Health & Illness 2 Final Exam--Practice Questions

Best education for new parents to avoid SIDS?

"Back to sleep, tummy to play"

COPD patients should practice A) Breathing in a bag B) Pursed-lip breathing C) Slow Breathing D) Fast breaths

B) Pursed-lip breathing Teach client to take slow, deep breaths and exhale through pursed lips; strengthens muscles of respiration

A 56-year-old normally healthy patient at the clinic is diagnosed with bacterial community-acquired pneumonia. Before treatment is prescribed, the nurse asks the patient about an allergy to A) amoxicillin B) erythromycin C) sulfonamides D) cephalosporins

B) erythromycin Rationale: Outpatient drug therapy options for a healthy person with community-acquired pneumonia will be consist of macrolides (erythromycin) or doxycycline. If the patient is allergic to macrolides, doxycycline would be prescribed.

Emphysema

Characterized by destruction of the walls of alveoli

What precautions need to taken for RSV patients?

Contact Precautions (gown and gloves help protect the spread of RSV) The virus (RSV) that usually causes bronchiolitis can spread to other babies if extra precautions are not taken.

What priorities are important to educate patient to pay attention to help decrease their risk for the most common cause of death?

Determine and review clients prior blood glucose records to determine their usual blood glucose control Blood glucose control has been shown to directly impact mortality outcomes after an MI and is the immediate priority!!!!! Nutrition Management Balance nutrients, expenditure of energy, dose and timing of meds Maintain near normal BGLs Exercise Management

What needs to be assessed before removal of an NG tube?

Instill air into tube to assess placement--This clears the tube of any contents such as feeding or gastric drainage and decreases the changes of dragging any drainage through the esophagus and nasopharynx

What age do babies commonly die from SIDS?

Most deaths occur between 1 and 4 months

Why are children at risk for respiratory alkalosis?

Older adults and young children at risk with large-dose salicylate ingestion

What is Acromegaly? What changes might occur in the patient?

Rare condition characterized by an overproduction of growth hormone. changes resulting from excess GH in adults can occur slowly, over a number of years, and may go unnoticed by the person, family and friends Thickening and enlargement of the boy and soft tissues on the face, feet and head

If a patient has Hashimoto's thyroiditis AND a goiter, what are important nursing actions and why?

Teaching patient no to discontinue medications abruptly Tell patient to report to the HCP any change in symptoms, such as difficult breathing or swallowing, swelling to the and extremities or rapid weight gain or loss Reach those receiving thyroid hormone about the side effects of these drugs Patient is at risk for other autoimmune diseases such as Addison's disease, pernicious anemia, or Grave's disease

Wait-to-hip ratio for those with obesity....

Upper body obesity >1 in men > 0.8 in women Lower body obesity <0.8 in women

Which child is at the highest risk for blunt trauma associated with the indirect entry (hematogenous stage) of microorganisms? a. 8-year-old boy b. 10-year-old girl c. 13-year-old girl d. 14-year-old boy

a. 8-year-old boy e. The indirect entry of microorganisms, which is the hematogenous stage of osteomyelitis, most frequently affects the growing bones of boys younger than 12 years of age. Therefore an 8-year-old boy would be at the highest risk for blunt trauma.

When caring for a patient with acute bronchitis, the nurse will prioritize a. auscultating lung sounds. b. encouraging fluid restriction. c. administering antibiotic therapy. d. teaching the patient to avoid cough suppressants.

a. auscultating lung sounds.

A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority? a. Hypoglycemia b. Chest wall trauma c. Airway obstruction d. External hemorrhage

c. Airway obstruction The highest priority intervention is to establish a patent airway because inadequate oxygen supply to the brain may cause brain death. Assessing the metabolic conditions is done after the airway is cleared. Once the airway is cleared, then the chest wall of the client is assessed. Hemorrhage is assessed after the airway of the client is cleared.

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? a. Cyanosis b. Cool, clammy skin c. Unexplained restlessness d. Retraction of interspaces on inspiration

c. Unexplained restlessness Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.

Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? a. Decreasing PEEP b. Increasing the tidal volume c. Use of permissive hypercapnia d. Use of positive pressure ventilation

c. Use of permissive hypercapnia

5. moderate pain with short periods of severe pain during dressing changes is a. probably exaggerating his pain. b. best treated by referral for surgical treatment of his pain. c. best treated by receiving a long-acting and a short-acting opioid. d. best treated by regularly scheduled short-acting opioids plus acetaminophen.

c. best treated by receiving a long-acting and a short-acting opioid.

Providing opioids to a dying patient who is experiencing moderate to severe pain a. may cause addiction. b. will probably be ineffective. c. is an appropriate nursing action. d. will likely hasten the person's death.

c. is an appropriate nursing action.

A patient with diabetes has a serum glucose level of 824 mg/dL (45.7 mmol/L) and is unresponsive. After assessing the patient, the nurse suspects diabetic ketoacidosis rather than hyperosmolar hyperglycemic syndrome based on the finding of a. polyuria. b. severe dehydration. c. rapid, deep respirations. d. decreased serum potassium.

c. rapid, deep respirations.

Encephalopathy

cerebral edema and accumulation of neurotoxins in the blood • High ammonia levels are a sign Assessment: *Asterixis—flapping tremor *

Ascites and encephalopathy are signs of?

cirrhosis

Stage IV (Severe) COPD has a REV1 rate of __________of predicted value a) >80 % b) 50-80% c) 30-50% d) less than 50 %

d) less than 50 %

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? a. "You may be able to lessen your feelings of guilt by seeking counseling." b. "It would be helpful if you become involved in volunteer work at this time." c. "I recognize it's hard to deal with this, but try to remember that this too shall pass." d. "Joining a support group of people who are coping with this problem may be helpful."

d. "Joining a support group of people who are coping with this problem may be helpful."

What is Asterixis?

flapping hand tremor (sign of encephalopathy)

Clinical Manifestations of Emphysema

o Air trapping o Possible wheezing o Dyspnea o Barrel chest o Pursed lip breathing o Posturing

Best position for ARDS patient?

prone (face-down)

A nurse is caring for a client who is experiencing an underproduction of thyroxine (T 4). Which client response is associated with an underproduction of thyroxine? a. Myxedema b. Acromegaly c. Graves disease d. Cushing disease

a. Myxedema Myxedema is the severest form of hypothyroidism. Decreased thyroid gland activity means reduced production of thyroid hormones. Acromegaly results from excess growth hormone in adults once the epiphyses are closed. Graves disease results from an excess, not a deficiency, of thyroid hormones. Cushing disease results from excess glucocorticoids.

An example of distraction to provide pain relief is a. TENS. b. music. c. exercise. d. biofeedback.

b. music.

12. A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain? a. "Can you describe your pain to me?" b. "Is your pain associated with movements?" c. "Can you rate your pain on a scale of 0 to 10?" d. "Do you notice your pain worsening with any activity?"

a. "Can you describe your pain to me?" The nurse may ask the client to describe the pain or to point the area that hurts. It may help to assess the nature of the pain. Asking about effect on pain with movement may help to assess precipitating factors. The severity of a pain could be identified by asking the client to rate it on a scale from 0 to 10. The precipitating factors can be identified by asking the client about worsening of the pain with a particular activity.

A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" What is the nurse's best response? a. "Most peptic ulcers heal with medical treatment." b. "Clients with peptic ulcers have pain while eating." c. "Early surgery is advisable, especially after the first attack." d. "If ulcers are untreated, cancer of the stomach can develop."

a. "Most peptic ulcers heal with medical treatment." Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence. Clients with duodenal ulcers have pain after eating and especially at night; gastric ulcers cause pain during or close to eating. Surgery may be done after multiple recurrences and for treating complications. Perforation, pyloric obstruction, and hemorrhage, not cancer, are major complications.

The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which blood glucose levels should the nurse identify as hypoglycemia? a. 68 mg/dL (3.8 mmol/L) b. 78 mg/dL (4.3 mmol/L) c. 88 mg/dL (4.9 mmol/L) d. 98 mg/dL (5.4 mmol/L)

a. 68 mg/dL (3.8 mmol/L) Normal blood glucose level for an adult is 72-108 mg/dL (4-6 mmol/L). Clients who have blood glucose levels below 72 mg/dL (4 mmol/L) may experience hypoglycemia; 78 mg/dL (4.3 mmol/L), 88 mg/dL (4.9 mmol/L), and 98 mg/dL (5.4 mmol/L) are normal blood glucose levels.

A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? a. 7.20 b. 7.35 c. 7.45 d. 7.48

a. 7.20 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.

Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a. A1C 9% b. BP 126/80 mm Hg c. FBG 130 mg/dL (7.2 mmol/L) d. LDL cholesterol 100 mg/dL (2.6 mmol/L)

a. A1C 9%

What pain scale is used to measure the intensity of pain in preschoolers? a. FACES scale b. Visual analogue scale c. Numerical rating scale d. Verbal descriptor scale

a. FACES scale

A plan of care for the patient with COPD could include (select all that apply) a. exercise such as walking. b. high flow rate of O2 administration. c. low-dose chronic oral corticosteroid therapy. d. use of peak flow meter to monitor the progression of COPD. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

a. exercise such as walking. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.

a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load.

