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A nurse notes documentation in the medical record that a woman in labor is at +1 station. Based on this finding, what does the nurse determine is the presenting part of the fetus? 1. 1 cm below the ischial spines 2. 1 cm above the ischial spines 3. At the level of the ischial spines 4. Above the level of the ischial spines

1. 1 cm below the ischial spines Rationale Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. Station is expressed in centimeters above or below the spines. When the presenting part is 1 cm below the ischial spines, the station is noted as +1. When the presenting part is 1 cm above the ischial spines, the station is noted as -1. When the presenting part is at the level of the ischial spines, the station is noted as zero.

A nurse in a daycare center is planning play activities for a group of toddlers. which choice are the Most appropriate play material for these children? 1. Videos, compact disc player, board games. 2. Rattles, stuffed animals, sneaky dolls, soft mobiles. 3. Cards, Monopoly games, sewing kits, paints by number kits 4. Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper

4. Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper Rationale: The toddler engages in parallel play. Appropriate toys promote increased locomotive skills, meet the need for tactile play, and are safe. Blocks, a rocking horse, finger paints, wooden puzzles, thick crayons, and paper are all appropriate toys for a toddler. Videos, a compact disc player, board games, sewing kits, and paint-by-number kits are more appropriate for a school-age child. Rattles, stuffed animals, squeaky dolls, and soft mobiles are more appropriate for an infant.

A nurse has provided information to a 16-year-old girl about adequate nutritional intake. Which statement by the girl indicates a need for additional information? 1. It is all right to eat pizza for breakfast once in awhile 2. It is important to eat at least two servings of fruit per day. 3. it is acceptable to eat an occasional hamburger and fries at a fast food restaurant 4. It is acceptable to replace the daily milk requirement with a protein food such as a cheeseburger

4. It is acceptable to replace the daily milk requirement with a protein food such as a cheeseburger Rationale According to the MyPlate food plan, three servings per day should be consumed from the dairy group. Protein foods are not acceptable substitutes for this food group. The other statements are accurate.

Mrs. Frances Valenti, 85 years old, lives in a residential home for older adults. She visits the clinic and tells the nurse that she is having persistent diarrhea. During the physical assessment, the nurse notes that Mrs. Valenti appears weak when walking, that she is intermittently confused, and that her skin is dry. Her temperature is 101° F; 38.3°C, her apical pulse is 92 beats/min and irregular, her respiratory rate is 28 breaths/min, and her blood pressure is 108/70 mm Hg. Mrs. Valenti tells the nurse that she has been able to eat and drink small amounts but that the diarrhea will not stop. The nurse suspects that Mrs. Valenti is dehydrated.

Answer the following questions

Joanna Burns has brought her 2-year-old son, Joel, to the well-baby clinic for a scheduled visit. She expresses concern to the nurse about her son's behavior, telling the nurse that she has a great deal of difficulty getting Joel to bed at night. Joel throws temper tantrums to postpone the event, she reports. Joanna also tells the nurse that because of this behavior she is worried about being able to toilet-train Joel. Joanna asks the nurse about strategies to deal with Joel's behavior.

Answer the following questions

Marilyn Formosa, 27 years old, schedules an appointment at the family planning clinic. Marilyn tells the nurse that she will be getting married in 1 month, that she is seeking a convenient form of contraception, and that she would like to take the pill. She tells the nurse that her relationship with her fiancé has been mutually monogamous since she started seeing him, 8 years ago. Marilyn says that she and her fiancé plan to have children at some point.

Answer the following questions

A nurse is planning to determine the presentation and position of the fetus, using the Leopold maneuver. Prioritize and number the nursing action in order in which they are performed. (The number 1 would indicate the first and the number 6 represents the last action) Ask the woman to empty her bladder Palpate the side of her uterus to determine the location of the fetal back Wash hands and don gloves Palpate the uterine fundus to determine the fetal part felt Palpate the suprapublic area determine whether the presenting part is engaged Explain the procedure to the woman

Explain the procedure to the woman Ask the woman to empty her bladder Wash hands and don gloves Palpate the uterine fundus to determine the fetal part felt Palpate the side of her uterus to determine the location of the fetal back Palpate the suprapublic area determine whether the presenting part is engaged

Priority points to remember! (Infants, Child, Adolescents)

Human milk is the best food for infants. skim and low-fat milk should not be used for infants because the essential fatty acids are inadequate and the solute concentration of protein and electrolyte is too high Fluoride supplementation may be needed starting around 6 months of age, depending on the infants intake of fluoridated tap water Introduce solids foods one at a time,usually at intervals of 4 to 7 days, to identify food allergies. Avoid giving solid foods that place the child at risk for chocking, such as nuts,food with seeds, raisins, popcorn, grapes, and pieces of hot dog Baby-proof the home; hazards items must be stored out of reach Toddlers are eager to explore the world around them Preschoolers are active and inquisitive;because of their magical thinking, they may believe that the daring feats seen in cartoons are possible and may attempt them Children should always wear a helmet when riding a bike,using inline skates or skateboards,or participating in other activities that may result in falls Teach children to avoid speaking to strangers and to never accept rides,toys,or gifts from strangers Teach children how to call 911 in an emergency situation Teach parents to keep the poison-control hotline number available Adolescents are risk takers Discuss such issues as bullying, date rape, sexual relationships, and sexually transmitted infections and the dangers of the Internet with regards to communication and setting up meetings (dates) with unknown person.

A nurse is providing information to the parents of a 5-month-old about introducing sold foods to the infant. Which of the following instructions should the nurse give to the parents? 1. Cheese should not be used a substitute for meat. 2. Introduce one new food at a time at intervals of 4 to 7 days. 3. Mix soft solid food with formula if the infants refuses to eat. 4. Start with fruits and vegetables; if these are tolerated, add cereal to the diet.

Introduce one new food at a time at intervals of 4 to 7 days. Rationale: Solids may be added to feedings when the infant is 5 to 6 months old. Rice cereal is introduced first because of its low allergenic potential. The recommended sequence after the introduction of rice is weekly introduction of fruits, followed by vegetables and then meat. Cheese may be used as a substitute for meat or as a finger food. Parents are instructed to introduce one food at a time, usually at intervals of 4 to 7 days, as a means of identifying food allergies. Foods are never mixed with formula in the bottle

Which priority action would the nurse take after attaching an external electronic fetal monitor to a pregnant client? 1. Checking the fetal heart rate 2. Discussing the labor process with the client 3. Assessing the frequency of the contractions 4. Documenting the time that the monitor was attached

1. Checking the fetal heart rate Rationale Assessing the fetal heart rate is the priority action after an electronic fetal monitor is attached to a pregnant client. Although assessment of the frequency of contractions is important, it is not the priority. Likewise, documenting and discussing the labor process with the client are components of the plan of care but are not the priority

Penny's labor continues, and she is now at 9 cm of dilation. During contractions, the fetal heart monitor shows the patterns depicted on the graph. What does the nurse determine? Click to enlarge 1. No action is required 2. The oxytocin infusion must be stopped 3. Penny should be moved into a side-lying position 4. Oxygen, at a rate of 8 to 10 L/min by way of a face mask, needs to be administered

1. No action is required Rationale Early deceleration of the fetal heart rate (FHR) is an obvious gradual decrease and then return to baseline that is associated with uterine contractions. Early decelerations are considered benign, and nursing interventions are not required. Moving the mother into a side-lying position, administering oxygen, and stopping the oxytocin infusion are interventions that would be needed for late or variable decelerations of the FHR, which may indicate fetal distress.

A nurse has completed a family assessment and is documenting the information obtained during the interview. The household comprises a father, a mother, one son, and two daughters. What family type should the nurse document? 1. Nuclear 2. Blended 3. Extended 4. Multi-adult

1. Nuclear Rationale: A nuclear family consists of two partners, heterosexual or homosexual, and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint-living situation. An extended family includes relatives such as aunts, uncles, grandparents, and cousins in addition to the nuclear family. A multi-adult family is one in which more than one adult is living in a household.

Joanna asks the nurse about toilet-training Joel. She is not sure whether he is ready and anticipates that he will throw a temper tantrum if she begins to toilet-train him. The nurse tells Joanna to watch for certain signs and readiness to toilet-train. What are they? Select all that apply 1. Ability to remove clothing 2. Refusal to sit on the toilet 3. Impatience with a wet diaper during the day 4. An increased number of wet diapers during the day 5. A dry diaper when the child wakes from a nap

1. Ability to remove clothing 3. Impatience with a wet diaper during the day 5. A dry diaper when the child wakes from a nap Rationale Signs of readiness for toilet training include the ability to stay dry for 2 hours; waking dry from a nap; the ability to sit, squat, and walk; the ability to remove clothing; the ability to recognize the urge to defecate or urinate; the ability to sit on the toilet for 5 to 10 minutes without fussing or getting off; impatience with a wet or soiled diaper; and willingness to please the parent.

A nurse is performing an ophthalmoscopic examination of an older client. Which age-related change would the nurse expect to note while viewing the retina? 1. Clear fundus 2. Red blood vessels 3. Yellow-orange optic disc 4. Yellow spots near the macula

4. Yellow spots near the macula Rationale Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula. Red blood vessels, a clear fundus, and a yellow-orange optic disc are all normal findings, not age-related changes.

Which statement by Joanna reflects a need for further information? (Select all that apply) 1. He's too young to get cavities 2. I will use the car seat overtime we drive somewhere 3.He will probably swallow gum instead of just chewing it 4. He can eat most foods as long as I cut them into round pieces 5. I will apply sunscreen if we are outside for more than an hour 6. We need to make sure that our cleaning supplies are in a locked cabinet.

1. He's too young to get cavities 4. He can eat most foods as long as I cut them into round pieces 5. I will apply sunscreen if we are outside for more than an hour Rationale Cavities can occur in teeth of a person of any age, and parents of toddlers should be taught how to care for a toddler's teeth, and be provided with information about foods that are highly likely to cause cavities. Toddlers are at a very high risk for poisoning, and a major cause is improper storage of harmful items. Therefore, locking cleaning supplies and other toxic items is essential, along with constant vigilance in supervising the toddler. Toddlers can chew, but may have problems with large pieces of food. Food should be cut into small pieces; round pieces may be easily aspirated and are choking hazards. It takes practice for a toddler to learn how to chew gum, but not to swallow it. Sunscreen should be applied before any exposure to sunlight. Parents should always use a care safety seat, even if the trip is short.

Joanna ask the nurse how to deal with Joel's bedtime temper tantrums. Which strategy should the nurse recommend to Joanna? 1. Safely isolating Joel and ignoring temper tantrums 2. Giving in to Joel's demands and allowing him to stay up a little longer 3. Telling Joel that he will be punished if the temper tantrum continues 4. Telling Joel that a favorite toy will be taken away if the temper tantrum doesn't stop

1. Safely isolating Joel and ignoring temper tantrums Rationale Temper tantrums, a common toddler response to anger and frustration, are often a result of thwarted attempts at exerting mastery and autonomy. Generally the most effective method of handling a tantrum is to safely isolate and ignore the child. The child should learn that nothing, not even attention, is gained from a tantrum. Giving in to the child's demands or scolding and punishing the child will only worsen the behavior. Toddlers stop using tantrums when they do not achieve their goals and as their verbal skills increase.

A nurse monitoring lochial flow in a woman who delivered 2 hours earlier notes that the client's perineal pad shows drainage measuring less than 1 inch in a 1-hour period. How should the nurse report the lochial flow? 1. Scant 2. Light 3. Heavy 4. Excessive Submit

1. Scant Rationale Lochia is the discharge from the uterus in the postpartum period, consists of blood from the vessels of the placental site and debris from the decidua. The following guide may be used to determine the amount of flow: scant, less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light, less than 10 cm (4 inches) on pad in 1 hour; moderate, less than 15 cm (6 inches) on pad in 1 hour; heavy, saturation of pad in 1 hour; and excessive, saturation of pad in 15 minutes.

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson theory of psychosocial development. According to this theory, which choice represents the primary developmental task of the child? 1. To master useful skills and tools 2. To gain independence from parents 3. To develop a sense of trust in the world 4. To develop a sense of control over self and body functions

1. To master useful skills and tools Rationale

A pediatric nurse id developing nursing care plans on the basis of Erik Erikson's stages of psychosocial development. Using Erikson's stages of psychosocial development, number the psychosocial crises in order of occurrence on the basis of development stage, from birth (1) to 20 years of age (5). 1. Industry vs Inferiority 2. Identity vs role confusion 3. Initiative vs guilt 4. Autonomy vs shame and doubt 5. Trust vs mistrust

1. Trust vs Mistrust 2. Autonomy vs shame and doubt 3. Initiative vs guilt 4. Industry vs Inferiority 5. Identity vs role confusion Rationale: Erikson describes the human life cycle as series of eight ego-developmental stages, from both to death. Each stage presets a psychosocial crisis and focuses on psychosocial tasks that are accomplished. These orderly stages and associated psychosocial crises are: trust vs mistrust(infancy), autonomy vs shame and doubt (toddler), industry vs inferiority(school-aged), and identifies intimacy vs role confusion (adolescent). Erikson also identifies intimacy vs isolation for early adulthood, generatively vs stagnation for middle adulthood, and integrity vs despair for later adulthood (older adult)

A middle-aged couple comes to the family planning center to discuss methods of contraception and asks about sterilization. As a means of determining whether this method of sterilization is appropriate, which question should the nurse ask the couple? 1. "Has either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Does either of you have diabetes mellitus?" 4. "Does either of you have problems with high blood pressure?"

2. "Do you plan to have any other children?" Rationale Sterilization is a method of contraception for couples who have completed their families. It should always be considered a permanent end to fertility, because reversal surgery is difficult and expensive and may not be covered by insurance. Additionally, reversal surgery is not always successful, and it increases the risk of ectopic pregnancy. Therefore the nurse would ask the couple about plans for having children in the future to help determine the correct method of contraception. The assessment questions noted in the other options may be appropriate to ask a client who may be undergoing surgery, but they are not specifically related to sterilization.

A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? 1. 4 days 2. 10 days 3. 14 days 4. 21 days

2. 10 days Rationale Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.

A nurse monitoring the fetal heart rate (FHR) pattern of a woman in the first stage of labor whose cervix is dilated 6 cm notes the presence of early decelerations. Based on this finding, what action should the nurse take? 1. Contacting the nurse-midwife 2. Continuing to monitor the FHR pattern 3. Administering oxygen at 10 L by face mask 4. Preparing the woman for immediate delivery

2. Continuing to monitor the FHR pattern Rationale Early deceleration of the FHR is a visually apparent gradual decrease in and return to baseline FHR that occurs in response to fetal head compression during a contraction. It is a normal and benign finding, and therefore no intervention is necessary.

A nurse taking the vital signs of a client who delivered a healthy newborn infant 4 hours ago notes that the client's oral temperature is 101.2° F (38.4°C). Which action would be appropriate? 1. Documenting the findings 2. Notifying the health care provider 3. Retaking the temperature rectally 4. Telling the client that the temperature at this level is expected at this time

2. Notifying the health care provider Rationale Temperatures up to 100.4° F (38.0° C) in the 24 hours after birth are often related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. However, a temperature higher than 100.4° F indicates an infection, and the health care provider should be notified. Although the nurse also would document the findings, the appropriate action would be to contact the health care provider. There is no useful reason for taking the temperature rectally. Telling the client that her increased temperature is expected at this time is incorrect.

A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? 1. Week 1 2. Week 5 3. Week 8 4. Week 9

2. Week 5 Rationale By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore the other options are incorrect.

Which instructions should the nurse provide to the mother? 1. Place the child in the back seat of the var in a booster seat? 2. Place the child in the back seats in a forward-facing convertible seat with a harness 3. Restrain the child in the passenger side of the front seat as long as an air bag is in place 4. Place the child in the back seat of the car in a forward-facing position using the car seat belt.

2. Place the child in the back seat in a forward-facing convertible seat with a harness Rationale The convertible restraint is used for toddlers and preschoolers. It is best that the child ride in a rear-facing position for as long as possible, to the highest height and weight allowed by the manufacturer of their convertible seat. Once a child has outgrown the rear-facing seat, a forward-facing seat with a full harness should be used for as long as the child fits. Booster seats are for older children who have outgrown their forward-facing car safety seats. Air bags can be harmful or even lethal to small children.

What should the nurse tell Joanna? 1. Avoid letting Joel take any daytime naps 2. Provide a quiet activity for 30 minutes before bedtime 3.Providing a high-carbohydrate snack before bedtime to promote sleep 4. Allow the stalling tactics for 30 minutes, then tell Joel that he mist go to bed

2. Provide a quiet activity for 30 minutes before bedtime Rationale Toddlers often resist going to bed by stalling or even throwing temper tantrums to postpone the event. Firm, consistent limits are needed when toddlers try stalling tactics. Warning the child a few minutes before it is time for bed may reduce bedtime protests. Winding down with a quiet activity for 30 minutes before bedtime also helps the toddler prepare for sleep. Bedtime rituals are important and should be followed consistently. Daytime naps do not need to be avoided; a balance of activity, rest, and sleep is important. Avoiding high-carbohydrate snacks and excitement before bedtime promotes relaxation.

The nurse obtains information about Marilyn's health history. What is the most important question for the nurse to ask Marilyn to elicit data related to the contraindications to oral contraceptives? 1. "Are you dieting?" 2. "Did you have acne as an adolescent?" 3. "Have you ever had thrombophlebitis?" 4. "Do you have a family history of kidney disease?"

3. "Have you ever had thrombophlebitis?" Rationale Oral contraceptives are contraindicated in women with or with a history of thrombophlebitis, thromboembolitic disorders, stroke, or coronary artery disease and in women with other risk factors for thrombosis. They are also contraindicated during pregnancy and in women with known or suspected breast carcinoma, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumor, or undiagnosed genital bleeding. Dieting and a family history of kidney disease are not contraindications to the use of oral contraceptives. Oral contraceptives may improve acne.

A sexually active single female client is discussing methods of contraception with the family planning nurse. The client tells the nurse that her primary concern is avoiding contracting sexually transmitted infections (STIs). In responding to the client, which method of protection does the nurse say provides the best protection against many STIs? 1. A diaphragm 2. A cervical cap 3. A latex condom 4. An intrauterine device (IUD)

3. A latex condom Rationale Latex condoms provide the best protection available (other than abstinence) against many STIs. A diaphragm and a cervical cap provide a mechanical barrier to prevent the passage of sperm into the uterus but do not provide protection against STIs. An IUD, which is inserted into the uterus, provides no protection against STIs.

A nurse teaches the husband of a woman who is in the active phase of stage 1 labor how to perform effleurage on his wife. Which observation by the nurse indicates that the spouse is performing the procedure correctly? 1. The man lightly pushes on his wife's sacral area with his fist. 2. The man exerts steady pressure on his wife's abdomen during a contraction. 3. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. 4. The man exerts light pressure with the heel of the hand over the area of the uterine fundus.

3. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. Rationale Effleurage (light massage) and counterpressure are two methods that provide pain relief to a woman in the first stage of labor. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during a contraction. It is used to distract the woman from contraction pain. Counterpressure is steady pressure, applied to the sacral area with the fist or heel of the hand, that may help the woman cope with the sensations of internal pressure and pain in the lower back. Therefore the other options are incorrect.

The nurse developing a plan of care for Mrs. Valenti will prioritize the following concerns from the highest priority (1) to the lowest (2) 1. Potentially damaged skin 2. Possible injury 3. Loss of fluid volume 4. Confusion

3. Loss of fluid volume 4. Confusion 1. Potentially damaged skin 2. Possible injury Rationale The most appropriate (highest priority) concern for the client i=who is dehydrated is loss of fluid volume, Possible injury and confusion complete for second priority. Because confusion is an actual client problem and could place client at risk for an injury, confusion is the second priority and possible injury is the third priority. The possibility of damaged skin is the fourth priority.

A subarachnoid (spinal) block is administered to a woman before a cesarean section. During the immediate postpartum period, which vital sign does the nurse check most closely as part of monitoring for adverse effects of the block? 1. Temperature 2. Apical pulse 3. Respirations 4. Blood pressure

4. Blood pressure Rationale The injection site for a subarachnoid block is in the spinal subarachnoid space at L3-L5. This type of anesthesia, administered just before birth, relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities. The adverse effects of a subarachnoid block are maternal hypotension, bladder distention, and postdural puncture headache. Although the nurse would monitor the woman's temperature, pulse, and respirations, the blood pressure must be monitored most closely.

During the office visit, the nurse assesses Joel's development level, document the findings, and review the data. -Physical development: Chest circumference exceeding head circumference, Lateral diameter of chest exceeding anteroposterior diameter, has 16 primary teeth -Language development: Use pronouns "I","me","you", Refers to self by name, Talks incessantly, Understands directional commands -Socialization Development: Does not tolerate separation from parents, fears strangers, brief attention span, willing to share toys. Which statement correctly describes the nurse's assessment of these findings? 1. All findings are appropriate for a 2-year-old child 2.The physical findings are not appropriate for a 2-year-old child 3. The language findings are not appropriate for a 2-year-old child 4. The socialization findings are not appropriate for a 2-year-old child

4. The socialization findings are not appropriate for a 2-year-old child Rationale By the age of 2 years, children should have a sustained attention span, exhibit increased independence from their parents, be less likely to fear strangers, and have an awareness of ownership, as expressed by phrases such as "my toy." The findings listed under the "Physical Development" and "Language Development" tabs are appropriate for Joel's age.

Things to Remember (Maternity)

-Fertilization occurs in the upper region of the fallopian tubes. -Most substances in maternal blood can be transferred to the fetus. -The umbilical cord contains two arteries and one vein. -Positive signs of pregnancy include auscultation of the fetal heart rate, active fetal movements palpable by the examiner, and the outline of the fetus on ultrasound. -The gravid uterus partially occludes the vena cava and descending aorta when the mother lies in a supine position, sometimes resulting in supine hypotensive syndrome; this may be prevented or corrected by positioning the mother in a lateral position. -During the second and third trimesters (weeks 18-30), fundal height in centimeters approximately equals the fetus's age in weeks, plus or minus 2 cm. -An increase of about 300 calories per day is needed during pregnancy. -An increase of about 500 calories per day is needed during lactation. -A diet high in folic acid and folic acid supplementation are important. -The pregnant woman should drink at least eight to ten 8-oz (235ml) glasses of fluid each day, of which four to six glasses should be water. -The nonstress test reveals whether the fetal heart rate accelerates when the fetus moves. -The contraction stress test is used to evaluate the response of the fetal heart to recurrent short interruptions in placental blood flow and oxygen supply that occur with uterine contractions. Page 75 of 82

Things to Remember (Providing a Secure and Safe Environment)

-Follow agency policy and procedures for any intervention related to client care. -Always check an unclear, incomplete, or inaccurate prescription with the health care provider. -Identify clients at risk for injury and implement measures to ensure their safety. -Ensure that staff members have adequate knowledge of safety measures and procedures. -An incident report — a tool for identifying risk situations and improving client care —is completed when an accident, error, or other unusual event occurs. -Use the RACE mnemonic (rescue, alarm, confine, extinguish) to set priorities in the event of a fire. -Use the mnemonic PASS — pull the pin, aim the extinguisher at the fire, squeeze the handles, sweep the nozzle over the fire — to remember how to use a fire extinguisher. -Electrical equipment must be maintained in good working order and should be properly grounded. -In the event of accidental poisoning, assess the client's airway, breathing, and circulation. -The Poison Control Center should be contacted before any intervention is attempted in the event of a poisoning. -The nurse must assess the client's home environment for any unsafe conditions and initiate modifications as necessary.

Things to Remember (Grief and Loss)

-Grief, or the emotional responses to a loss, is a process that an individual must experience to finally accept the reality of loss. -A child's grief is based on his or her developmental level. -Loss is the absence of something desired or previously thought to be available. -The nurse must consider cultural and religious beliefs when assisting a client in grieving and coping with loss.

Things to Remember (Maternity: Postpartum Care)

- The priority nursing care of the mother after birth is to promote firm uterine contraction, promote comfort, and promote parent-infant attachment. -To most accurately determine the amount of lochial flow, weigh the perineal pad before and after use and keep track of the time between pad changes. -Encourage fluids in the postpartum period because of the dehydrating effects of the labor and delivery process. If the client's temperature rises higher than 100.4° F (38°C), health care provider is notified, because this could indicate infection. -In the postpartum period, a pulse rate greater than 100 beats/min could indicate blood loss or infection. -If the blood pressure drops, bleeding or hypovolemia should be suspected. -Women may ovulate without menstruating, so breastfeeding should not be considered a form of birth control. -All women should be assessed for depression during pregnancy and in the postpartum period.

