Hurst 12
Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? 1. Orthopnea. 2. Paroxysmal nocturnal dyspnea. 3. Petechiae on the trunk. 4. Increasing CVP with decreasing BP. 5. Pericardial friction rub. 6. Widening pulse pressure.
1., & 2. Correct: These are signs seen with valvular heart disease. Orthopnea is a condition where the client must sit or stand to breathe comfortably. Paroxysmal nocturnal dyspnea occurs when the client is reclining. It is sudden respiratory distress. 3. Incorrect: This is a sign of endocarditis. 4. Incorrect: This is the hallmark sign for cardiac tamponade. 5. Incorrect: This is a sign of pericarditis. 6. Incorrect: This is a sign of increased intracranial pressure.
When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.
1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. Pillows under the knees help with pressure on the lower back. However, if pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot.
A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy
3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. Administering an antacid will not fix the problem if PIH is worsing. This is delaying care. 2. Incorrect: Not a concern as much as impending seizure symptoms. Checking the client's blood pressure is not the priority in this situation. It will not fix the problem. 4. Incorrect: Not in this situation. Heartburn is a normal discomfort or right upper quadrant pain in a client with PIH may indicate impending rupture of the liver capsule which is a life threatening complication.
The nurse is teaching a group of clients who have osteoarthritis how to protect joints. What should the nurse include? 1. Use small joints and muscles. 2. Turn doorknobs clockwise. 3. Sit in a chair that has a low, straight back. 4. Push off with the palms of hands when getting out of bed. 5. Use hairbrush with extended handle.
4. & 5. Correct: Pushing off with the palms of the hands is using a larger joint and muscles. Using the fingers will cause more joint injury. Use long handled devices such as a hairbrush with an extended handle to decrease stress on joints (in this case the wrist). 1. Incorrect: Larger joints and muscles can take more stress and weight than smaller ones. Using small joints again and again puts more stress on them and may lead to deformity. Try to spread the strain and weight over several joints. This helps you use each part of your body to its best advantage. 2. Incorrect: Do not turn a doorknob clockwise. Turn it counterclockwise to avoid twisting the arm and promoting ulnar deviation. 3. Incorrect: Sit in a chair that has a high, straight back. This will provide more support for the back.
Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client's blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day.
1. Correct. A client in fluid volume overload may experience pitting edema in lower extremities, a bounding pulse, increased blood pressure, and shortness of breath. 2. Incorrect. This blood pressure reading is considered normal and is not a characteristic of fluid volume overload. 3. Incorrect. This CVP is within the normal range therefore not indicative of a fluid volume excess. In a fluid volume excess, the CVP would be elevated.4. Incorrect. A weight gain in excess of 2 pounds (0.9 kg) is of concern for fluid volume excess. Any weight gain overnight is reason for concern; however, the stem asked which finding was most indicative.
Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.
1. Correct: A private room will help to decrease stimulation. The client with bipolar disorder needs a calm environment especially when in the manic phase. Avoid excessive stimulation. 2. Incorrect: Don't put two manics together. This room assignment will not help to decrease stimulation which is what the manic client needs. 3. Incorrect: They need a private room. The client with psychosis maybe suspicious and have delusion or hallucinations. 4. Incorrect: There's no need for this right now. The client is hyperactive and has difficulty sleeping. A seclusion room is needed for severe agitation and acute aggression.
A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the most appropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.
1. Correct: The nurse is responsible for providing culturally sensitive client care. In the Chinese culture, it is important to show respect to the elders of the family. This option respects the client's father by addressing him personally and providing a sense of involvement in the client's health. This option does not ignore the client's father nor does it violate the client's confidentiality. In addition, questions about certain conditions can be answered without direct reference to the client. 2. Incorrect: Asking the father to leave the exam room would be disrespecting not only the father, but also the client who allowed the father to be present. 3. Incorrect: By failing to acknowledge the presence of the father, this demonstrates a lack of respect for the elder of the family. The nurse should not ignore the presence of others in a client room. 4. Incorrect: By providing information of assessment findings and plan of care, this could violate the client's rights to confidentiality. The client would need to provide expressed permission for specific information to be shared in the presence of another individual.