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? a. pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) b. pH 7.35, CO 2 47 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) c. pH 7.46, CO 2 30 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) d. pH 7.50, CO 2 50 mm Hg, HCO 3 - 22 mEq/L (22 mmol/L)

a. pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO 3 - will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO 2 ranges from 35 to 45 mm Hg, and HCO 3 - ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO 2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.

The injury that is least likely to result in a full-thickness burn is a. sunburn. b. scald injury. c. chemical burn. d. electrical injury

a. sunburn.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? a. Irritability, polydipsia, and polyuria b. Polyuria, polydipsia, and polyphagia c. Nocturia, weight loss, and polydipsia d. Polyphagia, polyuria, and diaphoresis

b. Polyuria, polydipsia, and polyphagia

Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. What is the nurse's priority action? a. Obtain a prescription for an antibiotic. b. Report the client's concern to the primary healthcare provider. c. Administer the prescribed medication for pain. d. Explain that this is typical after a cast is applied.

b. Report the client's concern to the primary healthcare provider. The client's concern indicates tissue hypoxia or breakdown and should be reported to the primary healthcare provider. Other data, such as elevated temperature or increased white blood cells, are not present to support the presence of an infection. Although administering the prescribed medication for pain will be done to provide relief of pain, the priority is to notify the primary healthcare provider. This is not a typical response to a cast and may indicate a complication.

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Secondary intention c. Regeneration of cells d. Remodeling of tissues

b. Secondary intention

In caring for a patient after a spinal fusion, the nurse would immediately report which of the following to the surgeon? a. The patient experiences a single episode of emesis. b. The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.

b. The patient is unable to move the lower extremities.

Which words are most likely to be used to describe neuropathic pain (select all that apply)? a. Dull b. Mild c. Burning d. Shooting e. Shock-like

c. Burning d. Shooting e. Shock-like

A client's wound is healing. Which event occurs in the proliferative phase of wound healing? a. Thinning of scar tissue b. Strengthening of collagen c. Formation of "granulation" tissue d. Increase in capillary permeability

c. Formation of "granulation" tissue "Granulation" tissue is formed in the proliferative tissue. Thinning of scar tissue and strengthening of collagen fibers is seen in the maturation phase of wound healing. The increase in capillary permeability occurs in the inflammatory phase of wound healing.

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

Why are children at risk for Metabolic acidosis?

children are vulnerable to acid-base imbalance because their metabolic rates are faster and their ratios of water to total body weight are lower o Severe diarrhea and intestinal malabsorption

A nurse is reviewing the laboratory report of a 13-year-old adolescent with type 1 diabetes. What test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time? a. Blood pH b. Serum protein level c. Serum glucose level d. Glycosylated hemoglobin

d. Glycosylated hemoglobin

A patient has the following arterial blood gas results: pH 7.52, PaCO2 30 mm Hg, HCO3− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.

Graves Disease

is a form of hyperthyroidism o Mimics hyperthyroidism Abnormal antibodies that mimic TSH Work overtime and exceed their normal quota

D.S. sadly states, "I have tried and failed at every diet there is. It just doesn't matter anyway." What should you tell her about the importance of weight loss and the treatment options and resources available to her?

Weight loss can help reduce the complications associated with obesity, including cardiovascular disease and hypertension, type 2 diabetes, osteoarthritis, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, nonalcoholic steatohepatitis, and cancer. Drug therapy for weight reduction, such as Alli, or bariatric surgery Support groups or individual therapy sessions Talk with her about HER reasons for wanting to lose weight. (motivation

Which instructions would the nurse include in a teaching plan for a patient with mild gastroesophageal reflux disease (GERD)? a. "The best time to take an as-needed antacid is 1 to 3 hours after meals." b. "A glass of warm milk at bedtime will decrease your discomfort at night." c. "Do not chew gum; the excess saliva will cause you to secrete more acid." d. "Limit your intake of foods high in protein because they take longer to digest

a. "The best time to take an as-needed antacid is 1 to 3 hours after meals."

Which radiographic test is used to view the entire skeleton? a. Bone scan b. Gallium and thallium scan c. Computed tomography (CT) d. Magnetic resonance imaging (MRI) scan

a. Bone scan

A nurse collaborates with a depressed client to increase self-esteem. What behavior should the nurse recall as typical of this type of client? a. Sets unrealistic goals b. Engages in criminal activity c. Attempts to manipulate others d. Overestimates current strengths

a. Sets unrealistic goals A depressed client may formulate goals that are unrealistic and therefore unattainable because of a lack of physical or emotional energy

Teach the patient with fibromyalgia the importance of limiting intake of which foods (select all that apply)? a. Sugar b. Alcohol c. Caffeine d. Red meat e. Root vegetables

a. Sugar b. Alcohol c. Caffeine

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? a. pH: 7.28; PCO 2: 28; HCO 3: 18 b. pH: 7.30; PCO 2: 54; HCO 3: 28 c. pH: 7.50; PCO 2: 49; HCO 3: 32 d. pH: 7.52; PCO 2: 26; HCO 3: 20 .

a. pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are most appropriate (select all that apply)? a. Acute pain related to tissue damage and inflammation b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke e. Ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area

b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure

The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.

b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space.

A client is receiving total parenteral nutrition. The nurse assesses for which client response that indicates hyperglycemia? a. Paralytic ileus b. Respiratory rate below 16 c. A fruity odor to the breath d. Serum glucose of 105 mg/100 mL

c. A fruity odor to the breath Hyperglycemia is indicated by a fruity odor to the breath. Paralytic ileus is not associated with hyperglycemia. With hyperglycemia there is hyperventilation. Serum glucose of 105 mg/100 mL is within the expected range.

A depressed client has feelings of failure and a low self-esteem. In what activity should the client initially be encouraged to become involved? a. Joining other clients in playing a board game b. Singing in a karaoke contest to be held at the end of the week c. Assisting a staff member in working on the monthly bulletin board d. Selecting the movie to be played during the evening recreation period

c. Assisting a staff member in working on the monthly bulletin board Working on the bulletin board with staff members involves minimal energy and decision-making and is the least threatening activity

Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer? a. Pack the ulcer with foam dressing. b. Turn and position the patient every hour. c. Clean the ulcer every shift with Dakin's solution. d. Assess for pain and medicate before dressing change

c. Clean the ulcer every shift with Dakin's solution.

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease a. frequently results in toxic megacolon. b. causes fewer nutritional deficiencies than ulcerative colitis. c. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. d. is manifested by rectal bleeding and anemia more often than is ulcerative colitis.

c. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy.

If D.S. wants to have bariatric surgery, what risks does the surgery pose?

-Postanesthesia problems due to her weight and pain following surgery. -There will need to be psychologic support as well as medical follow up.

A client with contact dermatitis is about to undergo skin testing to determine the cause of the skin reaction. The client asks the nurse, "How will the doctor know which allergens to test me for?" The best response by the nurse is that the tests are: A) A routine selection that most individuals react to B) Based on the client's history C) A prepackaged test kit D) The client' decision

B) Based on the client's history The nurse and the doctor each take a detailed history to determine the possible allergens that provoke the reaction and then test for those possibilities. Some common substances may be included in the test, but the history determines most of the allergens used. There is no prepackaged test kit. The client gives information that helps in the decision, but the doctor ultimately decides what to include in the test.

A patient is concerned that he may have asthma. Of the symptoms that he relates to the nurse, which ones suggest asthma or risk factors for asthma (select all that apply)? a. Allergic rhinitis b. Prolonged inhalation c. History of skin allergies d. Cough, especially at night e. Gastric reflux or heartburn

a. Allergic rhinitis c. History of skin allergies d. Cough, especially at night e. Gastric reflux or heartburn

A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply. a. Fatigue b. Dry skin c. Insomnia d. Intolerance to heat e. Progressive weight gain

a. Fatigue b. Dry skin e. Progressive weight gain

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client meeds immediate medical attention? a. Oxygen Saturation: 89% b. Body temperature: 101°F c. Blood Pressure: 130/80 mmHg d. Respiratory rate: 26 beats/minute

a. Oxygen Saturation: 89% An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? a. Sodium and chloride levels b. Bicarbonate and sulfate levels c. Magnesium and protein levels d. Calcium and phosphate levels

a. Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

a. blisters. d. intact nerve endings. e. red, shiny, wet appearance.

