most adolescents because they are not only losing their parents while they grow apart from them but also their carefree childhood. When using therapeutic communication, it is important for the nurse to accept the client's verbalization as real. Support should be real. Telling the adolescent that things will be better in college provides false reassurance. Telling the adolescent to "look on the bright side of things" or that "being a teen is hard work" offer platitudes and interrupt the client's interactions.

Which best defines a community support system in relation to mental illness?

A network that helps to meet the needs of people with mental illness and to realize their potential without unnecessary isolation Explanation: A community support system is a network of people committed to helping a vulnerable population meet its needs and reach its potentials without unnecessary isolation or exclusion.

What is the term used to identify a person's inability to experience pleasure in things that use to result in pleasure?

Anhedonia Explanation: Anhedonia is the inability to experience pleasure, while alogia is the tendency to speak very little. Avolition is the lack of motivation towards goals. Affective flattening is the lack of emotional expression.

A nurse is caring for a 25-year-old client who has been prescribed an adrenergic drug for shock. Which action should the nurse implement?

Continually assess the client for physiological changes and notify the primary care provider with changes. Explanation: When caring for a client receiving an adrenergic medication for shock, the nurse will continually assess the client for changes in his vital signs, perfusion, and any adverse reactions. Telling a family that their loved one might die is not an appropriate nursing action at that time. Seizures, hypothermia, and dementia are not common side effects of adrenergic medications, and an adrenergic medication should not be abruptly stopped. The nurse needs to stay close to a client to do frequent assessments; sleep deprivation may occur, but it is not the primary concern when a client is in shock.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

A nurse is developing a plan of care for a patient diagnosed with post-traumatic stress disorder (PTSD). Which of the following would be the priority?

Establishing a trusting nurse-patient relationship Explanation: The priority when caring for a patient with PTSD is establishing a trusting nurse-patient relationship, because the patient is physically compromised and struggling emotionally with situations that are not considered part of the normal human experience. Once trust is established, then the nurse can assist the patient in working through the traumatic experience, teach coping skills for recovery and self-care, and administer prescribed medications.

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met?

Grab bars are installed in a client bathroom to facilitate safe showering. Explanation: According to Maslow, safety and security needs follow basic physiologic needs; therefore, grab bars in a bathroom helps ensure safety in the client's shower. Enrolling in an art class would meet love and belonging, self-esteem, or self-actualization needs. Arranging for a teenager to have friends visit would help in meeting love and belonging needs. Identifying strengths in a client demonstrates self-esteem needs.

The nurse is admitting a client directly from a healthcare clinic. The healthcare provider's orders are illegible. What should the nurse do next? Select all that apply.

Hold all orders. Call the healthcare provider to clarify orders. Explanation If the nurse cannot correctly interpret the components of a medication order, the nurse should hold the orders and call the healthcare provider for clarification. The only person that can interpret the components of the orders are the person who wrote the orders.

The mother of a child with myasthenia gravis has called the clinic and reports her child appears very anxious and the child's heart is beating very fast. What action by the nurse is indicated?

Instruct the child be brought to the emergency department promptly. Explanation: Myasthenia gravis is an autoimmune disorder that is characterized by weakness and fatigue. There is no cure. The disease may be aggravated by stress, exposure to extreme temperatures, and infections, resulting in a myasthenic crisis. Myasthenic crisis is a medical emergency with symptoms including sudden respiratory distress, dysphagia, dysarthria, ptosis, diplopia, tachycardia, anxiety, and rapidly increasing weakness. The symptoms reported are consistent with a crisis and prompt care is indicated. Waiting 24 hours to have the child seen by the physician is not appropriate. Questions about changes in routine and medication compliance may be asked but the first priority is to have the child seen.