A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant? 1. Ventricular fibrillation 2. Ventricular tachycardia 3. 2nd degree AV block 4. Atrial fibrillation
1. Correct: V-fib is the most common lethal dysrhythmia in the initial period following a myocardial infarction. 2. Incorrect: V-tach is significant as it may occur prior to V-Fib. However, V-fib is most significant. 3. Incorrect: The client will still have a cardiac output in second degree heart block. There is no cardiac output with V-fib. The most lethal is V-fib. 4. Incorrect: Atrial fibrillation involves chaotic contractions of the atria, but there is a cardiac output. It is not life-threatening.
A client who has diabetes calls the nurse hot-line reporting shakiness, nervousness, and palpitations. Which questions would yield information that would help the nurse decide that this is a hypoglycemic episode? 1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level? 5. Does your skin feel hot and dry?
1., 2., 3. & 4. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. Insulin type will give the nurse information about duration of action and peak time. Hunger is a symptom of hypoglycemia.If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now.5. Incorrect. Hot and dry skin is not an indicator of hypoglycemia and would not help the nurse determine if the client is experiencing a hypoglycemic episode. Cool, clammy skin is a symptom of hypoglycemia.
Which nursing interventions should the nurse initiate for a client post-thoracotomy with two chest tubes in place connected to a chest drainage unit (CDU)? 1. Elevate head of bed 45 degrees. 2. Educate on use of incentive spirometry. 3. Support chest incision with pillow when client coughs. 4. Document amount and color of drainage. 5. Notify the primary healthcare provider if tidaling is noted in the water-seal chamber.
1., 2., 3., & 4. Correct: Elevate HOB to promote breathing. Educate on incentive spirometry to promote lung expansion. Supporting chest incision decreases pain and can help client produce a productive cough and can improve deep breathing efforts. Assessing for excessive bleeding is important. Keep sterile water at bedside in case the tubing becomes disconnected. 5. Incorrect: Tidaling—fluctuations in the water-seal chamber with respiratory effort—is normal. The water level increases during spontaneous inspiration and decreases with expiration.
A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care? 1. Elevate head of bed to a semi-fowlers position. 2. Monitor the color of urine and stools. 3. Turn every 2 hours. 4. Instruct about a 1200 calorie diet. 5. Monitor creatinine levels daily.
1., 2., 3., & 5. Correct: The client needs to have the head of the bed elevated in order to relieve the pressure of ascites off of the diaphragm. The client with ascites is in a fluid volume deficit (FVD) and has the risk for postural hypotension and falls. It is important to monitor for jaundice. When jaundice is present the urine may be dark brown and the stool light gray to tan color. The distended tissue with ascites is fragile and can breakdown. Remember that the problem is the loss of protein into peritoneal cavity. Protein is necessary for tissue repair. This lab level would indicate renal function that can occur due to shock.4. Incorrect: Diet instructions should focus on low salt, not low calories.
The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? 1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 2. Gestational age less than 36 weeks. 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.
1., 3., 4., & 5. Correct: Factors placing the infant or toddler at risk for developmental problems include birthweight less than 3pounds, 4 ounces (1.5 kg), chronic otitis media with effusion for more than 3 months, lead levels above 5.0 mg/dL, and parents with less than a high school education. The months a baby spends in the uterus, along with the first 12 months after birth, are the most important time of brain development. During this period neurons are forming connections with each other, creating the networks that underlie thinking, learning, and feeling. In the last weeks of pregnancy, as many as 40,000 new synapses are being formed every second. Preterm birth (less than 37 weeks gestational age) and low birth weight (less than 2.5 kg) are well-documented risk factors. In addition to threatening healthy overall growth and maturation, premature infants and low birth weight term infants may experience a disruption of important processes involved in early brain development. As a result, preterm and low birth weight children, are at increased risk for a variety of developmental problems related to health, psychological adjustment, and intellectual functioning. There is evidence that sensorineural hearing loss may result from chronic otitis. There is also evidence that the auditory deprivation associated with childhood otitis media may lead to language and speech delays. Lead is a neurotoxic substance that has been shown in numerous research studies to affect brain function and development. Children who have been exposed to elevated levels of lead are at increased risk for cognitive and behavioral problems during development. Studies show that low socioeconomic status, as measured by low income, wealth, or parental education, is associated with poor child development outcomes. 2. Incorrect: Gestational age less than 37 weeks places the infant or toddler at risk for developmental problems.