A nurse is caring for an infant whose vomiting is intractable. Which complication is most likely to occur? a. Acidosis b. Alkalosis c. Hyperkalemia d. Hypernatremia

b. Alkalosis Excessive vomiting causes an increased loss of hydrogen ions (hydrochloric acid), leading to metabolic alkalosis, an excess of base bicarbonate. Acidosis is caused by retention of hydrogen ions and a loss of base bicarbonate, which is more likely to occur with diarrhea. Hypokalemia, not hyperkalemia, will occur. With the loss of chloride ions, hyponatremia is more likely to occur.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. a. Dementia b. Multiple losses c. Declines in health d. A milestone birthday e. An injury requiring hospitalization

b. Multiple losses c. Declines in health Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

A 6-year-old child who has colicky abdominal pain and guarding, as well as nausea, anorexia, and a low-grade fever, is admitted to the pediatric unit. During the admission assessment, a nurse palpates the abdomen and elicits pain in the right lower quadrant. What care does the nurse expect to implement in light of this assessment? a. Symptomatic, until the viral infection resolves b. Preoperative, for removal of an inflamed appendix c. Preparatory, to test for the cause of an irritable bowel d. Anticipatory, for administration of a drug for the parasitic infestation

b. Preoperative, for removal of an inflamed appendix Preoperative care, for removal of an inflamed appendix; the signs and symptoms described are the classic signs and symptoms related to acute appendicitis. They are caused by inflammation and altered gastrointestinal function. Symptomatic, until the viral infection resolves does not apply since appendicitis is not related to a viral infection. The child will have diarrhea if there is an irritable bowel. Anticipatory, for administration of a drug for the parasitic infestation does not apply since appendicitis is not related to a parasitic infestation.

A client falls at home and is brought to the emergency department by family members. The client reports intercostal pain and is confused and disoriented. Which is the best way for the nurse to determine whether this behavior is new for the client? a. Interview the client to identify when the confusion started. b. Question the family members about the client's usual behavior. c. Ask the primary healthcare provider when the confusion was noted first. d. Observe the client for a few hours before determining the onset of confusion.

b. Question the family members about the client's usual behavior. Family members usually know the client's behavior and serve as important sources of information when a client is confused. The primary healthcare provider is an additional source, but family members are the nurse's best source of information when the client is confused. In the presence of confusion, the client is an unreliable source. Observing the client will not alter the information.

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? a. Hiking b. Swimming c. Sewing classes d. Watching television

b. Swimming Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

Pain is best described as a. a creation of a person's imagination. b. an unpleasant, subjective experience. c. a maladaptive response to a stimulus. d. a neurologic event resulting from activation of nociceptors.

b. an unpleasant, subjective experience.

Appropriate nonopioid analgesics for mild pain include (select all that apply) a. oxycodone. b. ibuprofen (Advil). c. lorazepam (Ativan). d. acetaminophen (Tylenol). e. codeine with acetaminophen (Tylenol #3).

b. ibuprofen (Advil). d. acetaminophen (Tylenol).

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

b. observe the wound for signs of infection during dressing changes.

A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies? a. "How have you managed your problems in the past?" b. "What do you feel that you've learned from this suicide attempt?" c. "How will you manage the next time your problems start piling up?" d. "Were there other things going on in your life that made you want to die?"

c. "How will you manage the next time your problems start piling up?" How will you manage the next time your problems start piling up?" focuses the interaction toward the future and invites the client to explore alternative coping strategies.

How would the nurse describe the exudate characteristic of a serosanguineous wound? a. Greenish-blue pus b. Creamy yellow pus c. Blood-tinged amber fluid d. Beige pus with a fishy odor

c. Blood-tinged amber fluid Blood-tinged amber fluid is characteristic of serosanguineous wound exudate. Greenish-blue pus, creamy yellow pus, and beige pus with a fishy odor are characteristics of purulent wound exudate.

What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability? a. Call the physician. b. Administer insulin as ordered. c. Check the patient's blood glucose level. d. Assess for other neurologic symptoms

c. Check the patient's blood glucose level.

A nurse teaches an elderly client safety tip to prevent falls. Which physiologic change may have occurred in the client? a. Slowed movement b. Cartilage degeneration c. Decreased bone density d. Decreased range of motion (ROM)

c. Decreased bone density Teaching safety tips to prevent falls would best help a client with decreased bone density. If a client experiences slow movements, the nurse should not rush the client because the client may become frustrated if hurried. Providing a client with cartilage degeneration with a moist heat source such as a shower or a warm compress is beneficial because this action may increase blood flow to the area. A nurse should assess a client's ability to perform activities of daily living and mobility to help improve the self-care skills of clients with a decreased range of motion.

A client feeling increasingly tired seeks medical care. Type 1 diabetes is diagnosed. What causes increased fatigue with type 1 diabetes? a. Increased metabolism at the cellular level b. Increased glucose absorption from the intestine c. Decreased production of insulin by the pancreas d. Decreased glucose secretion into the renal tubules

c. Decreased production of insulin by the pancreas Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue. With diabetes there is decreased cellular metabolism because of the decrease in glucose entering the cells. Glucose is not absorbed from the intestinal tract by the cells; fatigue is caused by decreased, not increased, cellular levels of glucose. Filtration and excretion of glucose by the kidneys do not regulate energy levels; if insulin production is adequate, glucose does not spill into the urine.

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? a. PO 2 value is 80 mm Hg. b. PCO 2 value is 60 mm Hg. c. HCO 3 value is 50 mEq/L (50 mmol/L). d. Serum potassium value is 4 mEq/L (4 mmol/L).

c. HCO 3 value is 50 mEq/L (50 mmol/L). The HCO 3 value is elevated. The urinary system compensates by retaining H + ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO 3 value is 21 to 28 mEq/L (21 to 28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO 2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO 2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis [1] [2] the PCO 2 level may be increased, it is the increased HCO 3 level that indicates compensation. A K + level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? a. Fluid loss b. Glycosuria c. Kussmaul respirations d. Increased blood glucose level

c. Kussmaul respirations Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.

A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue? a. Provide small, frequent meals b. Encourage pursed-lip breathing c. Schedule nursing activities to allow for rest d. Encourage bed rest until energy level improves

c. Schedule nursing activities to allow for rest Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

Maintenance of fluid balance in the patient with ARDS involves a. hydration using colloids. b. administration of surfactant. c. fluid restriction and diuretics as necessary. d. keeping the hemoglobin at levels above 9 g/dL (90 g/L).

c. fluid restriction and diuretics as necessary.

The primary purpose of hospice is to a. allow patients to die at home. b. provide better quality of care than the family can. c. coordinate care for dying patients and their families. d. provide comfort and support for dying patients and their families.

d. provide comfort and support for dying patients and their families.

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively to bring secretions to the mouth.

d. teach the patient how to cough effectively to bring secretions to the mouth.

What is Hashimoto's thyroiditis?

-Chronic autoimmune thyroiditis -----Caused by the destruction of thyroid tissue by antibodies -Goiter present -Risk factor for hypothyroidism

Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis? a) Monitoring for signs of hypoglycemia resulting from treatment b.) Withholding glucose in any form until the situation is corrected c.) Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally d.)Regulating insulin dosage according to the amount of ketones found in the client's urine

a) Monitoring for signs of hypoglycemia resulting from treatment During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage; the prescription usually depends on the client's blood glucose level rather than ketones in the urine.

The nurse is teaching a group of students about assessing for respiratory system manifestations of alkalosis as a nursing priority. Which statement made by the student nurse indicates the need for further teaching? Select all that apply. a. "I should assess for low blood pressure." b. "I should assess for increased digitalis toxicity." c. "I should assess for a decreased rate of ventilation in respiratory alkalosis." d. "I should assess for an increased depth of ventilation in respiratory alkalosis." e. "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis."

a. "I should assess for low blood pressure." b. "I should assess for increased digitalis toxicity." c. "I should assess for a decreased rate of ventilation in respiratory alkalosis." The nurse should assess for low blood pressure and increased digitalis toxicity as cardiovascular manifestations of alkalosis, not respiratory manifestation. The nurse should assess for increased rate of ventilation in respiratory alkalosis. The nurse should assess for increased depth of ventilation in respiratory alkalosis. It is imperative that the nurse check for decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis.

An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? a. Breathe into cupped hands. b. Pant using rapid, shallow breaths. c. Use a rapid deep-breathing pattern. d. Hold the breath for as long as possible

a. Breathe into cupped hands. Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

A client who underwent spinal surgery reports pain at bony prominences. On assessing, the nurse finds skin breakdown and tears. Which interventions performed by the nurse are appropriate? Select all that apply. a. Cleansing the ulcer with saline b. Removing the loose bits of tissue c. Measuring wound size every alternate week d. Repositioning the client at least every 5 hours e. Removing the old dressings daily if the ulcer is covered

a. Cleansing the ulcer with saline b. Removing the loose bits of tissue e. Removing the old dressings daily if the ulcer is covered The client who underwent spinal surgery may be bedridden for long periods of time. The client assessed with skin breakdown and tears is at a risk of pressure ulcers. The nursing interventions in the client include cleaning the ulcer with saline or a prescribed solution. The loose bits of tissue should be removed or trimmed. The nurse should remove old dressings or coverings daily if the ulcer is covered. Measuring wound size should be performed weekly or more often. The client with pressure ulcers should be repositioned at least every 1 or 2 hours.

A client visits the clinic because of concerns about insomnia and recent weight loss. A tentative diagnosis of hyperthyroidism is made. What symptom might the nurse identify when assessing this client? a. Fatigue b. Dry skin c. Anorexia d. Bradycardia

a. Fatigue Excessive metabolic activity associated with hyperthyroidism causes fatigue. Warm, moist skin is expected because of increased peripheral perfusion associated with increased metabolism. Increased appetite is expected because of the increased metabolism associated with hyperthyroidism. Tachycardia is expected because of the increased metabolism associated with hyperthyroidism.

