test 5

A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply. A) Tachycardia B) Increased blood glucose level C) Decreased breath sounds D) Confusion E) Thick, tenacious bronchial secretions

A, C, D) Clinical manifestations of DIC include tachycardia, decreased breath sounds, and confusion. Increased blood glucose and thick bronchial secretions are not associated with this health problem.

The nurse selects the diagnosis of Risk of Infection for a child who sustained a brain injury during an automobile accident. Which nursing intervention would be appropriate to include in this client's plan of care related to this diagnosis? A) Teach the family the importance of using seat belts. B) Change the client's dressings on a prescribed basis. C) Refer the family to support services in the community. D) Explain rules for visiting in the Intensive Care Unit.

B) While families may need education about seat belts and sources of support, it is not the optimal time to implement such teaching at this point in the crisis. A nursing intervention that would support the diagnosis of Risk of Infection would be changing the client's dressings on a prescribed basis because wet dressings can be a source of infection Timelines for visitation are appropriate but are not the priority.

A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of A) decreased hydration. B) decreased blood flow to the skin. C) inflammation and elevated body temperature. D) hypothyroidism

C) Warm, red skin indicates inflammation and elevated body temperature. Decreased skin temperature is indicative of decreased blood flow to the skin. Excessively dry skin is indicative of hypothyroidism. Poor skin turgor is indicative of decreased hydration.

Which lobe of the brain stores memory and interprets auditory stimuli? A) Frontal B) Occipital C) Parietal D) Temporal

D) The temporal lobe of the brain stores memory and interprets auditory stimuli. The frontal lobe is involved with speech, thought, learning, emotion, and voluntary movement. The occipital lobe, where the visual cortex is located, processes vision. The parietal lobe processes sensory information, including shapes, temperature, pain, and two-point discrimination.

Which events are associated with the loss of autoregulation? A) Both intracranial pressure and cerebral perfusion decrease. B) Both intracranial pressure and cerebral perfusion increase. C) Intracranial pressure decreases and cerebral perfusion increases. D) Intracranial pressure increases and cerebral perfusion decreases.

D) With loss of autoregulation, ICP continues to increase and cerebral perfusion decreases. Cerebral tissue becomes ischemic, and manifestations of cellular hypoxia appear.

A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology? A) An immune response that leads to issues with tissue integrity B) Impaired tissue integrity that leads to an immune response C) Impaired tissue integrity that leads to an infection D) Decreased perfusion that leads to issues with tissue integrity

A) Allergic reactions are an example of an immune response that leads to issues with tissue integrity. Impaired tissue integrity, such as a cut, can lead to an immune response, but that is not the case in this scenario. If left untreated or exposed to bacteria or other infectious agents, the dermatitis could lead to an infection, but there is no evidence of that in this scenario. Decreased perfusion can lead to tissue damage or death, but not dermatitis

Which pathological change related to disseminated intravascular coagulation (DIC) occurs late in the course of the disease? A) Hemorrhage B) Formation of small clots C) Damage to the endothelium D) Brain ischemia

A) Damage to the endothelium is one of the triggers that stimulates the clotting cascade. This increases the presence of thrombin, which causes small clots to form in the microvasculature. If these thrombi and emboli impair tissue perfusion, ischemia of organs such as the brain can occur. When clotting factors are depleted and fibrin degradation products are released, hemorrhage occurs.

The nurse is planning care for a client who is experiencing increased intracranial pressure (IICP) secondary to a head injury sustained during a motor vehicle crash. Which intervention is a priority for this client? A) Ensuring adequate oxygenation B) Maintaining a calm environment C) Monitoring for nausea and vomiting D) Controlling pain

A) Ensuring adequate oxygenation to support brain function is the most important step in management of IICP. Although pain control, a calm environment, and vomiting (a sign of increased ICP) would be important, they are secondary to maintaining adequate oxygenation.

The staff nurses are discussing interventions to reduce the risk of infection for the client population. Which intervention is the most important to decrease client infection? A) Practice appropriate hand hygiene. B) Assess vital signs once daily. C) Raise the temperature in the client's room. D) Wear a mask for all client care.

A) Hand hygiene is always the first and best way to stop the spread of microorganisms, which cause infections. Assessing vital signs is important but should be done more frequently than once daily. Raising the temperature in a client's room would contribute to the growth of microorganisms. Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client. The nurse notes that the client has hypopigmentation of the skin on both hands. The nurse should recognize that this condition is related to which age-related skin change? A) Hyperplasia of melanocytes B) Decreased perfusion of the dermis C) Increased permeability of the epidermal layer D) Hyperplasia of capillaries

A) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.

Which of the following statements best describes the state of dynamic equilibrium of the Monro-Kellie hypothesis? A) An imbalance in the volumes of the brain, blood, and cerebrospinal fluid (CSF) will trigger a compensatory response. B) Normal intracranial pressure requires that the volumes of the brain, blood, and CSF are low. C) The brain can compress dynamically to compensate for an increase in blood or CSF volume. D) The volume of the blood must remain constant regardless of the volume of the brain and CSF.