Things to Remember (Client Rights)

-A client (patient) bill of rights provides a list of the rights of the client and responsibilities that the health care agency may not violate. -The nurse must educate the client about his or her rights and responsibilities and verify that the client understands. -The nurse must discuss treatment options and decisions with the client and recognize the client's right to refuse treatment or procedures. -The client has the right to decide to become an organ donor and the right to refuse organ transplant as a treatment option. -The nurse must ensure that other health care providers are educated about client rights and act as an advocate to uphold client rights.

Things to Remember (Addictions)

-A client with a substance abuse problem recurrently uses substances and may experience significant harmful consequences related to the use of the substance. -Alcohol withdrawal delirium is a medical emergency; death may occur as a result of myocardial infarction, fat embolus, peripheral vascular collapse, electrolyte imbalance, aspiration pneumonia, or suicide. -Thiamine (vitamin B1) deficiency is a complication of chronic alcohol use and results in Korsakoff syndrome (manifesting as disorientation and loss of short-term memory). -Encourage the client with a substance abuse problem to attend a self-help group (Alcoholics Anonymous, Narcotics Anonymous). -An overdose of central nervous system depressants may produce cardiovascular or respiratory depression, coma, shock, seizures, or death. -An overdose of central nervous system stimulants may produce respiratory distress, ataxia, hyperpyrexia, seizures, coma, stroke, myocardial infarction, or death. -An overdose of narcotics (opioids) may produce respiratory depression, coma, shock, seizures, or death. -The nurse needs to provide care and support to a client with a non-substance-related dependency such as gambling or sexual addiction.

Things to Remember (Crisis Intervention)

-A crisis begins when coping mechanisms or problem-solving methods, initiated when a threat to well-being is perceived, fail for the individual. -Crisis intervention is an immediate, short-term, goal-directed therapy that focuses on solving the client's immediate problem and allowing the client to return to the precrisis level of function. -Obtain informed consent before electroconvulsive therapy; if the client does not have the capacity to provide consent, the document may be signed by a legally designated person. -Encourage the client to discuss his or her feelings, including myths regarding ECT. -ECT may be followed by temporary memory loss. -Assess the client with depression for suicide clues and intervene to implement safety precautions as necessary. -When depression lifts, the client has more energy available to carry out a suicide plan. -Ensure one-on-one supervision at all t imes of a suicidal client.

Things To Remember (Emergency Response Plans, disasters, and Triage)

-A disaster is any event, human-made or natural, that results in destruction or large-scale injury that cannot be addressed without assistance (i.e., medical, local, or federal government assistance). -A disaster preparedness plan is a formal plan of action for coordinating the response of a health care agency's staff in the event of a disaster, either within the agency or in the surrounding community. -The nurse must be aware of disaster preparedness plans, security plans, and evacuation procedures at his or her place of employment and in the community. -If a disaster occurs within a health care agency, the agency's disaster preparedness plan is immediately activated and the nurse responds by following the directions identified in the plan. -A nurse who is the first responder to a disaster in the community attends first to individuals with life-threatening problems; once rescue workers have arrived on the scene, immediate plans for triage should be made. -Various rating systems are used in different clinical settings; the nurse must be familiar with the rating system of the health care agency in which he or she is employed. -One rating system commonly used in the emergency department consists of three tiers: "emergent," "urgent," and "nonurgent"; such categories may also be identified with the use of color coding or numbers. -The purpose of primary assessment is to identify any problem that poses an immediate or potential threat to the life of the client in question.

Things to Remember (Use of Safety Devices; Restraints)

-A safety device (restraint) is any appliance used to restrict client movement. -Federal, provincial, state, and agency policy and procedures regarding the use of safety devices must be followed; the application of safety devices in violation of these regulations constitutes abuse. -Side rails used to restrict a client's mobility may be considered a type of restraint. -A health care provider's prescription, including the duration and circumstances under which the restraints are to be used, is required. -A restraint should be used only to ensure the physical safety of the client or other clients and only when other measures have failed to ensure safety. -The least restrictive type of restraint should be used. -Skin integrity and neurovascular and circulatory status must assessed every 30 minutes in a client who is being physically restrained. -The restraint is removed every 2 hours for 30 minutes to permit muscle movement, r ange-of-motion exercise, and promotion of circulation. -Continually assess the need for restraints and provide documentation with regard to the restraint.

Things To Remember (Principles of Delegation and Prioritization Care)

-Accountability is accepting responsibility for one's actions. The nurse is always responsible for his or her actions when providing care to a client. -Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to fulfill that task. -Even though a task may be delegated to someone else, the nurse who delegates maintains accountability for the overall nursing care of the client. -Time management is a technique designed to assist in the completion of tasks within a definite time period; it requires the ability to anticipate the day's activities, to combine activities when possible, and to not be interrupted by nonessential activities. -Prioritizing is the process of deciding which needs or problems require immediate action and which may be delayed because they are not urgent. - Clients needs that involve life-threatening issues or that could result in harm to the client if left unaddressed are high priorities. -The nurse can use Maslow's Hierarchy of Needs theory, the ABCs, and the steps of the nursing process as guidelines in determining priorities.

Priority Points to Remember! (Early Adulthood, Middle Adulthood,and Later Adult)

-Aging is a natural process that is common to all individuals. -The young adult tends to ignore physical symptoms and postpone seeking health care. -The task of middle adulthood is to achieve generativity. -Age-related changes can increase the older client's risk for injury. -Excess bathing may result in dryness, itching, and skin disruption. -Regular exercise helps maintain muscle tone and strength and improves circulation. -The reduced respiratory function associated with aging places the client, particularly the immobile client, at risk for pneumonia. -Age-related decline in immune system function increases the older client's risk of infection. -Age-related changes can alter the mechanism of medication absorption, putting the client at risk for adverse medication reactions. -One common sign of an adverse reaction to a medication in the older client is an acute change in mental status. -Any suicide threat by an older client should be taken seriously.

Things to Remember (Mental Health Disorders)

-Always assess a client's safety and his or her risk for suicide. -Always provide a safe environment for the client and others. -Anxiety may occur as a result of threats to identity or self-esteem, may result when the client's values are threatened, or may precede new experiences. -Stay with the anxious client. -If the client exhibits physical symptoms as a manifestation of a panic disorder, attend to the client's physical needs first. -A client with posttraumatic stress disorder may relive the traumatic event in recurrent and intrusive dreams or flashbacks. -A phobia may cause panic-level anxiety if the object, situation, or activity cannot be avoided. -An obsession is a preoccupation with persistent intrusive thoughts and ideas. -A compulsion is a repeated performance of rituals or purposeless behaviors designed to prevent some event, divert unacceptable thoughts, and ease anxiety. -Bipolar disorder is characterized by episodes of mania and depression interspersed with periods of normal mood and activity. -Monitor the physical needs of a client with mania, including nutritional intake, rest, and sleep.

Things to Remember (Advance Directives)

-An advance directive is a document that sets forth directions concerning the provision of care when a client is unable to make his or her own treatment choices. -A durable power of attorney is a legal document that appoints a person (health care proxy) chosen by the client to carry out his or her wishes as expressed in the advance directive or to make decisions on the client's behalf if and when the client is unable to do so. -The nurse should provide the client with information about advance directives. -An advance directive is integrated into the plan of care and becomes part of the client's medical record. -The nurse ensures that the health care provider has been notified of the existence of an advance directive. -All health care workers must follow the directions set forth in an advance directive.

Things to Remember (Ethical and Legal Issues)

-An ethical dilemma occurs when a conflict arises between two or more ethical principles. -The nurse must recognize ethical dilemmas, take appropriate action, and evaluate the outcomes of interventions. -It is important for the nurse to inform the client or health care providers, or both, of ethical issues that affect client care. -The nurse must function in the role of an advocate and represent the client's viewpoint to other members of the health care team. -The nurse must identify legal issues affecting the client and educate the client and health care providers on these issues. -The nurse must provide care within the legal scope of practice and practice in a manner consistent with a code of ethics. -Every nurse is responsible for knowing the provisions of the nurse practice act for the state in which he or she works. -It is the nurse's responsibility to receive and transcribe the health care provider's prescriptions in accordance with the agency's policies and procedures. -A nurse is obligated to carry out a health care provider's prescription unless he or she believes that a prescription may cause harm to the client. -Documentation is legally required, and agency guidelines for documentation must be followed. -Nurses are required to report to authorities certain communicable diseases, dog and other animal bites, and criminal activities (e.g., abuse or neglect, gunshot and stab wounds, assaults, homicides, suicides).

Things to Remember (Managed Care and Case Management)

-Case management is an interprofessional approach to health care delivery in which available resources are used to provide quality, cost-effective, comprehensive care throughout the client's illness. -A case manager is a nurse who assumes responsibility for coordinating the client's care from the time of admission and after discharge. -Discharge planning begins when the client is admitted to the hospital or health care facility. -Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. -Quality improvement is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. -Care planning can be accomplished through referrals to or consultations with other health care specialists and through client care conferences involving members of all health care disciplines. -Continuity of care is important in ensuring that the client receives the necessary care from all health care providers in a way that will achieve the desired outcomes.

Things to Remember (End-of-Life)

-End-of-life care refers to issues related to death and dying and the role of the health care provider in the care of the dying client. -Palliative care is focused on caring interventions and symptom management, rather than cure, for diseases that no longer respond to treatment. -Hospice care consists of supportive care for clients in the last phases of incurable diseases that will allow them to live as fully and comfortably as possible. Client and family needs are the focus of any intervention. -Avoid repeated unnecessary assessments of the dying client; assessment of the dying client should be limited to essential data. -Do not delay or deny pain medication to the terminally ill client. -Maintain respect for and the dignity of the client, even in death.

Things to Remember (Violence, Abuse, and Neglect)

-Ensure the safety of the client and others if a client becomes abusive. -Always ensure the safety of a victim of abuse. -Report abuse to the appropriate legal authorities in accordance with state and agency guidelines. -Assess the victim of abuse for physical injuries and treat these injuries first. -Remove a child from an abusive environment and place him or her in a safe environment, thereby preventing further injury. -Help the victim of family violence develop self-protective abilities and other problem-solving abilities. -The older client at greatest risk for abuse is the one who is dependent because of immobility or altered mental status. -Refer victims of abuse to crisis intervention and support groups. -Restraints (safety devices) and seclusion require a psychiatrist's written prescription, which must be reviewed and renewed every 24 hours; agency policy and procedures for the use of these methods must always be followed.

Things to Remember ( Informed Consent)

-Informed consent is the client's understanding of the reason for a proposed intervention, as well as its benefits and risks, confirmed by the signature on a consent form. -A client may withdraw his or her consent at any time. -The client must be informed, in understandable terms, of the risks and benefits of the surgery or treatment, the consequences of not undergoing the surgery or procedure in question, treatment options, and the name of the health care provider performing the surgery or procedure. -The nurse must act as a client advocate and ensure that the legal guidelines regarding informed consent are implemented. -A client who has been given sedative medications or any other medication that might affect the client's cognitive abilities should not be asked for informed consent. -An unemancipated minor may not give legal consent; consent must be obtained from a parent or legal guardian. -An emancipated minor is considered legally capable of giving informed consent.

Things to Remember (Maternity: Intrapartum care)

-Normal labor is characterized by a consistent progression of contractions, cervical dilation and effacement, and fetal descent. -In true labor, contractions increase in duration and intensity. -In false labor, contractions are irregular and do not produce dilation, effacement, or descent. -If fetal bradycardia or tachycardia occurs, change the position of the mother and administer oxygen, then assess the mother's vital signs; the health care provider is notified immediately. -Decreased variability may result from fetal hypoxemia, acidosis, or the use of certain medications. -Interventions for late decelerations include improving placental blood flow and fetal oxygenation. -Assess the color of the amniotic fluid if the membranes have ruptured, because meconium-stained fluid may indicate fetal distress. -If the membranes rupture, the priority nursing action is to assess the fetal heart rate. -Monitor lochia discharge. Lochia may be red and moderate in amount in stage 4. -General anesthesia presents a danger of respiratory depression, vomiting, and aspiration. -An oxytocin infusion is discontinued if uterine contraction frequency is less than 2 minutes or duration is longer than 90 seconds, or if fetal distress is noted.

Things to Remember (Stress Management)

-Stress is the body's arousal response to any perceived threat or demand. -A stressor is any event or occurrence that requires the individual to adapt. Individuals may respond differently to the same stressor. -General adaptation syndrome comprises three stages: the alarm reaction stage, the stage of resistance, and the stage of exhaustion. -The use of herbal substances is contraindicated in some cases, and the client is advised to consult with the health care provider regarding their use. -A variety of noninvasive techniques are available to reduce stress, and the nurse should teach the client these techniques.

Things to Remember (Confidentiality and Information Technology/Security )

-The client has the right to privacy in the health care system. -HIPAA requires health care agencies to keep PHI private, provides information to the client about the agencies' legal responsibilities with regard to privacy, and explains the client's rights with respect to PHI. -Nurses are bound to protect client confidentiality and privacy. -Information technology is a means of enhancing client care, but the nurse must apply his or her knowledge of the client's rights and agency guidelines when using technology. -The nurse must intervene appropriately if confidentiality or client privacy has been violated by a health care provider. -Disclosure of confidential information exposes the nurse to liability for invasion of the client's privacy.

Points to Remember (Family systems and Family Dynamics)

-The family strongly influences the health behaviors of its members, and the health status of each individual influences how the family unit functions and its ability to achieve goals. -The nurse should identify the family structure and roles of the family members and assess family dynamics to formulate a plan of care. -The nurse must recognize the cultural and religious influences that affect family function. -Until the young toddler feels secure in the affection of his or her parents, expecting the toddler to welcome a newborn infant into the family is not realistic. -Older children often enjoy taking responsibility for the care of a younger sibling. -Adolescents are more likely to take risks with sexual activity because they believe that the chance of becoming pregnant is small. -Several factors, including the need or desire for contraception, personal preference, cultural and religious beliefs and practices, effectiveness, and safety, should be considered in the choice of a method of birth control. -The nurse must identify the expected outcomes for family planning and discuss the contraindications for the chosen method of contraception. -Oral contraceptives are contraindicated in women with a history of thrombophlebitis, thromboembolitic disorders, stroke, or coronary artery disease; other risk factors for thrombosis; known or suspected breast carcinoma; benign or malignant liver tumors; undiagnosed abnormal genital bleeding. They are also contraindicated in pregnant women. -Oral contraceptives should be used with caution by women with diabetes mellitus, women who are smokers, woman who have risk factors for cardiovascular disease (e.g., hypertension, obesity, hypercholesterolemia), and women anticipating elective surgery in which postoperative thrombosis might be expected. -Most condoms are made of latex, which is impermeable to bacteria and viruses; therefore, in addition to protecting against pregnancy, latex condoms protect against STIs. (Polyurethane condoms also protect against STIs, but condoms made from lamb intestines are permeable to viruses and do not protect against STIs.) -Because of the risk of toxic shock syndrome, a diaphragm should not remain in place for more than 24 hours. -Natural family planning methods involve the use of physiological cues to predict ovulation; coitus is avoided when conditions are favorable for fertilization. -Natural family planning methods are acceptable to most religious groups because they do not involve the use of medications, chemicals, or devices.

Things to Remember (Cultural Awareness and Health Practices)

-The nurse should ask the client about his or her health care practices and preferences and incorporate these practices, if possible, into the plan of care. -Health care recommendations, interventions, and treatments that do not fit within the client's cultural beliefs and practices will not be embraced by the client. -Treat the client with respect and appreciate the differences and diversity of beliefs regarding health, illness, and treatment modalities. -If a language barrier poses a problem, seek a qualified medical interpreter; to avoid the transmission of incorrect information and breach of client privacy, avoid using ancillary staff or family members as interpreters. -Some herbs have been found to be safe, but others, even in small amounts, are toxic or may interact negatively with prescription medications; advise the client to discuss herbal therapies with the health care provider before using them.

Things to Remember (Care of the newborn)

-The priority nursing care of the newborn after birth is to promote normal respiration, maintain normal body temperature, place identification bracelets on the newborn infant and mother, and promote attachment. -The newborn's Apgar score is assessed and recorded at 1 and 5 minutes after birth. -An intramuscular dose of vitamin K is prescribed to prevent hemorrhagic disorders; administer in the lateral aspect of the middle third of the vastus lateralis muscle. -Eye medication is prescribed to prevent ophthalmia neonatorum; administer within 1 hour of birth. -When performing the physical examination, keep the newborn warm; begin with general observations and then perform assessments that are least disturbing to the newborn first. -Cold stress causes oxygen consumption and energy to be diverted from maintaining normal brain cell function and cardiac function, resulting in serious metabolic and physiological conditions. -Acrocyanosis (peripheral cyanosis) is normal in the first few hours after birth and then may be noted intermittently for next 7 to 10 days. -Slight tremors may be a common finding but may also signal hypoglycemia or drug withdrawal. -Normal, or physiological, jaundice appears after the first 24 hours in full-term newborns and after the first 48 hours in premature newborns; jaundice occurring before this time (pathological jaundice) may indicate early hemolysis of red blood cells and must be reported to the health care provider. -First voiding should occur within 24 hours of birth. -Meconium stool, which is greenish black, with a tarlike consistency, is usually passed during the first 24 hours of life. - The mother must be taught to check the identification of any person who comes to remove the baby from her room as one of the precautions against newborn abduction (e.g., nurses must be wearing photo identification or some other security badge). Page 41 of 48

Things to Remember (Standard Precaution and Surgical Asepsis)

-Use strict aseptic technique for all procedures. -Keep the client in a private room — with, if possible, a high-efficiency particulate air filtration (HEPA) or laminar airflow system — with the door closed. -Limit the number of staff entering the client's room. -Keep supplies for the client separate from those for other clients, and keep frequently used equipment in the room for the client's use only. -See that the client, family, and health care providers engage in frequent and thorough handwashing. -Staff and visitors with known infections or exposure to communicable diseases must avoid contact with the client until the risk of infectious spread has passed. -Reduce exposure to environmental organisms by thoroughly washing or eliminating fresh or raw fruits and vegetables (low-bacteria diet) from the diet; eliminate fresh flowers and live plants from the client's room and avoid leaving standing water in the client's room. Be sure that the client's room is cleaned daily. -Assist the client with daily bathing, using an antimicrobial soap. -Help the client perform frequent oral hygiene. -Monitor temperature for signs of infection. -Monitor the white blood cell and neutrophil counts. -Notify the health care provider if signs of infection are present, and prepare to obtain specimens for culture of the blood, open lesions, urine, and sputum; a chest x-ray may also be ordered.

Thomas undergoes amputation of the foot, has an uneventful recovery, and is discharged home. He is to receive home care visits from a visiting nurse and a physical therapist for rehabilitation measures, including preparation for a prosthesis. Angela, his wife, tells the visiting nurse that Thomas has been agitated and refuses to talk to anyone or allow any of his friends from the limousine company to visit him. During the home care visit, Thomas says to the nurse, "I can't drive my limousine! Life just isn't worth living anymore. Some days I wish I were dead." Which response should the nurse make first? 1. "Are you having thoughts of suicide?" 2. "Things will work out. It's just going to take some time." 3. "Tell me why you don't want to talk to or see any of your friends." 4. "Once you learn how to walk with the prosthesis, you'll feel better about yourself."

1. "Are you having thoughts of suicide?" Rationale If the client makes a statement indicating a desire to end his or her life, the nurse must immediately validate the statement. The statement made by Thomas is one such overt verbal clue. Other such clues include "I can't take it any more" and "Everyone would be better off if I died." If a client makes such a statement, the nurse should specifically ask the client about his or her intention of committing suicide. Telling the client, "Things will work out" or "Once you learn to walk with the prosthesis, you will feel better" is nontherapeutic and provides false reassurance. Asking the client why he does not want to talk or see his friends may be appropriate at some point but, in light of Thomas' statement, is not the initial concern.

A client with polycystic kidney disease requires a kidney transplant. After several tests, it is determined that the client's brother is a histologically compatible donor. The client is told about the findings and informed that kidney transplant surgery will be scheduled. The client tells the nurse that he does not want the kidney transplant and asks to speak to his health care provider about other treatment options. Which statement by the nurse is appropriate? 1. "Can we talk about the reasons that you do not want the kidney transplant?" 2. "You're probably just nervous about the surgery. Sleep on it, and then we'll talk about it tomorrow." 3. "Your brother was so excited about being able to help you. What a disappointment it's going to be for him to hear this." 4. "Are you kidding? Do you know how lucky you are to have a compatible donor? Not too many people get a second chance at life!"

1. "Can we talk about the reasons that you do not want the kidney transplant?" Rationale The client has the right to accept or refuse a treatment. This includes the right to decide to become an organ donor and the right to refuse an organ transplant as a treatment option. The appropriate nursing response is to focus on the client's feelings and provide an opportunity for the client to verbalize his thoughts and concerns. Placing the client's feelings on hold, instilling guilt in the client, and showing disapproval are all inappropriate and nontherapeutic responses.

After a year, Marilyn calls the nurse to report that she may be pregnant. She says, "I missed 2 days of pills, so we've been using the rhythm method. Do I still take today's pill?" Which responses by the nurse are appropriate? Select all that apply. 1. "Can you stop by the office this afternoon for a pregnancy test?" 2. "Keep taking the birth control until your pregnancy is confirmed." 3. "The rhythm method is quite accurate. You probably are not pregnant." 4. "Wait a week, and if you still think you're pregnant stop the birth control pill." 5. "Do not take the birth control until you are tested in the office for pregnancy."

1. "Can you stop by the office this afternoon for a pregnancy test?" 5. "Do not take the birth control until you are tested in the office for pregnancy." Rationale Pregnancy, or possible pregnancy, is a contraindication to the use of oral contraceptives. The client should be told to stop taking the contraceptive until pregnancy is confirmed or ruled out. The rhythm method, though commonly used, is not always effective, because ovulation is often irregular. The nurse cannot determine whether the client is pregnant with just a telephone conversation. A pregnancy test should be performed as soon as possible.

Thomas tells the nurse that even though he is upset about his situation, he sometimes says things that he doesn't really mean. The nurse talks to Thomas about counseling, and he agrees to speak with a crisis counselor. The nurse also talks to Thomas about a no-suicide contract, and Thomas agrees to sign one. Which statement should be included in the contract? 1. "I will call my crisis counselor if I have any thoughts of harming myself." 2. "If I start feeling that I want to kill myself, I will try to ignore the thought." 3. "I will ask my wife to hide my medication if I have any thoughts of harming myself." 4. "I will try to do something such as watching television or reading the newspaper if I have any thoughts of harming myself."

1. "I will call my crisis counselor if I have any thoughts of harming myself." Rationale A no-suicide contract should provide an appropriate resource for the client in the event that the client experiences thoughts of self-harm. Calling the crisis counselor is the only option that is an appropriate resource for the client. Ignoring the thoughts does not provide a resource for the client; instead, it relies on the client to deal with the thoughts of self-harm. Placing the responsibility on the client's wife is an inappropriate intervention.

Maureen and Robert decide to have James Nicholas circumcised before he is discharged from the hospital. The nurse conducts teaching for home care of the circumcised newborn. Which statement by Maureen indicates a need for further instruction? 1. "I'll clean the penis with a baby wipe during each diaper change." 2. "I'll check the circumcision site for bleeding during each diaper change." 3. "I'll apply petroleum jelly to the penis during each diaper change until it heals." 4. "If his penis turns red, swells, or has a discharge, I'll call the pediatrician right away."

1. "I'll clean the penis with a baby wipe during each diaper change." Rationale Many newborn infants are discharged soon after circumcision, and thorough client teaching is important. Parents should be taught to check carefully for bleeding, to cleanse the site with warm water until the circumcision is healed (5 to 6 days), and to apply petroleum jelly during each diaper change until the site is healed. Redness, swelling, or discharge indicates infection, and the health care provider should be notified immediately if any of these findings is noted. Commercial baby wipes should not be used because they contain alcohol, which may delay healing and cause discomfort for the newborn.

After a week, Claudia's lithium level is within the normal range and she is preparing to go home. The nurse has reviewed client teaching about lithium therapy with Claudia. Which statements by Claudia reflects the need for further teaching? Select all that apply. 1. "I'll cut down on the salt I eat." 2. "I'll take the pills on an empty stomach." 3. "I'll take the pill every day at the same time." 4. "I need to be very careful, because lithium can be addictive." 5. "It's important for me to see my doctor to have my lithium level checked."

1. "I'll cut down on the salt I eat." 2. "I'll take the pills on an empty stomach." 4. "I need to be very careful, because lithium can be addictive." Rationale Lithium, which can be irritating to the lining of the stomach, should be taken with meals. The client must be taught that lithium is not addictive and that consistent dosing is important. The client should be taught to consume a normal amount of sodium, not to cut down on sodium, because a low sodium level can lead to an increase in the lithium level, leading in turn to toxicity. Periodic follow-up appointments are important for monitoring of the drug level and of kidney and thyroid function, which may be affected by lithium therapy.