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem? a. Low self-esteem b. Deficient memory c. Intolerance of activity d. Disturbed personal identity

a. Low self-esteem When a client has an adjustment disorder, anxiety may be related to a disturbance in self-esteem and depression may be related to impaired social interaction. Problems with memory are not specifically related to an adjustment disorder. Activity intolerance, which is related to oxygenation problems, is not associated with adjustment disorders. A client with an adjustment disorder does not experience a disturbance in personal identity.

A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention? a. Nasogastric tube for decompression b. Antiemetic for nausea/vomiting c. Intravenous (IV) lactated Ringer for fluid replacement d. Stat electrolytes to assess for probable electrolyte imbalance e. Decompression removes collected secretions behind the nonfunctioning bowel segment

a. Nasogastric tube for decompression Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing. Vomiting will subside as the bowel is decompressed. Although IV lactated Ringer for fluid replacement is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy.

Six hours after major abdominal surgery, a client reports severe abdominal pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) (Physiological Aspects of Care record) and determines that the client can receive another injection of pain medication in an hour. Which is the most appropriate action by the nurse? a. Notify the healthcare provider about the client's symptoms b. Explain to the client that it is too early to have an injection for pain c. Reposition the client for greater comfort and turn on the television as a distraction d. Prepare the injection to administer it to the client early because of the severe pain

a. Notify the healthcare provider about the client's symptoms The client's signs and symptoms suggest the possibility of shock; the primary healthcare provider must be alerted to this possible life-threatening condition. Explaining to the client that it is too early is missing the big picture; the client may be hemorrhaging. The client has unmet needs that must be addressed first. Distraction is effective with mild, not severe, pain. Preparing and administering the pain medication early are outside the scope of nursing practice. Healthcare provider prescriptions must be followed as prescribed, or the healthcare provider should be notified.

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)? a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding

a. Patient with seizures b. Patient with head injury e. Patient who is receiving nasogastric tube feeding

What is Ascites?

accumulation of serious fluid in the peritoneal or abdominal cavity *Assessment—shifting dullness in abdomen, Board-like, hard*

The health care provider prescribes levothyroxine for a patient with hypothyroidism. After teaching regarding this drug, the nurse determines that further instruction is needed when the patient says a. "I can expect the medication dose may need to be adjusted." b. "I only need to take this drug until my symptoms are improved." c. "I can expect to return to normal function with the use of this drug." d. "I will report any chest pain or difficulty breathing to the doctor right away."

b. "I only need to take this drug until my symptoms are improved."

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

b. WBC count and differential

Which drug does the nurse recognize as an effective mood-stabilizing drug used in clients with bipolar disorder and in the acute treatment of mania and prevention of recurrent mania and depressive episodes? a. Doxepin b. Clozapine c. Amitriptyline d. Lithium carbonate

d. Lithium carbonate Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to calm acute manic symptoms and relieve recurrent mania.

What is Bariatric surgery and what is the BMI requirement ?

For those with BMI >40 Restrictive/malabsorptive process ------Bypass ------Causes rapid weight loss

Hypoxemia & Hypercapnia in COPD

Gas exchange abnormalities result in hypoxemia and hypercapnia (increased CO2) as the disease worsens. As the air trapping increases, walls of alveoli are destroyed, and bullae (large air spaces in the parenchyma) and blebs (air spaces adjacent to pleurae) can form. Bullae and blebs are not effective in gas exchange, since they do not contain the capillary bed that normally surrounds each alveolus. Therefore a significant ventilation-perfusion (V/Q) mismatch and hypoxemia result.

What is the most common cause of death for patients who have DM?

Heart Attack (Myocardial infarction...MI)

Assessment of palpation of the thyroid gland

Stand behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow As the client swallows, displace the left lobe while palpating the right lobe Repeat the process, but displace the right lobe while palpating the left lobe The normal sized thyroid gland is not usually palpable

A male client with the diagnosis of bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." What is the best response by the nurse? a. "Everyone has a bed. This one is yours." b. "You are not allowed to sleep on the floor." c. "I don't understand why you're on the floor." d. "You're a valuable person. You don't need to lie on the floor."

a. "Everyone has a bed. This one is yours." A matter-of-fact approach helps prevent a cycle in which the nurse expresses concern to a client who feels unworthy, which increases feelings of unworthiness

In evaluating an asthmatic patient's knowledge of self-care, the nurse recognizes that additional instruction is needed when the patient says, a. "I use my corticosteroid inhaler when I feel short of breath." b. "I get a flu shot every year and see my HCP if I have an upper respiratory tract infection." c. "I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies." d. "I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath."

a. "I use my corticosteroid inhaler when I feel short of breath."

The nurse is involved in a therapeutic relationship with a depressed client. Which question and/or statement by the nurse is appropriate for stage 1 of this relationship? Select all that apply. a. "I'm here to talk with you about how you've been feeling." b. "How do you feel about keeping a journal regarding how you are feeling?" c. "Are you experiencing any suicidal or homicidal thought?" d. "Are you open to the prospect of being prescribed antidepressant medication?" e. "What we talk about will be shared only with your treatment team."

a. "I'm here to talk with you about how you've been feeling." c. "Are you experiencing any suicidal or homicidal thought?" e. "What we talk about will be shared only with your treatment team."

Which individuals would be at high risk for low back pain (select all that apply)? a. A 63-year-old man who is a long-distance truck driver b. A 36-year-old construction worker who is 6 ft 2 in and weighs 260 lb c. A 44-year-old female chef with prior compression fracture of the spine d. A 30-year-old nurse who works on an orthopedic unit and smokes e. A 28-year-old female yoga instructor who is 5 ft 6 in and weighs 130 lb

a. A 63-year-old man who is a long-distance truck driver b. A 36-year-old construction worker who is 6 ft 2 in and weighs 260 lb c. A 44-year-old female chef with prior compression fracture of the spine d. A 30-year-old nurse who works on an orthopedic unit and smokes

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? a. A 65-year-old with pulmonary fibrosis b. A 24-year-old with uncontrolled type 1 diabetes c. A 45-year-old who has been vomiting for 3 days d. A 54-year-old who takes sodium bicarbonate for indigestion

a. A 65-year-old with pulmonary fibrosis The low pH and elevated Pco 2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? a. Ammonia level b. Culture and sensitivity c. White blood cell count d. Alanine aminotransferase (ALT) level

a. Ammonia level Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas.

An infant has developmental dysplasia of the hip. What clinical finding should the nurse expect to note during an assessment? a. Apparent shortening of one leg b. Limited ability to adduct the affected leg c. Narrowing of the perineum with an anal stricture d. Inability to palpate movement of the femoral head

a. Apparent shortening of one leg The affected leg appears to be shorter because the femoral head is displaced upward. The child's ability to abduct, not adduct, the affected leg is limited. Narrowing of the perineum with an anal stricture does not occur with hip dysplasia. When the femoral head slips out of the acetabulum, it is palpable.

What is the role of unlicensed assistive personnel (UAP) in caring for a client with a cast or in traction? Select all that apply. a. Applying ice to the cast b. Positioning the casted extremity above heart level c. Marking the circumference of any drainage on the cast d. Looking for clinical manifestations of compartment syndrome e. Teaching range-of-motion exercises to the client and caregiver

a. Applying ice to the cast b. Positioning the casted extremity above heart level The role of unlicensed assistive personnel (UAP) in caring for the client with a cast or in traction involves applying ice to the cast and positioning the casted extremity above heart level. The licensed practical/vocational nurse (LPN/LVN) marks the circumference of any drainage on the cast. The registered nurse (RN) assesses the client for clinical manifestations of compartment syndrome and teaches the client and caregiver range-of-motion exercises.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress? a. Bland foods b. Regular diet c. Gluten-free foods d. Low-carbohydrate foods

a. Bland foods A bland, nonirritating diet is recommended during the acute symptomatic phase. During the acute phase, a regular diet can cause discomfort. Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

After abdominal surgery a client returns to the unit with a nasogastric (NG) tube to low intermittent wall suction. The primary healthcare provider prescribes an antiemetic every six hours as needed for nausea. When the client complains of nausea, what should the nurse do first? a. Check for correct placement of the NG tube. b. Administer the prescribed antiemetic. c. Irrigate the NG tube with normal saline. d. Notify the primary healthcare provider immediately.

a. Check for correct placement of the NG tube. With a nasogastric (NG) tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking placement can determine whether it is in the stomach; once placement is verified, then fluid can be instilled to ensure patency. The antiemetic may relieve the discomfort, but it will not determine the cause. If the tube is displaced it may be in the trachea or bronchi, and instillation of fluid will cause respiratory impairment before placement is confirmed. The nurse should always assess a situation carefully before notifying the healthcare provider.