A client with a history of posttraumatic stress syndrome reports frequently reliving the traumatic event. The nurse documents that the client is experiencing:

Intrusion Explanation: The nurse documents that the client is experiencing intrusion, defined as the occurrence of flashbacks or nightmares in which the traumatic event is relived in vivid detail.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever. Explanation: The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing.

A client arrives in the emergency department by ambulance with a family member stating, "He took an overdose of sleeping pills and I found him breathing very shallowly." For which type of acid-base disturbance will the nurse anticipate this client will be treated?

Respiratory acidosis Explanation: Respiratory acidosis occurs in conditions that impair alveolar ventilation and cause an increase in plasma PCO2, also know as hypercapnia, along with a decrease in pH. Respiratory acidosis can occur as an acute or chronic disorder but occurs most often as a result of decreased ventilation. Other acid-base imbalances may occur if the respiratory acidosis is not immediately treated.

A nurse is completing a health assessment with an adult client in a healthcare provider's office. What assessment data will the nurse report to the healthcare provider as indications of fluid volume excess? Select all that apply.

bounding pulses pitting extremity edema feelings of fatigue Explanation: The nurse will report bounding pulses, pitting edema, and feelings of fatigue as indications of fluid volume excess due to the stress of fluid on the circulatory system. A The blood pressure and heart rate will be elevated with fluid volume excess.

The nurse examines laboratory findings for a client. What result should the nurse investigate further?

platelet count of 115,000/mm3 (115 x109/L) Explanation: A platelet count of 115,000/mm3 (115 x109/L) is below normal (N = 150,000-400,000/mm3 [150-400/109/L]) and requires further investigation. All other offered results are within normal range.

A client has just begun treatment with busulfan, 4 mg by mouth daily, for chronic myelogenous leukemia. The client receives busulfan until their white blood cell (WBC) count falls to between 10,000/mm3 and 25,000/mm3. Then the drug is stopped. When should treatment resume?

when the WBC count rises to 50,000/mm3 Explanation: Busulfan treatment should resume when the WBC count rises to 50,000/mm3. Hair growth and anemia aren't appropriate markers for resuming busulfan treatment.

A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first?

"Have him use his short-acting bronchodilator right away." Explanation: The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.

Teaching for women of childbearing years who are receiving antipsychotic medications includes which statement?

Continue previous contraceptive use even if you're experiencing amenorrhea. Explanation: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Because amenorrhea doesn't indicate cessation of ovulation, the client who experiences amenorrhea can still become pregnant. She should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and the depressant effect generally decreases libido.

In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly?

Crisis Explanation: In the crisis phase, seclusion or restraint may be used to deal with aggression quickly.

A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment, what does the nurse expect to find?

continuous drooling Explanation: Signs of a TEF include continuous drooling, excessive oral secretions, and choking and coughing, which are especially pronounced during feeding. TEF doesn't cause diaphragmatic breathing, a slow response to stimuli, or passage of frothy meconium.

A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?

hyperemesis gravidarum Explanation: Hyperemesis gravidarum differs from the nausea and vomiting (morning sickness) that normally occur during pregnancy. It's characterized by excessive vomiting that can lead to dehydration and starvation. Without treatment, metabolic changes can lead to severe complications, even death, of the fetus or mother. Eclampsia is the most serious form of gestational hypertension. It's characterized by hypertension, seizures, coma, edema, and proteinuria. Hydramnios is an overproduction of amniotic fluid that causes uterine distension.

The nurse is caring for a client whose pain is being treated with pentazocine. What would be an appropriate nursing diagnosis for this client's care plan?

impaired gas exchange related to respiratory depression Explanation: Nursing diagnoses may include impaired gas exchange related to respiratory depression. The drug is more likely to cause constipation due to slowing of the GI tract instead of diarrhea. The drug has no effect on immune function. Autonomic dysreflexia is not caused by CNS depression and is limited to clients with spinal cord injuries.

The parents of a toddler have just learned that their child has profound hearing loss. The parents are very upset and state to the nurse, "It just isn't fair. We did everything right during our pregnancy all the way to this point." How should the nurse respond?