Louise tells the nurse that she will try the deep-breathing exercises but asks whether there is anything else that she can try to help her feel calmer. The nurse reviews several stress-reducing strategies with Louise. Which of these statements by Louise indicate a good understanding of stress-reduction techniques? Select all that apply. 1. "I'll start going to bed 30 minutes earlier." 2. "I'll limit my coffee to one cup in the morning." 3. "I'll go to the gym at least three times a week after work." 4. "I'll exercise just before bedtime to help improve my sleep." 5. "A cup of hot tea will help me relax in the evening." 6. "During my break at work, I can find a quiet place and focus on feeling calmer."

1. "I'll start going to bed 30 minutes earlier." 2. "I'll limit my coffee to one cup in the morning." 3. "I'll go to the gym at least three times a week after work." 6. "During my break at work, I can find a quiet place and focus on feeling calmer." Rationale People who are stressed are often fatigued; for this reason, going to bed 30 to 60 minutes earlier each night may be helpful. Reducing or even eliminating caffeine can help a person feel more relaxed, and both tea and coffee contain caffeine. Exercise can help reduce stress, but it is best to exercise at least 3 hours before going to bed. Exercising for at least 30 minutes three or more times a week is recommended. Meditation takes practice, but it can help produce a relaxation response by quieting the sympathetic nervous system.

A few weeks later, while under the care of a hospice program, Isabel dies peacefully at home. Her parents and her children, who have been at her side, are understandably upset. Which statements by the hospice nurse are appropriate at this time? Select all that apply. 1. "It's OK to cry." 2. "Everything will be fine." 3. "I'll be here if you want to talk." 4. "Don't cry. She wouldn't want that." 5. "You need to be strong for your little brother." 6. "Let me know if I can make any phone calls for you."

1. "It's OK to cry." 3. "I'll be here if you want to talk." 6. "Let me know if I can make any phone calls for you." Rationale The nurse's statements should not minimize the family members' loss. The nurse must avoid trite statements such as "Everything will be fine," "Don't cry," and "You need to be strong." These statements are actually barriers to communication and do not demonstrate care and concern. The nurse should offer supportive statements, acknowledge the family's feelings, be ready to listen, remain present, and offer to help as needed.

The next day, the newborn's blood type comes back as A-positive. Annie is type B-negative. The obstetrician prescribes an intramuscular dose of Rho(D) immunoglobulin (RhoGAM) for Annie. The nurse explains the purpose of the RhoGAM, and prepares the injection. Which statement by Annie reflects a need for further education? 1. "My baby will need a dose of this medication, too." 2. "My husband doesn't need to have a dose of this medication." 3. "This shot will prevent a reaction in my body from the blood of my baby." 4. "This shot will make it safer for my future babies if they have a positive blood type."

1. "My baby will need a dose of this medication, too." Rationale Rho(D) immunoglobulin (RhoGAM) is given within 72 hours of delivery to prevent antibody sensitization in an Rh-negative woman who has given birth to an Rh-positive infant, in whom fetomaternal transfusion may have occurred. The immune globulin promotes the destruction of any fetal Rh-positive cells that may have entered the mother's bloodstream before her body has had a chance to form antibodies against them. As a result, future pregnancies with Rh-positive infants will not be at risk for hemolysis. Only the mother receives the injection.

Brenda hears a few minutes of taped report from a new graduate nurse about a client who is scheduled for a colectomy today. Which statements by the new nurse indicate that the nurse needs a review of giving hands-off report? Select all that apply. 1. "She can be sort of demanding at times." 2. "She had pain medication, with good results." 3. "Her bowel sounds are hypoactive in all four quadrants." 4. "She had trouble getting to sleep, but I gave her a sleeping pill at 0100 and after that she slept for 5 hours." 5. "The preoperative checklist is completed except for administration of the preop medication, which is on call."

1. "She can be sort of demanding at times." 2. "She had pain medication, with good results." Rationale It is important to conduct oneself professionally when giving report about clients. The nurse should provide objective measurements or observations about the client, not use critical comments or judgmental language such as "demanding" or "difficult." The nurse should also provide evaluation of the results of nursing or medical measures in specific, objective terms and avoid the use of vague terms such as "good" or "poor," which do not provide sufficient information about the client.

The nurse is assessing Mrs. Valenti's nutritional status. Which statements by Mrs. Valenti indicate a risk for malnutrition? Select all that apply. 1. "Sometimes I have to make myself eat." 2. "My weight stays about the same each week." 3. "Food just doesn't taste the same as it used to." 4. "I have to wear my dentures to chew my food." 5. "Sometimes I have trouble swallowing my food." 6. "I try to eat fruits and vegetables with each meal."

1. "Sometimes I have to make myself eat." 3. "Food just doesn't taste the same as it used to." 5. "Sometimes I have trouble swallowing my food." Rationale Several factors - including dysphagia, decreased enjoyment of food because of a diminished sense of taste, and a lower motivation to eat - may increase the risk of malnutrition in an older adult. Many older adults require dentures to eat, but this is only a problem if they are ill fitting. A stable weight and consumption of several servings of fruits and vegetables every day are signs of good nutrition.

The nurse is talking to a client in the mental health unit. The client says, "I'm really angry with my boyfriend about the things he says to me. Women always get put down, as if we don't matter or have anything important to offer." Which response is the most appropriate one for the nurse to make? 1. "Tell me how you feel as a woman." 2. "I know how you feel. I see that happening with some of my friends." 3. "Yes, it's sad that women are treated that way. I guess we need to deal with it." 4. "Many women's groups are developing ways to deal with this. I'll give you the names and contact numbers of some of these groups before you're discharged from the hospital."

1. "Tell me how you feel as a woman." Rationale Focusing helps a client expand on a topic of importance. It also helps the client become more specific, move from vagueness to clarity, and concentrate on reality. The nurse should focus on the client's verbalization of concern. Agreeing with the client and avoiding the issue does not address the client's concern. Although the client may need to be provided with referrals to self-help or support groups before discharge, offering the names and contact numbers of women's groups is not the most appropriate response because it does not address the client's concern at the current time.

Suicide precautions are enacted for Joseph, and the nurse assigned to care for Joseph sits down to talk with him. During the conversation Joseph states, "I don't want to live if I can't see my son. He's the only thing that matters to me." How should the nurse respond to Joseph? 1. "Tell me more about how important your son is to you." 2. "Do you have other family members whom you enjoy spending time with?" 3. "I'm concerned about you, Joseph. You need to look for other activities to occupy your free time." 4. "I understand what you mean. I have a daughter, and I always look forward to seeing her when I get home from work."

1. "Tell me more about how important your son is to you." Rationale The correct option focuses on Joseph's thoughts and feelings and encourages Joseph to talk about them. It also indicates that the nurse is listening to the client. The remaining statements are nontherapeutic, focus on other issues, and avoid the client's concern.

Louise reads an article about herbal therapies for stress relief and decides that she wants to try drinking tea made with kava. She calls the company nurse to ask about using kava. Which instructions should the nurse provide? Select all that apply. 1. "You shouldn't use kava if you think you might be pregnant." 2. "Herbal products are safe to use, because they aren't really medications." 3. "This herb helps some people feel more relaxed and may help you sleep." 4. "It's safe to drink a small glass of wine at night with this tea right before bedtime." 5. "If you drink this tea long enough, you may notice a yellow discoloration of your skin.

1. "You shouldn't use kava if you think you might be pregnant." 3. "This herb helps some people feel more relaxed and may help you sleep." 5. "If you drink this tea long enough, you may notice a yellow discoloration of your skin Rationale Kava is commonly used to relieve anxiety and stress and to promote sleep. It may cause a temporary yellow discoloration of the skin, and it should not be taken with alcohol or psychoactive drugs or by women who are pregnant or breastfeeding. Even though kava is an herbal product, those who use it must be aware of potential side effects and contraindications.

The nurse is monitoring a Chinese-American client who is dying of gastric cancer. The nurse notes that the client's husband and two teenage children visit the client frequently but do not display affection toward the client. How should the nurse interpret this behavior? 1. A cultural norm 2. A sign of abnormal grieving 3. An indication of severe depression 4. An indication of acceptance of the impending loss

1. A cultural norm Rationale In Chinese-American culture, emotions— which are seen to interfere with self-control and considered weaknesses—are expressed openly only in very private circumstances. The behavior displayed by the client's husband and children is a cultural norm, not an indication of severe depression or abnormal grieving or a sign of acceptance of the family's impending loss.

Dr. Famm tells Lynn Ann that a biopsy of the pancreatic mass should be performed. After discussing this recommendation with Dianne, Lynn Ann decides that she would like a second opinion about the biopsy. She calls the nurse at Dr. Famm's office to discuss her decision. Which response by the nurse is appropriate? 1. A second opinion may be helpful in helping Lynn Ann make her decision. 2. Time is of the essence, and Lynn Ann should not waste time getting a second opinion. 3. A second opinion is really not necessary because Dr. Famm is one of the best health care providers for this type of problem. 4. Most people think about getting a second opinion but don't end up doing so because it takes a while to get an appointment with another health care providers

1. A second opinion may be helpful in helping Lynn Ann make her decision. Rationale The client has a right to make decisions about his or her plan of care before and during the course of treatment, to refuse a recommended treatment or plan of care, and to be informed of the consequences of such action. It is the client's right to request and receive a second opinion from another health care providers. Telling the client that time is the essence or that getting a second opinion is not really necessary is inappropriate and can induce fear in the client. The nurse should not make generalized statements such as telling the client that it takes too long to get an appointment with another health care providers.

Which action should the nurse implement first to treat the dehydration? 1. Administering oral Pedialyte 2. Instituting NPO (nothing-by-mouth) status 3. Encouraging Mrs.Valenti to drink sips of water 4. Starting an intravenous (IV) line and administer IV fluids

1. Administering oral Pedialyte Rationale Oral hydration is the first approach to the treatment of dehydration if the client is able to ingest fluids. Sport drinks, though high in sugar, are often recommended over tap water because are easily absorbed by the stomach, are generally palatable to clients, and will more quickly correct the dehydration. Pedialyte and other commercial fluid and electrolyte solutions are also available. The administration of IV fluids is a last-resort approach. There is no reason to maintain Mrs.Valenti on NPO status; in fact, this could worsen the dehydration.

The husband of a client who abuses alcohol tells a nurse at the mental health clinic that he is having a difficult time coping with his wife's behavior and that he is unsure how to deal with it. Which support group does the nurse suggest to the husband to help him deal with these issues? 1. Al-Anon 2. Narcotics Anonymous 3. Alcoholics Anonymous 4. Adult Children of Alcoholics

1. Al-Anon Rationale Al-Anon is a support for spouses and friends of individuals with alcoholism. Narcotics Anonymous is a support group for individuals addicted to narcotics (opioids). Alcoholics Anonymous is a support group for recovering alcoholics. Adult Children of Alcoholics is a support group for adults who were reared in alcoholic homes.

During a discussion with the nurse, Carl's wife says that she is supportive of Carl. She asks the nurse about obtaining help for her two sons, who believe that they were the cause of their father's drinking. Which support group should the nurse suggest for the boys? 1. Alateen 2. Al-Anon, with their mother 3. Adult Children of Alcoholics 4. Alcoholics Anonymous, with their father

1. Alateen Rationale Alateen is a support group for teens (children older than 10 years) with alcoholic parents. Similar to Al-Anon, the group helps eliminate feelings of guilt as the cause of the parent's drinking and restore feelings of self-worth. Al-Anon is a support group for spouses and friends of individuals with alcoholism. Adult Children of Alcoholics is a support group for adults who were reared in alcoholic homes. Alcoholics Anonymous is a support group for recovering alcoholics.

A client is admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. After the clinical intake assessment, the nurse observes that the client is repetitively wiping the furniture in her room with a facecloth and warm water. Which action should the nurse take initially? 1. Allow the client to perform the repetitive act 2. Stop the client from performing the repetitive act 3. Help the client wipe the furniture while talking to her about her repetitive act 4. Tell the client that it is not necessary to repetitively wipe the furniture because it has been thoroughly disinfected by the housekeeping staff

1. Allow the client to perform the repetitive act Rationale Initially the nurse should not interfere with the repetitive act, as long as the act is not harmful, and the nurse should never ridicule the client's behavior. The client is performing the repetitive act to keep anxiety at a tolerable level. Also, the nurse should not attempt to argue with the client about the repetitive behavior, attempt to reason with the client and persuade him or her to stop the behavior, or reinforce the ritual by focusing attention on it and talking about it a great deal. With time, the nurse can begin to set limits on the client's behavior to modify the behavior.

Oral contraceptive therapy has been prescribed for a client with a history of seizures who is taking phenytoin. Which information should the nurse provide to the client after reviewing the new prescription? 1. An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives. 2. An increased dosage of the phenytoin must be prescribed because phenytoin reduces the effectiveness of the oral contraceptive. 3. The primary care health care provider will need to increase the dosage of the phenytoin. 4. The effect of the phenytoin will be magnified while the client is taking the oral contraceptive

1. An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives. Rationale: Phenytoin is an anticonvulsant that reduces the effectiveness of oral contraceptives. When a client is taking a medication that diminishes the effectiveness of oral contraceptives, an increased dosage of the oral contraceptive may be required. An increased dosage of the phenytoin would not be necessary; additionally, this could be harmful to the client and lead to phenytoin toxicity. The effect of the phenytoin is not magnified while the client is taking the oral contraceptive.

At 3 a.m., a nurse is making her rounds. She finds a client with Alzheimer's disease climbing over the side rails of his bed. The nurse rushes to the client and assists him back into bed. Which action should the nurse take first to ensure client safety? 1. Asking a unlicensed assistive personnel (UAP) to stay with the client 2. Calling the client's health care provider for a prescription for a safety device 3. Checking for a prescription for a sedative and administering the sedative 4. Asking another nurse to obtain a safety device from the supply closet so that the client may be restrained

1. Asking a unlicensed assistive personnel (UAP) to stay with the client Rationale Safety devices (restraints) are used when other measures have failed to keep the client from engaging in behavior that might cause injury. The least restrictive method of ensuring client safety should be employed before Safety devices (restraints) are applied to a client. Therefore the nurse would most appropriately ask the UAP to stay with the client. Restraining a client or obtaining a prescription for a Safety devices (restraints) are not the best first actions. Administering a sedative is not a method of Safety devices (restraints) and would not be the best action to take.

A 16-year-old girl arrives at the women's health center and tells the nurse that she thinks she is pregnant. The nurse obtains subjective data from the client and informs her about the laboratory procedures used to test for pregnancy. Which action should the nurse take in obtaining informed consent to treat the client? 1. Asking the 16-year-old girl to sign the informed consent 2. Asking the 16-year-old girl for permission to call one of her parents 3. Giving the 16-year-old girl permission forms to take home for her parents to sign 4. Telling the 16-year-old girl that her boyfriend will need to provide consent for her pregnancy test

1. Asking the 16-year-old girl to sign the informed consent Rationale A minor is a client under the age of legality (usually 18 years) as defined by state statute. Parental or guardian consent should be obtained before treatment is initiated for a minor except in the case of an emergency, in situations in which the consent of the minor is sufficient (e.g., treatment related to substance abuse or a sexually transmitted infection, testing for HIV and AIDS, birth control services, pregnancy, or psychiatric services, or if a court order or other legal authorization has been obtained). Asking anyone other than the client to sign the informed consent would be incorrect.

After 2 days Mrs. Valenti is feeling better, and the discharge planner begins arranging for her to be sent back to the residential home. The nurse gives report to the nurse at the home, and Mrs. Valenti arrives there late in the afternoon. Which measures should the nurse at the residential home implement to prevent recurrence of dehydration? Select all that apply. 1. Assessing urine output 2. Offering fluids with meals only 3. Offering fluids other than water, such as coffee and iced tea 4. Monitoring her pulse and respiratory rates, and blood pressure 5. Find out what fluids she prefers besides water and offer those

1. Assessing urine output 4. Monitoring her pulse and respiratory rates, and blood pressure 5. Find out what fluids she prefers besides water and offer those Rationale Measures to help prevent dehydration in older adults include monitoring pulse rate and respiration for increases and the blood pressure for a decrease, all of which may indicate dehydration. In addition, urine output should be monitored, because decreased urine output may indicate dehydration. Fluids should be offered every hour, including with the evening snack, and the nurse should find out what fluids are preferred and offer those, with the exception of drinks containing caffeine (e.g., coffee and iced tea), which acts as a diuretic.

Lisa, the case manager, contacts the family of the client in room 5116, Mr. Flint. He is scheduled for one more infusion of chemotherapy this morning and hopes to go home later today. His wife will need to give him injections when he goes home. At what time do discharge planning and teaching for Mr. Flint begin? 1. At the time of admission 2. Once he begins to feel better 3. The day of Mr. Flint's discharge 4. At the midpoint of the hospitalization

1. At the time of admission Rationale Discharge planning is a interprofessional process that ensures that the client will receive continuity of care after leaving the hospital or other health care facility. It is essential that discharge planning be started at the time of the client's admission to the hospital so that all the aspects of care may be arranged efficiently. For this reason, the other options are incorrect.

The nurse is providing preoperative instructions for a day surgery scheduled in 1 week to a client who speaks Spanish. Which action is the best way for the nurse to ensure that the client understands the instructions? 1. Calling for a hospital-designated interpreter to communicate with the client 2. Asking a family member who speaks English and Spanish to translate for the client 3. Relying on the use of hand signals and demonstrations to teach the client about the preoperative procedures 4. Writing the instructions on a piece of paper so that an English- and Spanish-speaking neighbor will be able to translate them for the client

1. Calling for a hospital-designated interpreter to communicate with the client Rationale Arranging for a hospital-designated interpreter is the best practice for communication with a client who speaks a different language. This action will ensure that the client clearly understands the preoperative instructions. Asking a family member or a neighbor is not an appropriate action, because the nurse cannot be sure that the client will receive the correct information. Also, asking a family member or neighbor to translate violates the client's privacy. Likewise, the use of hand signals and demonstrations will not ensure that the client understands the instructions.

A nurse manager is reviewing ethical principles with the nursing staff. Which example does the nurse manager provide to explain the concept of fidelity? 1. Keeping a promise made to the client 2. Supporting the client's right to informed consent 3. Determining the order in which clients are cared for 4. Avoiding harm to the client in the performance of nursing care

1. Keeping a promise made to the client Ethical principles are codes that direct or govern nursing actions. Fidelity is the duty to do what one has promised. Autonomy refers to respect for an individual's right to self-determination. Justice is the equitable distribution of potential benefits and tasks and determining the order in which clients should be cared for. Nonmaleficence refers to the obligation to do or cause no harm to another.

A hospital nurse transcribing a health care providers prescriptions for a client is unable to read a prescribed dosage because the health care providers handwriting is unclear. Which action should the nurse take? 1. Calling the health care provider 2. Asking the client about the usual dosage of the medication 3. Calling the pharmacy to ask about the usual dosage of the prescribed medication 4. Contacting the nursing supervisor for clarification of the health care provider's prescriptions

1. Calling the health care provider Rationale It is the nurse's responsibility to follow the health care provider's prescriptions unless the nurse believes that a prescription is in error or would cause harm to the client. If the nurse implements a prescription that is inaccurate and causes harm to the client, the nurse is responsible. If a health care provider's prescription is illegible, it is the nurse's responsibility to clarify the prescription with the health care provider. The nurse would contact the nursing supervisor if he or she were unable to make contact with the health care provider for any reason, but, because of the unclear handwriting, asking the nursing supervisor for clarification of the health care provider's prescription is not the best action; the health care provider must make the prescription clear. Calling the pharmacy to ask about the usual dosage is incorrect, for the same reason; the health care provider must make the prescription clear. Asking the client about the usual dosage is incorrect, in part because the health care provider may have changed the dosage.

Janice brings Christyna to the emergency department to be examined and tells the nurse that she suspects child abuse. The nurse escorts Janice and Christyna to a private examining room. Which action should the nurse perform next? 1. Checking Christyna's bruises 2. Calling child protective services 3. Asking Christyna questions about what caused the bruises 4. Obtaining information about how to contact Christyna's parents

1. Checking Christyna's bruises Rationale Nursing assessment of actual or potential child abuse begins with an assessment of the physical injuries. Once the physical injuries have been assessed and treated, the nurse obtains subjective data related to the abuse. However, Christyna may be fearful and reluctant to answer questions. When child abuse is suspected, the nurse must also report it to the appropriate authorities (child protective services) in accordance with state and agency guidelines, but this is not the priority action in this situation. Removing the child from the unsafe environment is also a priority. The nurse will most likely need to contact Christyna's parents, but the child's physical injuries must be attended to first.

A nurse is preparing to apply erythromycin ophthalmic ointment to a newborn's eyes. Which action should the nurse plan to take? 1. Cleansing the infant's eyes before applying the ointment 2. Applying the ointment to the upper conjunctival sac of each eye 3. Rinsing the excess ointment from the eye using normal saline solution 4. Applying the ointment from the outer canthus to the inner canthus of the eye

1. Cleansing the infant's eyes before applying the ointment Rationale The infant's eyes are cleansed before the administration of eye ointment. The ointment is placed in the lower conjunctival sac of each eye and deposited from the inner canthus to the outer canthus. The ointment is not rinsed from the eye, although it may be wiped from the outer eye area after 1 minute.

The nurse goes to check on Margaret and finds her crying. Margaret says, "I don't know what to do. My doctor has just told me that I have hepatitis, and I may have given it to my family, but I don't want them to know that I have this disease! Please don't tell them — it's none of their business." Which actions by the nurse are ethically correct? Select all that apply. 1. Consulting the hospital's ethics committee. 2. Documenting what the client has said in the medical record. 3. Telling Margaret, "If you don't tell your family, we will have to do it." 4. Telling her, "Margaret, I won't tell your family, but let's discuss what could happen if you don't tell them." 5. Promising not to tell Margaret's son but, when he visits, telling him what Margaret has said

1. Consulting the hospital's ethics committee. 2. Documenting what the client has said in the medical record. 4. Telling her, "Margaret, I won't tell your family, but let's discuss what could happen if you don't tell them." Rationale In this situation, the nurse is challenged to balance the client's wish for privacy and confidentiality against the safety of her family members. Telling her son after promising not to violates the ethical standard of fidelity (keeping promises). Threatening to tell her family violates the ethical standard of beneficence. Offering to discuss the situation with her is important. Though it is also important to document her statements, the nurse should go beyond that and also consult the hospital's ethics committee for assistance with this situation.

A nurse is caring for a client who is scheduled for surgery at 11 a.m. A member of the operating room staff calls the nurse at 9:30 a.m. and informs her that the client must be premedicated and transported to the operating room by 10 a.m. The nurse immediately administers the sedative medications as prescribed. At 10 a.m., as the nurse is getting the client ready for transport, she notes that the informed consent for surgery has not been signed by the client. Which action should the nurse take? 1. Contacting the client's surgeon 2. Having the client sign the informed consent 3. Calling the operating room and cancel the surgery 4. Asking the client's significant other to sign the informed consent

1. Contacting the client's surgeon Rationale Informed consent indicates the client's agreement to participate in the treatment or surgical procedure. Legally, the client must be mentally and emotionally competent to give consent. A client who has been administered sedative medications or any other medication that might affect his or her ability to make rational decisions should not be asked to sign a consent form. It is the health care provider's responsibility to obtain informed consent from the client or legal guardian; therefore the nurse should contact the surgeon. It is inappropriate and illegal to ask a significant other to sign an informed consent for a client who is legally competent to do so. It is not within the realm of a nurse's role to cancel surgery.

With her parents beside her, Isabel carefully explains her situation to her children and outlines the plans for surgery and chemotherapy over the next few months. The children listen, in tears, and ask questions about what Isabel is facing. Later in the day, Regina starts to talk about looking forward to next summer's trip to Florida, a trip they have taken every year. Isabel says nothing about it but worries that her daughter may not fully understand her situation. Which stage of grief is Regina exhibiting at this time? 1. Denial 2. Bargaining 3. Depression 4. Acceptance

1. Denial Rationale According to Elisabeth Kübler-Ross, a person who is undergoing a significant loss — the a person who is dying or people close to a dying person — will experience five stages of grief. The first of these stages is the denial stage, during which the person acts as if nothing has changed. The subsequent stages are anger, bargaining, depression, and finally, acceptance.