A client has been admitted with a stroke on the right side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? 1. Right sided hemiplegia 2. Impaired judgment 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech
2. & 5. Correct. The client with right sided brain damage will have left sided hemiplegia and will exhibit impulsive behavior and impaired judgment. 1. Incorrect. This is seen with left-brain damage. 3. Incorrect. This is seen with left-brain damage. 4. Incorrect. This is seen with left-brain damage. 6. Incorrect. This is seen with left-brain damage. Some signs and symptoms are different depending on where the stroke damage is located. The left hemisphere controls the right side of the body, and the right hemisphere controls the left side of the body. So with right sided brain injury you will see left sided hemiplegia. The left hemisphere is dominant for language skills in right handed people and most left handed people. Expression, comprehension of written and spoken words, and aphasia occur when a stroke damages the dominant hemisphere of the brain, most often the left hemisphere. Clients with left brain damage are aware of their deficits which leads to depression and anxiety. Whereas the client with damage to the right side of the brain tends to deny or minimize their problems. The client with right brain stroke tends to be impulsive and move quickly, whereas clients with left brain stroke are more likely to have memory problems related to language and are cautious in making judgments.
An elderly client with a history of CAD has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? 1. Request prescription for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provided incontinent pads to the client. 4. Have UAP ambulate client to the bathroom.
2. CORRECT. The exhibit shows sinus rhythm with premature ventricular contractions (PVC's), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating. 1. INCORRECT. Because the client has experienced syncope and is having frequent PVCs, keeping the client in bed is safer than ambulating to the bathroom. However, a foley catheter is an invasive procedure that could place the client at risk of infection. There is a better option. 3. INCORRECT. Using incontinent pads, either on the bed or personal pads for the client, is only appropriate if the client is unable to control urinary flow, or requests the use of same. It is embarrassing to ask clients who are continent to void onto a bed pad. 4. INCORRECT. This client is newly admitted with a diagnosis of syncope. The exhibit shows frequent PVC's, which are non-perfusing beats. Even with assistance from the UAP, ambulating to the bathroom is not the safest action for this client.
A hospitalized client using a K-pad on an injured muscle reports the pad is not warming up. What should be the nurse's initial action? 1. Unplug unit and plug into another wall outlet. 2. Check temperature setting on the heating unit. 3. Call maintenance to repair unit immediately. 4. Increase temperature on unit till pad heats up.
2. CORRECT. The nurse is utilizing the nursing process by first collecting data pertinent to the situation. The actual problem could be related to the temperature dial on the unit, or even a malfunction in the pad itself. However, the nurse must assess the situation by checking the basics, such as whether the equipment is even turned on. 1. INCORRECT. While it is possible the outlet itself may be defective, this is not likely in a large facility. Additionally, an electric appliance should never be re-connected to an outlet while still in contact with the client. 3. INCORRECT. It is unlikely maintenance would be available to examine the device immediately and most repairs should not be attempted in the client's room because of safety considerations. 4. INCORRECT. The exact problem with the heating unit has not yet been established. Simply turning up the temperature setting is not safe since the pad may quickly get hotter, injuring the client.
The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.