"I can't imagine how difficult this must be. When you're ready I would be happy to arrange a meeting with a support group of other parents with children who have hearing loss." Explanation: This comment is the most empathic and supportive. Encouraging a support group, when the parents are ready, is very helpful. Those in a support group know how these parents feel and can also offer helpful options for dealing with a hearing-impaired child. Telling the parents to "think positively" or that "things could be much worse" disregards the concern the parents have voiced to the nurse. The nurse generalizes the parents' feelings by telling them "many children who have a profound hearing loss function very well....."

The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS?

Decrease anxiety and fear during hospitalization and painful procedure. Explanation: The CLS is a specially trained individual who provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful (Child Life Council, 2010a, 2010b). The goal of the CLS is to decrease the anxiety and fear while improving and encouraging understanding and cooperation of the child. The CLS may use distraction techniques and act as a liaison, but that is not the primary goal of the CLS role. The CLS does not perform medical procedures.

While intubated for surgery, a client has inadvertently had his vagus nerve stimulated. What effect would the surgical team expect to observe?

Decreased heart rate as a result of parasympathetic innervation of the heart Explanation: Vagal stimulation results in a lowered heart rate as a result of parasympathetic stimulation. Vascular perfusion, contractility, and afterload would not be under direct effect. Acetylcholine reuptake would not be influenced.

Diabetic ketoacidosis (DKA) in a client with type 1 diabetes occurs when the lack of insulin leads to the release of which physiologic product?

Fatty acids Explanation: DKA most commonly occurs in type 1 diabetes, when the lack of insulin leads to unsuppressed adipose cell lipase activity that breaks down triglycerides into fatty acids and glycerol. The subsequent increase in fatty acid levels leads to ketone production by the liver. Serum potassium levels may be normal or elevated, despite total potassium depletion resulting from protracted polyuria and vomiting. Metabolic acidosis is caused by the excess ketoacids that require buffering by bicarbonate ions; this leads to a marked decrease in serum bicarbonate levels. Stress increases the release of cortisol and other gluconeogenic hormones and predisposes the person to the development of ketoacidosis.

The birth defects associated with thalidomide (Thalomid) resulted in legislation known as the:

Kefauver-Harris Act of 1962. Explanation: The Kefauver-Harris Act of 1962 gave the Food and Drug Administration (FDA) regulatory control over testing and evaluating drugs and set standards for efficacy and safety. The Controlled Substances Act defined drug abuse and classified drugs according to their potential for abuse. The Pure Food and Drug Act prevented the marketing of adulterated drugs. The Durham-Humphrey Amendment tightened control of certain drugs.

A stay-at-home father wants to purchase commercial toddler meals because his 16-month-old girl recently choked on table food. Which food items will the nurse suggest not be given to this child? Select all that apply.

Round foods such as hot dogs, whole grapes, and cherry tomatoes Hard foods such as nuts, raw carrots, and popcorn Sticky foods like peanut butter alone, gummy candies, and marshmallows Explanation: To offer soft round foods safely, cut hot dogs in uneven pieces and cut grapes and cherry tomatoes into quarters. This prevents food impacting in an airway. Avoid the hard and sticky foods due to aspiration and airway occlusion risks. The cooked vegetables listed are safe as are the soft fruits.

An older adult client is administered dimenhydrinate. Which is the priority nursing intervention for this client?

Protect from injury. Explanation: Dimenhydrinate causes drowsiness, especially in older adults, and therefore should be used cautiously. The nurse should protect the client from injury. There is no indication that fluids should be forced. The client will not require IV access unless fluid replacement is prescribed.

A nurse comes upon a automobile accident where smoke and flames are coming from the car's engine. What would be the nurse's priority in this situation?