A) In adults, the rigid cranial cavity created by the skull is normally filled to capacity with three essentially noncompressible elements: the brain, cerebrospinal fluid, and blood. A state of dynamic equilibrium exists: If the volume of any of the three components increases, the volume of the others must decrease to maintain normal pressures in the cranial cavity. This relationship is known as the Monro-Kellie hypothesis. Normally either the blood or CSF would shift out the cranium to compensate for increased volume of one of these three components. The brain is noncompressible. The volume of these components must remain in balance, not be low

An older adult client is admitted to the medical-surgical unit for a hip fracture. During postoperative recovery, the nurse notices a stage 1 pressure injury forming on the client's sacrum. Which action by the nurse is appropriate to reduce the progression of this injury? A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side. B) Apply a heat lamp to the area to increase circulation. C) Apply a dry dressing to the pressure injury. D) Maintain the head of the bed at a 45-degree angle.

A) Keeping the head of the bed at an angle of 30 degrees or less decreases pressure on the sacrum. An angle of 45 degrees would be too severe and could exacerbate pressure injury formation on the sacrum. Dry dressings are not indicated with this stage of pressure injury. Heat lamps are no longer used in the treatment of pressure injuries because they do not provide therapeutic benefit.

Softening of the skin as a result of prolonged wetting or soaking is also referred to as A) maceration. B) debridement. C) excoriation. D) shearing.

A) Maceration involves softening of the skin due to prolonged wetting or soaking. Excoriation is loss of the superficial layers of the skin. Debridement is the removal of necrotic material from a wound. Shearing occurs when one layer of tissue slides over another.

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis? A) Place the client in low-Fowler position to improve gas exchange B) Monitor the client's oxygen saturation intermittently C) Encourage frequent amulation D) Use continuous endotracheal suctioning instead of coughing and deep breathing

A) Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange. Oxygen saturation levels are a noninvasive means of assessing gas exchange and should be monitored continuously. The client must remain on bedrest to reduces oxygen demands and cardiac workload. Cautious nasotracheal suctioning is indicated only if cough is ineffective or an endotracheal tube is in place. Deep breathing increases respiratory depth and improves alveolar ventilation and oxygenation.

When a nurse performs or observes nursing practices that are not safe, the nurse has a responsibility to report those actions. This principle ties the concept of safety to what other nursing concept? A) Accountability B) Advocacy C) Assessment D) Clinical Decision Making

A) Nurses are accountable for their actions, so all unsafe nursing practices should be reported and addressed. This principle does not reflect advocacy, assessment, or clinical decision making.

The nurse is caring for a pregnant client with a history of idiopathic intracranial hypertension (IIH) and optic neuritis. What should the nurse least assume regarding this client? A) The client will deliver her baby via cesarean birth. B) Pregnancy-related weight gain should be kept to no more than 9 kg. C) The client has been prescribed a medication to treat the IIH. D) The second stage of labor should not be prolonged.

A) Pregnant clients with IIH usually have a normal vaginal delivery. If a client with IIH becomes pregnant, neurology and obstetrics should work together closely to ensure safety for both the mother and fetus. Medications to treat IIH can usually be taken throughout pregnancy. For these women, it is recommended that pregnancy-related weight gain be on the lower end (5-9 kg). If there is optic nerve dysfunction, the second stage of labor should not be prolonged, but otherwise no special care must be provided to the pregnant client with IIH.

A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client's airway. Which action should the nurse take next? A) Notify the primary healthcare provider. B) Notify the family of the need for restraints. C) Reassess the need for the restraints in 8 hours. D) Document the application of restraints in the chart.

A) Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.

A newly admitted adult client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6. Which of the following assessment findings is most likely in this client? A) Extension to painful stimuli B) Spontaneous eye opening C) Oriented to time, place, and person D) Withdraws to touch

A) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness that analyzes three components: eye opening, verbal response, and motor response. A score of 15 indicates full alertness, and the lowest possible score is 3, which indicates total neurologic unresponsiveness. The client's score is low, so the finding of extension to painful stimuli, a 2 out of a possible 6 for motor response, is most likely for this client. Findings of spontaneous eye opening (a 4 on the scale for eye opening, the maximum score) or orientation to time, place, and person (a 5 for verbal response and also the maximum score for that component) are unlikely. An assessment finding of withdraws to touch would be more typical of an infant or young child, not an adult, and would be a 5 out of 6 for motor response.

What part of the body controls reflexes and regulates activities such as vomiting, hiccupping, coughing, and sneezing? A) Brainstem B) Hypothalamus C) Spinal cord D) Thalamus

A) The brainstem is made up of the midbrain, pons, and medulla oblongata. The brainstem controls reflexes and influences all basic life functions including breathing, blood pressure, and heart rate. The brainstem also regulates activities such as vomiting, hiccupping, coughing, and sneezing. The hypothalamus is the autonomic control center, and it is involved in regulating activities such as heart rate, blood pressure, respiratory rate and depth, pain, pleasure, and fear. The spinal cord transmits impulses to and from the brain. The thalamus is the brain's relay center; it takes all incoming nerve impulses and sends those signals to the correct region of the brain.

The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client? A) Carefully repositioning the client every 2 hours B) Administering oxygen C) Monitoring oxygen saturation D) Encouraging deep breathing and coughing

A) The intervention appropriate for the client experiencing ineffective peripheral tissue perfusion is to carefully reposition the client every 2 hours because position changes facilitate circulation and tissue perfusion. The other interventions would be appropriate if the client were experiencing impaired gas exchange.