A nurse has been asked to become a member of a community group that will help ensure the community's disaster preparedness. At the first meeting, the group reviews FEMA's four disaster management phases. The group decides to focus on the mitigation phase. The group should take which action? 1. Determining the community's risk for a disaster 2. Identifying plans for rescue, evacuation, and care of disaster victims 3. Identifying concerns such as safety and the physical and mental health of both the victims and the members of the disaster response team 4. Determining actions that will prevent debilitating effects and those that will restore personal, economic, and environmental health and stability to the community

1. Determining the community's risk for a disaster Rationale FEMA, the Federal Emergency Management Agency, classifies disaster management into four phases: mitigation, preparedness, response, and recovery. Mitigation involves actions or measures that can prevent the occurrence of a disaster or reduce a disaster's damaging effects. In this phase, the group determines hazards and risks for a disaster in the community. This phase also involves identifying the resources available for the care of infants, older clients, the disabled, and those with chronic health problems. The preparedness phase involves the development of plans for the rescue, evacuation, and care of disaster victims. In the response phase, disaster planning services, including actions taken to save lives and prevent further damage, are put into action. Primary concerns in this phase include the safety and physical and mental health of both the victims and the members of the disaster response team. The recovery phase involves work to prevent debilitating effects and restore personal, economic, and environmental health and stability to the community.

A nurse checking the vital signs of an older client notes that the client's resting heart rate is 60 beats per minute. Which action should the nurse take on the basis of this finding? 1. Document the finding. 2. Recheck the heart rate in 30 minutes. 3. Assess the client for signs of infection. 4. Contact the health care provider to report the heart rate

1. Document the finding. Rationale: In an adult client, a heart rate slower than 60 beats per minute indicates bradycardia and a heart rate faster than 100 beats per minute indicates tachycardia. The heart rate decreases with age, so a rate of 60 beats per minute is within the normal parameters. Therefore, because the rate presented in the question constitutes a normal finding, the nurse would document the heart rate. On the basis of the data in the question, the other options are unnecessary.

A nurse performing an initial assessment of a newborn who is awake and alert counts the infant's apical heart rate and obtains a rate of 130 beats/min. Based on this finding, which action should the nurse take? 1. Documenting the finding 2. Contacting the pediatrician 3. Reassessing the heart rate in 5 minutes 4. Stimulating the infant and reassessing the heart rate

1. Documenting the finding Rationale The normal heart rate of a newborn infant is 100 to 160 beats/min. Therefore the nurse would document the finding. The other options are incorrect and unnecessary.

A nurse is watching a unlicensed assistive personnel (UAP) wash her hands. The nurse should intervene if the UAP performs which action? 1. Dries from the forearms down to the fingertips 2. Uses a clean, dry paper towel to turn off the water faucet 3. Uses plenty of lather and friction and scrubbing for 15 seconds 4. Keeps the hands and forearms lower than the elbows while washing

1. Dries from the forearms down to the fingertips Rationale When washing the hands, the nurse must avoid splashing water on his or her uniform. The hands and forearms are kept lower than the elbows. Abundant lather and plenty of friction are applied for at least 10 to 15 seconds, after which the fingers are interlaced and the palms and back of the hands rubbed in a circular motion at least five times each. The hands are dried from the cleanest area (fingertips) to the least clean (forearms). A clean, dry paper towel is used to turn off the faucet, and the nurse avoids touching the faucet handles with the hands.

The nurse is providing the family of a client with Alzheimer's disease with guidelines for caring for the client at home. Which statement should the nurse tell the family? 1. Encourage physical activity during the day 2. Dress the client to prevent client frustration 3. Restrain the client at night if the client tends to wander 4. Feed the client to ensure that the client receives adequate nutrition

1. Encourage physical activity during the day Rationale Physical activity during the day should be encouraged for the client with Alzheimer's disease. Exercise will help the client sleep at night and reduce the likelihood of nighttime wandering. If the client wanders, safety measures (e.g., placing complex locks on doors or placing locks at the tops of doors) may be instituted. The client should perform all tasks within the capacity of his or her condition. This will help maintain the client's self-esteem and minimize further regression. Providing step-by-step instructions whenever necessary will help the client focus on small pieces of information and allows the client to perform at an optimal level. The client should not be restrained. Restraints can cause the client to become more terrified and agitated, until he or she is exhausted to a dangerous degree.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of dissociative amnesia. Which intervention should the nurse include in the plan? 1. Encouraging the client to perform self-care activities 2. Encouraging the use of dissociation to cope with stress and anxiety 3. Orienting the client and frequently reminding him of events in his past 4. Making all decisions for the client to prevent him from feeling overwhelmed

1. Encouraging the client to perform self-care activities Rationale Dissociative amnesia refers to the client's inability to integrate memories. The memory loss serves the purpose of preventing anxiety. The client should be encouraged to do things for himself and to make decisions about routine tasks. This will enhance the client's self-esteem by reducing his sense of powerlessness. The nurse would not encourage the use of dissociation. Rather, the nurse would help the client see the consequences of using dissociation to cope with stress. Although the nurse would orient the client, flooding the client with information on past events is inappropriate. The nurse should encourage the client to make some decisions. This will increase the client's insight and help the client understand his own role in choosing behaviors.

Which choices are therapeutic nursing actions in dealing with the husband of a client who is dying? Select all that apply. 1. Encouraging the husband to express his feelings and concerns 2. Making decisions for the husband to lessen his burden of grief 3. Determining how much the husband wishes to know about the care being provided to his wife 4. Refraining from demonstrating emotion over the client's terminal situation in the presence of the husband 5. Telling the husband the it will be easier to accept the loss if he avoids reminiscing and talking about his life with his wife

1. Encouraging the husband to express his feelings and concerns 3. Determining how much the husband wishes to know about the care being provided to his wife Rationale The nurse needs to assist the client, family, and significant others through the process of grief. The use of therapeutic communication techniques is important in promoting the process. It is important for the nurse to determine the needs of the family or significant other and how much information they wish to receive about the client's condition and the care being provided to their loved one. The nurse should also encourage reminiscing and the expression of feelings and concerns, which will help loved ones move through the grief process. The nurse should not make decisions for the family unless they specifically request that the nurse do so. Instead, the nurse should assist with the decision-making process if asked and avoid interjecting personal views or opinions. The nurse should acknowledge his or her own feelings. It is also acceptable for the nurse to express his or her own emotions with the family as appropriate.

The nurse continues to assess Christyna, watching her for clinical signs of emotional abuse and neglect. Which findings suggest that the child has been subjected to emotional abuse and neglect? Select all that apply. 1. Enuresis 2. Unusual fearfulness 3. Withdrawn behavior 4. Poor personal hygiene 5. Unclean or inappropriate dress

1. Enuresis 2. Unusual fearfulness 3. Withdrawn behavior Rationale Findings that suggest emotional abuse and neglect include eating or feeding disorders, enuresis, sleep disorders, and such observations as unusual fearfulness, withdrawn behavior, and antisocial behavior. Poor personal hygiene and unclean or inappropriate dress are suggestive of physical neglect.

The nurse is assigned to work with a client who has just been admitted to the mental health unit. Which action should the nurse plan to take in the orientation or introductory phase of the nurse-client relationship? 1. Establish a contract with the client 2. Increase the client's independence 3. Promote the use of constructive coping mechanisms 4. Refer and transfer the client to other sources of support

1. Establish a contract with the client Rationale The tasks of the orientation or introductory phase of the nurse-client relationship are to establish trust, acceptance, open communication, and formulate a mutual contract with the client. The contract begins with the introduction of the nurse and client, the exchange of names, and the explanation of roles. Promotion of the use of constructive coping mechanisms and increasing the client's independence are tasks of the working phase. Referring and transferring the client to other sources of support is a task of the termination or separation phase.

According to HIPAA, in which situations could a client's PHI be used or disclosed? Select all that apply. 1. For treatment purposes 2. For any type of research 3. For health care payment purposes 4. To administer health care benefits 5. To provide information to a family member at any time during the client's hospital stay 6. For learning purposes for medical and nursing students if the client provides permission to do so

1. For treatment purposes 3. For health care payment purposes 4. To administer health care benefits 6. For learning purposes for medical and nursing students if the client provides permission to do so Rationale The Health Insurance Portability and Accountability Act (HIPAA) describes how personal health information (PHI) may be used and how the client can obtain access to the information. The use or disclosure of PHI is allowed in some situations, among them health care payment purposes, health care operations purposes, treatment purposes, the provision of information about health care services, data aggregation to make health care benefit decisions, administration of health care benefits, research purposes in limited circumstances, and release to a family member or significant other in a medical emergency or to a personal representative appointed by the client or designated by law. PHI is not disclosed for learning purposes unless the client gives permission.

Which characteristics describe constructive coping mechanisms? Select all that apply. 1. It is a protective response. 2. It is an effort to relieve anxiety. 3. It may involve behaviors such as using relaxation techniques. 4. It involves repression of a painful experience into the unconscious. 5. It is a mechanism used by the individual to consciously confront a threat.

1. It is a protective response. 2. It is an effort to relieve anxiety. 3. It may involve behaviors such as using relaxation techniques. 5. It is a mechanism used by the individual to consciously confront a threat. Rationale A coping mechanism is any effort to adjust and relieve anxiety. Constructive coping mechanisms are protective responses that an individual uses to consciously confront a threat. Constructive coping mechanisms can include distractions such as reading, praying, meditation; relaxation techniques; or seeking social support. Destructive coping mechanisms involve repression into the unconscious and tend to be ineffective. Examples of destructive coping mechanisms include withdrawal from social contacts, poor dietary habits, smoking, and alcohol and drug abuse.

A client discussing family planning methods with the nurse tells the nurse that she uses the calendar method because her menstrual periods are regular. Which information about the reliability of this method should the nurse provide to the client? 1. It is unreliable. 2. It is extremely reliable if menstrual periods are regular. 3. If it has prevented pregnancy so far, it is a reliable method. 4. It is very reliable if the basal body temperature method is also used.

1. It is unreliable. Rationale The calendar method is based on the fact that ovulation occurs approximately 14 days before the onset of menses. It is unreliable because many factors, such as illness or stress, can affect the time of ovulation. In the basal body temperature method, the woman charts her temperature each morning before getting out of bed. The basal body temperature may decrease slightly before ovulation and then increase slightly with ovulation. This method, which is not reliable because errors are frequent, is often used along with other methods. Therefore the other options are incorrect.

Thomas, quite upset, begins to cry. He tells the nurse that he feels overwhelmed because of what his health care provider has told him and that he just doesn't know what to do or how he will manage without his foot. The nurse determines that Thomas is experiencing a situational crisis and which problem? 1. Lack of control 2. Inability to grieve 3. Lack of family support 4. Inability to think clearly

1. Lack of control Rationale Thomas is expressing concern about how he will manage without his foot and therefore the problem he is experiencing is a lack of control over the current situation. There is no indication in that question that Thomas is unable or unwilling to acknowledge or mourn his loss. Additionally, there is no information in the question that indicates that Thomas lacks family support or is unable to think clearly.

During the assessment, the nurse notices that Lian has tied a string around her left wrist. Lian explains that she applied the string and burned incense at home to help her wrist feel better. Which actions by the nurse are appropriate? Select all that apply. 1. Making sure that the string is not tied too tightly around Lian's wrist 2. Listening as Lian explains how the string and incense burning works 3. Asking Lian whether she thinks the string and incense burning have helped her condition 4. Telling Lian that physical therapy will be more successful than the string and incense burning 5. Suggesting that Lian remove the string because she is about to begin taking medication for her wrist

1. Making sure that the string is not tied too tightly around Lian's wrist 2. Listening as Lian explains how the string and incense burning works 3. Asking Lian whether she thinks the string and incense burning have helped her condition Rationale People of Asian descent often engage in self-treatment of various ailments, even when simultaneously seeking traditional medical care. The nurse must differentiate self-care practices that are potentially harmful, potentially beneficial, or even neutral. It is important for the nurse to ensure that the string is not tied too tightly, to listen to Lian's explanations, and to determine whether Lian believes that the treatment has been effective. It is not necessary to remove the string unless the string is tied too tightly and affecting circulation. It is inappropriate to tell Lian that physical therapy will be more successful than her cultural practice.

The nurse treats the lacerations and prepares to interview Angela to gather additional subjective data about her injuries and medical history. Which action on the part of the nurse is appropriate? 1. Moving Angela to a private room for the interview 2. Calling Angela's husband and asking him to be present for the interview 3. Asking another nurse to sit in and listen during the interview because Angela's injuries were the result of abuse 4. Calling the police department and requesting that an officer be present to hear what Angela has to report about the abuse

1. Moving Angela to a private room for the interview Rationale Confidentiality is a client's right to privacy regarding his or her health care information. The nurse is legally bound to protect the client from indiscriminate disclosure of health care information that may cause harm. Disclosure of confidential information exposes the nurse to liability for invasion of the client's privacy. The nurse would move the client to a private room for the interview so confidential information is not overheard by others. The nurse would not call the client's husband. Having the client's husband present might prevent the client from providing accurate information and could provoke additional conflict. The client's permission must be obtained before another nurse is asked to sit in and listen during the interview. Although cases of abuse must be reported, it is inappropriate to request that a police officer be present during the interview. These options are inappropriate.

A client in the inpatient mental health unit suddenly becomes violent, posing a threat to the safety of other clients and staff on the nursing unit. The nurse tries to use nonrestrictive interventions to deescalate the client's behavior, but these attempts are unsuccessful and the client's behavior escalates. Which action should the nurse take next? 1. Obtain assistance from the nursing staff and place the client in seclusion 2. Bring the client to his room and lock his door until hospital security arrives 3. Ask the client to sign a consent form for the use of restraints (safety devices) and seclusion 4. Call the client's psychiatrist and wait for a return call to obtain a prescription for restraints and seclusion

1. Obtain assistance from the nursing staff and place the client in seclusion Rationale Client consent and a psychiatrist's written prescription are normally needed for the use of restraints and seclusion. In an emergency, a nurse may place a client in restraints or seclusion and obtain a written or verbal prescription from the health care provider as soon as possible thereafter. Federal law also requires the consent of the client unless an emergency situation exists in which an immediate risk of harm to the client or others can be documented. In most situations, a violent client cannot be reasoned with and is unlikely to sign a consent form on request. Locking the client in his room is a form of false imprisonment and could be physically harmful to the client.

The home care nurse arrives at Louis's home for a daily visit. Laura tells the nurse that she is fatigued and needs help taking care of her husband. She tells the nurse that her daughter and son are her only family but notes that they work all day. Which suggestion by the nurse is most appropriate? 1. Obtaining a referral for hospice care 2. Trying to rest when Louis is resting 3. Hiring a nursing assistant to help provide personal care 4. Asking her daughter and son to take some time off from work

1. Obtaining a referral for hospice care Rationale Hospice care ensures that the needs of the client and family are the focus of any intervention. Hospice exists to provide support and care for persons in the last phases of incurable diseases so that they may live as fully and comfortably as possible. Hospice services are available 24 hours a day, 7 days a week, to provide help to clients and families in their homes. Staff and volunteers are available, and a multidisciplinary team approach provides holistic health care. Trying to take rest periods while Louis is resting might be helpful for Laura but may not always be possible. Hiring a nursing assistant is also possible, but it is not the most appropriate suggestion by the nurse, because it would be inappropriate to place the additional burden of having to hire someone on the wife. Although asking her daughter and son to take time off from work would be helpful, it is not the most realistic or reasonable solution.

A client with a history of panic disorder is brought to the emergency department complaining of dizziness, palpitations, and chest pain. The client states that he feels as if he is "going crazy." Which action should the nurse take first? 1. Performing a physical assessment 2. Calling the crisis intervention team 3. Asking the client what brought on the panic attack 4. Asking the unit secretary to obtain records of the client's previous hospitalizations

1. Performing a physical assessment Rationale Panic attacks are a distinctive feature of panic disorder. Symptoms include dizziness, faintness, choking, palpitations, trembling, nausea or abdominal distress, numbness, chest pain, and the fear of dying or going crazy. The symptoms of panic disorder mimic a variety of medical conditions, so the nurse would first perform a physical assessment of the client to help rule out a medical problem. Once the client's physical needs have been attended to, other needs may be addressed. The nurse would then ask the client about the precipitant of the attack and obtain records of the client's previous hospitalizations. The crisis team may or may not be needed for intervention.

After Louis has died, his family members gather around his bedside to pray and mourn. A little later, Laura asks the hospice nurse to call the funeral home and requests help in preparing her husband's body before the funeral home arrives. Which actions are appropriate components of postmortem care? Select all that apply. 1. Placing a small pillow under the head 2. Elevating the head of the bed to 45 degrees or higher 3. Gently pulling the eyelids over the eyes to close them 4. Removing Louis' dentures and placing them in a denture cup 5. Washing soiled body parts and placing an absorbent pad under the buttocks

1. Placing a small pillow under the head 3. Gently pulling the eyelids over the eyes to close them 5. Washing soiled body parts and placing an absorbent pad under the buttocks Rationale Postmortem care should be performed as soon as possible to prevent tissue damage, because the body goes through many physical changes after death. The head of the bed is elevated 30 degrees to prevent livor mortis of the face, and a small pillow is placed under the head. Dentures should be left in the mouth, because they give the face a more natural appearance. Closing the eyes helps convey a calm, natural appearance. At the time of death, the urinary and bowel sphincters may relax, resulting in the release of urine and feces, so the perineal area may need to be cleansed and an absorbent pad placed under the buttocks. The nurse should allow the family members to assist with these actions if they want to help.

The nurse identifies which characteristics as part of the case management approach to health care delivery? Select all that apply: 1. Provides an individualized plan of care for the client 2. Represents an interprofessional health care delivery system 3. Involves one nurse who supervises all other health care providers 4. A comprehensive approach that promotes quality and cost-effective care 5. Requires only a case manager to implement the care for all of the clients in the facility

1. Provides an individualized plan of care for the client 2. Represents an interprofessional health care delivery system 4. A comprehensive approach that promotes quality and cost-effective care Rationale Case management is an interprofessional approach to health care delivery in which available resources are used to promote quality, cost-effective, comprehensive care. It comprises assessment and development of a plan of care, coordination of all services, consultation, referral, and follow-up. A case manager coordinates the client's care from the point of admission and after discharge. The case manager initiates an individualized nursing plan of care as appropriate, assesses the client's needs for equipment such as oxygen or wound care supplies, and explores available resources to provide the client with such supplies. The case manager provides resources that will help the client maintain the greatest possible degree of independence and provides the client with information on discharge procedures and the plan of care. The case manager is not responsible for supervising other health care providers and does not implement care for all of the clients in the facility.

A client with a paranoid disorder refuses to eat because he believes that the food being served in the mental health unit is poisoned. Which response is an appropriate way for the nurse to defuse the client's delusional thoughts? 1. Providing the client with food items in sealed containers 2. Telling the client that he is safe now that he is in the hospital 3. Setting firm limits and telling the client that the food is not poisoned 4. Asking the client whether he would like to visit the hospital kitchen to watch the food being prepared

1. Providing the client with food items in sealed containers Rationale A client with a paranoid disorder fears that others will exploit, harm, or deceive him or her, to the point of endangering the client's life. Adequate nutrition may be a problem with such clients. A common distortion or delusion is that food is poisoned, and the client may not eat as a result. In this situation, special foods should be provided in sealed containers to minimize the suspicion of tampering. The client should be allowed to prepare his or her own food, if possible. Although the nurse should assure the client that he or she is safe, this action alone will not eliminate the client's delusional thoughts. Likewise, inviting the client to visit the hospital kitchen to watch how the food is prepared and setting firm limits about discussion of food being poisoned will not help eliminate the client's delusional thoughts.

The home care nurse making a visit to a client who is receiving hospice care understands that hospice care is intended to achieve certain outcomes. What are these outcomes? Select all that apply. 1. Relief of symptoms 2. Postponement of death 3. Hastening of disease remission 4. Facilitation of a peaceful death 5. Provision of the best possible quality of life

1. Relief of symptoms 4. Facilitation of a peaceful death 5. Provision of the best possible quality of life Rationale In hospice care, an interdisciplinary approach is used to assess and address the holistic needs of clients and families to ensure the best possible quality of life and a peaceful death. The holistic approach neither hastens nor postpones death, nor does it hasten remission of the disease; instead, it provides relief of symptoms.

The nurse teaches Louise deep-breathing exercises to help her relax and reduce stress. She tells Louise that she may perform these exercises while sitting at her desk and that she should perform them whenever she begins to feel stressed. Which observation by the nurse indicates that Louise is performing the breathing exercises correctly? 1. Louise breathes in through her nose, holds her breath for 10 seconds, and then breaths out through her nose. The nurse teaches Louise deep-breathing exercises to help her relax and reduce stress. She tells Louise that she may perform these exercises while sitting at her desk and that she should perform them whenever she begins to feel stressed. Which observation by the nurse indicates that Louise is performing the breathing exercises correctly? 1. Louise breathes in through her nose, holds her breath for 10 seconds, and then breaths out through her nose. 2. Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. 3. Louise breathes in through her nose, holds her breath for 15 seconds, and then breathes out quickly through her mouth. 4. Louise quickly breathes in through her mouth, holds her breath for 10 seconds, and then quickly breathes out quickly through her nose. 3. Louise breathes in through her nose, holds her breath for 15 seconds, and then breathes out quickly through her mouth. 4. Louise quickly breathes in through her mouth, holds her breath for 10 seconds, and then quickly breathes out quickly through her nose.

2. Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. Rationale To perform deep-breathing exercises, the client should shift to relaxed abdominal breathing. The client breathes in through the mouth, holds the breath for 3 seconds, and slowly breathes out through the nose. With every breath, the client should pay attention to the muscle sensations that accompany the expansion of the abdomen.

Madeleine expresses concern about her condition and tells that nurse that even though her daughters would be upset, she does not "want anything done if my heart stops." Which response by the nurse is appropriate? 1. Reporting Madeleine's request to her health care provider 2. Telling Madeleine that one of her daughters will need to agree with her request 3. Telling Madeleine that it is important to let the health care provider decide what to do if her heart should stop 4. Telling Madeleine that during the 48 hours after admission, decisions regarding life-support measures are made by the health care provider

1. Reporting Madeleine's request to her health care provider Rationale A mentally competent adult has the right to make his or her own choices with regard to life-support measures. An advance directive is a document that identifies medical treatments a client has chosen to omit or refuse if he or she becomes incapacitated and is unable to make health care decisions. On admission to a health care facility, the client is asked about the existence of an advance directive; if one exists, it is included as part of the medical record. If the client signs an advance directive at the time of admission, this must be documented in the client's medical record. The health care provider must be notified of the client's wishes with regard to health care decisions and the existence of an advance directive. Having the health care provider or Madeleine's daughter make decisions is incorrect. A mentally competent client has the right to make his or her own choices with regards to health care decisions.

A nurse employed in a medical unit arrives at work and is told that she will be floated to work in the delivery room for the day because several nurses who work there have called in sick with the flu. The nurse is reluctant to float because she has never worked in the delivery room. The nurse takes which actions? Select all that apply. 1. Reporting to the delivery room 2. Contacting the hospital legal department and reporting the situation 3. Refusing to go to the delivery room because she has never worked in that unit 4. Requesting that she be allowed go home because she is also experiencing symptoms of the flu 5. Informing the supervisor of her lack of experience in caring for clients in the delivery room 6. Reporting to the delivery room and asking that she spend the day reading the procedure manual for the unit

1. Reporting to the delivery room 5. Informing the supervisor of her lack of experience in caring for clients in the delivery room Rationale Nurses are sometimes required to float from areas in which they normally practice to other nursing units. A nurse in a floating situation must not assume responsibility beyond his or her level of experience or qualification; he or she should inform the supervisor of any lack of experience in caring for the type of clients found on the new nursing unit. It is inappropriate and unnecessary to report the situation to the legal department. Asking to go home and refusing to go to the delivery room are both inappropriate actions that constitute abandonment. Although the nurse should request and be given orientation to the new unit, spending the day reading the procedure manual for the unit does not help alleviate the staffing situation in the delivery room.

A nurse is gathering subjective data from a client being admitted to the hospital. The client tells the nurse that she has already prepared an advance directive. On the basis of this information, which action should the nurse take? 1. Requesting a copy of the advance directive and placing it in the client's medical record 2. Telling the client that the new hospitalization invalidates the existing advance directive 3. Telling the client that it is best to prepare a new advance directive with each hospitalization 4. Asking the hospital's client advocate representative to review the hospital's policies regarding advance directives with the client

1. Requesting a copy of the advance directive and placing it in the client's medical record Rationale On admission to a health care facility, the client should be asked about the existence of an advance directive. If one exists, it must be documented, integrated into the plan of care, and included in the client's medical record. It is incorrect to tell the client that a new hospitalization invalidates the existing advance directive or that it is best to prepare a new advance directive with each hospitalization. Asking the client advocate representative to receive the hospital's policies regarding advance directives with the client has no useful purpose or reason.