2. Correct: In an upper GI series (sometimes called a barium swallow test), the client swallows barium contrast while x-rays are taken.1. Incorrect: Laxatives are taken the night before a colonoscopy to ensure stool is cleared from the colon. Waiting to take the laxative the morning of the test would be ineffective and uncomfortable for the client.3. Incorrect: Radiopaque dye injected before a CT (computed tomography) scan is not part of a GI series. This would be a totally different diagnostic test from the upper GI. 4. Incorrect: In a gastroscopy (sometimes called a gastric endoscopy), a scope is passed through the mouth to the stomach to visualize the inner lining of the upper GI tract.
A client, who is receiving an IV vesicant agent, reports pain at the intravenous site. What is the priority nursing action? 1. Apply a cold compress to the IV site 2. Stop the infusion 3. Check the IV for a blood return 4. Notify the primary healthcare provider
2. Correct: Stop the infusion to stop the vesicant from getting into the tissue and causing more extravasation. 1. Incorrect: This is a right response, but it's not what I would do first. You have to stop the infusion first. Why do we use a cold compress and not a warm compress? We don't want the vesicant to spread out through vasodilation (warm compress), we want to keep it contained, so cold compress to vasoconstrict. 3. Incorrect: You may do this but the priority with pain and swelling is to stop the infusion before more damage is done. 4. Incorrect: The healthcare provider may be notified, but first the infusion must be stopped to prevent further extravasation.
A client with a history of myasthenia gravis (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important? 1. Include daily weight lifting exercises. 2. Practice stress reduction techniques. 3. Complete chores early in the day. 4. Take medications on time and prior to meals. 5. Eat three large meals daily.
2., 3. & 4. Correct: Myasthenia gravis is a chronic autoimmune disorder characterized by progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day, contributing to the potential for complications. Stress reduction techniques are important since stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks, including ADL's, should be completed early in the day when the client has the most energy. Medications for MG, including neostigmine and pyridostigmine, must be taken on time and prior to meals. 1. Incorrect: Clients with myasthenia gravis are instructed to include gentle daily exercise combined with periods of rest throughout the day. Weight lifting would be too strenuous and would quickly tire this client, possibly leading to a myasthenia crisis. 5. Incorrect: Because of the difficulty in chewing or swallowing, multiple small meals throughout the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed in relation to meals, so consistent but smaller meals would be more beneficial for the client.
What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.
2., 3., & 5. Correct. Perform comparison check with another thermometer periodically to ensure there is no problem associated with equipment failure. For cooling treatments, extended periods of cooling can cause areas of decreased perfusion, skin burns, and tissue injury. Chilling can increase metabolism and body needs. 1. Incorrect: Check the client's temperature every 15 minutes. If the client is cooled too quickly, chilling, increased metabolism, and adverse reactions may occur. 4. Incorrect: The blanket will not immediately return to room temperature and will continue to cool the client even after it is turned off. Turning it off shortly before the goal temperature is achieved will prevent altering the client's core temperature beyond the desired outcome.
What should the nurse teach the client following a right knee arthroscopy? 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.
2., 3., 4. & 5. Correct: Elevating the joint for several days will reduce swelling and pain. Tingling to the extremity could mean nerves have been damaged. Exercise is gradually started to strengthen muscles surrounding the joint and prevent scarring of surrounding soft tissues. The client needs to keep the site as clean and dry as possible. 1. Incorrect: Continuous ice can cause tissue damage.
Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails
2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. 1. Incorrect: Atelectasis is collapse of alveolar lung tissue, and findings reflect presence of a small, airless lung. This condition is caused by complete obstruction of a draining bronchus by a tumor, thick secretions, or an aspirated foreign body, or by compression of lung. 5. Incorrect: Client tends to lean forward (orthopnea) and uses accessory muscles of respiration to breathe.
A gunshot victim is brought by ambulance to the emergency room with an open pneumothorax. A bio-occlusive dressing to the chest. The nurse then notes increased dyspnea and sub-q emphysema in the client. What is the nurse's priority action? 1. Prepare client for insertion of chest tube. 2. Apply a non-rebreather with 100% oxygen. 3. Loosen one side of the bio-occlusive dressing. 4. Obtain a tracheostomy kit and call the surgeon.