A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept. Which statement will the educator include in the teaching session? A) "The newborn's skin is about 40% to 60% thinner than an adult's skin at birth." B) "The newborn's skin contains less water than an adult's and has tightly attached cells." C) "The newborn's thicker skin decreases absorption of harmful chemical substances and topical medications." D) "The newborn's skin has a greater percentage of underlying subcutaneous fat compared to adults."

A) The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin has less subcutaneous fat compared to adults.

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be prescribed for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids

A) Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.

When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? Select all that apply. A) Initiate a frequent toileting schedule. B) Raise the client's heels off the bed. C) Turn the client every 4 hours. D) Use inflatable doughnut-style devices to reduce pressure on the sacrum. E) Massage pressure areas with lotion every 4 hours.

A, B) Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and the potential for skin breakdown. The client's heels should be raised off the bed to remove pressure on this area of the body. The client should be turned at least every 2 hours. Massaging pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, because they increase pressure and reduce perfusion to affected areas.

The nurse is planning care for an older adult client with a head injury secondary to a motor vehicle crash. Which information should the nurse keep in mind when planning this client's care? Select all that apply. A) Anxiety, illness, and pain can alter the ability to learn. B) Baseline reflexes may be slower or diminished. C) Impulse transmission and reactions to stimuli are slower. D) Neurologic assessment should be completed in a single session. E) Impairment in vision and hearing should be taken into consideration.

A, B, C, E) For an older client, full neurologic assessment can be lengthy. Conduct the assessment in several sessions if indicated, and cease the tests if the client is noticeably fatigued. In the older client, anxiety, illness, and pain can alter the ability to learn. Reflexes may be slower or diminished in an older client. Responses to stimuli are slower because of reduced impulse transmission. Many older adults have some impairment of hearing and vision, which should be taken into consideration when planning care.

Which practices support promotion of health safety? Select all that apply. A) Exercise every day B) Avoid driving when sleepy or tired C) Eliminate all foods containing fat D) Wear seat belts E) Only see healthcare providers when sick

A, B, D) Health promotion involves many different practices, including staying physically active, following guidelines for motor vehicle safety, eating an appropriate diet, and monitoring personal health status. Eliminating all foods containing fat would eliminate necessary nutrients from the diet, and clients should see a healthcare provider at least annually for a checkup even if not sick.

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. Which actions should the nurse take to support this client's care need? Select all that apply. A) Limit the client's visitors. B) Teach family to speak softly and minimize touching. C) Elevate the head of the bed. D) Raise pads and bedrails. E) Keep the room dark and quiet.

A, B, E) A dark, quiet room is important to reduce stimuli. Family members should be encouraged to talk to the client in a soft voice with minimal touching. Visitors should be limited. Elevating the head of the bed is important to reducing intracranial pressure but has no effect on stimulation. Raising pads and bedrails is important because of the possibility of seizures but does not relate to stimulation.

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply. A) Monitor the client's level of consciousness and mental status. B) Elevate the client's knees on the bed or with a pillow. C) Minimize the use of tape on the client's skin. D) Assess extremity pulses, warmth, and capillary refill. E) Carefully reposition the client at least every 2 hours.

A, C, D Explanation: A) Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding.

While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. Which interventions are appropriate for the nurse to teach the family member regarding this client's care? Select all that apply. A) Maintain head of the bed elevated to 30 degrees. B) Position client in a supine position. C) Decrease stimuli. D) Keep bedrails raised. E) Keep the client in a stationary position.

A, C, D) For clients with increased ICP, the bedrails should be raised, and the head of the bed should be elevated. The degree depends on the reaction of the client to the position; 30 degrees is usually appropriate, but this can vary by the client. Decrease stimuli for a client with IICP. Clients with IICP must not remain stationary, but position changes should be done less frequently than for other clients because turning, skin care, and passive range of motion exercises can elicit posturing, which also causes increased ICP.

client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which classifications of medications should the nurse anticipate administering to this client? Select all that apply. A) Loop diuretics B) Antibiotics C) Antiseizure drugs D) Histamine H2 antagonists E) Antipyretics

A, C, D, E) Medications play an important role in the management of IICP. Loop diuretics are commonly used to reduce ICP. Antipyretics such as acetaminophen are used alone or in combination with a hypothermia blanket to treat hyperthermia. Antiseizure drugs are often required to manage seizure activity associated with brain injury and IICP. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists is often used because clients with IICP are at increased risk for developing stress gastritis and ulcers. Antibiotics are not routinely prescribed as treatment for IICP.

A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute (bpm). What is the client's cardiac output (CO) rounded to the nearest liter?

Answer: 6 Liters (L) Explanation: CO = SV × HR 85mL = 0.085 L CO = 0.085 × 71 = 6.035 = 6 L

What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

B) A stage 2 pressure injury is characterized by partial-thickness skin loss involving the dermis. It presents as a shallow open ulcer with a viable, moist wound bed that is red or pink. Granulation tissue, slough, and eschar are not present. A stage 2 injury may also present as an intact or open serum-filled blister.

The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for increased intracranial pressure (IICP). The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met? A) "If our child has a bulging soft spot, we will call the doctor." B) "If our child develops an altered level of consciousness, we will notify the doctor." C) "If we notice our child's head is expanding, we will notify the doctor." D) "If our child vomits, we will call the doctor."