The next morning, a nursing student walks into the room and awakens Lynn Ann. The student greets her: "Hi, I'm here to take care of you today. I hope you don't mind." The student then begins to ask Lynn Ann questions about her past health history and surgery. Lynn Ann is tired, needs some medication for pain, and does not really want to talk at the moment. She tries to tell the student that another time would be better. The student insists, "No, I need to do this now to finish my paperwork" and continues to ask questions. Which client rights did the student violate in this situation? Select all that apply. 1. Right to privacy 2. Right to consent or refuse a treatment 3. Right to considerate and respectful care 4. Right to expect that the hospital will provide necessary health services 5. Right to know the names and roles of the persons who are involved in care

1. Right to privacy 3. Right to considerate and respectful care 5. Right to know the names and roles of the persons who are involved in care Rationale The client has the right to know the names and roles of the persons involved in her care. In this situation, the student did not introduce herself. The right to privacy also means that a person must be left alone and remain anonymous if he or she chooses. The student has ignored Lynn Ann's request to talk at another time, another violation of the client's right to considerate and respectful care. This situation does not illustrate violation of the right to consent to or refuse treatment, because the student did not administer a treatment. The right to expect the hospital to provide necessary health services is also not an issue in this situation.

A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. The nurse should tell the client: 1. To increase her daily intake of high-fiber foods 2. That this is a normal occurrence during pregnancy 3. To take the iron supplement every other day instead of every day 4. To start taking an oral laxative daily until the constipation resolves

1. To increase her daily intake of high-fiber foods Rationale Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.

The emergency department nurse completes the interview with Angela, and with Angela's permission calls a social worker to speak to her. While the social worker is talking with Angela, Angela's husband arrives at the emergency department and requests information about Angela's physical status. Which action should the nurse take initially? 1. Telling Angela's husband that this information cannot be shared with him 2. Dialing 911 and letting the police know that Angela's husband is at the emergency department 3. Telling Angela's husband that this information will be shared with him once the social worker has completed the interview 4. Calling the security department and requesting that a security guard be sent to the emergency department to ask Angela's husband to leave hospital property

1. Telling Angela's husband that this information cannot be shared with him Rationale Confidentiality is a client's right to privacy regarding his or her health care information. Health care information is not shared with others, including family members or friends of the client, without the client's consent. Therefore the nurse would initially tell Angela's husband that the information cannot be shared with him. Contacting the police is not appropriate unless the client has formally filed charges against her husband. Calling the security department and requesting that a security guard ask the client's husband to leave hospital property is not appropriate initially and could cause agitation in a person who is believed to have violent tendencies.

A nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. Which outcomes are desired and should be selected by the nurse for the plan of care? Select all that apply. 1. The client is not shivering. 2. The client's body temperature is 98° F (36.7°C). 3. The client's fingers and toes are cool to touch. 4. The client remains in a fetal position when in bed. 5. The client complains of coolness in the hands and feet only.

1. The client is not shivering. 2. The client's body temperature is 98° F (36.7°C). Rationale: Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include warm hands and feet; relaxed, uncurled body; body temperature higher than 97° F; absence of shivering; and no complaints of feeling cold.

The nurse calls Margaret's health care provider to report the fall, completes an incident report, and documents the occurrence in Margaret's medical record. Which statements should be included in Margaret's medical record? Select all that apply. 1. The client's health care provider was notified. 2. The client was found lying on the floor. 3. An incident report was placed in the medical record. 4. The client had no complaints of discomfort or pain after the fall. 5. The client was not instructed in the use of the call bed. 6. The client fell to the floor while ambulating from the bathroom back to bed.

1. The client's health care provider was notified. 2. The client was found lying on the floor. 4. The client had no complaints of discomfort or pain after the fall. Rationale An incident report is a tool used to identify risk situations and improve client care. The report form should not be copied or placed in the client's record, and no reference should be made to the report form in the client's record. The incident report is not a substitute for a complete entry in the client's record regarding the incident. The nurse documents only an objective description of what was actually observed and any follow-up care that was rendered.

A client has a prescription for an intravenous (IV) infusion of 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride at a rate of 100 mL/hr. The nurse obtains an infusion control device with which to administer the prescription and hangs the IV solution at 7 a.m. At 10 a.m. the nurse notes that 500 mL of solution has infused. The nurse assesses the client, checks the infusion rate, obtains a new infusion control device, and contacts the health care provider. The health care provider prescribes a decrease in the rate of infusion to 50 mL/hr and orders a serum potassium level. The potassium level is 3.5 mEq/L (3.5 mmol/L). Which information should be included on the incident report in regard to this event? Select all that apply. 1. The health care provider was contacted. 2. The serum potassium level at 10:30 a.m. was 3.5 mEq/L (3.5 mmol/L). 3. A total of 200 mL of IV fluid was accidentally infused into the client. 4. There was 500 mL of solution remaining in the IV bag at 10 a.m. 5. The infusion control device malfunctioned causing an excess amount of IV fluid to infuse into the client

1. The health care provider was contacted. 2. The serum potassium level at 10:30 a.m. was 3.5 mEq/L (3.5 mmol/L). 4. There was 500 mL of solution remaining in the IV bag at 10 a.m. Rationale The incident report should contain the client's name, age, and diagnosis. The report should also contain a factual description of the incident, any injuries sustained by those involved, and the outcome of the situation. The nurse avoids the use of subjective data and documents objective data. The nurse also avoids any implication that an accident occurred or that an error was made. The statement that 200 mL of IV fluid was accidentally infused into the client implies that an accident resulted from an error. Likewise, the statement that the infusion control device malfunctioned, causing an excess amount of IV fluid to be infused into the client, poses an implication. The remaining statements identify factual and observable data free of unwanted implications.

The nurse asks Madeleine whether she has discussed her health care decisions with her daughters. Madeleine tells the nurse that she plans to do so when they visit and that she would like to have a living will completed. Madeleine asks the nurse about the procedure for preparing a living will and wonders whether it can be done while she is in the hospital. How should the nurse respond? 1. The living will must be legally prepared. 2. Madeleine's health care provider may prepare the living will. 3. The hospital's client-advocate representative may prepare the living will. 4. Madeleine must have the living will prepared after she is discharged from the hospital.

1. The living will must be legally prepared Rationale An instructional living will is a document that instructs the health care provider to withhold or withdraw life-sustaining procedures when death is imminent. The document must be legally prepared, with appropriate witnessing of the client's signature. Requirements for the execution of living wills vary from state to state, but generally two witnesses, neither of whom may be a relative or health care provider, are needed when the client signs the document. The client's lawyer may prepare the document while the client is hospitalized.

Several family members are sitting at the hospital with a client who is dying of cancer of the bladder. The dying client's roommate is found waiting outside the room after visiting hours have ended. He tells the nurse that he wants to give his roommate's family privacy. Which action should the nurse take? 1. Transferring the roommate to another room 2. Reminding the dying client's family that visiting hours have ended 3. Informing the dying client's family that the client may have just two visitors at a time 4. Telling the roommate that he may return to his room and that the curtain will be drawn around the dying client's bed to provide privacy

1. Transferring the roommate to another room Rationale When a client is dying, it is important for the client and family members to acknowledge their sadness and say goodbye. The client and family should be given privacy to express their feelings and comfort one another. However, the nurse should also consider the needs of nearby clients, such as the client's roommate. Because the client is dying, it is inappropriate to prohibit family from visiting or to require them to leave once visiting hours have ended. In this situation, it would be best to transfer the roommate to another room. This action will meet the needs of both clients.

Before beginning the charge nurse report, Brenda steps into the staff nurses' report room to listen to a few minutes of the taped report. Brenda identifies which pieces of information as components of an effective hands-off report? Select all that apply: 1. Treatments 2. Priority needs 3. Discharge plan 4. Assessment findings 5. Biographical information

1. Treatments 2. Priority needs 3. Discharge plan 4. Assessment findings Rationale An effective hands-off report describes the health status of each client and tells the members of the oncoming shift what care and priorities the client will need. Simply reading documented or biographical information, which is easily obtained from the client's record, is not sufficient or necessary. Nurses must review significant information about the client to have a baseline for comparison during the next shift. Items in a hands-off report include background information, assessment, nursing diagnosis, priority needs, treatments, teaching plan, family information, and discharge plan.

What type of fire extinguisher will you use to extinguish the fire? 1. Type A 2. Type B 3. Type C 4. Any type is appropriate.

1. Type A Rationale The most commonly used fire extinguishers are categorized as type A, B, or C. Type A is used for ordinary combustibles (e.g., wood, cloth, paper, and many plastic items). Type B is used for flammable liquids (e.g., gasoline, oil, grease, tar, and oil-based paint). Type C is used for electrical equipment. Because this fire involves cloth and was ignited by a match used by the client, Type A extinguisher would be used.

A week later, Thomas calls his crisis counselor. "I feel totally useless and I know my wife would be better off without me," he says, "but I promised to call you, because I signed that contract." The counselor evaluates the lethality of Thomas' suicide plan. Which of these methods are considered higher risk, or "hard," methods of suicide? Select all that apply. 1. Using a gun 2. Ingesting pills 3. Slashing one's wrists 4. Jumping from a high place 5. Inhaling carbon monoxide

1. Using a gun 4. Jumping from a high place 5. Inhaling carbon monoxide Rationale Lethality is how quickly or easily a person would die if he or she used that method to attempt suicide. Higher-risk, or hard, methods include using a gun, jumping from a high place, inhaling carbon monoxide, hanging, and staging a car crash. Lower-risk, or "soft," methods include slashing one's wrists, ingesting pills, and inhaling natural gas.

The nurse assumes which responsibilities during the process of informed consent? Select all that apply. 1. Witnessing the client's signing of the consent form 2. Providing detailed information about the surgical procedure 3. Clarifying the information that was given to the client by the health care provider 4. Dispelling any misunderstandings that the client may have about the surgery 5. Witnessing the client's understanding of the information given about the surgery

1. Witnessing the client's signing of the consent form 3. Clarifying the information that was given to the client by the health care provider 4. Dispelling any misunderstandings that the client may have about the surgery Rationale The surgeon is responsible for getting the consent form signed, which must be done before sedation is given and the procedure is performed. The surgeon, not the nurse, is also responsible for providing detailed information about the procedure. The nurse's role is to clarify the information that has been given to the client, to dispel any misunderstandings about the procedure that the client may have, and to verify that the client has signed the form (witnessing the signature).

A terminally ill Hispanic client is surrounded at the bedside by his family members. Which behavior, a characteristic of Hispanic culture, should the nurse expect to encounter? 1. Women openly expressing their grief 2. Family members avoiding physical contact with the client 3. Family members formulating a schedule for one-on-one visits with the client 4. Family members formulating decisions about organ donation after the death of their family member

1. Women openly expressing their grief Rationale The Hispanic/Latino population comprises diverse cultural variations. Generally, however, the family makes decisions and may request that the diagnosis or prognosis be withheld from the client. Members of the extended family often are involved in end-of-life care however pregnant women may be prohibited from caring for the dying or attending funerals. Usually several family members are at the client's bedside, and vocal expressions of grief are acceptable and expected. Members of this culture often refuse procedures, such as organ donation and autopsy, that result in alterations to the body.

A nurse assessing a newborn's reflexes tests the Babinski (plantar) reflex. The nurse notes that when the reflex is elicited, the infant's toes hyperextend and the big toe dorsiflexes. How should the nurse document this finding? 1. Positive 2. Negative 3. Unresponsive 4. Depressed

1. Positive Rationale To elicit the Babinski reflex, the nurse begins at the heel of the foot and strokes upward along the lateral aspect of the sole of the foot, then moves the finger across the ball of the foot. In the characteristic response, all toes hyperextend and the big toe dorsiflexes. This is recorded as a positive sign. Although the response depends on general muscle tone and condition of the infant, an absence of response requires neurological evaluation. Therefore the other options are incorrect.

Brenda leaves the until at 1 pm to attend the quality improvement committee meeting. The committee is beginning an audit of medication errors, and the committee members have expressed a desire to use evidence-based practice as they study this problem. The committee members participate in a review of the evidence-based practice by completing a short exercise. Place the steps of evidence-based practice in order, with 1 as the first step and 6 as the last. 1. Evaluate the practice decisions or change 2. Ask a clinical question 3. Communicate your results 4. Apply or integrate evidence along with your clinical expertise, client preference, and values in making practical decision or change 5. Collect the best and most relevant evidence 6. Critically appraise the evidence you gather

1. Ask a clinical question 2.Collect the best and most relevant evidence 3.Critically appraise the evidence you gather 4.Apply or integrate evidence along with your clinical expertise, client preference, and values in making practical decision or change 5. Evaluate the practice decisions or change 6. Communicate your results

Mary has completed the orientation program and is now working on the client care unit with a nurse mentor, Libby. Together they review their assigned clients. The client in room 1104 has just been admitted. Which factors in this client's admission assessment and earlier history (click "Chart" below) indicate that she is at risk for falls? Select all that apply. 1. Her age 2. Disorientation 3. History of falls 4. Taking a "fluid pill" daily 5. History of hypothyroidism 6. Use of an assistive device (walker)

1. Her age 2. Disorientation 3. History of falls 4. Taking a "fluid pill" daily 6. Use of an assistive device (walker) Rationale Several factors can indicate that a person is at risk for falls. Generally people over age 60, those with an unsteady gait, and those who use assistive ambulatory devices are at risk. In addition, certain medications, such as diuretics, sedatives, and antihypertensives, increase the risk for falls because of the possibility of orthostatic hypotension. Thyroid-replacement medication does not put the client at risk for falls. People with confusion or disorientation are also at higher risk. A history of previous falls also increases risk greatly.

Before Lian leaves the office, the nurse stresses the importance of taking the NSAID, diclofenac, with food. The nurse provides several suggestions for snacks, but Lian states emphatically that one of them is "not possible." Which of these foods poses a problem for Lian? 1. Milk and crackers 2. Peanut butter and crackers 3. Carrot sticks with hummus 4. Banana and whole-wheat bread

1. Milk and Crackers Rationale Many Asian Americans have lactase deficiency, resulting in their being unable to tolerate fresh milk. A person of Asian ancestry who drinks milk may experience abdominal cramps, flatus, and diarrhea. Therefore, Lian may not be able to tolerate the milk in a snack of milk and crackers. The food items in the other options should be tolerated by the client.

Two weeks later, while at a friend's house, Carl takes a few sips of his friend's home-brewed wine, saying, "A little sip won't hurt me." Within 10 minutes, Carl begins to feel ill and asks his wife to take him home. Both Carl and his wife know that the disulfiram has caused these symptoms, but she does not say anything to him because he is so sick. Which symptoms is Carl likely experiencing at this time? Select all that apply. 1. Vomiting 2. Diarrhea 3. Sweating 4. Dry mouth 5. Facial pallor 6. Throbbing headache

1. Vomiting 3. Sweating 4. Throbbing Headache Rationale The adverse reaction that occurs when a person drinks alcohol while taking disulfiram, which within minutes to a half-hour after exposure to alcohol, includes facial flushing, sweating, throbbing headache, hypotension, nausea, vomiting, neck pain, tachycardia, and difficulty breathing.

A client with depression who is scheduled to undergo electroconvulsive therapy (ECT) for the first time says to the nurse, "I'm nervous about this treatment. Someone told me there's a risk of electrocution." The nurse should make which response to the client? 1. "Did your health care provider talk to you about this when you signed the informed consent?" 2. "Electrocution is not a risk associated with this treatment. Let's discuss your concerns." 3. "Electrocution can only happen during a thunderstorm. That's why we always check the weather report before starting a treatment." 4. "The side effects of this treatment are minimal, so don't worry. Your health care provider can talk to you about them in greater detail if you'd like."

2. "Electrocution is not a risk associated with this treatment. Let's discuss your concerns." Rationale Electroconvulsive therapy, or ECT, is a treatment in which a brief seizure is artificially induced in an anesthetized client by the passage of an electrical stimulus through electrodes applied to the client's head. The stimulus is generally adjusted to the lowest level of energy that will produce a seizure. While the client is being prepared for the treatment, it is important for the nurse to give the client the opportunity to express his or her feelings, including myths, about ECT. Clients may describe fears related to pain, dying of electrocution, suffering permanent memory loss, or experiencing impaired intellectual function. ECT is not associated with electrocution. Telling the client that electrocution can only happen during a thunderstorm is inaccurate and will instill additional fear in the client. Asking the client whether he or she has spoken with the health care provider regarding side effects avoids the client's concerns.

Mary is reviewing the medication prescriptions for her clients. Libby asks Mary about medication safety: "Tell me how to prevent medication errors." Which of Mary's responses, below, indicate that Mary understands measures for ensuring medication safety? Select all that apply. 1. "I should assess the client for allergies after giving the medications." 2. "I should use two client identifiers before giving medications." 3. "I should keep verbal and telephone prescriptions to a minimum." 4. "I won't give a medication that another nurse has drawn up in a syringe." 5. "I should use trade names instead of generic names for drugs to avoid confusion."

2. "I should use two client identifiers before giving medications." 3. "I should keep verbal and telephone prescriptions to a minimum." 4. "I won't give a medication that another nurse has drawn up in a syringe." Rationale Measures to prevent medication errors include using two client identifiers, avoiding the use of verbal and telephone prescriptions, and giving only medications that the nurse has drawn up or prepared him- or herself. Assessment for allergies should be done before medications are given. Generic names should be used to avoid the many sound-alike trade names of medications.

The lactation consultant nurse visits Annie to discuss breastfeeding and to observe as Annie breastfeeds her baby. The nurse discusses mastitis, its signs and symptoms, how to prevent it, and what to do if it occurs. Which statements by Annie reflect understanding of the information that is being presented? Select all that apply. 1. "It won't hurt to miss a few feedings if I'm too tired." 2. "I'll wash my nipples carefully before and after feedings." 3. "I should expect to have sore, cracked nipples when starting to breastfeed." 4. "If I get mastitis, I'll have to stop breastfeeding from that side until it is healed." 5. "If my nipples are sore, I should apply warm water compresses before breastfeeding." 6. "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours."

2. "I'll wash my nipples carefully before and after feedings." 5. "If my nipples are sore, I should apply warm water compresses before breastfeeding." 6. "If I get mastitis, I can continue to breastfeed and will make sure to empty the breast every 2 to 4 hours." Rationale Mastitis, a breast infection, may affect one or both breasts. It may be prevented with the use of proper technique and positioning for breastfeeding, preventing the development of cracked nipples, and emptying the breasts at regular intervals by means of breastfeeding, manual expression, or breast pumping. Cleanliness is also important. If mastitis occurs, breastfeeding is still recommended, because it is important to empty the breasts. Missed feedings can contribute to mastitis. The nipples may be sore (but not cracked) at the beginning of breastfeeding, and warm water compresses may be comforting before breastfeeding.

The health care provider performs a physical examination and gives Marilyn a prescription for an oral contraceptive. The nurse then provides information to Marilyn about how to take the medication. Which statement by Marilyn indicates a need for further information? 1. "If I miss a pill, I should take it as soon as I remember." 2. "Once I start taking the pill, I don't need to worry about getting pregnant." 3. "f I miss a period and think that I might be pregnant, I should stop taking the pill." 4. "I should use another contraceptive method during the first week of the first cycle of pills."

2. "Once I start taking the pill, I don't need to worry about getting pregnant." Rationale Because maintaining a constant hormone level is important for effectiveness, the woman using oral contraceptive must take a pill at the same time each day. Unless a woman begins the pills during the first 7 days of the menstrual cycle, she should use another contraceptive method during the first week of the first cycle until blood hormone levels are established. If the woman misses a pill, she should take it as soon she remembers. If the woman misses a period and thinks that she might be pregnant, she should stop taking the pill and have a pregnancy test immediately.

After 2 weeks, Isabel undergoes surgery to remove her ovaries and surrounding tissues. One week later, she visits her surgeon and gets the news that the cancer has spread to three lymph nodes in the area. "Not the best prognosis," she is told, "but we can still give it a good try." The nurse, helping Isabel get ready to leave, sees that she is sitting very still with her eyes closed. She tells the nurse, "I don't know how I'm going to get through this. I don't want to leave my children alone!" Which response to Isabel's statement is therapeutic? 1. "If I were you, I'd get a second opinion before doing anything." 2. "This must be a terrible time for you. Would you like to talk about it?" 3. "It's too early to be upset. You haven't even had any chemotherapy yet!" 4. "Don't worry. Everything will be all right. Dr. Smythe is the best oncologist in the area."

2. "This must be a terrible time for you. Would you like to talk about it?" Rationale When a person who is experiencing grief or facing death wants to talk, the nurse needs to take the time to listen and avoid creating barriers to communication. Offering to take the time to listen to Isabel's concerns is a therapeutic response. Providing unsolicited advice is nontherapeutic. Telling Isabel that it's "too early to be upset" essentially denies her grief; telling her not to worry offers false reassurance. These three options are examples of barriers to communication.

The home care nurse makes a phone call to arrange a visit from a hospice nurse. A few hours later, the hospice nurse arrives to talk to the family and set up the hospice program. Laura takes the nurse into Louis' room, and says "He's been so sleepy for the last few hours. It won't bother him if we talk in here." Which of these responses by the hospice nurse would be appropriate? Select all that apply. 1. "Sure. How long has he been like this?" 2. "Well, first I'd like to introduce myself to your husband." 3. "OK. Do you have his advance directive for me to review?" 4. "Mrs. Mast, let's step into the next room to talk for a few minutes." 5. "Yes, let's pull up some chairs and chat about what's going on."

2. "Well, first I'd like to introduce myself to your husband." 4. "Mrs. Mast, let's step into the next room to talk for a few minutes." Clients who are near death may be withdrawn from the external environment, but it is believed that the sense of hearing remains intact until death. Family members and caregivers should converse in the client's room or near the client as if the client is alert. This includes introducing yourself directly to the client. The caregiver should talk directly to the client in a soft tone. Reviewing the client's advance directive and having a conversation about him in his presence are inappropriate response.

The nurse is providing physical care to a client who has recently been told that he has inoperable lung cancer with a poor prognosis. The client says to the nurse, "I am so scared of dying. You hear so many stories about death. If only someone could tell me what it is really like." Which response should the nurse give the client? 1. "What stories have you heard?" 2. "You're scared of dying. Let's talk about what makes you scared." 3. "I've heard a lot of stories, too. I wish I could give you an answer to this one." 4. "People who have died and been resuscitated say it's a beautiful experience."

2. "You're scared of dying. Let's talk about what makes you scared." Rationale The nurse should use the therapeutic communication technique of paraphrasing and a response that is open-ended, which is also therapeutic. The nurse should restate the client's message and provide the client an opportunity to express his feelings, concerns, and fears. The responses in the incorrect options do not focus on the client's concern.

The nurse determines that which clients are capable of giving consent? Select all that apply. 1. A 15-year old who seeks treatment in a clinic for symptoms of the flu 2. A 17-year old who is seeking treatment for a substance abuse problem 3. A married 17-year old who requires treatment for a suspected respiratory infection 4. A 17-year old soldier in the U.S. Army who requires sutures for a laceration sustained while home on leave 5. A 14-year old who requires an ankle x-ray for a fall sustained while vacationing with a friend's family

2. A 17-year old who is seeking treatment for a substance abuse problem 3. A married 17-year old who requires treatment for a suspected respiratory infection 4. A 17-year old soldier in the U.S. Army who requires sutures for a laceration sustained while home on leave Rationale Although guidelines for legal consent for medical treatment are guided by state law, generally situations in which minors can provide consent for treatment include: lawfully married or a parent (emancipated); pregnancy (excluding abortions); venereal disease; or a drug or other substance abuse problem. The15-year-old who seeks treatment in a clinic for symptoms of the flu, and the 14-year-old who requires an ankle x-ray for a fall sustained while vacationing with a friend's family require the consent of a parent or legal guardian before treatment can be provided.

A nonstress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? 1. Fetal well-being has been established. 2. A contraction stress test will be scheduled. 3. Placental function and oxygenation are adequate. 4. The results are inadequate and the nonstress test must be repeated.

2. A contraction stress test will be scheduled. Rationale A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if nonstress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.