A 10-year-old girl with diabetes joins the school's soccer team. Her mother is unsure whether to tell the coach of her child's condition. The mother asks the school nurse for guidance. On what information should the nurse base the response? a. Children with diabetes who participate in active sports can have episodes of hypoglycemia. b. Children may have to leave athletic teams if school authorities learn that they have diabetes. c. The school nurse will treat the child if clinical findings of hypoglycemia are recognized early. d. The coach might violate confidentiality by discussing the child's condition with other faculty members.

a. Children with diabetes who participate in active sports can have episodes of hypoglycemia. The people associated with the school who are interacting with the child should be told about the child's condition. Knowledgeable people can be alert for early signs of hypoglycemia and have snacks available for the child to help prevent a hypoglycemic episode. Forcing the child to leave the team is a form of discrimination; children with diabetes are allowed to engage in activities as long as their diabetes remains under control. The adult who is with the child when the signs of hypoglycemia first appear should be prepared to treat the child; this person may or may not be the nurse. Information about the child's health status is on a "need to know" basis; professionals are expected to honor confidentiality.

A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect? Select all that apply. a. Dry skin b. Abdominal pain c. Kussmaul respirations d. Absence of ketones in the urine e. Blood glucose level of less than 72 mg/dL (3.3 mmol/L)

a. Dry skin b. Abdominal pain c. Kussmaul respirations Dry skin is a sign of dehydration in response to polyuria associated with the osmotic effect of an elevated serum glucose level. Abdominal pain is associated with diabetic ketoacidosis. In the absence of insulin, glucose cannot enter the cell or be converted to glycogen, so it remains in the blood. Breakdown of fats as an energy source causes an accumulation of ketones, which results in acidosis. The lungs, in an attempt to compensate for lowered pH, will blow off CO 2 (Kussmaul respirations). An absence of ketones in the urine indicates adequate production of glucose for energy. Insulin deficiency stimulates production of ketones as a by-product of fat oxidation for energy. Blood glucose level of less than 72 mg/dL (4 mmol/L) indicates hypoglycemia, not ketoacidosis.

When a client is expressing severe anxiety by sobbing in the fetal position on the bed, what is the nurse's priority? a. Ensuring a safe therapeutic milieu b. Monitoring and documenting vital signs c. Eliminating the cause of the client's anxiety d. Ensuring that the client's physical needs are met

a. Ensuring a safe therapeutic milieu Client safety is the nurse's first priority, and because the client has not experienced any physical injuries and is not at risk, attention should be directed toward psychiatric risk, in this case crisis control. The severely stressed individual is likely to experience increased vital signs and will continue to have physiologic needs such as food and water; however, these issues do not take priority over a psychiatric crisis. The client will not be able to concentrate on therapy related to identifying the source of the anxiety until the crisis has been managed.

You are caring for a patient with newly diagnosed type 1 diabetes. What information is essential to include in your patient teaching before discharge from the hospital (select all that apply)? a. Insulin administration b. Elimination of sugar from diet c. Need to reduce physical activity d. Use of a portable blood glucose monitor e. Hypoglycemia prevention, symptoms, and treatment

a. Insulin administration d. Use of a portable blood glucose monitor e. Hypoglycemia prevention, symptoms, and treatment

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply. a. Nonintention tremors b. Frequent bouts of diarrhea c. Masklike facial expression d. Hyperextension of the neck e. Rigidity to passive movement

a. Nonintention tremors c. Masklike facial expression e. Rigidity to passive movement Nonintention tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? a. Sodium b. Potassium c. Chloride d. Calcium

a. Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.

A client newly diagnosed with type 2 diabetes is receiving glyburide and asks the nurse how this drug works. What mechanism of action does the nurse provide? a. Stimulates the pancreas to produce insulin b. Accelerates the liver's release of stored glycogen c. Increases glucose transport across the cell membrane d. Lowers blood glucose in the absence of pancreatic function

a. Stimulates the pancreas to produce insulin Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.

The nurse is alerted to possible anaphylactic shock immediately after a patient has received IM penicillin by the development of a. edema and itching at the injection site. b. sneezing and itching of the nose and eyes. c. a wheal-and-flare reaction at the injection site. d. chest tightness and production of thick sputum.

a. edema and itching at the injection site.

An 80-year-old female patient is receiving palliative care for heart failure. The primary purpose(s) of her receiving palliative care is (are) to (select all that apply) a. improve her quality of life. b. assess her coping ability with disease. c. have time to teach patient and family about disease. d. focus on reducing the severity of disease symptoms. e. provide care that the family is unwilling or unable to give

a. improve her quality of life. d. focus on reducing the severity of disease symptoms.

A client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt? a. "I don't feel too good today." b. "I feel much better; today is a lovely day." c. "I feel a little better, but it probably won't last." d. "I'm really tired today, so I'll take things a little slower."

b. "I feel much better; today is a lovely day." A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide.

The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with hypocalcemia. Which statements provided by a student nurse indicate the need for further learning? Select all that apply. a. "The client would show signs of twitching." b. "The client would show signs of hyporeflexia." c. "The client would show signs of paresthesias." d. "The client would show signs of muscle cramping." e. "The client would show signs of skeletal muscle weakness."

b. "The client would show signs of hyporeflexia." c. "The client would show signs of paresthesias." The neuromuscular manifestation of alkalosis with hypocalcemia is hyperreflexia, not hyporeflexia. Paresthesias is a symptom of alkalosis, which is manifested in the central nervous system not the neuromuscular system. The manifestation of alkalosis is neuromascular and can be observed through twitching, muscle cramping, and skeletal muscle weakness.

The home health nurse visits a 40-year-old patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (0-10 point scale). In prioritizing activities for the visit, what should the nurse do first? a. Auscultate for breath sounds. b. Administer PRN pain medication. c. Check pressure points for skin breakdown. d. Ask family about patient's food and fluid intake.

b. Administer PRN pain medication.

A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature? a. Use a cooling blanket while the patient is febrile. b. Administer antipyretics on an around-the-clock schedule. c. Provide increased fluids and have the UAP give sponge baths. d. Give prescribed antibiotics and provide warm blankets for comfort.

b. Administer antipyretics on an around-the-clock schedule.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? a. Interview the client for a health history. b. Assess the client's heart and lung sounds. c. Monitor the client's pulse and temperature. d. Obtain the client's blood specimen for electrolytes.

b. Assess the client's heart and lung sounds. With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

A 40-year-old client with a terminal illness wishes to die at home in the presence of his or her spouse and child. Who will be the primary concern of the nurse viewing this family as context? a. Child b. Client c. Spouse d. Whole family

b. Client When the family is viewed as context, the primary focus is the client and fulfilling the basic needs of the client. The nurse may focus on the child and spouse when the family is viewed as client. The whole family will be considered when the nurse sees the family as a system in which the client and each family member are considered. Needs will be fulfilled with the use of all available environmental, social, psychologic, and community resources.

A client with type 1 diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? a. Notify the physician immediately about the client's symptoms. b. Determine the client's blood glucose level. c. Administer the client's prescribed insulin. d. Give the client a peanut butter and graham cracker snack.

b. Determine the client's blood glucose level.

While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist. Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife? a. A priest b. Dying wife c. Hospice staff d. Husband of dying wife

b. Dying wife

The nurse is providing home care to an older adult client with decreased bone density. Which nursing intervention will be most beneficial for the client? a. Teaching isometric exercises b. Encouraging the client to do weight-bearing exercises c. Instructing the client to sit in supportive chairs with arms d. Providing moist heat such as shower or moist compresses

b. Encouraging the client to do weight-bearing exercises Older adults are at risk of developing decreased bone density. Elderly clients with decreased bone density should be encouraged to do weight-bearing exercises. Teaching isometric exercises would be beneficial for a client with muscular atrophy. A client with kyphotic posture should be instructed to sit in supportive chairs with arms. Providing moist heat would be beneficial for a client with cartilage degeneration.

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? a. Fatigue related to weight loss secondary to COPD b. Imbalanced nutrition: less than body requirements, related to fatigue c. Imbalanced nutrition: less than body requirements, related to COPD d. Ineffective breathing pattern, related to alveolar hypoventilation

b. Imbalanced nutrition: less than body requirements, related to fatigue The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.

An older adult fell at home and fractured the left hip. Which response should the emergency department nurse identify as a typical clinical indicator associated with a fractured hip? a. Affected hip is ecchymotic. b. Left leg is noticeably shorter than the right. c. Left extremity is internally rotated. d. Affected hip is tender when touched.

b. Left leg is noticeably shorter than the right. There is overriding of bones in the fractured hip, and the leg on the affected side appears noticeably shorter than the unaffected leg. Ecchymosis is evidence of soft tissue and blood vessel damage; this may or may not be associated with a fractured hip. The affected leg is externally, not internally, rotated with a fractured hip. Pain associated with a fractured hip is not mild; it causes extreme pain.

What client factor does the nurse consider to have the greatest impact on the effectiveness of bariatric surgery? a. Freedom from concurrent high-risk conditions b. Motivation to cooperate with required lifestyle changes c. Willingness to have a panniculectomy a year after weight is stabilized d. Ability to tolerate the large abdominal incision necessary for this surgery

b. Motivation to cooperate with required lifestyle changes Bariatric surgery requires the client to engage in significant postoperative lifestyle changes (e.g., radically modifying eating habits, taking nutritional supplements, meeting numerous emotional challenges, engaging in exercise); clients who cannot cooperate with the postoperative program are not considered candidates for bariatric surgery

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of what? a. Tactile illusions associated with severed blood vessels b. Nerve endings in the limb that are still intact and react to stimuli c. An unconscious phenomenon to aid with grieving over the lost body part d. Hallucinations secondary to emotional symptoms associated with the distress of amputation

b. Nerve endings in the limb that are still intact and react to stimuli

Which is the priority intervention for the dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? a. Apply oxygen b. Place the client in a side-lying position c. Prepare to administer packed red blood cells d. Assess the client's pulse and blood pressure

b. Place the client in a side-lying position Recall the airway, breathing, and circulation (ABCs) of priority care. The client who needs assistance to manage self-care (dependent) should be placed in the side-lying position when vomiting to prevent aspiration.