B) An altered level of consciousness would be a symptom of shunt malfunction and increasing intracranial pressure. Because the bones in the skull have not yet fused, an infant with IICP may have bulging fontanels, separated sutures on the skull, drowsiness, or vomiting. In most children by age 8, the cranial suture lines have fused and the fontanels are closed, so a bulging soft spot and expanding head size would not be common symptoms of shunt malfunction and an increase in intracranial pressure. In children, and as ICP increases in infants, the signs and symptoms of IICP present similarly to adults. Examination may reveal headaches, weakness, eye movement disturbances, behavioral changes, decreased level of consciousness (LOC), or seizures.

A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test

B) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.

When a nurse provides a client with the guidance to wear seat belts and avoid mobile device use while driving, this measure is intended to lower the risk of which of the following? A) Cerebral edema B) Head trauma C) Hydrocephalus D) Intracranial tumors

B) Guidance related to wearing seat belts and avoiding mobile device use while driving is intended to lower the risk of cerebral trauma, not cerebral edema, hydrocephalus, or intracranial tumors. Any factor that increases the client's risk of trauma increases the risk of cerebral trauma resulting in IICP. Risk factors for cerebral trauma are plentiful but increase when normal safety considerations, such as wearing protective equipment, are ignored. Other than trying to prevent cerebral trauma, there is really no means to prevent IICP.

A client who is living independently but needs skilled nursing services may take advantage of what type of healthcare? A) Long-term care B) Home healthcare C) Telehealth D) Assisted living

B) Home healthcare provides a variety of medical, therapeutic, and nonmedical services, such as wound care, dietary counseling, physical therapy, occupational therapy, skilled nursing services, and homemaker services. These services are available in private homes from healthcare professionals. Telehealth would not be adequate for providing skilled nursing services. Assisted living facilities do not typically include skilled nursing services. One aspect of long-term care is skilled nursing services, but the clients do not live independently.

Hydrocephalus results from an imbalance between production and absorption of which of the following? A) Blood B) Cerebrospinal fluid C) Oxygen D) Water

B) Hydrocephalus results from an imbalance between production and absorption of cerebrospinal fluid (CSF)—not blood, oxygen, or water—which causes too much CSF to accumulate in the brain and the ventricles to widen.

The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this client? A) Frequent ambulation B) Maintenance of skin integrity C) Preparation for radiograph procedures D) Restricting fluids

B) Impairment of skin integrity can lead to bleeding in DIC. The client with DIC should be placed on bedrest. DIC is not diagnosed with radiograph examination but by serum lab studies. Fluids need to be monitored but will not be restricted.

A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client? A) Splints B) Cool compresses C) Heat D) Ice

B) Joint pain associated with DIC can be reduced by applying cool compresses to the affected joints to reduce the transmission of pain impulses. Splints may hinder joint mobility and are not indicated for the care of this client. Heat will encourage bleeding and should not be applied to this client. Ice should not be applied but rather cool compresses.

The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.

B) Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.

A novice nurse has accepted a position on a medical-surgical unit at a local university hospital. In order to provide safe care to clients, the nurse should plan to develop which competency? A) Creating a culture of trust within the hospital B) Functioning as a member of the healthcare team C) Promoting appropriate values that clients should adopt D) Reporting families for bringing food to the client's room

B) New nurses should learn about the healthcare team members and determine whom to collaborate with in certain situations. Rather than reporting families, the nurse would work with families to help meet their needs if food is not allowed in the room. The nurse would respect the values of clients and not seek to impose any on the clients. Creating a culture of trust is a system change that is implemented by the administration.

After completing an assessment, the nurse determines a client is at risk for safety issues. Which data supports the nurse's conclusion? A) Lives with adult married daughter and family B) Occasional dizziness with walking C) Follows a vegetarian diet D) Receives an annual ophthalmologic examination

B) Risks to safety include factors that can impact falls such as mobility issues or balance. Living with family, eating a vegetarian diet, and having annual eye examinations do not increase the client's risk for safety issues.

What impact might corticosteroids have on tissue integrity? A) It may increase sensitivity to sunlight, leading to sunburns. B) It may cause thinning of the skin, making skin more easily injured. C) It may make skin appear shiny and lose its hair distribution. D) It may cause the skin to become overly dry.

B) Some medications, such as corticosteroids, cause thinning of the skin, making it much more easily damaged. Antibiotics, chemotherapy drugs, and some psychotherapeutic drugs increase sensitivity to sunlight and can predispose the individual to sunburns. Impaired peripheral arterial circulation in the lower extremities may produce skin that appears shiny and has lost its hair distribution. Excessive cleansing can cause the skin to become overly dry.

The nurse is caring for a client in the neurologic intensive care unit (ICU) with head trauma. The client is being monitored for increased intracranial pressure (IICP). Using the Monro-Kellie hypothesis as a basis for explanation, which comment by the nurse to the client's family would be most appropriate? A) "It is normal for brain pressure to increase in times of stress." B) "Increasing brain pressure decreases the amount of blood flow to the brain itself." C) "The pressure in the brain is increasing because the brain is shrinking." D) "Because there is more pressure in the brain, the blood flow is also increasing."