After several months and six rounds of chemotherapy treatments, Isabel begins to experience an aching pain in her back and hips. A bone scan reveals that the cancer has spread to her bones, and her oncologist tells her that her prognosis at this time is poor. He also tells her that she may have only weeks to live. Isabel again calls her family together and shares the news with them. She has been quietly working with an attorney to get her affairs in order, and her parents have agreed to serve as legal guardians of her children after her death. She has a living will and has included Regina in these discussions about the arrangements. Isabel has noticed that Regina has been quieter and has not talked to Isabel as much as usual. Isabel talks to the social worker at the oncology office about this, and the social worker suggests that Regina may be experiencing anticipatory grieving. Which examples are characteristics of anticipatory grieving? Select all that apply. 1. The person experiences grief weeks after the actual loss. 2. A family member begins to withdraw emotionally from the terminally ill person. 3. A family member may choose to be with friends instead of staying with a dying family member. 4. A person is overwhelmed by grief and cannot carry out day-to-day actions such as going to work. 5. A family member is unable to sleep after a loss but does not connect the altered sleeping pattern to the loss

2. A family member begins to withdraw emotionally from the terminally ill person. 3. A family member may choose to be with friends instead of staying with a dying family member. Rationale Anticipatory grief is the process of letting go that occurs before an actual loss (such as death) has occurred. It occurs when there is time for the person or family members to accept the reality of a terminal illness. However, some family members may actually begin withdrawing emotionally from the ill person as a self-protective mechanism, leaving the ill person with less support at the end of his or her life. Delayed grief occurs later, some time after the actual loss, instead of at the time of loss. Exaggerated grief is when a person experiences grief to such a degree that he or she cannot carry out daily functions. Masked grief is when a person is unable to recognize that the physical or emotional symptoms he or she is experiencing is a result of the loss that has been experienced.

The nurse employed in hospice care is reading the records of her assigned clients. Which client does the nurse identify as being at risk for disenfranchised grief? 1. The mother of a child who was killed in an automobile accident 2. A same-sex partner of a client with acquired immunodeficiency syndrome 3. A client with terminal cancer who is receiving a great deal of support from his wife 4. A client with end-stage renal disease who relies heavily on religious beliefs for hope

2. A same-sex partner of a client with acquired immunodeficiency syndrome Rationale Disenfranchised grief occurs when societal norms do not define a loss as a loss within its traditional definition. Basically, the survivor is not acknowledged for the loss and as a result is not given support by others. One example of disenfranchised loss is the death of a same-sex lover. In such a situation, grief may need to be hidden for the surviving partner to avoid negative social pressure. The mother of a child killed in an automobile accident, a client with terminal cancer, and a client with end-stage renal disease who relies heavily on religious beliefs for hope are not at risk for disenfranchised grief.

A mother changing her newborn daughter's diaper notes the presence of a small amount of blood on the infant's labia. The mother is concerned and tells the nurse that the infant is bleeding from the vaginal area. After assessing the infant, what response does the nurse provide to the mother? 1. The pediatrician will need to check the infant. 2. A small amount of vaginal bleeding is normal. 3. The bleeding is nothing to be concerned about. 4. The bleeding is probably a result of trauma from the birth process

2. A small amount of vaginal bleeding is normal. Rationale In the full-term female infant, edema of the labia and a white mucous vaginal discharge are normal. A small amount of vaginal bleeding, known as pseudomenstruation, may occur as a result of the sudden withdrawal of the mother's hormones at birth. It is not a result of trauma. Because the finding is normal, the pediatrician will not need to check the infant. Telling the mother that the finding is nothing to be concerned about is not the most appropriate option, because it is nontherapeutic.

On arriving at the scene of the train accident, Julianne is directed to triage and assist as many victims as possible. Which victim should Julianne care for first as the highest priority? 1. A victim who is huddled and screaming, "I can't find my daughter!" 2. A victim with a laceration of the right calf that is bleeding profusely 3. A victim who is in pain with an obvious fracture of the right humerus 4. A dead victim who obviously sustained severe head trauma and hemorrhage resulting from amputation of the left arm

2. A victim with a laceration of the right calf that is bleeding profusely Rationale In a disaster situation, the nurse must triage victims according to severity of injury and potential for recovery. Victims with life-threatening injuries that are readily corrected are classified as emergent and are the first priority (in this case, the victim with a laceration of the right calf that is bleeding profusely). Victims with injuries that do not require immediate treatment but that will need to be treated within 1 to 2 hours are classified as urgent and are the second priority (here, the victim who is in pain and has an obvious fracture of the right humerus). Victims with no injuries, those whose condition is noncritical, and victims who are ambulatory are classified as delayed (nonurgent) and are the third priority (in this case, the victim who is huddled and crying). Helping the victim who is dead, in this situation, is not the priority.

After the assessment, x-rays are taken of Christyna's arms and it is discovered that Christyna has bilateral greenstick fractures of the humerus. The emergency health care provider admits Christyna to the pediatric unit for treatment and calls her parents, requesting that they come to the hospital. When Christyna's parents arrive, the nurse notes that her father is very angry. He yells at Janice because he and his wife have had to cut their vacation short and accuses her of causing Christyna's injuries. When the nurse asks Christyna's father about his behavior, he becomes even angrier and tells the nurse that he is taking Christyna home immediately. Which action should the nurse take first? 1. Telling him that the police will be called if he tries to take Christyna home 2. Acknowledging his feelings of anger and describing the plan of care for Christyna to him 3. Informing him that he may not take Christyna anywhere until child protective services has investigated the situation 4. Telling him that if he tries to take Christyna out of the hospital he will be handcuffed and charged with kidnapping

2. Acknowledging his feelings of anger and describing the plan of care for Christyna to him Rationale When child abuse is suspected, the nurse must report it to protective services. An investigation by the state protective-service agency is legally mandated, and it reinforces to the family the seriousness of the problem. Children in whom abuse is suspected may be hospitalized for treatment of their injuries. Hospitalization also provides a safe environment until the investigation by protective services is complete. If the parent of an abused child exhibits angry behavior, the nurse should first acknowledge the anger and then describe the plan of care for the child. Threatening the parents is inappropriate and would escalate the father's anger. Although it is legally mandated that protective services investigate the situation, it is best for the nurse to describe the procedure and protocols for the investigation to the parents.

After a thorough mental health assessment, Joseph is transferred to the mental health unit in a voluntary admission. The nurse in the mental health unit reviews the emergency department notes in preparation for the interview with Joseph. Which would the nurse determine because Joseph has consented to voluntary admission? 1. Joseph cannot request and be granted hospital discharge 2. Admission to the mental health unit was sought by Joseph 3. Admission to the hospital was made without Joseph's consent 4. Joseph will not be making decisions about his treatment or care

2. Admission to the mental health unit was sought by Joseph Rationale Voluntary admission is generally sought by the client or by the client's guardian. Voluntary admitted clients have the right to request and be granted release from the hospital. Clients admitted to a mental health facility do not lose the right to informed consent or decision-making. Involuntary admission is made without the client's consent.

Julianne goes on to the hospital's emergency department to prepare for the arrival of victims. An outside area is set up to receive clients. As clients arrive, they are grouped with the use of a color-coded system of triage tags. Which clients would be placed in the yellow-tag category? Select all that apply. 1. A teenager with a sprained ankle 2. An older woman with a fractured arm 3. A child who is unconscious with a head injury 4. A young woman with a large bleeding laceration on her lower leg 5. A young man who has a fractured leg and reports a history of asthma 6. A middle-aged man who has a severe crushing head injury and is unresponsive

2. An older woman with a fractured arm 5. A young man who has a fractured leg and reports a history of asthma Rationale The emergent (red) classification, the highest priority, is given to clients who have life-threatening injuries and need immediate attention and continuous evaluation but have a high probability of survival once they have been stabilized. Such clients include those with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, or acute neurological deficits and those who have sustained chemical splashes to the eyes. The urgent (yellow) classification, the second priority, is given to clients who require treatment and whose injuries have complications that are not life-threatening, provided that they are treated within 1 to 2 hours; these clients require evaluation every 30 to 60 minutes thereafter. Such clients include those with simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, and renal stones. The nonurgent (green) category, the third priority, is for clients with local injuries who do not have immediate complications and who can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter.

A month later, the community's disaster preparedness council holds a meeting to review the response to the train wreck and discuss other disaster situations that require planning. Julianne presents a summary on "Anthrax Exposure" for the group. Julianne should include which points about anthrax in presentation? Select all that apply: 1. There is no vaccine against anthrax. 2. Anthrax infection is treatable with antibiotics such as ciprofloxacin. 3. Anthrax occurs in inhalation, cutaneous, and gastrointestinal form. 4. The inhalation form of anthrax is the most severe and can lead to potentially fatal bacteremia. 5. Victims who may have been exposed to anthrax will be taken to a decontamination area first. 6. Victims who may have been exposed to anthrax will be admitted to the emergency department, then taken to the decontamination area.

2. Anthrax infection is treatable with antibiotics such as ciprofloxacin. 3. Anthrax occurs in inhalation, cutaneous, and gastrointestinal form. 4. The inhalation form of anthrax is the most severe and can lead to potentially fatal bacteremia. 5. Victims who may have been exposed to anthrax will be taken to a decontamination area first. Rationale An anthrax vaccine is available to those who will be in situations where exposure is possible, such as military service; exposure and infections are treated with specific antibiotics. There are three forms of anthrax: inhalation, cutaneous, and gastrointestinal. The inhalation form of anthrax is deadlier than the cutaneous and gastrointestinal forms. Anthrax infection may be treatable with antibiotics such as ciprofloxacin. Victims of anthrax exposure will not be taken directly into the emergency department, because this could result in the exposure of other personnel and clients to the disease. Instead, they will be taken directly to a decontamination area.

Which action should Carol plan to take as she functions in the role of team leader? 1. Assigning herself the most difficult clients 2. Assigning clients to each team member and coordinating each client's care plan 3. Assigning the licensed practical nurse to take the vital signs of all of the clients 4. Assigning the nursing assistants the tasks of replenishing the clients' water pitchers and changing beds

2. Assigning clients to each team member and coordinating each client's care plan Rationale Team nursing involves the delivery of care by staff of various educational preparations. A registered nurse leads the team, which may comprise other registered nurses, licensed practical nurses, and nursing assistants. The team members provide direct client care to groups of clients, under the direction and coordination of the team leader. Functional nursing involves the division of tasks. The team leader usually does not have a direct client care assignment. Functional nursing involves the assignment of specific nursing tasks to team members.

When the fire is discovered, what will you do first? 1. Activate the fire alarm 2. Assist the client in leaving the room 3. Get the fire extinguisher located outside the client's room 4. Assist the client into a corner of the room, as far away from the fire as possible, and shut the oxygen off

2. Assist the client in leaving the room Rationale In the event of a fire, the nurse would use the mnemonic RACE to set priorities. The nurse's first action would be to rescue and remove all clients in immediate danger away from the fire. The nurse would next activate the fire alarm, confine the fire by closing doors and windows and turning off oxygen and electrical equipment, and then extinguish the fire, using a fire extinguisher.

A health care provider writes a prescription for furosemide, 80 mg/day by mouth, for a hospitalized client with a diagnosis of heart failure. When the nurse brings the medication to the client, the client states that he normally takes only 40 mg of the medication each day. Which action on the part of the nurse would be most appropriate? 1. Administering 40 mg instead of 80 mg 2. Calling the health care provider who wrote the prescription 3. Explaining to the client the need for the higher dose 4. Checking the drug formulary and asking the client to read the information about safe dosage of the medication

2. Calling the health care provider who wrote the prescription Rationale A nurse is obligated to fulfill a health care provider prescription unless he or she believes a prescription to be harmful to the client. A nurse who fulfills an inaccurate prescription may be legally responsible for any harm inflicted on the client. The nurse is responsible for clarifying an unclear or inappropriate prescription, or any prescription that is otherwise in question, with the health care provider. If the client questions a prescription, the nurse should contact the health care provider for clarification. Administering 40 mg instead of 80 mg, explaining to the client the need for additional medication, and asking the client to read information about safe dosage of the medication are all inappropriate actions.

A nurse assists an obstetrician in performing an amniotomy on a woman admitted to the labor unit. Which action should the nurse take immediately after the procedure? 1. Helping the woman walk 2. Checking the fetal heart rate 3. Assisting the woman in bathing 4. Checking the woman's temperature

2. Checking the fetal heart rate Rationale Amniotomy is the artificial rupture of membranes that is performed by the health care provider to stimulate labor. The primary risk associated with amniotomy is that the umbilical cord will slip down in the gush of fluid and become compressed between the fetal presenting part and the woman's pelvis, obstructing blood flow to and from the placenta and reducing gas exchange. Therefore the nurse's action immediately after the procedure would be to check the fetal heart rate. Although the nurse would monitor the woman's temperature and help the woman bathe, these are not immediately necessary actions. The woman would not be allowed to walk unless this has specifically been prescribed.

Carl's withdrawal symptoms get worse. The nurse reviews his prescribed medications and prepares to administer them. Which medications does the nurse recognize as having been prescribed for management of acute symptoms of withdrawal from alcohol? Select all that apply. 1. Secobarbital, a barbiturate 2. Chlordiazepoxide, a benzodiazepine 3. Atenolol, a beta-adrenergic blocker 4. Clonidine, an alpha-adrenergic blocker 5. Acamprosate, an alcohol abuse deterrent

2. Chlordiazepoxide, a benzodiazepine 3. Atenolol, a beta-adrenergic blocker 4. Clonidine, an alpha-adrenergic blocker Rationale Chlordiazepoxide and a few other benzodiazepines, as well as beta-adrenergic blockers such as atenolol, are used to help decrease withdrawal symptoms, stabilize vital signs, and prevent seizures in acute alcohol withdrawal delirium. Alpha-adrenergic blockers, such as clonidine, ease autonomic symptoms of withdrawal. Acamprosate is used not during acute detoxification but instead as an alcohol abuse deterrent; similarly, barbiturates, such as secobarbital, are not used for acute alcohol withdrawal delirium.

Michael tells the hospital nurse that he really doesn't understand this surgical procedure and that he is somewhat concerned because he will be awake during the surgery. Which action on the part of the nurse is appropriate? 1. Asking Michael why he signed the consent form 2. Contacting the surgeon to report that Michael has questions and concerns about the surgery 3. Telling Michael not to be concerned about being awake, because a large drape will be used to cover his abdomen 4. Telling Michael that he will not be awake during surgery and that the anesthesiologist will be visiting him to talk about the medication that will be administered

2. Contacting the surgeon to report that Michael has questions and concerns about the surgery Rationale If the client raises questions about the surgical procedure, the nurse must determine whether the client is truly informed about the procedure. If the nurse determines that questions need to be answered and concerns addressed, he or she must contact the surgeon to ensure that the client receives whatever additional clarification or information is necessary. Telling Michael not to be concerned about the surgery and asking him why he signed the consent form are nontherapeutic actions. Surgical procedures must be addressed by the surgeon, who must discuss the client's concerns with the client and provide explanations to the client.

The nurse reads the following information in a client's medical record: "Client verbalizes an inability to survive if left alone. Client states inability to select day's wardrobe without considerable reassurance or guidance. Client is passive and states inability to separate self from others or to work or partake in activities independently." Which type of personality disorder does the nurse recognize in this report? 1. Antisocial 2. Dependent 3. Narcissistic 4. Obsessive-compulsive

2. Dependent Rationale The person with dependent personality disorder has a sense of being incapable of survival if he or she is left alone. This may be expressed in a lack of ability even to pick out the day's wardrobe without considerable reassurance or guidance. Affected clients perceive themselves as being unable to separate from others or to work independently. They believe that it is necessary to depend on others to function at all. They are passive and follow other people's preferences or advice, even when they know it to be inaccurate and potentially harmful to themselves or others. With antisocial personality disorder the client exhibits a pattern of irresponsible and antisocial behavior characterized by selfishness, inability to maintain lasting relationships, poor sexual adjustment, failure to accept social norms, irritability, and aggressiveness. A narcissistic personality disorder is characterized by an increased sense of self-importance; the client is preoccupied with fantasies, including that of unlimited success, and has a constant need for attention and admiration. With obsessive-compulsive personality disorder, the client is inflexible, preoccupied with details and rules, orderly, a perfectionist, overly conscientious, and devoted to work and lacks leisure activities and friendships.

Which findings are normal age-related physiological changes? Select all that apply. 1. Increased heart rate 2. Diminished visual acuity 3. Decline in long-term memory 4. Increased susceptibility to urinary tract infections 5. Increased incidence of awakening after onset of sleep

2. Diminished visual acuity 4. Increased susceptibility to urinary tract infections 5. Increased incidence of awakening after onset of sleep Rationale Anatomic changes in the eye affect the older individual's visual ability acuity, sometimes leading to problems in carrying out activities of daily living. Light adaptation is diminished and visual fields reduced. The heart rate slows and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Sleep pattern changes are common with increasing age. Older persons generally experience an increased incidence of awakening after sleep onset.

In his first appointment with the crisis counselor, Thomas shares how helpless he feels now that he has only one foot and says he is worried about how he will be able to earn a living. The counselor listens to Thomas and implements interventions to help him at this time. Which interventions are examples of primary prevention interventions for mental health? Select all that apply. 1. Ensuring Thomas' safety 2. Exploring other possible occupational roles 3. Referring Thomas to a critical incident stress debriefing program 4. Assisting Thomas in his support system and coping style 5. Assisting Thomas in evaluating his experience of stressful life events 6. Teaching specific coping skills, such as problem-solving and relaxation techniques

2. Exploring other possible occupational roles 5. Assisting Thomas in evaluating his experience of stressful life events 6. Teaching specific coping skills, such as problem-solving and relaxation techniques Rationale Primary care interventions promote mental health by helping reduce the incidence of crisis. Examples of primary care interventions include helping the client evaluate how he has responded to stressful life events; teaching specific skills, such as coping skills, problem-solving, and relaxation techniques; and assisting the client in exploring ways to reduce the negative impact of stress by making decisions and even discussing occupational changes. Secondary care interventions, such as ensuring the client's safety and assisting the client in his assessing support system and coping style, are implemented during an acute crisis to prevent prolonged anxiety from reducing personal effectiveness. Tertiary care interventions, such as a critical incident stress debriefing program, provides support for the client who has experienced a severe crisis and is trying to recover.

A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? 1. The umbilical cord holds two veins and one artery. 2. Fetal blood circulation takes place strictly in the placenta. 3. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. 4. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.

2. Fetal blood circulation takes place strictly in the placenta. Rationale The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.

An emergency department (ED) nurse receives a telephone call from the local police department and is told that several victims of an industrial explosion will be brought to the ED. Which action should the nurse take immediately? 1. Calling as many off-duty nurses as possible and having them come to the hospital to care for the victims 2. Following the directions outlined in the hospital's disaster preparedness (emergency response) plan 3. Asking the housekeeping department to deliver an extra cart of linen containing several blankets to the ED 4. Calling the operating room to inform the staff that the hospital may be receiving numerous victims requiring surgery

2. Following the directions outlined in the hospital's disaster preparedness (emergency response) plan Rationale The ED nurse has an important role in emergency and disaster planning. Knowledge of the agency's emergency response plan, including the roles and responsibilities of the members of the response team, is vital. An ED nurse who is notified that several victims of a disaster will be arriving at the department should immediately activate the emergency response plan by notifying his or her supervisor and following the directions in the plan. Although asking for extra supplies, calling employees at home to come in to care for victims, and informing the necessary areas of the hospital to be on alert may be implemented, none is the immediate choice.

The nurse completes Janice's obstetric history. How does the nurse record Janice's history of gravidity and parity? 1. Gravida 2, para 2 2. Gravida 3, para 2 3. Gravida 3, para 3 4. Gravida 2, para 3

2. Gravida 3, para 2 Rationale Gravida refers to the number of pregnancies, including the current one. Parity is the number of births (not the number of fetuses - e.g., twins) carried past 20 weeks at delivery, whether or not the fetus was born alive. Because this is the client's third pregnancy, her gravidity is 3. Because Janice is in her first trimester of this pregnancy and also has one son who was born at 40 weeks' gestation and one daughter who was born at 36 weeks' gestation, her parity is 2.

The forensic nurse who is preparing to counsel a criminal sex offender in a psychological treatment program plans to use a cognitive-restructuring approach. Which action should the nurse take first? 1. Generating alternatives for dealing with the dysfunctional behavior 2. Identifying what is reinforcing and maintaining the client's dysfunctional thinking 3. Encouraging the client to look at the dysfunctional behavior from different perspectives 4. Focusing on incorporating the client's strengths and coping resources into his or her treatment

2. Identifying what is reinforcing and maintaining the client's dysfunctional thinking Rationale Forensic nurses provide direct service to individual crime victims, as well as to clients accused of or incarcerated for crimes by law enforcement agencies. One common approach to treating sex offenders is cognitive restructuring. Changing cognition begins with identifying what is reinforcing and maintaining the client's dysfunctional thinking and maladaptive behavior. Although the other options may be a part of cognitive restructuring therapy, none of them is the initial component.

Carl calls his wife, Jane, to tell her that he is undergoing treatment for his alcohol problem. Later that afternoon, Jane visits. During the visit, the nurse notes that Carl is anxious and confused and that he is experiencing tremors. The nurse suspects that Carl is experiencing alcohol withdrawal. Which action should the nurse take? 1. Asking Jane to leave 2. Implementing seizure precautions 3. Planning to place Carl in the seclusion room 4. Asking Carl for permission to apply restraints

2. Implementing seizure precautions Rationale When a client demonstrates signs of alcohol withdrawal, careful assessment and appropriate medical and nursing interventions can prevent the more serious withdrawal reaction of delirium. The nurse would administer medication as prescribed and assess Carl frequently. The nurse would also implement seizure precautions because of the potential for seizures. Providing a quiet, nonstimulating environment and allowing a family member to stay with the client will minimize anxiety and confusion. Restraints and seclusion are used for a client who presents a threat to him- or herself or to others and is unable to control his or her behavior. Asking Carl for permission to apply restraints might increase his anxiety.

A home-care nurse is providing information to an older client about measures to prevent constipation. Which action should the nurse tell the client to take? 1. Take an oral laxative daily. 2. Include bran in the daily diet. 3. Eat less fresh fruit each day. 4. Keep fluid intake to 1000ml per day

2. Include bran in the daily diet. Rationale: Diet is a common cause of constipation in older adults. Usually a lack of certain foods, rather than the consumption of certain foods, leads to the problem. Fresh fruits and vegetables contain natural laxatives and should be included in the daily diet. Another dietary cause of constipation is the lack of fiber or bulk and reduced fluid intake. Therefore the client should include fiber, such as bran, in the diet and should drink 2000 mL of fluid daily unless it is contraindicated because of a medical condition. Constipation may be caused by overuse or improper use of laxatives stemming from the client's excessive concern about the frequency of bowel movements. The client would not be instructed to take a laxative on a daily basis.

A client is seen in the emergency department for complaints of chest pain and difficulty breathing. The results of laboratory and diagnostic tests are normal, indicating that there is no physiological basis for the complaints. On further assessment, the client tells the nurse that chest pain and difficulty breathing are the symptoms that his wife had before she died. Which type of defense mechanism does the nurse recognize in this behavior? 1. Projection 2. Introjection 3. Rationalization 4. Reaction formation

2. Introjection Rationale Introjection is a type of identification in which the individual incorporates the traits or values of another into himself or herself. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. Reaction formation is the development of conscious attitudes and behaviors and acting out behaviors opposite of what one really feels.

Claudia's has exhibitied constant motor activity and is showing signs of exhaustion. The nurse plans for which appropriate activity for Claudia? 1. Dancing 2. Writing 3. Exercise 4. Walking

2. Writing Rationale The constant motor activity of the manic client can lead to physical exhaustion, so the nurse must provide frequent rest periods for the client. The nurse would plan structured and solitary activities such as writing and drawing or tearing rags. A structured solitary and noncompetitive activity provides security and focus for the client and permits the use of energy and the expression of feelings. Dancing, exercising, and walking are appropriate for the client who is exhibiting aggressive behavior.

A nursing student arrives at the clinical nursing unit and presents her plan of care for her assigned client to the nursing instructor. The assigned client requires the use of mitten restraints because he has been pulling at his endotracheal tube. Which interventions regarding restraints in the plan of care require revision? Select all that apply. 1. Ensuring that the restraint straps are attached to the bed frame 2. Making sure that one finger can be inserted under the restraint 3. Using a quick-release tie to secure the restraint to the bed frame 4. Checking for a renewal of the health care provider's prescription for the restraints 5. Checking skin integrity and neurovascular and cardiovascular status every hour 6. Removing the restraints every 2 hours for 30 minutes to perform range-of-motion exercises

2. Making sure that one finger can be inserted under the restraint 5. Checking skin integrity and neurovascular and cardiovascular status every hour Rationale A restraint is a physical device used to limit the physical activity of a client or to immobilize a client or an extremity for safety purposes. Specific guidelines must be followed when a client is under restraint. Federal, state, and agency guidelines regarding the use of restraints must be followed. A health care provider's prescription is needed, and the prescription must be renewed within a period set forth by federal, state, or agency guidelines. To prevent injury when side rails are raised or lowered, restraint straps should be attached to the bed frame. A quick-release tie is used so that the restraint may be quickly removed if necessary, such as in an emergency. The nurse must ensure that the restraint is not too tight and see that 2 fingers can be inserted under the restraint. The nurse should check skin integrity and neurovascular and cardiovascular status every 30 minutes. Also, the nurse must remove the restraints every 2 hours for 30 minutes to perform range of motion exercises.