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization? a. Board game b. Project involving drawing c. Small aerobic exercise group d. Card game with three other clients

b. Project involving drawing An art project that may be worked on successfully at one's own pace is appropriate for a depressed client. A board game or card game with three other clients require too much concentration and may increase the client's feelings of despair. This client is probably experiencing psychomotor retardation, and at this time an aerobic exercise group would not be appropriate.

A school-aged child is receiving 45 units of intermediate-acting insulin at 7:00 AM and 7:00 PM. What will the nurse tell the parents regarding a bedtime snack? a. Offer a snack at bedtime if there are signs of hyperglycemia. b. Provide a bedtime snack to prevent hypoglycemia during the night. c. Withhold the snack after dinner to prevent hyperglycemia during sleep. d. Leave a snack at the bedside in case the child becomes hungry during the night.

b. Provide a bedtime snack to prevent hypoglycemia during the night. Intermediate-acting insulin peaks in 4 to 12 hours; a bedtime snack will prevent hypoglycemia during the night. Offering a snack at bedtime if there are signs of hyperglycemia is unsafe because it will intensify the hyperglycemia; if hyperglycemia is present, the child needs insulin. Bedtime snacks are recommended for people taking intermediate-acting insulin. When hypoglycemia develops, the child will be asleep; the snack should be eaten before bed.

The nurse is providing care for parents who have experienced a stillbirth. What is the most appropriate intervention at this time? a. Giving a detailed explanation of what may have caused the stillbirth b. Providing the parents the opportunity to say goodbye to their newborn c. Explaining that autopsy is not recommended in the setting of a stillbirth d. Waiting to provide any information about follow-up care until the parents have had an opportunity to adjust to the grief

b. Providing the parents the opportunity to say goodbye to their newborn

A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? Select all that apply. a. Polyuria b. Sedation c. Bradycardia d. Dilated pupils e. Slow respirations

b. Sedation c. Bradycardia e. Slow respirations The central nervous system (CNS) depressant effect of morphine causes sedation. The CNS depressant effect of morphine causes bradycardia. The CNS depressant effect of morphine causes bradypnea. Morphine does not increase urine output. Morphine causes constriction of pupils.

A nurse plans to use family therapy as a means of helping a family cope with their child's terminal illness. The nurse bases this choice on what principle? a. It is more efficient to interact with the whole family together. b. The entire family is involved because what happens to one member affects them all. c. It will prevent the parents from deceiving each other about the true nature of their child's condition. d. The nurse can control manipulation and alliances better by using this mode of intervention.

b. The entire family is involved because what happens to one member affects them all. Family therapy views the whole (gestalt) within the context in which the emotional problems are occurring. Efficiency is not an adequate rationale for choosing this therapeutic approach. The nurse may or may not control manipulation and alliances better; an astute nurse can control manipulation and alliance within any group. Promotion of truthfulness is a secondary gain achieved with this mode of therapy.

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response. c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician must be notified about her condition.

b. The patient is having a normal inflammatory response.

A 6-year-old child who was rescued from a burning building is admitted to the burn unit with a diagnosis of smoke inhalation. For which priority complication should the nurse assess the child? a. Systemic infection b. Tracheobronchial edema c. Posttraumatic stress disorder d. Generalized adaptation to stress

b. Tracheobronchial edema Heat and inhaled smoke-related irritants may cause fluid to shift from the intravascular compartment into the interstitial compartment, resulting in edema, which obstructs the airway. Although monitoring for infection is important, a patent airway is the priority. Although monitoring for posttraumatic stress disorder is important because the condition could occur later, maintaining a patent airway is the priority. Although monitoring for physical and emotional responses to stress is important, maintaining a patent airway is the priority.

A client who has been pregnant for 5 months experiences a spontaneous abortion after an accident. The client tells the nurse that she feels depressed over the loss of her son. She describes how he would have looked and how bright he would have been. What is the client demonstrating? a. Panic level of anxiety b. Typical grief syndrome c. Pathological grief reaction d. Diminished ability to test reality

b. Typical grief syndrome The client is grieving the loss of a fantasized child; talking about it is part of the typical grief reaction.

A client with arthritis states that the prescribed aspirin causes stomach irritation even when taken with food. How does the nurse instruct the client to take the aspirin? a. An hour before a meal b. With a full glass of water c. With sodium bicarbonate d. At the same time as the other drugs

b. With a full glass of water A full glass of water helps decrease gastric irritation by diluting the acidic substances in the stomach. If aspirin is taken on an empty stomach, gastric irritation is increased. Although taking the medicine with sodium bicarbonate will limit gastric irritation, it will also decrease the effect of aspirin by increasing its renal excretion. Aspirin has a gastric-irritating and ulcerogenic effect, which may be potentiated by other drugs.

The son of a terminally ill woman is concerned about his mother's condition. He asks the nurse, "Will she get better?" What is the most appropriate response by the nurse? a. "Her vital signs are stable. Right now she's holding her own." b. "Of course she will. You can't give up. You have to hope for the best." c. "Her condition is very serious. It might help you if we discuss your concerns." d. "I don't know; you'll have to ask her oncologist. I'll leave a note that you're here."

c. "Her condition is very serious. It might help you if we discuss your concerns." Offering to discuss the situation provides the son with an opportunity to express his feelings. Telling the son that the woman is holding her own does not address the family member's concern. Telling the son that the woman will pull through is false reassurance and cuts off communication. Telling the son to speak with the health care provider shuts off communication and abdicates nursing responsibility to the client.

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? a. "Most individuals with your disease live a normal life span." b. "Is your family here? I would like to explain your disease to all of you." c. "The prognosis is variable; most individuals experience remissions and exacerbations." d. "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

c. "The prognosis is variable; most individuals experience remissions and exacerbations." "The prognosis is variable; most individuals experience remissions and exacerbations" is a truthful answer that provides some realistic hope. The response "Most individuals with your disease live a normal life span" provides false reassurance; repeated exacerbations may reduce the life span. The response "Is your family here? I would like to explain your disease to all of you" avoids the client's question; the family did not ask the question. The response "Why don't you speak with your healthcare provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply. a. Sweating b. Retinopathy c. Acetone breath d. Increased arterial bicarbonate level e. Decreased arterial carbon dioxide level

c. Acetone breath e. Decreased arterial carbon dioxide level A fruity odor to the breath (acetone breath) occurs when the ketone level is elevated in ketoacidosis. Metabolic acidosis initiates respiratory compensation in the form of Kussmaul respirations to counteract the effects of ketone buildup, resulting in a decreased arterial carbon dioxide level. As the glucose level decreases in hypoglycemia, the sympathetic nervous system is activated, and epinephrine and norepinephrine are secreted, causing diaphoresis. Retinopathy is a long-term complication of diabetes caused by microvascular changes in the retina; it is not a sign of ketoacidosis. With ketoacidosis, the serum bicarbonate level is decreased, not increased, in an effort to neutralize ketones when seeking acid-base balance.

A depressed client says, "I'm no good. I'm better off dead." What is the priority nursing intervention? a. Responding, "I'll stay with you until you're less depressed." b. Replying, "I think you're good; you should think about living." c. Alerting the staff to schedule 24-hour observation of the client d. Unobtrusively removing those articles that may be used in a suicide attempt

c. Alerting the staff to schedule 24-hour observation of the client Alerting the staff to schedule 24-hour observation of the client is the most therapeutic approach to preventing suicide. A staff member also provides special attention to help the client meet dependency needs and reduce a self-defeating attitude

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? a. Hypertension b. Tenacious sputum c. Altered mental status d. Slow rate of breathing

c. Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.

Windows in the recreation room of the adolescent psychiatric unit have been broken on numerous occasions. After a group discussion one of the adolescents confides that another adolescent client broke them. What should the nurse do when using an assertive intervention instead of aggressive confrontation? a. Confront the adolescent openly in the group, using a controlled voice and maintaining direct eye contact. b. Knock on the door of the adolescent's room and ask whether the adolescent would come out to talk about the situation. c. Approach the adolescent when the client is alone and, after making direct eye contact, inquire about the involvement in these incidents. d. Use a trusting approach toward the adolescent and imply that the staff doubts the adolescent's involvement but requests a denial for the record.

c. Approach the adolescent when the client is alone and, after making direct eye contact, inquire about the involvement in these incidents. A private confrontation with presentation of reported facts allows verification; a calm, direct manner is most assertive

A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." How should the nurse interpret the client's communication? a. As a call for help to prevent the client from acting on suicidal thoughts b. As a manipulative attempt to persuade the nurse to call the daughter c. As a reflection of depression that is causing feelings of hopelessness d. As a request for information about social support groups in the community

c. As a reflection of depression that is causing feelings of hopelessness This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented should not lead the nurse to conclude that the client is looking for help to prevent suicidal activities, is attempting to manipulate the nurse, or is looking for information about community social support groups.