B) The Monro-Kellie hypothesis states that a dynamic equilibrium exists among the three components (brain, cerebrospinal fluid, and blood) of the skull. A change in the volume of any component risks a decrease in the remaining components to maintain normal intracranial pressures. The other statements by the nurse would be incorrect according to this hypothesis.

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Encouraging ambulation every 30 minutes B) Instructing on deep breathing C) Administering medications appropriate to increase heart rate D) Positioning to increase blood return

B) The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.

A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which is the priority nursing diagnosis for this client? A) Acute Pain B) Impaired Gas Exchange C) Ineffective Peripheral Tissue Perfusion D) Anxiety

B) The decrease in oxygen saturation is a result of impairment in the client's gas exchange. Anxiety could contribute to the client's impaired gas exchange but is not the primary problem to address. Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of Ineffective Peripheral Tissue Perfusion and Acute Pain.

The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply. A) Multiparity B) Placental abruption C) Preterm labor D) Fetal death E) Gestational diabetes

B) The risk of developing DIC increases in pregnant women who have preeclampsia, fetal death, amniotic fluid embolism, placental abruption, or septic abortion. Multiparity, preterm labor, and gestational diabetes do not cause DIC.

A school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 132/58 mmHg, and respiratory rate 28 and irregular. Based on this data, which conclusion by the nurse is the most appropriate? A) These vital signs indicate respiratory distress. B) These vital signs indicate increased intracranial pressure. C) These vital signs indicate cardiovascular disease. D) These vital signs indicate that this child has a spinal cord injury.

B) These vital signs show a wide pulse pressure (increased systolic blood pressure and lowered diastolic blood pressure), slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. Normal heart rate for an awake child at this age is 70-110. Normal blood pressure is 92-126/55-86. Normal respirations are 20 and regular. These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. Respiratory distress is often indicated by a respiratory rate that is lower than normal. Cardiovascular disease is a chronic condition, not an acute condition that results from trauma.

The nurse is caring for a 3-year-old child who is in the hospital for the first time. The child appears frightened and is clinging to her parents. What action can the nurse take to help the child feel more secure if the child needs to stay at the hospital without her parents? A) Stay with the child when the parents go home B) Have the parents bring comfort items from home to leave with the child C) Keep dangerous medications and equipment out of the child's reach D) Make sure the child wears proper identification at all times

B) To help a child feel more secure, the nurse can suggest that parents bring in a few comfort items the child is familiar with, such as photos, a favorite blanket, or a favorite toy. Having the nurse stay with the child at all times once the parents have left is not practical and could cause harm to other clients under the nurse's care. Although the nurse should keep dangerous medications and equipment out of the child's reach and make sure the child wears proper identification at all times, these actions will likely not help the child feel more secure.

Several nurses are discussing the Joint Commission's 2016 National Patient Safety Goals during a staff meeting. Which element of performance should the nurses implement to meet the goal of identifying clients correctly? A) Labeling all medications with the client's name B) Consistently using two methods to identify the client C) Asking the client's name before conducting assessments D) Marking the intended surgical site on the client

B) Two elements of performance that accompany the goal to identify clients correctly include consistently using two methods to identify the client and ensuring that clients receiving blood transfusions are correctly identified prior to transfusion. Labeling medications with the medication information helps prevent medication errors, and marking the intended surgical site on the client helps prevent surgical errors. Asking the client's name before conducting assessments is not associated with a National Patient Safety Goal.

A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate? A) "I will need to get an order from the physician." B) "Using the doughnut can cause skin breakdown." C) "You will need to wait until discharge, then use the doughnut at home." D) "I will obtain the device for you."

B) Use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened with use of the device, but this is due to the loss of sensation. Use of a doughnut-style device should be avoided whether at the hospital or at home.

The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse? A) At the fifth intercostal space B) At the left nipple C) At the right nipple D) At the eighth intercostal space

B) When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.

The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply. A) Limit exercise to 15 minutes a day B) Reduce saturated fats in the diet C) Avoid cigarette smoking D) Wear elastic hose E) Limit fluid intake

B, C) Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.

The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care? Select all that apply. A) Apply physical restraints if the client gets out of bed. B) Assess the client's vision and make sure he is using any prescribed eyewear. C) Use side rails on client beds. D) Keep frequently used items within easy reach. E) Provide slippers for the client to wear while ambulating.

B, C, D) Assessing the client's vision and making sure he is using any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Using side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if the client gets out of bed. The nurse should ensure that the client wears shoes with adequate traction while ambulating. Slippers may increase the risk for falls.

The nurse is reviewing results of diagnostic testing performed on a client with increased intracranial pressure (ICP) in preparation for an evaluation to be done by the healthcare provider during morning rounds. Which diagnostic test results should the nurse make available to the healthcare provider for review? Select all that apply. A) Bronchoscopy results B) MRI result C) Head CT scan with and without contrast D) Electroencephalogram E) Cerebrospinal fluid differential cell count

B, C, D, E) Diagnosis of increased ICP is made on the basis of observation and neurologic assessment; even subtle changes can be clinically significant. Testing can include CT scan with and without contrast, MRI, electroencephalogram, and cerebrospinal fluid evaluation. Bronchoscopy is not performed routinely for a client with increased intracranial pressure.