The office nurse reviews the signed consent form and determines that which pieces are components of informed consent? Select all that apply. 1. Cost of the procedure/surgery 2. Name of the procedure/surgery 3. Description of the procedure/surgery 4. Person(s) performing the procedure/surgery 5. Potential risks and adverse effects of procedure/surgery

2. Name of the procedure/surgery 3. Description of the procedure/surgery 4. Person(s) performing the procedure/surgery 5. Potential risks and adverse effects of procedure/surgery Rationale Information needed for informed consent includes the name and description of the procedure, the name of the person(s) performing the procedure, and risks and potential adverse effects of the procedure. Informed consent does not include the cost of the surgery. Other information includes the approximate length of recovery time needed and the consequences of refusing the proposed treatment.

A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nägele's rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? 1. October 17, 2016 2. November 17, 2016 3. September 17, 2016 4. December 17, 2017

2. November 17, 2016 Rationale For Nägele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.

The next day, Carol's report sheet for her client assignment reads as follows: -Sal DeCarlo, 56 years old, was admitted to the hospital at 6:30 AM with respiratory distress and a fever of 101.8°F. Bilateral pneumonia was diagnosed after chest radiography. He is receiving oxygen by nasal cannula, and intravenous antibiotics will be started after a sputum specimen is obtained. -James Fiore, 65 years old, was admitted to the hospital 2 days ago. He has a diagnosis of angina pectoris. His condition is stable, and he is scheduled for a cardiac catheterization at 1 PM. -Judy Sharon, 62 years old, underwent abdominal surgery yesterday. The nurse who gives report to Carol notes that Judy has received pain medication as needed every 4 hours and that she is due to receive her next dose at 8:30 AM. -Carla Sorenson, 65 years old, was told yesterday that she has inoperable lung cancer and will need to undergo radiation therapy. The nurse who gives report to Carol notes that Carla received a prescribed sedative at bedtime and has slept soundly through the night. Carla is scheduled to meet with the radiologist at 11 AM. Which action should Carol plan to take first after receiving report from the night nurse? 1. Preparing the pain medication for Judy Sharon 2. Obtaining a sputum specimen from Sal DeCarlo 3. Talking to Carla Sorenson about what to expect when she meets with the radiologist 4. Assisting James Fiore with morning care and helping him prepare for the cardiac catheterization

2. Obtaining a sputum specimen from Sal DeCarlo Rationale The nurse would first obtain a sputum specimen from Sal so that the prescribed antibiotics may be started. Judy's pain medication should be prepared at the time of administration. Additionally, the report contains no data that indicate that Judy will need the medication at 8:30 a.m. Carla is scheduled to meet with the radiologist at 11 a.m., and James is scheduled for cardiac catheterization at 1 p.m.; therefore it is not urgent that Carole attend to these clients first.

Christyna's father decides that he is going to leave the hospital and tells Christyna's mother, "I'm sick of this treatment. I'm leaving. You handle this from here on." After he leaves, Christyna's mother says to the nurse, "We really need some help. I feel so guilty for all of this. He's always so rough with her — I knew something like this would happen eventually." To which support group should the nurse refer Christyna's mother? 1. Al-Anon 2. Parents Anonymous 3. Alcoholics Anonymous 4. Parents United International Inc.

2. Parents Anonymous Rationale Parents Anonymous is a self-help group for parents who have abused a child or fear that they may abuse a child. It is designed to address physical, not sexual, abuse. Al-Anon is a support for spouses and friends of individuals with alcoholism. Alcoholics Anonymous is a support group for recovering alcoholics. Parents United International Inc. is a group devoted to helping families affected by sexual abuse.

Joseph is discharged from the hospital, but his new mental health contract states that he will attend twice-weekly cognitive therapy sessions. During the working phase of the nurse-client relationship, what specific tasks does the nurse plan? Select all that apply. 1. Establishing a rapport 2. Promoting Joseph's problem-solving skills 3. Gathering further data about Joseph's problems 4. Summarizing the goals achieved in the relationship 5. Discussion of problems and goals, and redefining as needed 6. Helping Joseph explore how to practice alternative adaptive behaviors

2. Promoting Joseph's problem-solving skills 3. Gathering further data about Joseph's problems 5. Discussion of problems and goals, and redefining as needed 6. Helping Joseph explore how to practice alternative adaptive behaviors Rationale During the working phase of a nurse-client relationship, nurse and client work together to identify and explore issues that are causing problems in the client's life, then set goals for the sessions. It is also a time for data-gathering and identifying and promoting the client's problem-solving skills, as well as for exploring new behaviors for problem-solving. Establishing a rapport is part of the first phase of the nurse-client relationship, the orientation phase. Summarizing the goals that have been achieved is part of the termination phase.

A nurse spending the day with friends at an amusement park is sitting on a bench, watching people ride a roller coaster. Suddenly the nurse hears panicked screaming and sees that one car of the coaster has struck another one stopped on the track. What action should the nurse take immediately after rushing to the scene? 1. Calling 911 2. Providing care to victims with life-threatening problems 3. Triaging the victims and providing directions to laypersons who are willing to help the victims 4. Asking someone to call the nearest hospital to let the staff know that victims of the accident will be arriving there shortly

2. Providing care to victims with life-threatening problems Rationale In the community setting, a nurse who is the first responder to a disaster must first attend to the victims life-threatening problems. Once rescue workers have arrived on the scene, immediate plans for triage should be made. Although 911 must be called, doing so would not be the first action of the nurse — instead, the nurse should continue attending to any life-threatening conditions and ask someone else to call 911. Asking someone to call the nearest hospital to inform the staff about the accident and warn them that victims will be coming is not an immediate priority; the victims will be transported by emergency medical services once those with urgent needs have been attended to.

Carol has finished planning the assignments for the day, has provided a client report, and has given directions about client care to each member of the team. Carol understands that: 1. Accountability for each assignment lies with the team member it was given to 2. She must evaluate each team member's performance and each client's outcomes 3. It is not necessary to follow up with each team member unless a client complains about care 4. She must develop a written and specific time-management outline for each team member that identify the priorities of care for each client

2. She must evaluate each team member's performance and each client's outcomes Rationale Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to fulfill that specific task. It involves achieving outcomes and sharing activities with other individuals who have the authority to accomplish the task. Even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability, may be delegated to another. The nurse provides clear directions about the task and ensures that the team member understands the expectations. The nurse is also responsible for follow-up with each team member and must evaluate the team member's performance and the client's outcomes. It is not necessary for the nurse to develop a written and specific time-management outline for each team member, but the nurse must provide guidance and assistance to the team member as needed.

A client arrives at the clinic, extremely upset and crying, and asks to talk to someone. She tells the nurse that her husband has just told her that he wants a divorce because he is in love with someone else. The client says "I don't know what I'm going to do or how i'm going to deal with this. He was my whole life!" Which type of crisis does the nurse determine that the client is experiencing? 1. Disaster 2. Situational 3. Maturational 4. Adventitious

2. Situational Rationale A situational crisis arises from an external rather than an internal source. Some examples of external situations that could precipitate a crisis include loss of a job, death of a loved one, a change in financial status, and divorce. A maturational crisis relates to developmental stages and associated role changes. An adventitious crisis relates to a crisis of disaster or an event that is not a part of everyday life.

A female client with anorexia nervosa is transferred to the mental health unit from a medical unit after being treated for an electrolyte imbalance. Which action does the nurse in the mental health unit plan to take to ensure adequate nutritional intake? 1. Being supportive but feeding the client if she refuses to eat 2. Staying with the client during mealtimes and encouraging the client to eat 3. Telling the client that an intravenous line or a nasogastric tube will be inserted if she does not eat 4. Asking the client to call the nurse when she is done eating so that her calorie intake and fluid intake can be calculated

2. Staying with the client during mealtimes and encouraging the client to eat Rationale Anorexia nervosa is an eating disorder in which the individual experiences hunger but refuses to eat because of a distorted body image. It can lead to life-threatening physiological disorders. To ensure adequate nutrition, the nurse should stay with the client during meals and snacks, watch the client eat, and remain with the client for at least 1 hour after the meal. These actions will ensure that the client does not hide or throw away food or purge after the meal or snack. Feeding the client is an inappropriate action that will lead to a power struggle between the client and nurse. Telling the client that an intravenous line or nasogastric tube will be inserted if she does not eat is threatening the client. This is also an inappropriate action.

During the assessment, Joseph discusses his feelings of self-harm with the nurse and hints that he even had a plan for carrying out his suicide if his life "got worse." Which methods of suicide are considered of lower risk, or "soft"? Select all that apply. 1. Hanging 2. Swallowing pills 3. Inhaling natural gas 4. Slashing one's wrists 5. Staging a high-speed car crash into a cement wall

2. Swallowing pills 3. Inhaling natural gas 4. Slashing one's wrists Rationale The evaluation of a suicide plan is extremely important in determining the degree of suicide risk. The lethality of a method in person's suicide plan indicates how quickly the individual would die if that plan were enacted. Guns, hanging, carbon monoxide, and car crashes are extremely lethal and are therefore considered higher-risk, or 'hard,' methods. Slashing the wrists, inhaling natural gas, and ingesting pills are lower-risk, or 'soft,' methods.

A rape victim is brought to the emergency department by a neighbor. The nurse assists the client into a private examining room and conducts an interview with the client. The nurse explains the procedures for physical examination, and the client refuses the examination. Which action should the nurse take next? 1. Obtaining a court order for the physical examination 2. Telling the victim that the physical examination cannot be refused 3. Encouraging the victim to discuss the reasons for refusing the physical examination 4. Telling the victim that the physical examination must be performed to obtain evidence of the rape

3. Encouraging the victim to discuss the reasons for refusing the physical examination Rationale The rape victim or survivor of a sexual assault has the right to refuse a legal or a medical examination. Consent forms must be signed for photographs, pelvic examination, and any other procedures that might be needed to collect evidence and provide treatment. If the victim refuses the examination, it cannot be performed. Telling the victim that he or she must have the exam for evidence to be obtained, that the exam cannot be refused, and that a court order will be obtained for the exam are all inappropriate.

A nurse is describing the situations that constitute invasion of client privacy to a group of staff members. The nurse is violating the client's privacy in which situations? Select all that apply. 1. Describing a treatment to a client in a secluded area 2. Telling a family member about the client's condition 3. Taking photographs of the client during the client's birthday party 4. Asking the client for permission to allow a nursing student to observe a procedure 5. Accessing a neighbor's medical record to find out about his or her health care status

2. Telling a family member about the client's condition 4. Asking the client for permission to allow a nursing student to observe a procedure 5. Accessing a neighbor's medical record to find out about his or her health care status Rationale The client has a right to privacy and the right to protection against unreasonable and unwarranted interference in his or her private affairs. Some of the situations that violate this right include taking photographs of the client, releasing medical information to an unauthorized person, leaving the curtains or room door open while a treatment or procedure is being performed, allowing individuals unconnected to the client's care to observe a treatment or procedure without the client's consent, leaving a confused or agitated client sitting in the nursing unit hallway, interviewing a client in a room with only a curtain between clients or where conversation can be overheard, and accessing medical records when one is not unauthorized to do so. Describing a treatment to a client in a secluded area and asking the client for permission to allow a nursing student to observe a procedure are measures to protect the client's privacy.

The emergency department nurse is sitting in the conference room attached to the nurses' station, using the computer to update Angela's medical record. The nurse hears the two unit secretaries, who are in the nurses' station, talking about Angela. One secretary says to the other, "Gosh, that girl has been here so many times for injuries. I wouldn't stand for that abuse. I hope she'll finally do something about that big bully." Which action on the part of the nurse is appropriate? 1. Ignoring the secretaries and continuing to work 2. Telling the secretaries that Angela's information is confidential and should not be discussed 3. Stopping what she is doing and letting the secretaries know that Angela is finally doing something about the abuse 4. Telling the secretaries that they can find out all of the information about Angela's plan by reading her medical record

2. Telling the secretaries that Angela's information is confidential and should not be discussed Rationale Information about a client's medical condition and any issues related to the client is confidential and should not be discussed openly. In a nurse-client relationship, information is not to be shared with a third party who is not directly involved in the client's care. If the nurse overhears an individual who is not directly involved in the client's care talking about a client's condition, the nurse must intervene to stop the conversation and remind the individual that the conversation is inappropriate. Ignoring the secretaries and telling them that Angela is doing something about her abuse are inappropriate actions. A client's record is confidential, and no one should be reading a client's medical records unless that person are involved in the client's care.

Which statements about Amish culture are correct? Select all that apply. 1. The Amish do not use alternative health care measures. 2. The Amish believe that clean living and a balanced diet help maintain health. 3. The Amish have more risk factors for disease than do members of the general American population. 4. Barriers to modern health care for many Amish people include distance, lack of transportation, cost, and language. 5. Some Amish people do not carry health insurance because it is a "worldly product" showing a lack of faith in God. 6. Amish people generally must have church (bishop and community) permission to be hospitalized because it is the community that will pay the costs.

2. The Amish believe that clean living and a balanced diet help maintain health. 4. Barriers to modern health care for many Amish people include distance, lack of transportation, cost, and language. 5. Some Amish people do not carry health insurance because it is a "worldly product" showing a lack of faith in God. 6. Amish people generally must have church (bishop and community) permission to be hospitalized because it is the community that will pay the costs. Rationale People of Amish descent may use both traditional health care and alternative health care measures and practices such as healers, herbs, and massage. Many Amish believe that health is a gift from God and that clean living and a balanced diet help maintain it. The Amish are at lower risk for disease than the general American population because of their belief in manual labor, consumption of fresh foods, and rare consumption of tobacco and alcohol. An increased risk of some genetic disorders and sexual abuse exists in this culture. Many Amish choose not to have health insurance, instead maintaining mutual aid funds to help defray medical costs. Barriers to modern health care for Amish people include distance, lack of transportation, cost, and language (many Amish do not understand scientific terminology). Most Amish must get church permission (bishop and community) permission to be hospitalized because it is the community that will help pay the costs.

The nurse is evaluating the grief process for a woman whose husband died in an automobile accident 2 months ago. Which outcomes would the nurse identify as successful? Select all that apply. 1. The client refuses to take on new responsibilities. 2. The client demonstrates lengthening periods of stability. 3. The client expresses positive expectations about the future. 4. The client reports decreased preoccupation with the loss of her husband. 5. The client's daughter reports that her mother has not paid any bills since the death of her husband. Submit

2. The client demonstrates lengthening periods of stability. 3. The client expresses positive expectations about the future. 4. The client reports decreased preoccupation with the loss of her husband. Rationale Grieving is a normal process in which people come to terms with losses. Successful outcomes associated with the grief process include the ability to tolerate intense emotions, reduced preoccupation with the deceased (loss), demonstration of increasing periods of stability, tending to previous responsibilities, taking on new roles and responsibilities, having the energy to invest in new endeavors, the expression of positive expectations about the future, and remembering positive as well as negative aspects of the deceased loved one. Refusing to take on new responsibilities and not attending to responsibilities are unsuccessful outcomes.

Three weeks after the birth of her baby, Sara, Annie calls her obstetrician's office and speaks to the nurse. She tells the nurse that she has been feeling "hot" and very fatigued, even though she has been resting and has had her husband at home to help with the baby. The nurse asks Annie to come to the office for a checkup, and notes the assessment findings in Annie's record. Based on these assessment findings (click "Chart" below), what problem does the nurse suspect? 1. Mastitis 2. Influenza 3. Endometritis 4. Bladder infection

3. Endometritis Rationale Endometritis (infection of the uterine lining) is common during the postpartum period. Signs include fever, quickened pulse, nausea and anorexia, increased fatigue, lower abdominal pain, uterine tenderness, and increased lochial flow with a strong foul odor. Leukocytosis is also present. Mastitis is a breast infection; there is no information in Annie's record to indicate that mastitis is present. There are no specific data indicating that influenza (flu) is present. If a bladder infection were present, the urine would be cloudy and the urinalysis results would be abnormal.

A nurse is conducting a psychosocial assessment of a 40-year-old client. Which findings would the nurse recognize as a sign of emotional health in a person in middle adulthood? 1. The client is establishing intimate bonds of love and friendship. 2. The client provides guidance during interactions with his children. 3. The client verbalizes readiness to assume parental responsibilities. 4. The client is making decisions concerning career, marriage, and parenthood.

2. The client provides guidance during interactions with his children. Rationale: Middle adulthood is the period between the middle to late thirties and the middle sixties. According to Erikson's developmental theory, the psychosocial crisis of middle adulthood is generativity versus stagnation. The developmental task is to fulfill life's goals involving family, career, and society; successful resolution is demonstrated by the willingness to give to and care for others and to guide others. Middle adults can achieve generativity with their own children or the children of close friends or through other social interactions with the next generation. Making decisions about career, marriage, and parenthood; verbalizing readiness to assume parental responsibilities; and establishing intimate bonds of love and friendship are signs of emotional health in the early adult years.

A nurse is preparing a report for a client who is being transferred from the coronary care unit to a medical nursing unit. The nurse plans to include which information in the transfer hands-off report? Select all that apply: 1. The client's home address 2. The client's resuscitation status 3. The client's medical record number 4. The client's needs and priorities for care 5. Client assessments or interventions that are required after transfer

2. The client's resuscitation status 4. The client's needs and priorities for care 5. Client assessments or interventions that are required after transfer Rationale A transfer report is made to provide continuity of care. It may be given by one nurse to another nurse by phone or in person, such as when a client is being transferred from one nursing unit to another. The report should include the following information: client's name, age, health care provider, and diagnosis; current health status, current plan of care, and client requests; client's needs and priorities for care; any assessments or interventions that are needed after transfer (e.g., laboratory tests, medication administration, dressing changes); the need for any special equipment; and any additional considerations for care (e.g., resuscitation status; precautionary considerations; cultural, religious, or family issues). The receiving nurse must be given an opportunity to repeat the information and to ask questions about the client's status. The client's home address and medical record number are not a part of the transfer report and are not directly related to client needs.

A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? 1. The client is definitely pregnant. 2. The nurse-midwife noted softening of the cervix. 3. The client exhibits a presumptive sign of pregnancy. 4. The nurse-midwife noted a violet coloration of the cervix.

2. The nurse-midwife noted softening of the cervix Rationale In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.

A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? 1. She must come to the clinic to be checked. 2. This is an expected occurrence during pregnancy. 3. This is frequently the first sign of a breast infection. 4. She should notify the nurse-midwife of this finding

2. This is an expected occurrence during pregnancy. Rationale Colostrum, the creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples as early as 16 weeks' gestation. This is an expected occurrence during pregnancy. It is not necessary for the client to notify the nurse-midwife or to report to the clinic to be checked. It is not a sign of infection.

Mrs. Crenshaw, in room 5129, is scheduled to be transferred to a nearby long-term care facility at 4 p.m. Lisa asks Mrs. Crenshaw's nurse, Mike, to give a transfer report to the nurse at the long-term care facility. What is the primary purpose of this transfer report? 1. To document client care 2. To ensure continuity of care 3. To communicate the client's allergies 4. To summarize the client's plan of care

2. To ensure continuity of care Rationale A transfer report is given when a client moves from one unit to another or from one facility to another. The primary purpose of the transfer report, as with any type of nursing report, is to ensure continuity of care even though the circumstances or location has changed. Communicating information about a client's allergies and summarizing a client's plan of care are components of a transfer report but not its primary purpose. Documentation of client care is also not the purpose of a transfer report. Documentation is a continuous and ongoing process carried out during the client's hospital stay.

The nurse determines that which situations represent the use of evidence-based practice in clinical decision-making for client care? Select all that apply: 1. Encouraging a client to take a laxative twice a week to prevent constipation 2. Using information about the client's preferences and values when planning care 3. Using a research-based scale to routinely assess a client's risk for skin breakdown 4. Manually lifting a client rather than using a slider board to transfer a client from a bed to a stretcher 5. Asking a health care provider for a prescription to insert a urinary catheter for a client who is experiencing incontinence

2. Using information about the client's preferences and values when planning care 3. Using a research-based scale to routinely assess a client's risk for skin breakdown Rationale Evidence-based practice is an approach to client care in which the nurse integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. Encouraging a client to take a laxative to prevent constipation promotes laxative dependency; rather, the nurse would encourage practices such as increased fluid intake and consumption of a high-fiber diet. Manually lifting a client rather than using a slider board to transfer a client from a bed to a stretcher could result in injury to health care workers and does not reflect good practice; rather, the nurse would use assistive devices that will help prevent injury. Inserting a urinary catheter might result in an infection; rather, the nurse would institute noninvasive measures for the client experiencing incontinence.

After Madeleine talks to her physician, a do-not-resuscitate (DNR) order is written. However, Madeleine's daughter expresses concern: "My mother isn't near death, is she? Does this mean you're going to stop giving her medical care?" Which of these responses by the nurse are correct? Select all that apply. 1. "Unfortunately, yes — it does mean that she will die soon." 2. "She will still be taking medications to treat her heart failure." 3. "A do-not-resuscitate order means that your mother wishes to have all medical treatment stopped at this time." 4. "It means that if her heart stops, she has chosen to let nature take its course rather than let us take measures to keep her alive." 5. "A do-not-resuscitate order does not indicate that her death is coming soon. It just helps us follow her wishes in the event that her heart does stop."

2. "She will still be taking medications to treat her heart failure." 4. "It means that if her heart stops, she has chosen to let nature take its course rather than let us take measures to keep her alive." 5. "A do-not-resuscitate order does not indicate that her death is coming soon. It just helps us follow her wishes in the event that her heart does stop." Rationale A "do not resuscitate" or "no code" order indicates that the client wishes that no extraordinary measures be taken if cardiac arrest occurs. It does not mean that all medical treatment will be stopped or signal that the end of life is near. The DNR order must be written by the health care provider after consultation with the client.

Phenytoin is an anticonvulsant that reduces the effectiveness of oral contraceptives. When a client is taking a medication that diminishes the effectiveness of oral contraceptives, an increased dosage of the oral contraceptive may be required. An increased dosage of the phenytoin would not be necessary; additionally, this could be harmful to the client and lead to phenytoin toxicity. The effect of the phenytoin is not magnified while the client is taking the oral contraceptive. 1. "I need to use spermicidal cream with the diaphragm." 2. "I shouldn't leave the diaphragm in for more than 24 hours." 3. "I have to insert the diaphragm immediately before intercourse." 4. "The diaphragm should stay in place for at least 6 hours after intercourse."

3. "I have to insert the diaphragm immediately before intercourse." Rationale When in place over the cervical os, the diaphragm blocks access of sperm to the cervix. Because the device does not fit tightly enough to completely block penetration of sperm, however, it must be filled with spermicidal jelly or cream before insertion. (Spermicide must be reapplied with repeated intercourse.) It may be inserted as long as 6 hours before intercourse. The diaphragm must remain in place for at least 6 hours after intercourse, but, because of the risk of toxic shock syndrome, it should not be left in place for more than 24 hours.

A nurse provides instructions to a breastfeeding mother about measures that will provide relief from breast engorgement. Which statement by the mother indicates an understanding of the instructions? 1. "I should switch to formula to feed my baby for 1 week." 2. "I need to stop breastfeeding until the engorgement resolves." 3. "I should apply warm packs to my breasts before each feeding." 4. "I need to apply ice packs to my breasts 20 minutes before a feeding."

3. "I should apply warm packs to my breasts before each feeding." Rationale When breast engorgement occurs, the breasts become edematous, hard, and tender, making feeding and even movement painful. The nurse should encourage the woman to begin breastfeeding early after delivery and to feed frequently as a means of preventing engorgement. The nurse would also teach the woman about the application of cold and heat, massage, and breastfeeding techniques. Cold is used after feeding to reduce edema and pain. Heat is applied just before feedings to increase vasodilation and milk flow. Massage of the breasts causes release of oxytocin and increases the speed of milk release. This decreases the length of time that the infant nurses on painful breasts.

One of Madeleine's daughters comes in for a visit and talks to Madeleine about her wishes. She is willing to call an attorney for assistance but asks the nurse, "What's the difference between a durable power of attorney for health care and an instructional living will? I'm so confused!" Which of these responses by the nurse is correct? Select all that apply. 1. "They're the same thing, actually." 2. "With a durable power of attorney for health care, the family decides who will serve as the client's representative." 3. "The client specifies who will hold the client's durable power of attorney for health care, and that person does not have to be a family member." 4. "With either of these documents you are telling your health care provider that you no longer want any medical care and that you want to die." 5. "The living will is a legal document that tells the health care providers and family members what your wishes are about life-sustaining treatments if you can no longer make decisions." 6. "The durable power of attorney for health care is a legal document in which you name someone else to make decisions about your health care if you are no longer able to make these decisions."