A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern? a. Chronic pain b. Risk for injury c. Electrolyte imbalance d. Inadequate gas exchange

c. Electrolyte imbalance The stomach produces about 3 L of secretions per day. Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to dysrhythmias and death. Although pain is associated with gastric ulcers and requires intervention, it is not life threatening as is an electrolyte imbalance. Although the risk for injury is a concern, it is not the priority. Although respirations may be shallow when the client is experiencing pain, this is not the priority.

After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? a. Postural drainage b. Pursed-lip breathing c. Incentive spirometry d. Sustained exhalation

c. Incentive spirometry Incentive spirometry expands collapsed alveoli and enhances surfactant activity, thereby preventing atelectasis. Postural drainage helps clear accumulated secretions from the pulmonary tree; it does not directly promote alveolar expansion. Pursed-lip breathing promotes sustained exhalation, not inhalation. Sustained exhalation promotes the collapse, not expansion, of alveoli.

The nurse prepares an intravenous solution of lactated Ringer solution to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. Which condition will improve if the administration of lactated Ringer solution is effective? a. Urinary stasis b. Paralytic ileus c. Metabolic acidosis d. Increased potassium level

c. Metabolic acidosis Lactated Ringer solution is an alkaline solution that replaces bicarbonate ions lost from T-tube bile drainage, thus preventing or treating acidosis. Urinary stasis is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. Paralytic ileus is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. An increased potassium level is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution.

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? a. Hypocapnia b. Hyperkalemia c. Metabolic alkalosis d. Respiratory acidosis

c. Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Which is the primary nursing concern? a. Acute pain b. Risk for injury c. Metabolic alkalosis d. Ineffective breathing

c. Metabolic alkalosis Prolonged vomiting results in fluid loss and acid (hydrochloric) loss; the client's adaptations reflect dehydration and metabolic alkalosis. Although it is important to address the client's pain, the fluid and electrolyte/acid/base imbalance must be addressed first because this imbalance can be life threatening. Although risk for injury is a potential problem, the priority is the fluid and electrolyte/acid/base problem. The ineffective breathing pattern most likely is caused by the metabolic alkalosis; the fluid and electrolyte/acid/base imbalance is a higher priority and must be addressed first.

Which statement best describes the etiology of obesity? a. Obesity primarily results from a genetic predisposition. b. Psychosocial factors can override the effects of genetics in the etiology of obesity. c. Obesity is the result of complex interactions between genetic and environmental factors. d. Genetic factors are more important than environmental factors in the etiology of obesity.

c. Obesity is the result of complex interactions between genetic and environmental factors.

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? a. Urinary retention b. Gastric hyperacidity c. Rebound tenderness d. Increased lower bowel motility

c. Rebound tenderness Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis The pH indicates acidosis [1] [2]; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include? a. Foster self-activity whenever possible. b. Plan care to be completed at one time followed by a long rest. c. Teach family members how to assist with the client's basic care. d. Limit visiting to evening hours before the client goes to sleep.

c. Teach family members how to assist with the client's basic care.

An important nursing responsibility related to pain is to a. leave the patient alone to rest. b. help the patient appear to not be in pain. c. believe what the patient says about the pain. d. assume responsibility for eliminating the patient's pain.

c. believe what the patient says about the pain.

Unrelieved pain is a. expected after major surgery. b. expected in a person with cancer. c. dangerous and can lead to many physical and psychologic complications. d. an annoying sensation, but it is not as important as other physical care needs.

c. dangerous and can lead to many physical and psychologic complications.

The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's. d. 5% dextrose in 0.45% saline.

c. lactated Ringer's.

A 65-yr-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles.

c. promoting physical exercise and a well-balanced diet.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the HCP. b. check the patient's temperature. c. take the patient's blood pressure. d. elevate the head of the bed to 90 degrees.

c. take the patient's blood pressure.

An x-ray film indicates that an older client has a fractured femur. The client asks the nurse, "Will I be able to walk again?" What is the best response by the nurse? a. "I have no idea because only time will tell." b. "You only broke a bone. It could have been worse." c. "You'll walk again. This is a common issue in older people." d. "Tell me more about your concerns about being able to walk."

d. "Tell me more about your concerns about being able to walk." The phrase "Tell me more" shows interest in the client's concerns, is nonjudgmental, and encourages expression and exploration of feelings. First the client's feelings must be explored before providing a direct answer that may cut off communication. The responses "I have no idea" and "You only broke a bone. It could have been worse" places the client on the defensive; it is demeaning to the client and discourages further communication. The general response "You'll walk again. This is a common issue in older people" dismisses the client's concerns; the client is not recognized as an individual whose injury is a traumatic and personal event.

A client with a diagnosis of major depression refuses to participate in unit activities, claiming to be "just too tired." What is the best nursing approach? a. Planning one rest period during each activity b. Explaining why the staff believes that the activities are therapeutic c. Encouraging the client to express negative feelings about the activities d. Accepting the client's feelings about activities calmly while setting firm limits

d. Accepting the client's feelings about activities calmly while setting firm limits Fatigue and apathy are symptoms of depression and should be accepted; however, limits should be set to facilitate participation in unit activities. Planning one rest period during each activity allows the client to manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not change the client's mind about them, and this response does not show an understanding of the client's needs. Encouraging the client to express negative feelings about the activities will reinforce negative feelings about participating in them.

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone, and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician.

d. Anticipate the need for endotracheal intubation and notify the physician.

A client with a fractured head of the right femur and osteoporosis is placed in Buck extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? a. Remove the weights from the traction every 2 hours to promote comfort. b. Turn the client from side to side every 2 hours to prevent pressure on the coccyx. c. Raise the knee gatch on the bed every 2 hours to limit the shearing force of traction. d. Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.

d. Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.

A nurse in a mental health unit of the emergency department of a hospital frequently cares for adolescents who attempt suicide. What is important for the nurse to remember about adolescent suicide behavior? a. Boys account for more attempts than do girls. b. Girls use more dramatic methods than do boys. c. Girls talk more about suicide before attempting it. d. Boys are more likely to use lethal methods than are girls.

d. Boys are more likely to use lethal methods than are girls. The finding that boys are more likely to use lethal methods than are girls is supported by research; girls account for 90% of suicide attempts, but boys are three times more successful because of the methods they use

A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished? a. By spending a day with the client b. By asking the client at least one question daily c. By waiting for the client to initiate the conversation d. By visiting frequently for short periods with the client each day

d. By visiting frequently for short periods with the client each day Frequent short visits with the client each day demonstrate to the client that the nurse feels that the client is worth spending time with and helps restore and build trust.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? a. Osteoarthritis b. Osteoporosis c. Muscle atrophy d. Contracture

d. Contracture Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints caused by wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles because of a lack of physical activity or a neurologic or musculoskeletal disorder.

A client's blood gases reflect diabetic ketoacidosis. Which clinical indicator should the nurse identify when monitoring this client's laboratory values? a. Increased pH b. Decreased PO 2 c. Increased PCO 2 d. Decreased HCO 3

d. Decreased HCO 3 The bicarbonate-carbonic acid buffer system helps maintain the pH of body fluids; in metabolic acidosis, there is a decrease in bicarbonate because of an increase of metabolic acids. The pH is decreased. The PO 2 is not decreased in diabetic acidosis. The PCO 2 may be decreased by the body's attempt to eliminate CO 2 to compensate for a decreased pH.

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? a. Slow, deep respirations b. Normal oral temperature c. Dry, unproductive cough d. Diminished breath sounds

d. Diminished breath sounds Because atelectasis [1] [2] involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.

The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client? a. Cystitis b. Thin and dry skin c. Decreased bone density d. Frequent yeast infections

d. Frequent yeast infections Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen.

A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? a. Refer the client to the primary healthcare provider only if other neurologic deficits are present. b. Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. c. Stress the importance of having the client call the primary healthcare provider as soon as possible. d. Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.

d. Make arrangements immediately for further medical evaluation by the client's primary healthcare provider. Numbness, a sensory deficit, is inconsistent with parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending brain attack (cerebrovascular accident, CVA). This symptom is not caused by parkinsonism; increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary healthcare provider as soon as possible can cause a delay in the client's receiving immediate medical attention.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? a. Alkalosis b. Renal failure c. Hypervolemia d. Pulmonary edema

d. Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

A mental health crisis occurs as a result of what stress-related factor? a. The stress is chronic and maturational in nature. b. The stress is perceived rather than real in nature. c. The stress is extremely severe and situational in its origin. d. The stress is not managed by the individual's usual methods.

d. The stress is not managed by the individual's usual methods. An individual experiences a crisis when stress, either real or imagined, cannot be controlled by the person's usual coping mechanisms. It would not be considered a crisis if it was chronic and maturational, severe and situational, or perceived rather than real.