3. CORRECT: An open pneumothorax, also referred to as a sucking chest would, allows outside air to rush into the chest cavity. Because outside air has greater pressure than intrathoracic air, the pressure builds up quickly creating a mediastinal shift that collapses all structures in the thoracic cavity. This is referred to as a tension pneumothorax and can be caused by securing all four sides of the bio-occlusive dressing. The nurse should check to see that the dressing is loose on one side. If it is not, one side of the dressing must be released to allow the air to escape from the chest. 1. INCORRECT: Although this client will ultimately need a chest tube to remove the air that entered the chest cavity, this is not the nurse's priority action. 2. INCORRECT: A dyspneic client may certainly need supplemental oxygen; however, there are not enough parameters provided to determine whether the client is truly hypoxic. 4. INCORRECT: An emergency tracheostomy is not the initial treatment for dyspnea or sub-q emphysema. Such an invasive procedure would be used only in a life-threatening situation.
A client admitted to the hospital following a fall has a history of Alzheimer's disease with apraxia. The nurse knows the client will need priority assistance with what activity? 1. Ambulating to the bathroom. 2. Understanding instructions. 3. Using utensils at mealtime. 4. Identifying objects in room.
3. Correct: Apraxia is a motor disorder of voluntary movements in which the individual can no longer execute purposeful activity, even though there is adequate mobility, strength, and coordination. This loss of ability to carry out previously learned movements could occur secondary to brain injury or a disease process such as Alzheimer's disease. The client has the ability to pick up utensils but is unable to use them correctly, which may affect the client's nutritional status. 1. Incorrect: Apraxia does not affect the ability to ambulate to the bathroom, although the client may not be able to follow cleanliness procedures once in the bathroom. However, there is another activity is of more concern. 2. Incorrect: The ability to understand is not affected by apraxia, which is a disorder in which the client loses the ability to perform purposeful movement. The client is still able to comprehend instructions at this point. There is another situation in which the client will need assistance. 4. Incorrect: The client is still able to identify objects in the environment; however, the diagnosis of apraxia indicates the client cannot use previously known objects correctly. Because of this situation, there is another area in which assisting the client is of more importance.
The nurse is caring for a client with a closed head injury. Three days after admission, urinary output for 8 hours was 1800 mL. In response to this data, what would be the appropriate nursing action? 1. Hydrate the client with 500 mL of IV fluid in the next hour. 2. Monitor BUN and creatinine. 3. Check urine specific gravity. 4. Recognize this as a side effect of dexamethasone.
3. Correct: For any client with a head injury and abnormally high urinary output, the nurse knows the client is at risk for ADH (anti-diuretic hormone) problems. The pituitary gland is located in the brain. ADH is produced in the pituitary gland. In head injured clients, ADH can get messed up. If the client does not have enough ADH large volumes of water will be lost in the urine. The name of this disease is diabetes insipidus (DI). Large volume losses place the client at risk for shock. The nurse knows to further investigate the problem by checking a urine specific gravity. For clients in DI, the urine specific gravity will be very, very low because they are losing so much water. When you see the letters DI, think of the "D" for diuresis and think SHOCK first. 1. Incorrect: Administration of 500 mL of fluid over one hour is possible if the client were in shock. The stem of the question, however, does not indicate this client is in shock. 2. Incorrect: Monitoring BUN and creatinine does not help identify diabetes insipidus. 4. Incorrect: Decadron can cause fluid retention, not increased urinary output.
Which side effect of vincristine should the nurse immediately report to the primary healthcare provider? 1. Nausea 2. Fatigue 3. Paresthesia 4. Anorexia
3. Correct: Paresthesia is a side effect of some chemotherapeutic medications and if it occurs, the primary healthcare provider needs to modify the dosage or discontinue. 1. Incorrect: Nausea and vomiting are common side effects of many chemotherapeutic medications. 2. Incorrect: Fatigue is a common side effect of many chemotherapeutic medications. 4. Incorrect: Anorexia is a common side effect of many chemotherapeutic medications.