The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands D) Thinner subcutaneous skin layer E) Poor nutrition

B, C, E) As the individual ages, moisture transfer from the dermis to the epidermis declines. This contributes to a dry, rough skin appearance. Sebaceous glands also decrease in size with age, resulting in skin that is dry and easily bruised, damaged, or broken. Poor nutrition could also cause dry skin. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.

A client has a documented stage 3 pressure injury on the right hip. Which nursing diagnosis is most appropriate for this client? A) Impaired Skin Integrity B) Risk for Injury C) Impaired Tissue Integrity D) Ineffective Peripheral Tissue Perfusion

C) Because a stage 3 pressure injury involves tissue, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure injuries result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity involves the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury, so Risk for Injury does not apply.

A client has a pressure injury on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use? A) Partial-thickness loss of dermis B) Nonblanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss

C) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Nonblanchable erythema refers to a stage 1 pressure injury. Partial-thickness loss of dermis refers to a stage 2 pressure injury. Full-thickness tissue loss refers to stage 3, stage 4, and unstageable pressure injuries.

A nurse is assessing a client during labor and delivery. Which condition should the nurse recognize as a risk factor for disseminated intravascular coagulation (DIC)? A) Gestational diabetes B) Polyhydramnios C) Placental abruption D) Placenta previa

C) Acute DIC can occur in pregnant clients, most often with pregnancies complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion. Gestational diabetes, polyhydramnios, and placenta previa are not risk factors for DIC.

The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP). Which assessment data indicates that the nurse is successful? A) Body temperature elevated 1 degree in 4 hours B) Absent gag reflex C) Pupils equal and reactive to light D) Sluggish response to verbal stimuli

C) Assessment areas include level of consciousness (LOC); behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. A sluggish response to verbal stimuli could indicate increasing ICP.

A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC? A) Decreased prothrombin time B) Increased platelet count C) Decreased fibrinogen level D) Decreased partial thromboplastin time

C) Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors. Platelet count is also decreased.

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern? A) Pulse 103 bpm B) Blood pressure 108/70 C) Hematocrit 24% D) WBC count 10,340/mm3

C) During pregnancy, red blood cell (RBC) production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.

The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity? A) Poor turgor B) Ascites C) Peripheral edema D) Hypothermia

C) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Skin turgor is the skin's elasticity and is assessed by gently pinching the skin over the sternum or collarbone. Skin temperature is assessed through palpation

What nursing intervention is appropriate for a client with dry and cracked feet? A) Provide slippers for the client to wear at all times B) Soak the client's feet in water several times daily C) Apply lotion to the client's feet after bathing D) Massage the client's feet daily

C) For clients with dry and cracked feet, the nurse should apply lotion to the client's feet after the client's bathing time. Providing slippers and massaging the client's feet will not heal dry and cracked feet. Soaking the client's feet in water without any added moisturizers may make the client's condition worse.

A hospital has created a culture of safety by providing organizational support for safety initiatives and by training and encouraging healthcare employees in the area of safety. What other step is needed to promote safety for everyone in the healthcare environment? A) Keep a mindset for quality of safe practice B) Post signs related to safety on the walls C) Engage clients in their own safety D) Be a safety advocate for others

C) Healthcare facilities should use a three-pronged approach to quality and safety for everyone, including organizational support for keeping safety a priority, encouraging employees to consistently choose to follow health safety rules and standards, and actively engaging clients in every aspect of their care, including safety. Keeping a mindset for quality of safe practice and posting signs related to safety relates to the organizational support for safety. Being a safety advocate for others is related to employees maintaining safety standards.

What does the nurse anticipate finding in a client with impetigo? A) An infection in the hair follicles B) Loss of skin color in blotches or sections C) An itchy rash with clusters of fluid-filled vesicles D) A fungal infection in the skinfolds

C) Impetigo is a superficial skin infection common on the face, arms, and legs of children that presents as an itchy rash with clusters of fluid-filled vesicles that rupture easily. Ruptured vesicles develop a honey-colored crust over the lesions. Folliculitis is an infection of hair follicles. Vitiligo is a loss of skin color in blotches or sections that occur when the cells that produce melanin die or stop functioning. Candidiasis is a fungal infection commonly known as thrush and found in skinfolds.

While reviewing safety precautions with the staff in a long-term care facility, which step should the nurse emphasize that helps to promote a safe environment for the clients? A) Keep clutter out of the hallway and inside the client's room. B) Provide dim lighting. C) Turn off alarms to reduce noise. D) Have the client wear shoes with rubber skid-resistant soles.

D) Having the client wear shoes with rubber skid-resistant soles is the most appropriate intervention to decrease the risk of client falls, which will promote a safe environment. Dim lighting will increase the risk of client falls. Both the hallways and the clients' rooms should be clutter free. Noise should be kept to a minimum, but turning off alarms would endanger clients.

The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor? A) The rubber doughnut pressure relief device was not delivered by central supply. B) The client's serum albumin increased over the last month. C) A right side-back-left side-back turning schedule was used. D) Nurses did not document disinfection of the wound with alcohol at each dressing change.

C) Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.

The nurse observes flakes of greasy white dandruff in a client's hair. The nurse should correctly identify this as which type of secondary lesion? A) Nodule B) Macule C) Scales D) Crusts

C) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, to gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric

C) The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.