Which guideline would be a part of teaching patients how to use a metered-dose inhaler (MDI)? a. After activating the MDI, breathe in as quickly as you can. b. Estimate the amount of remaining medicine in the MDI by floating the canister in water. c. Disassemble the plastic canister from the inhaler and rinse both pieces under running water every week. d. To determine how long the canister will last, divide the total number of puffs in the canister by the puffs needed per day.

d. To determine how long the canister will last, divide the total number of puffs in the canister by the puffs needed per day.

SAFETY Alerts for administering IV KCL, include all of the following, EXCEPT: A) Administer the KCL as a rapid IV bolus B) Never give KCL via IV push C) IV KCL must always be diluted and never given in concentrated amounts D) Continue cardiac monitoring during the infusion

A) Administer the KCL as a rapid IV bolus

Anxiety can arise from lack of knowledge and patients may become anxious when facing hospital admissions because of the unknown. When anxiety levels are high, the nurse knows that the following can be reduced in the patient, except:. A) Intelligence B) Cognition C) Decision Making D) Coping Abilities

A) Intelligence

You are admitting a patient with complaints of abdominal pain and constipation. The patient also states they have been vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? A) Metabolic Alkalosis B) Respiratory Acidosis C) Respiratory Alkalosis D) Metabolic Acidosis

A) Metabolic Alkalosis

Spironolactone (Aldactone), a potassium sparing diuretic, is prescribed for a patient. The nurse teaches all of the following EXCEPT: A) You may combine this drug with other potassium-sparing diuretics B) This drug may cause hypotension C) This drug inhibits potassium excreting effects, causing hyperkalemia D) This drug inhibits the sodium retaining effects, causing hyponatremia

A) You may combine this drug with other potassium-sparing diuretics

The four hallmark clinical manifestations of an obstruction are all of the following, except: A) diarrhea B) abdominal pain C) vomiting D) distention and constipation

A) diarrhea

IV potassium chloride (KCL) is prescribed for treatment of a patient with severe hypokalemia. IV KCL infusion rates should NOT exceed __________ unless the patient is in a critical care setting with continuous ECG monitoring and central line access for administration. A) 10 mEq/hr B) 20 mEq/hr C) 40 mEq/hr D) 60 mEq/hr

A) 10 mEq/hr

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement, by the patient, indicates that the teaching about this medication has been effective? A. "I will eat peaches for a snack instead of honeydew." B. "I will use a salt-substitute to decrease my sodium intake" C. "I will increase my intake of avacados, tomatoes and peanut butter." D. "I will include yogurt in my diet"

A. "I will eat peaches for a snack instead of honeydew."

What is Trousseau's sign

Carpal spasms induced by inflating a BP buff on the arm

A client with type 1 diabetes receives 30 units of NPH insulin at 7 am. At 3:30 pm the client becomes diaphoretic, weak, and pale. What does the nurse determine that these physiologic responses are associated with? a. Diabetic coma b. Somogyi effect c. Diabetic ketoacidosis d. Hypoglycemic reaction

d. Hypoglycemic reaction

What is a glycosylated hemoglobin level (HgA1c)? How often are these drawn? What are normal values?

Indicates the amount of glucose linked to hemoglobin ---Assess long-term glycemic control during previous 3 months ---Nurse Responsibility—inform patient that fasting is not necessary and that blood sample will be drawn Normal range: 4%-6% A1C of 6.5% or higher indicates poorly managed diabetes mellitus

Clinical Manifestations of COPD

Barrel chest Tripod position Dyspnea Mucus hypersecretion (gray, white or yellow) Hyperinflation of lungs

What does the nurse teach patients, as a high priority, when discussing diabetes management practices related to the increased risk of the most common cause of death?

Blood pressure control is priority to reduce the risk of an MI Diabetes and blood glucose MUST be controlled!

An important factor associated with both short-term and long-term weight-loss success is A) Higher initial body mass index. B) Simultaneous smoking cessation. C) A strong desire to improve appearance. D) Fewer dieting attempts in the past year

C) A strong desire to improve appearance. Motivation to lose weight is essential for a favorable and successful outcome.

D.S. is noted to have an apple-type body shape. What do you know about body shape in relation to obesity problems and what other problems is she likely to have related to her weight?

Individuals with fat located primarily in the abdominal area (apple-shaped body) are at a greater risk for obesity-related complications than those whose fat is primarily located in the upper legs (pear-shaped body). Pain in joints, high cholesterol, sleep apnea

What are the signs and symptoms of Thyroid Storm?

Cardio-tachyarrhythmia, chest pain, CHF, pulmonary edema, shortness of breath Neuro-agitated, confusion, psychotic; seizures GI-increased vomiting/diarrhea; hypotension and shock Untreated hyperthyroidism or stressor/trigger Life-threatening Rapid increase in metabolic rate requiring Rapid treatment

What is Chvostek's sign?

Contraction of facial muscles in response to a tap over the facial nerve of in front of the ear

The nurse is caring for a patient with pneumonia. If a pleural effusion is developing, the nurse would expect which finding? A) Barrel-shaped chest B) Paradoxical respirations C) Hyperresonance on percussion D) Localized decreased breath sounds

D) Localized decreased breath sounds Rationale: Clinical manifestations of pleural effusion include diminished breath sounds over the affected area, decreased movement of the chest on the affected side, dullness to percussion, dyspnea, cough, and occasional sharp and nonradiating chest pain that is worse on inhalation.

What post-op manifestations might be present after a thyroidectomy?

Laryngeal stridor: (harsh, vibratory sound) may occur doing inspiration and expiration because of edema of the laryngeal nerve.

Goiter-physiological reason for a goiter

Enlargement of the thyroid gland Thyroid cells are stimulated to grow May result in an overactive thyroid or underactive thyroid

Behavior Modifications for Obesity

Food diary Eliminate cues that precipitate eating Recognize factors that affect eating behaviors social support group, group programs

What activity or sport is good for children with asthma ?

Swimming

What should the nurse do when talking with a client with a history of panic disorder who is displaying many of the emotional and physiologic symptoms of a panic attack? a. Use short sentences and an authoritative voice. b. Describe the possible reasons for the client's anxiety. c. Keep asking questions, because the client is probably not going to volunteer much information. d. Suggest that the client refrain from crying, because most of the time crying makes matters worse.

a. Use short sentences and an authoritative voice. During a panic attack the attention span is shortened, making it difficult to follow long sentences. An authoritative voice lets the client know that the nurse is in control of the situation; the client is unable to set controls because of the anxiety level. Describing to the client the possible reasons for the anxiety may increase the client's anxiety level further. Asking questions may increase the client's anxiety level further. Crying is an outlet and should not be discouraged; telling someone not to cry usually worsens the crying and the anxiety.

Pain management for the burn patient is most effective when (select all that apply) a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of the pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

a. a pain rating tool is used to monitor the patient's level of pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

The most common early clinical manifestations of ARDS that the nurse may observe are a. dyspnea and tachypnea. b. cyanosis and apprehension. c. hypotension and tachycardia. d. respiratory distress and frothy sputum.

a. dyspnea and tachypnea.

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about three times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

a. eat a high-protein, high-carbohydrate diet.

A client sustained minor skin injuries following an accident. Which event occurs close to the time of injury? a. Thinning of the scar tissue b. Formation of granulation tissue c. Migration of leukocytes to the site of injury d. Arrival of fibroblasts to the site of infection

c. Migration of leukocytes to the site of injury Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of "granulation" tissue and migration of fibroblasts occurs in the proliferative phase.

On the first postoperative day after a total hip replacement a client asks for assistance onto the bedpan. What should the nurse instruct the client to do? a. "Use your elbows and hands to lift your pelvis off the bed." b. "Extend both legs and pull on the trapeze to lift your pelvis." c. "Turn gently toward the operative side while lifting your pelvis off the bed." d. "Flex the knee on the unoperated leg and pull on the trapeze to lift your pelvis."

d. "Flex the knee on the unoperated leg and pull on the trapeze to lift your pelvis."

A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching? a. "I should inspect the client's skin daily." b. "I should manage the client's incontinence as quickly as possible." c. "I should properly dispose of the client's contaminated dressings." d. "I should not worry about what the client eats."

d. "I should not worry about what the client eats." The nurse should teach the caregiver about the role that good nutrition plays in enhancing a client's healing to correct this misconception. All the other statements are correct and require no further teaching. The nurse should teach the caregiver to conduct daily skin inspections. The nurse should instruct the caregiver about how to manage a client's incontinence and how to properly dispose of contaminated dressings.

A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment? a. A client who is scheduled for a bronchoscopy b. A client who is scheduled for a thoracentesis c. A client with pleural effusion and decreased breath sounds d. A client with acute asthma and 85% oxygen saturation

d. A client with acute asthma and 85% oxygen saturation A client with acute asthma may have low peripheral arterial oxygen saturation. Pulse oximetry results less than 86% requires immediate assessment and treatment. Scheduled bronchoscopies and thoracenteses do not require immediate action. Pleural effusions with decreased breath sounds are an issue, but this condition does not require immediate assessment.

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops a. muscle weakness and weight loss. b. hyperthermia and severe tachycardia. c. hypertension and difficulty swallowing. d. laryngospasms and tingling in the hands and feet.

d. laryngospasms and tingling in the hands and feet.