The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? 1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse.
3. Correct: The client is likely to be most comfortable with solitary activities. When the client is extremely distrustful of others, solitary activities are best. Activities that demand concentration keep the client's attention on reality and minimize hallucinatory and delusional preoccupation. 1. Incorrect: The client is paranoid; therefore, he would not be comfortable within a group. Noisy environments may be perceived as threatening. 2. Incorrect: The client is likely to be very suspicious of the other players, thereby increasing their own anxiety level. The noisy basketball game may be too threatening for the client. Physical games are not the best choice for the paranoid schizophrenic client. 4. Incorrect: As trust builds with the nurse, this may be an appropriate activity, but there is a better answer. The "most" appropriate is an individual art project. The second best answer would be a card game with the nurse.
A client reports excruciating paroxysmal facial pain occurring after feeling a cool breeze and drinking cold beverages. Based on this client's reports, what disorder does the nurse suspect? 1. Bell's palsy 2. Submucous cleft palate 3. Trigeminal neuralgia 4. Temporomandibular joint disorder (TMD)
3. Correct: Trigeminal neuralgia is an ongoing pain condition that affects the trigeminal nerve in the face. People who have this condition say the pain feels like an intense electric shock. The pain is triggered by things such as brushing teeth, washing the face, shaving, or putting on makeup. Even a light breeze against the face might trigger the onset of pain. 1. Incorrect: Bell's palsy is a condition in which the muscles on one side of the face become weak or paralyzed. It affects only one side of the face at a time, causing it to droop or become stiff on that side. It is caused by trauma to the facial nerve. 2. Incorrect: A submucous cleft palate (SMCP) results from a lack of normal fusion of the muscles within the soft palate as the fetus is developing in utero. An SMCP can include a very wide or split (bifid) uvula, translucency of the tissue along the middle of the soft palate, and a notch in the back of the hard palate. 4. Incorrect: The temporomandibular joint is a hinge that connects the jaw to the temporal bones of the skull. It allows the jaw to move up and down and side to side, so a person can talk, chew, and yawn. Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when chewing, speaking, or opening the mouth wide are signs/symptoms of TMD.
The nurse is caring for a client on the oncology unit. The client asks, "Why do I need this LifePort to receive my chemotherapy?" What evidence should the nurse consider when answering? 1. IV infusions can be more rapidly administered via an implantable IV port 2. Implantable IV ports are kept sterile and therefore do not become infected 3. Chemotherapeutic agents are more readily absorbed from implantable IV ports 4. Implantable ports are beneficial when long-term and/or multiple IV therapy is indicated.
4. Correct: Clients requiring long-term and/or multiple IV therapy benefit from implantable ports, because they reduces the number of IV sticks, preserve the integrity of peripheral veins, and provide a vessel with adequate blood flow. The part allows chemotherapy agents to be given in a larger vein, decreasing risk of tissue damage that can occur with peripheral administration. 1. Incorrect: Rate of administration is not an indicator for an implantable port, and chemotherapeutic agents are administered at a slower rate than most IV medications. Chemo agents should be given at the prescribed rate. 2. Incorrect: Infection is a concern for any implantable device. Sterile technique is used when accessing port. Inspection of the site is essential, in addition to monitoring vital signs and WBCs. 3. Incorrect: Rate of absorption is not affected by the type of central line or implantable IV port. Implantable ports promote safety and reduce problems during medication administration.