Blood pressure is influenced by all except which factor? A) Pumping action of the heart B) Peripheral vascular resistance C) Heart rate D) Blood volume

C) The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.

Which nursing intervention related to perfusion can be performed independently? A) Administration of drug regimens B) Insertion of device to measure central venous pressure (CVP) C) Teaching relaxation techniques D) Thoracentesis

C) The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.

The nurse is caring for a client with a self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this client? A) Wear hypoallergenic gloves B) Wear gloves with powder C) Wash hands after taking gloves off D) Keep beta adrenergic agonists on hand

C) The nurse should wear latex-free gloves that are hypoallergenic and powderless. Not all hypoallergenic gloves are latex-free. Powder from the gloves can absorb the latex and be transferred to clients through touch or through the air. Therefore, it is important to wash hands after removing gloves, especially gloves with powder. Beta adrenergic agonists are used for the treatment of asthma, which may develop with chronic latex exposure in a sensitive individual, but it will not affect the early symptoms of latex allergy.

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate? A) "You will need to have an echocardiogram to determine the reason for the extra sound." B) "You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy." C) "You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy." D) "You have what is known as atrial gallop, and this is cause for concern."

C) Two other heart sounds may be present in some healthy individuals. The third heart sound (S3) may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can also be present in health individuals.

A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment? A) Aspirin B) Warfarin (Coumadin) C) Fresh frozen plasma and platelets D) Heparin

C) When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Aspirin and Coumadin are not indicated in the treatment of DIC. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems.

The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply. A) Age 54 B) Body temperature within normal limits C) Low serum albumin level D) Continence of urine and stool E) Prescribed bedrest

C, E) Risk factors for pressure injury development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure injury development. Although advanced age increases the risk of pressure injuries, this client is only 54 years old. Finally, normal body temperature does not increase the client's risk for pressure injury development.

The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client? A) Heart rate 110 beats per minute B) Oxygen saturation level 86% C) Urine output 20 mL per hour D) No evidence of bleeding

D) Care provided to a client with DIC is successful when there is no further bleeding. Heart rate of 110 beats per minute, oxygen saturation of 86%, and urine output of 20 mL per hour would indicate the need for further treatment.

A nurse is performing a neurologic assessment on a 9-year-old child who has displayed unexplained changes in behavior. Which assessment finding is consistent with a neurologic deficit? A) Child has a negative Babinski reflex. B) Child recalls names of well-known cartoon characters. C) Child is able to walk backward heel to toe. D) Child is incapable of balancing on one foot.

D) Children should be able to walk backward by 2 years of age, balance on one foot for 5 seconds by 4 years of age, heel-toe walk by 5 years of age, and heel-toe walk backward by 6 years of age. A positive Babinski reflex is abnormal after the child ambulates or reaches 2 years of age. Ability to recall names of well-known cartoon characters would show a normal level of recall.

1) A client asks the nurse if the staff members make many mistakes because there are so many posters and signs about safety on the walls. Which response by the nurse is best? A) "The nurses here are safe. The posters are directed at certain members of the healthcare team who have been making more mistakes than usual." B) "You don't need to worry about posters on the wall. Our primary concern is getting you well." C) "We never make mistakes here. We want the public to know that we have client safety goals here." D) "There is a potential for errors in all healthcare settings. The posters remind the staff and the clients of the need to work together to prevent them."

D) Client safety initiatives address collaborative efforts by staff and clients to promote safety in healthcare settings. These initiatives require collaboration by all members of the team, including clients. Mistakes can occur in all healthcare settings; behaviors, not goals, help to prevent them.

Which of the following clients would be the most appropriate candidate for autolytic debridement? A) A 47-year-old client with a stage 2 pressure injury B) A 68-year-old client with a suspected deep tissue injury C) A 71-year-old client with a stage 1 pressure injury D) A 59-year-old client with a stage 3 pressure injury

D) Debridement, regardless of type, is typically reserved for pressure injuries with full-thickness tissue loss. This includes stage 3 pressure injuries, stage 4 pressure injuries, and (in some cases) unstageable pressure injuries. Thus, only the client with a stage 3 injury would be an appropriate candidate.

The nurse is providing care to a pregnant client who has type 2 diabetes mellitus. The client has asked about how the medications she is taking will affect her fetus. How should the nurse respond? A) "The medications you are taking will not adversely affect your fetus. You should continue taking them as you did before your pregnancy." B) "The medications you are taking have a risk of causing fetal defects. You should stop taking your medications while you are pregnant." C) "The medications you are taking will not work as well when you are pregnant, so you should increase the dose of your medications." D) "If you have any concerns about how your medication will affect your fetus, you should talk to your primary care physician."

D) Encouraging the client to change medication dosages, stop taking medications, or continue with the present treatment plan after a major change in health status is outside the nursing scope of practice. If the client has concerns about medications, she should talk to her primary care physician or other provider. Depending on the medication and the client's health status, the provider may recommend increasing, decreasing, or stopping treatment during pregnancy, or the client may continue the present treatment plan. However, the nurse can reinforce any teaching provided by the physician.

Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent alterations to intracranial regulation related to what? A) Prescription drug side effects B) Congenital hydrocephalus C) Stroke D) Trauma

D) Health promotion efforts concerning intracranial regulation that focus on the proper use of protective equipment for outdoor activities and vehicle restraint systems are designed to anticipate and prevent trauma as a cause for alterations to intracranial regulation. Congenital hydrocephalus can cause increased intracranial pressure in infants but is genetic and can't be affected by anticipatory guidance. Stroke and prescription drug side effects are medical conditions that can't be prevented with protective equipment or vehicle restraint systems.

A nurse is assessing the hospital environment in order to decrease the risk for client falls. Which intervention should the nurse implement to decrease the risk of client falls? A) Encourage the client to wear diapers. B) Read label directions. C) Lower side rails on client beds. D) Clean the environment of clutter.

D) Keeping the environment tidy and free of clutter will go a long way in preventing falls. Lowering side rails on client beds would increase the risk of falls. Reading label directions will prevent the wrong use of substances given to the client but would not directly prevent falls. Encouraging the client to wear diapers would increase functional decline, and it is not an appropriate strategy to help reduce falls.

A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate? A) "I will need to obtain an order from the healthcare provider to perform a massage." B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care." C) "I will record these findings in the medical record." D) "Massage may actually cause more harm to a potentially compromised area of skin."

D) Redness may indicate the presence of a stage 1 pressure injury. Evidence suggests that massage over bony prominences like the coccyx can cause or worsen deep tissue trauma in patients at risk for a pressure injury. Massage should thus be restricted when problems are noted. Even when appropriate and therapeutic for a client, massages do not require a healthcare provider's order.

A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best? A) "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage." B) "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries." C) "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity." D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity."

D) Several factors put older adults at increased risk for pressure injuries; these include loss of lean body mass; generalized thinning of the epidermis; decreased strength and reduced elasticity of the skin; and diminished venous and arterial flow due to aging vascular walls. Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands also increases the risk for impaired skin integrity in older adults. Although excess body heat is a risk factor for pressure injuries, older adults tend to have lower average body temperatures than younger clients.

A middle-age adult client states to the nurse, "I do not want to have brown spots on my skin like my parents did as they got older." Which instruction by the nurse is appropriate? A) Spend at least 15 minutes each day in the sun. B) Increase the intake of calcium. C) Increase the intake of dietary fat. D) Avoid the sun or use a sunscreen to reduce skin damage.

D) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun. The intake of dietary fat or calcium will not affect the development of liver spots.

An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown? A) Using the bed sheet to slide the client up in bed B) Placing the bed in reverse Trendelenburg position C) Using the client's arms to pull the client up in bed D) Lifting the client, using the client's legs and arms for assistance

D) The client is of advanced age and has poor skin turgor. Both of these factors put the client at increased risk for alterations in skin integrity, including damage due to shearing forces. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client up in bed may cause skin shearing. Sliding the client on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg position will not facilitate appropriate positioning of the client in the bed.

A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries. Which nursing intervention is appropriate when caring for this client? A) Clean the pressure injury as needed. B) Use hydrogen peroxide for chemical debridement of wound bed as needed. C) Maintain the head of the client's bed at 30 degrees. D) Avoid placing the client in the side-lying position.

D) The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. In addition, the nurse should clean the client's pressure injury at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.

The statement "A decrease in level of consciousness may lead to a decrease in respiration" best describes the relationship between intracranial regulation and which of the following? A) Acid-base balance B) Cognition C) Mobility D) Oxygenation

D) The statement "A decrease in level of consciousness may lead to a decrease in respiration" describes the relationship between intracranial regulation and oxygenation. An increase in CO2 leading to vasodilation and increased intracranial pressure is involved in the relationship between intracranial regulation and acid-base balance. Alterations in intracranial regulation can lead to impaired cognitive function, ranging from mild confusion to lack of consciousness. Clients with alterations in intracranial regulation will have different mobility needs based on the underlying pathology.

The nurse is caring for a 230-lb client who needs to be repositioned every 2 hours. While repositioning the client, the nurse injured a muscle in her back. To prevent the injury and ensure safety for both the nurse and client, what should the nurse have done differently in this situation? A) She should have used proper lifting techniques. B) She should have repositioned the client only if the client requested it. C) She should have questioned the physician about the need to reposition the client. D) She should have asked for help from another nurse.

D) When moving or repositioning clients, especially larger clients, the nurse should always ask for help from another healthcare worker to prevent injury. Although using proper lifting techniques is important, they do not guarantee that injuries will not occur. In addition, there is no evidence that the nurse was not already using proper lifting techniques. The nurse should question physician orders if she is unclear about the reasoning for the order, but this is a standard best practice and would likely not require questioning. The nurse should reposition the client as ordered, not only when the client requests it.

The nurse is providing care to a client who is experiencing skin inflammation and pruritus. Which of the following medications does the nurse anticipate will be prescribed for this client? Select all that apply. A) Erythromycin B) Bacitracin C) Gentamycin D) Desoximetasone E) Desonide

D, E) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

Which statements are correct regarding the various layers of the heart? Select all that apply. A) The endocardium covers the entire heart and great vessels. B) The endocardium is the muscular layer of the heart that contracts during each heartbeat. C) The outermost layer of the heart is the epicardium. D) The myocardium consists of myofibril cells. E) The myocardium has four layers

c, D) The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.