1012 Informatics
A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? "Moderate amount of drainage." "No change in drainage since yesterday." "A 10-mm-diameter area of drainage at 1900 hours." "Drainage is doubled in size since last dressing change."
"A 10-mm-diameter area of drainage at 1900 hours." A 10-mm-diameter area of drainage at 1900 hours is an objective fact and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.
A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates an understanding? "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." "Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." "Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava." "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."
"Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta." Stating that blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta correctly describes the flow of blood through the heart after birth. The ductus arteriosis is a fetal structure that is not present in the adult heart. Blood enters the right side of the heart via the inferior and superior vena cava; blood flows from the right atrium, to the right ventricle, to the lungs, and then to the left atrium. Blood exits, not enters, the heart from the aorta.
The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion? "Surgery will correct the palsy." "This is a progressive disorder with no cure." "Recovery usually occurs in about 3 months." "Physical therapy will be necessary for 1 year."
"Recovery usually occurs in about 3 months." The nerves that are stretched take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis usually is excellent. Physical therapy is necessary for about 3 months, not a year.
A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What should the informed consent include? (multiple) Duplicate of the Patient's Bill of Rights Explanation of available alternative treatments Answers to questions and concerns about the procedure Complete description of the possible dangers and discomforts Countersignature by the person designated in the client's living will
*Explanation of available alternative treatments *Answers to questions and concerns about the procedure *Complete description of the possible dangers and discomforts Alternative treatment regimens should be discussed so the client may make an informed choice about which course of treatment to pursue. All questions should be answered honestly and in terms that the client can understand. A description of all potential complications is required for a client to give informed consent. A copy of the Patient's Bill of Rights is not necessary for informed consent for treatment. A countersignature is not necessary if the client is an independent adult.
A client has a hypoglycemic reaction to insulin. Which client responses should the nurse document as clinical manifestations of hypoglycemia? (multiple) Pallor Tremors Glycosuria Acetonuria Diaphoresis
*Pallor *Tremors *Diaphoresis Hypoglycemia triggers the sympathetic nervous system, which releases epinephrine, in turn causing vasoconstriction and pallor. Tremors are a sympathetic nervous system response to hypoglycemia. Diaphoresis results from the release of epinephrine by the sympathetic nervous system. Because blood glucose concentration is decreased in hypoglycemia, the renal threshold is not exceeded and there is no glycosuria. Acetonuria is associated with hyperglycemia; it is caused by the breakdown of fats as a result of inadequate insulin supply.
Which pregnant client does the nurse suspect is most likely to have placenta previa? 19 years old, gravida 1, para 0 30 years old, gravida 6, para 5 25 years old, gravida 2, para 1 40 years old, gravida 3, para 2
30 years old, gravida 6, para 5 Multiple past pregnancies can scar the endometrial lining, rendering it vulnerable to an abnormal implantation. Primigravidas are the least prone to placenta previa; the endometrium is receptive to implantation. Two pregnancies have not compromised the endometrium to the extent that an abnormal implantation is likely to occur. Age is not known to be a significant factor; also, three pregnancies should not have compromised the endometrium.
A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2013. Using Naegele's Rule, what date in June 2014 is the client's estimated date of birth (EDB)? Record your answer as a whole number.
Add 7 days to the 1st day of the and subtract 3 months.
A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes and withdraws appropriately, but has no verbal response to the stimulus. Using the Glasgow Coma Scale, the nurse determines the client's score is: 7 9 12 15
7 The Glasgow Coma Scale is a three-part neurological assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma. Nine and 12 are too high a rating for the behaviors exhibited by the client. A rating of 15 indicates that the client is opening the eyes spontaneously, obeying commands, and fully oriented.
The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding? Procedures for a client's benefit do not require a signed consent. Clients who are aphasic are incapable of signing an informed consent. A separate signed informed consent for routine treatments is unnecessary. A specific intervention without a client's signed consent is an invasion of rights.
A separate signed informed consent for routine treatments is unnecessary. This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.
A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent? A nursing diagnosis An inaccurate interpretation A correct nursing assessment An accurate conclusion if crepitus was ruled out
An inaccurate interpretation Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.
For the last three days, the client has expressed a complete lack of interest in food. How should the nurse document this in the client's record? Apathy Aphasia Adactyly Anorexia
Anorexia Anorexia refers to loss of appetite. Apathy refers to lack of concern or emotion. Aphasia is the absence of or inability to provide communication through speech. Adactyly refers to the absence of digits on the hands or feet
The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the: Black 55-year-old White 45-year-old Asian 55-year-old Hispanic 45-year-old
Black 55-year-old Cancer of the prostate is rare before age 50 but increases with each decade; black men develop cancer of the prostate twice as often and at an earlier age than white men. White men develop prostatic cancer half as often as black men, but more commonly than Asian or Hispanic men. Asian and Hispanic men have a lower incidence of prostatic cancer and a lower mortality rate than white and black men.
A nurse is preparing to counsel a client whose two previous pregnancies were uneventful, ending in term vaginal births of healthy children. What should the nurse consider about multiparas with previous uneventful pregnancies before beginning prenatal counseling? Multiparas cope more successfully with pregnancy than do primigravidas. Each pregnancy is a unique experience that is stressful despite multiparity. This pregnancy will provoke a situational crisis because the client has two children at home. Support people play a lesser role because the client has had two prior experiences with pregnancy.
Each pregnancy is a unique experience that is stressful despite multiparity. Each pregnancy creates a stress situation because it is a developmental crisis. It has not been determined that multiparas are more successful in coping with pregnancy than primigravidas are. Each pregnancy is unique, and this pregnancy may or may not be more stressful than the others. In addition, pregnancy is a developmental, not a situational, crisis. Support people are important during any crisis or stressful situation.
The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented? Stork bites Forceps marks Mongolian spots Ecchymotic areas
Mongolian spots Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.
When reviewing the history of a client admitted in preterm labor during her 30th week of gestation, the nurse suspects a risk factor associated with this client's preterm labor. What is this risk factor? Primigravida Android-shaped pelvis Anticonvulsant medication therapy Multiple urinary tract infections
Multiple urinary tract infections Infections, especially urinary tract infections, are a risk factor for preterm labor. The number of pregnancies is not a risk factor for preterm labor. An android-shaped pelvis is more likely to cause dystocia than preterm labor. Clients receiving anticonvulsant medications are not at an increased risk for preterm labor.
When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. The nurse should document: Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds
Vesicular breath sounds These are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. Adventitious is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with pulmonary edema. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