Stop the fire or remove the person from the vehicle. Explanation: Regardless of the type of burn, it is priority to stop the fire and provide a safe environment for the people affected. The heat source should be removed, and flames should be doused with water or smothered with a blanket. The people should be removed from the vehicle, especially if the fire cannot be contained. The risk of spinal trauma moving the victims is secondary to the imminent threat of the fire. After moving the people to a safe distance, their airways should be assessed next. If the cell phone is working, the nurse should call 911 and report the findings. That way, help will be on the way.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia Explanation: Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.

While assessing a client, the nurse notes the client is functioning at the fourth level according to Maslow's hierarchy of needs. Which observation of the client led the nurse to conclude this?

The client longs to have validation for success and accomplishments. Explanation: According to Maslow's hierarchy of needs, the fourth level involves the need related to esteem needs, which includes the need for self-esteem and respect from others. Hunger and sexual expression are captured within the first level of Maslow's hierarchy of needs. Feeling unsafe indicates the client is functioning on the second level and is focused on security needs.

The pediatric nurse is preparing to administer ibuprofen to an 8-month-old infant. The infant's weight is listed in the computer as 15 kg (33 lb) and the medication is prescribed to be given 10 mg/kg. The nurse notices that the dose of 150 mg seems high for an infant. The nurse clarifies the prescription with the healthcare provider, who states that it is the correct dose. What should the nurse do?

Verify child's weight is accurate and, if it is correct, give the medication. Explanation: Pediatric medication dosages are weight-based. In this scenario, the nurse has already verified the prescription is correct with the healthcare provider, and 10 mg/kg is a safe and standard dose for ibuprofen in pediatric clients. The nurse should verify the child's weight is accurate, because 15 kg (33 lb) for an 8-month-old infant is higher than the 99th percentile and, if it is accurate, the medication should be given as prescribed. The nurse should not just give the medication just because the healthcare provider said it is correct and should not notify a superior unless there is clearly an unsafe situation that cannot be resolved otherwise. The nurse should document the interaction but the priority is verifying the weight and accuracy of the prescription.

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. Explanation: An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

The nurse assesses a 7-year-old child after dinner and notes the child has developed urticaria. What priority assessment should the nurse perform next?

respiratory Explanation: The child is showing evidence of an allergic reaction. The priority is to ensure anaphylaxis is not developing. This makes respiratory the priority system for assessment as anaphylaxis can result in angioedema of the airway and bronchoconstriction. The next priority would be blood pressure due to vasodilation that leads to hypovolemic shock. The neurological system is not directly affected by anaphylaxis unless it is related to hypoxia, and integumentary assessment is definitely not a priority when there are potentially life-threatening complications to address. While trying to determine the source of the reaction may be beneficial in the future, this is often difficult to ascertain since meals contain more than one potential allergen.

During which phase of the nurse-client relationship does the client identify and explore specific problems?

working Explanation: During the working phase, the client uses the relationship to examine specific problems and learn new ways of approaching them. Debriefing is not a phase of the nurse-client relationship. During the orientation phase the nurse and client get to know each other. The final phase, resolution, is the termination stage of the relationship and lasts from the time the problems are resolved to the close of the relationship.

A newborn requires resuscitation secondary to asphyxia. The resuscitation team frequently assesses the newborn's response and continues resuscitation efforts based on which assessment finding?

heart rate of 70 beats/min Explanation: Resuscitation is continued until the newborn has a heart rate higher than 100 beats/min, a good healthy cry, or good breathing efforts and a pink tongue. This last sign indicates a good oxygen supply to the brain.

A public health nurse is teaching a community seniors group about the risk of falls. Which aging characteristic increases the risk of falls in elderly individuals?

forward-flexed posture Explanation: As people age, the spine tends to flex forward, causing a shift in balance and an increased risk for falls. Decreased ability to adapt quickly is not a characteristic of aging. Inability to take responsibility has no application to the question. Increased reaction time is incorrect; it would be decreased.