A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse? 1. Tenesmus 2. Hyperactive bowel sounds 3. Ten bloody diarrhea stools in 8 hours 4. Abdominal guarding
4. Correct: Guarding is a completely involuntary response of the muscles. In other words, you have no control over it. It's a sign that your body is trying to protect itself from pain. It can be a symptom of a very serious and even life-threatening medical condition. 1. Incorrect: Tenesmus is the urge to move your bowels even if you've just emptied your colon. This is a common symptom of an ulcerative colitis flair and would not be of immediate concern to the nurse. 2. Incorrect: Hyperactive bowel sounds can mean there is an increase in intestinal activity. This may happen with diarrhea or after eating. This client has ulcerative colitis so hyperactive bowel sounds during a flare is expected. 3. Incorrect: The colon is ulcerated and unable to absorb water, so 10-20 bloody diarrhea stools are the most common symptom of ulcerative colitis and would not be of immediate concern to the nurse.
A client arrives at the emergency room with 20% partial thickness burns to bilateral lower extremities following a grass fire. Prior to the arrival of the ambulance, friends had soaked the client's legs in cold water for pain relief. The client is now requesting more cold water on legs because of intense pain. What statement by the nurse would be most accurate? 1. "I can soak some towels in water to place on your legs." 2. "I will call the doctor to ask for an order to use wet gauze." 3. "I need to finish my nursing assessment first before treatment." 4. "I must cover your legs with dry gauze to prevent complications."
4. Correct: Initial burn interventions involve stopping the burning process. In order to do so, the burned area should be submerged in cool (not cold) water for ten to fifteen minutes. Any longer may subject the client to hypothermia as well as allowing bacteria to enter the damaged tissue. Therefore, after the initial cooling period, the burn must be covered with dry sterile gauze to prevent further complications. 1. Incorrect: Towels are not sterile and would be inappropriate for a fresh burn. Wet towels would also be too heavy on damaged tissue, may stick to the sloughing skin and moist cloth is not suitable for post-burn care. 2. Incorrect: Wet dressings are not the correct treatment for fresh burns, with or without an order from the healthcare provider. Moisture after the initial cooling period can cause complications. 3. Incorrect: While this statement by the nurse is correct, it does not address the client's request. The nursing process requires all of the assessment to be completed prior to any intervention (except for an airway emergency). Despite the accuracy of the statement, the nurse has not responded to the client's need.
A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful? 1. Teach the client to perform active facial exercises several times a day. 2. Provide a liquid diet high in protein and calories that will be easily swallowed. 3. Provide oral hygiene after eating. 4. Teach the client to chew food on the unaffected side of the mouth.
4. Correct: Maintenance of good nutrition is most important. Teaching the client to chew on the unaffected side will help the client avoid food trapping. This will decrease the risk of aspiration which prioritizes higher than the other options. 1. Incorrect: Performances of facial exercises is important in recovery from Bell's palsy and will help over a long period of time. This intervention is not the highest priority. 2. Incorrect: Liquids are too difficult for the client to manage, as lip closure and chewing are impaired. A purely liquid diet increases the risk for aspiration. 3. Incorrect: Providing oral hygiene is important to prevent dental caries; however, this is not more important than preventing aspiration.
Following hip replacement surgery, an elderly client is being transferred to a long term care facility for therapy. What priority action by the nurse best promotes continuity of care for the client? 1. Explain future care requirements to the family. 2. Call facility's nurse manager to give oral report. 3. Discuss client's needs with healthcare provider. 4. Send written summary of client needs to facility.
4. Correct: Written documentation is the most complete legal record for continuity of client care. In this format, the same specific information is then available to all staff having direct care contact with the client. 1. Incorrect: While the family will definitely need to be informed of the client's current and future therapeutic needs, such a discussion would have taken place prior to being discharged to long term care. Another action takes priority. 2. Incorrect: An oral report is vital prior to the client's arrival at a new facility so that an appropriate room and needed equipment can be available for the client's arrival. Though such an action is important, there is a better method to promote continuity of care. 3. Incorrect: Talking with the primary healthcare provider must be done at the time orders for transfer have been written to clarify specifics, which would then be relayed to the long term care facility. This is not the nurse's current priority.