3. "The client specifies who will hold the client's durable power of attorney for health care, and that person does not have to be a family member." 5. "The living will is a legal document that tells the health care providers and family members what your wishes are about life-sustaining treatments if you can no longer make decisions." 6. "The durable power of attorney for health care is a legal document in which you name someone else to make decisions about your health care if you are no longer able to make these decisions." Rationale Both the living will and durable power of attorney for health care are legal documents in which a person specifies his or her wishes about health care decisions in the event that the person cannot make these decisions on his or her own. The instructional living will is a document that provides instructions for health care providers and family members. The durable power of attorney for health care is a legal document in which a person designates another person, such as a family member or a friend, to make health care decisions when the person becomes unable to do so. The client selects the proxy, not the family members.

Just before her discharge, Lynn Ann decides that she wants to review her medical record. She calls the nurse and says, "I'd like to read my chart before I leave. I want to see the pathology report for myself." Which responses by the nurse are appropriate? Select all that apply. 1. "Sure! Let me go make a copy for you." 2. "Well, that's not really allowed. Why don't you believe what your doctor told you?" 3. "The nursing supervisor will be glad to review your record with you in case you have questions." 4. "We can't let you look at it now, but you can ask your doctor about reviewing it when you are discharged." 5. "Yes, you'll be able to review your record. Let me go and check on the correct procedure for doing that first, though."

3. "The nursing supervisor will be glad to review your record with you in case you have questions." 5. "Yes, you'll be able to review your record. Let me go and check on the correct procedure for doing that first, though." Rationale Per HIPAA regulations, the client has the right to inspect and have a copy of his or her medical record. Lynn Ann just wants to review her record; she is not asking for a copy at this time. However, clients may have questions about what is in the chart, and the institution's policies for client review of medical records must be followed. Asking a client why he or she wants to read the record is challenging the client and not therapeutic; it is not necessary to delay the review by asking the health care provider, although the health care provider should be informed of the client's request.

Isabel has begun outpatient chemotherapy. After each session, she goes home to rest, and she has been unable to care for her children. Her mother comes over in the afternoons to be there when the children come home from school and to cook dinner for the family. Trevor comes home one day with a note from his teacher. He has been rude at school, using "bad language" and talking back to the teacher. When asked about this, Trevor replies, "I'm fine. The teacher is stupid." Isabel calls the clinic nurse to talk about Trevor's behavior. Which statement by the nurse provides the best interpretation of Trevor's behavior? 1. "Yes, he's being rude and insensitive, but he'll grow out of it soon." 2. "Trevor needs to accept what's happening to you and stop acting out." 3. "This may be his way of running away from the situation. Let's try to get him to talk about it." 4. "The teacher just doesn't understand the difficult time that Trevor is going through right now."

3. "This may be his way of running away from the situation. Let's try to get him to talk about it." Rationale For a school-age child, the realization of impending death and loss is a major threat to the child's sense of security and ego strength. At this age, children are likely to show their fear through verbal uncooperativeness —using rude or bad language or being impolite and stubborn. The nurse should recognize this as an attempt to "run away" from stress and should encourage Trevor to talk about his feelings. The incorrect options avoid the situation and do not address Trevor's behavior or feelings.

A health care provider asks a client to participate in a cardiac research study, and the client agrees. After the health care provider leaves the client's room, the client says to the nurse, "I don't really want to participate in the study, but I didn't want to say no to my doctor. He's done so much for me — I guess this is the least I can do for him." How should the nurse respond to the client? 1. "Well, you've signed the consent form, so you're committed to participating." 2. "Yes, he has done a lot for you, hasn't he? But all that you need to do is tell him that you changed your mind." 3. "You have the right to consent to or decline participation in a research study. Even though you have agreed to participate, you have the right to change your mind." 4. "I know other clients who have participated in this study, and they didn't mind it at all. You might as well participate; before you know it, the study will be over with."

3. "You have the right to consent to or decline participation in a research study. Even though you have agreed to participate, you have the right to change your mind." Rationale A client has the right to consent or decline to participate in research and the right to change his or her mind about the treatment plan. Even though the client has signed the consent form, he or she is not committed to participating. Telling the client that he or she is committed to participating because the consent form has been signed violates the client's rights. The health care provider may or may not have done a lot for the client; regardless, agreeing with the client is a nontherapeutic communication technique. Telling the client that other clients who participated in the study did not mind participating at all is generalizing, which is nontherapeutic.

At 30 weeks' gestation, Janice is seen in the maternity clinic for a follow-up visit. The nurse checks the fundal height. Which measurement does the nurse expect to see? 1. 20 cm 2. 26 cm 3. 30 cm 4. 34 cm

3. 30 cm Rationale From 22 weeks to term, the fundal height, which is measured in centimeters, is roughly equal (±2 cm) to the gestational age of the fetus in weeks. Therefore, because this client is at 30 weeks' gestation, her fundal height would be 30 (±2 cm). If fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause of the unexpectedly large uterine size. If fundal height is less than expected on the basis of gestational age, the estimated date of delivery must be confirmed. If the dates are accurate, further assessment may be necessary to determine whether the fetus' growth is inadequate.

The nurse determines that which situations violate the rights? Select all that apply. 1. A client with anxiety is offered the opportunity to participate in an experimental drug research program. 2. A client with somatization disorder is allowed to keep her clothing and personal effects with her during the hospitalization. 3. A client is refused acceptance into a university health sciences program because of a diagnosis of obsessive-compulsive disorder. 4. A health care provider prescribes an intramuscular sedating medication for a client who is hyperactive without discussing the treatment with the client. 5. A client with a paranoid disorder is informed that once he is hospitalized he will not have telephone rights and will not be able to communicate with anyone outside the hospital.

3. A client is refused acceptance into a university health sciences program because of a diagnosis of obsessive-compulsive disorder. 4. A health care provider prescribes an intramuscular sedating medication for a client who is hyperactive without discussing the treatment with the client. 5. A client with a paranoid disorder is informed that once he is hospitalized he will not have telephone rights and will not be able to communicate with anyone outside the hospital. Rationale The mentally ill client has rights similar to those of the client who does not have a mental illness. The mentally ill client has the right to refuse participation in experimental treatments or research such as a drug research program. The hospitalized mental health client also has the right to keep clothing and personal effects with him or her. The client has the right to education, so denying him or her acceptance into a university because of mental illness is a violation of the client's rights. The client also has the right to give informed consent, so prescriptions must be discussed with the client. Not allowing a hospitalized client to communicate with persons outside the hospital is a violation of the client's rights.

Penny is admitted to the labor room in the first stage of labor. Which breathing pattern should the labor room nurse teach Gilbert so that he may coach Penny? 1. Pushing in short bursts when the urge is very strong 2. Exhaling small amounts of air through an open glottis during pushing 3. A deep inspiration and expiration at the beginning and end of each contraction 4. Taking a cleansing breath at the beginning of a contraction, holding her breath, then pushing as hard as she can for as long as possible

3. A deep inspiration and expiration at the beginning and end of each contraction Rationale Breathing exercises provide a focus during contractions, interfering with the transmission of pain sensation. During the first stage of labor, the client uses cleansing breaths (a deep inspiration and expiration at the beginning and end of each contraction), slow-paced breathing, modified-paced breathing, pattern-paced breathing, and breathing to prevent pushing. If the woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and fetal head.

Janice asks the nurse about her expected date of delivery. Using Nägele's rule, the nurse calculates the estimated date of delivery (EDD) as: 1. May 25, 2017 2. May 31, 2017 3. June 1, 2017 4. July 1, 2017

3. June 1, 2017 Rationale For Nägele's rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse subtracts 3 months from the first day of the last menstrual period, adds 7 days, and then adjusts the year as necessary. Subtracting 3 months from August 25, 2016, yields May 25, 2016. Adding 7 days yields June 1, 2016. Adding 1 year to June 1, 2016 brings the EDD to June 1, 2017.

Which situation is an example of the maladaptive defense mechanism known as identification? 1. A client criticizes the nurse after his family fails to visit him. 2. A married man flirts with his secretary and then brings flowers home to his wife. 3. A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. 4. A nursing student who fears failure on a final exam develops a terrible headache and is unable to take the exam.

3. A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. Rationale Identification is an unconscious attempt to change oneself to resemble an admired person. A young boy's belief that a neighborhood gang leader who sells illegal drugs is someone to look up to is identification as a maladaptive defense. Displacement is a defense mechanism in which feelings toward one person are directed at another who is less threatening, thereby satisfying an impulse with a substitute object. The client who criticizes a nurse after his family fails to visit him is engaging in displacement. Undoing is engaging in behavior that is considered the opposite of a previous unacceptable behavior, thought, or feeling (e.g., a married man flirts with his secretary and then brings flowers home to his wife). Conversion is the expression of emotional conflicts through physical symptoms. A nursing student who fears failure on a final exam and develops a terrible headache becoming unable to take the exam is an example of conversion.

The nurse employed in the mental health unit of a hospital is leading a group psychotherapy session. Which is the nurse's role in the termination of stage of group development? 1. Encourage problem-solving 2. Encourage accomplishment of the group's work 3. Acknowledge the contributions of each group member 4. Encourage members to become acquainted with one another

3. Acknowledge the contributions of each group member Rationale In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and help one another prepare for the future. Encouragement of problem-solving and accomplishment of the group's work is part of the working stage. Encouragement of members to become acquainted with one another is a task of the orientation stage.

The nurse is reviewing Angela's laboratory results and discovers that her pregnancy test result is positive. The nurse asks Angela, "When was your last menstrual period?" Angela answers, "I'm not sure. Am I pregnant?" The nurse tells Angela that the pregnancy test result was positive, and Angela starts sobbing: "That's all I need right now!" Who else should the nurse notify? Select all that apply. 1. Angela's mother 2. Angela's husband 3. Angela's health care provider 4. The nurse's co-workers on the same shift 5. The nurse on the oncoming shift, during report 6. The radiology technician who comes in to perform a chest x-ray

3. Angela's health care provider 5. The nurse on the oncoming shift, during report 6. The radiology technician who comes in to perform a chest x-ray Rationale HIPAA requires that health care providers not disclose information about the client to anyone, without the client's consent, except to those who need to know to implement the client's treatment plan. The client's health care provider, the nurse on the oncoming shift, and the technician performing an x-ray need to know the information, but Angela must provide consent before her husband or mother or anyone else is notified.

A nurse receives a telephone call from her next-door neighbor, who is frantically seeking help because her 3-year-old son has swallowed pills from a bottle of ibuprofen. The neighbor tells the nurse that her teenage daughter takes the pills for menstrual cramps and apparently forgot to put the bottle away before leaving for school this morning. After the nurse rushes to the neighbor's house, which action should she take first? 1. Calling the poison center 2. Asking the mother to call an ambulance 3. Assessing the child for airway patency and removing any visible material from the child's mouth 4. Asking the neighbor to call the school and ask her daughter how many pills remained in the bottle

3. Assessing the child for airway patency and removing any visible material from the child's mouth Rationale In the event of an accidental poisoning, the nurse would first assess airway patency, breathing, and circulation. The nurse would remove any visible material from the child's mouth and then try to identify the type and amount of substance ingested, because this may help determine the correct antidote. The Poison Control Center is also called, but airway is the priority. If the Poison Control Center says that the child should be taken to an emergency department, an ambulance is called. It may be necessary to contact the daughter at school, but this would not be the first action.

The nurse is discussing Claudia's nutritional status with the hospital dietitian. Which menu is best for Claudia? 1. Roast beef, mashed potatoes, broccoli, fruit, and coffee 2. London broil, baked potato, green beans, gelatin, and tea 3. Cheeseburger, French fries, carrot sticks, fruit, and a milkshake 4. Turkey breast with gravy, sweet potatoes, cranberry sauce, spinach, and milk

3. Cheeseburger, French fries, carrot sticks, fruit, and a milkshake Rationale The client with mania may be too active, distracted, agitated, or disorganized to sit down and eat. Because of the client's constant activity, adequate intake of fluids and calories is needed. Therefore high-calorie protein drinks and milkshakes and finger foods such as sandwiches and fruit should be offered. Such foods allow the client to eat "on the run." Foods that require the client to sit and beverages containing caffeine should be avoided in the diet of the client with mania.

A nurse receives a telephone call from the admissions office and is told that a child with respiratory syncytial virus (RSV) is being admitted to the hospital. Which type of precautions does the nurse prepares to institute for the child? 1. Enteric 2. Droplet 3. Contact 4. Airborne

3. Contact Rationale Contact precautions are instituted for any client with a known or suspected illness that is easily transmitted by way of direct client contact or through contact with items in the client's environment. RSV, respiratory syncytial virus, is easily communicable, mainly through contact with contaminated surfaces. RSV is not transmitted by way of the enteric or airborne route or in droplets.

Claudia says to the nurse "I don't need your help! I can control my own behavior!" and storms out of the lounge. A few minutes later she rushes back into the lounge, wearing a tight miniskirt and a halter top. She sits down in front of Charles and says to him, "Look, Charles. Do you like what I'm wearing?" Which action by the nurse is appropriate? 1. Telling Claudia to behave 2. Telling Claudia to go to her room 3. Escorting Claudia to her room and helping her change clothes 4. Escorting Charles to another chair and telling him to ignore Claudia's behavior

3. Escorting Claudia to her room and helping her change clothes Rationale A client with mania has poor judgment and may choose clothing that is noticeably inappropriate. The client's speech may be marked by sexual or obscene comments, and the client may make inappropriate sexual propositions to strangers. The nurse should escort Claudia to her room and help her change clothes. This action will help Claudia maintain her dignity. The nurse should supervise the client's choice of dress and discourage the use of flamboyant and bizarre clothing to lessen the potential for ridicule, which lowers self-esteem and increases the need for manic defense. Telling Claudia to behave or to go to her room and telling Charles to ignore Claudia are all inappropriate because they do not maintain Claudia's dignity and may escalate Claudia's mania.

A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? 1. Gravida 2, para 4 2. Gravida 3, para 5 3. Gravida 4, para 2 4. Gravida 5, para 3

3. Gravida 4, para 2 Rationale Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.

A client says to the nurse, "I give you a lot of credit for what you do. I could never be a nurse or do anything that has to do with the medical profession — I have a panic attack whenever I see blood." Which type of phobia does the nurse identify from the client's statement? 1. Acrophobia 2. Agoraphobia 3. Hematophobia 4. Claustrophobia

3. Hematophobia Rationale A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to an intense desire to avoid the object, activity, or situation. Hematophobia is the fear of blood. Acrophobia is the fear of heights. Agoraphobia is the fear of open spaces. Claustrophobia is the fear of enclosed spaces.

The nurse is demonstrating client advocacy in which of these situations? Select all that apply. 1. Helping a client bathe 2. Changing a client's abdominal dressing 3. Including the client in the formulation of a nursing care plan 4. Ensuring that the client has been informed of the treatment plan 5. Sharing the client's viewpoint regarding treatment during an interdisciplinary health care conference

3. Including the client in the formulation of a nursing care plan 4. Ensuring that the client has been informed of the treatment plan 5. Sharing the client's viewpoint regarding treatment during an interdisciplinary health care conference Rationale The nurse must act as a client advocate and speak up for or act on the behalf of the client, protect the client's right to make his or her own decisions, and uphold the principle of fidelity. The nurse serves as an advocate by ensuring that the client has been informed of the treatment plan and including the client in developing the plan of care. The nurse should also share the client's viewpoint with others, such as the interdisciplinary health care team, involved in the client's care. Helping a client bathe and changing a client's abdominal dressing are nursing interventions but are not specifically associated with the role of advocacy.

As Penny's labor progresses, the obstetrician performs another examination and concludes that Penny is in the second stage of labor. Which of these assessment findings should the nurse expect to note at this stage of labor? Select all that apply. 1. Descent of 1 to 2 cm 2. Pink to bloody mucus 3. Increase in bloody show 4. Increased urge to bear down 5. Cervical dilation of 10 cm with 100% effacement 6. Contractions 2 minutes apart, 90 seconds in duration

3. Increase in bloody show 4. Increased urge to bear down 5. Cervical dilation of 10 cm with 100% effacement 6. Contractions 2 minutes apart, 90 seconds in duration Rationale The second stage of labor is the stage during which the infant is born. The stage begins with cervical dilation of 10 cm and complete (100%) cervical effacement. The increase in bloody show, increased urge to bear down, and increased duration and frequency of contractions are part of the descent, or active pushing, phase of the second stage of labor. Mucus that is pink to bloody and descent of 1 to 2 cm are findings that are characteristic of the first stage of labor.

After the victims have been cared for and transported to local emergency departments for further assessment and treatment, to which function of the recovery phase does the emergency response team turn? 1. Providing disaster training programs 2. Checking the function of emergency equipment 3. Initiating actions that will return the community to normal 4. Trying to find facilities that will care for infants, older client, the disabled, and clients with chronic health problems

3. Initiating actions that will return the community to normal Rationale The recovery phase consists of actions taken to return the community to normal after a disaster. It involves preventing debilitating effects and restoring personal, economic, and environmental health and stability to the community. In the mitigation phase of disaster planning (the first phase), the team determines which resources are available for the care of infants, older clients, the disabled, and clients with chronic health problems. Providing disaster training programs and checking the function of emergency equipment are actions taken in the preparedness phase.

The mother of a newborn is upset because her newborn has a birthmark on the left side of the forehead. The mother, on being told that it is a nevus vasculosus (strawberry mark), asks the nurse whether the mark is permanent. What should the nurse tell the mother? 1. It is a permanent mark 2. It will need to be removed with surgery 3. It will disappear on its own by the early school years 4. It is nothing to be concerned about because it is so small

3. It will disappear on its own by the early school years Rationale Nevus vasculosus (strawberry mark) consists of enlarged capillaries in the outer layers of the skin. It is dark red and raised, with a rough surface, giving it a strawberry appearance. Usually located on the head, a nevus vasculosus may grow larger for 5 to 6 months but usually disappears by the early school years. No treatment is necessary.

A registered nurse orienting a new nursing graduate provides the graduate with ideas that will help her with time management. Which tips should the registered nurse provide? Select all that apply. 1. Keeping a log of daily activities takes too much time and is not at all useful. 2. Jot quick notes during the day and perform all client documentation at the end of the day. 3. Make client rounds at the beginning of the work shift and collect assessment data on each assigned client. 4. Avoid delegating tasks to others, because others may think that the graduate can't manage the assignment. 5. Try anticipating a client's needs before care so that all necessary supplies and items may be brought to the client at one time.

3. Make client rounds at the beginning of the work shift and collect assessment data on each assigned client. 5. Try anticipating a client's needs before care so that all necessary supplies and items may be brought to the client at one time. Rationale Time management involves using techniques and principles to limit the time spent on low-priority needs and to ensure that time is invested in activities of high priority. The nurse should make client rounds at the beginning of the work shift and collect assessment data on each assigned client. The nurse can anticipate the client's needs before care so that all necessary supplies and items may be brought to the client at one time. The nurse should also plan to document task completion and necessary client data throughout the day rather than waiting until the end of the day, delegate tasks when appropriate, and keep a daily hour-by-hour log to help provide structure to the tasks that must be accomplished.

A nurse is watching a nursing student implement standard precautions as she delivers care. The nurse should intervene if the nursing student performs which incorrect action? 1. Washing the hands after removing a pair of soiled gloves 2. Putting on a gown and gloves to change the bed linens of an incontinent client 3. Manually placing the cap on a needle after administering an IV push medication 4. Wearing gloves, eyewear, and a face shield when emptying a urine drainage bag

3. Manually placing the cap on a needle after administering an IV push medication Rationale Standard precautions must be practiced with all clients in every setting. These precautions involve handwashing and the use of gloves, masks, eye protection, and gowns, as well as other protective devices, as appropriate for client contact. Standard precautions are used to help prevent contact with blood, body fluids, nonintact skin, and mucous membranes. A mask, eye protection, or face shield is worn if client care activities have the potential to result in splashes or sprays of blood or other body fluids. A gown is worn if soiling of clothing is likely. The hands are always washed when gloves are removed. Needles are not recapped manually because of the risk of a needlestick; rather, they are discarded in a puncture-resistant container immediately after use (a mechanical device for recapping the needle may be used if one is available).

Now that Claudia is medically stabilized, plans are being made for her discharge home. Which should the nurse plan to ensure? 1. Claudia promises to attend a self-help group twice a week 2. Claudia will be able to return to her previous job immediately 3. Measures are instituted to help Claudia maintain medication compliance and prevent relapse 4. Claudia's mother will take responsibility for administering Claudia's medication as prescribed

3. Measures are instituted to help Claudia maintain medication compliance and prevent relapse Rationale After the manic phase of bipolar disorder and as the client is preparing for discharge from the hospital, measures are taken to maintain medication compliance and prevent relapse. Interventions are planned accordingly, depending on the client's interpersonal and stress-reduction skills, cognitive function, employment status, substance abuse problems, and social-support systems. During this time, psychoeducational teaching is critical. Evaluation of the need for communication and problem-solving skills training is also important. The need for referrals to community programs or self-help groups is evaluated, but the nurse should not ask the client to promise to do something. The client may not be ready to return to his or her previous employment immediately after discharge from the hospital. Asking Claudia's mother to take responsibility for administering Claudia's medication is inappropriate because the client needs to take responsibility for taking her own prescribed medications.

The nurse determines that which statements are accurate with regard to advance directives? Select all that apply. 1. The advance directive must be revised on a monthly basis. 2. The health care provider must serve as a witness when a client signs an advance directive. 3. On admission to a health care agency, the client must be asked about the existence of an advance directive. 4. The nurse is responsible for integrating the client's wishes as noted in the advance directive into the plan of care. 5. An advance directive is a document that supplies directions concerning the provision of care when a client is unable to make his or her own treatment choices

3. On admission to a health care agency, the client must be asked about the existence of an advance directive. 4. The nurse is responsible for integrating the client's wishes as noted in the advance directive into the plan of care. 5. An advance directive is a document that supplies directions concerning the provision of care when a client is unable to make his or her own treatment choices Rationale An advance directive is a written document that supplies directions concerning the provision of care when a client is unable to make his or her own treatment choices. On admission to a health care facility, the client must be asked about the existence of an advance directive. If one exists, it must be documented, integrated into the plan of care, and included in the client's medical record. It does not need to be revised on a monthly basis; however, the client has the right to make changes to the document at any time he or she wishes. The advance directive is a legal document, and agency and/or state guidelines must be followed in regard to witnesses to the document. The health care provider would not serve as a witness to the document. Individuals other than health care providers should serve as a witness.

Police officers bring a victim of physical and emotional abuse to the emergency department. They tell the nurse that this is the client's fifth visit to the department in the last 4 months because of violent attacks by her husband. After assessing and treating the client's physical wounds, the nurse prepares to conduct an interview on the client. Which finding does the nurse expect to note while interviewing the client? 1. The client has high self-esteem. 2. The client is angry and aggressive. 3. The client accepts the blame for the attack. 4. The client is talkative, energetic, and anxious.

3. The client accepts the blame for the attack. Rationale With each repeat of the violence patterns, the self-esteem of the victim erodes more and more. The victim either believes that the violence was deserved or accepts blame for it. This can lead to feelings of depression, hopelessness, dependency, depression, and powerlessness. High self-esteem, anger, aggressiveness, talkativeness, and displays of energetic or anxious behavior are not characteristics of an abuse victim.

Margaret's health care provider calls back to prescribe an x-ray and some blood chemistry studies. Which actions taken the nurse who is taking a verbal prescription are correct? Select all that apply. 1. Asking the unit secretary to write the prescription in the client's medical record 2. Delaying implementation of the prescriptions until the health care provider can come in to sign them 3. Reading back the prescriptions to the health care provider before the health care provider hangs up the phone 4. Writing the prescriptions in the client's medical record as soon as the health care provider hangs up the phone 5. Recognizing that the verbal prescription must be signed by the health care provider as soon as possible, usually within 24 hours

3. Reading back the prescriptions to the health care provider before the health care provider hangs up the phone 4. Writing the prescriptions in the client's medical record as soon as the health care provider hangs up the phone 5. Recognizing that the verbal prescription must be signed by the health care provider as soon as possible, usually within 24 hours Rationale Ideally the health care provider or prescriber writes a prescription, but if a verbal prescription is necessary, the nurse should read the prescription back to the health care provider and write it in the client's medical record immediately. The health care provider or prescriber must sign the prescription as soon as possible; most policies specify that this must be done within 24 hours. The nurse would not ask the unit secretary or any other person to write the prescription; this is illegal and could also result in an error. Implementation of verbal prescriptions is not delayed until a signature is received.

A nurse calculates an infant's Apgar score 1 minute after birth and obtains a score of 8. Based on this finding, which action should the nurse take? 1. Notifying the infant's pediatrician 2. Administering oxygen to the infant 3. Recalculating the infant's Apgar score 5 minutes after birth 4. Attempting to stimulate the infant by rubbing the infant's back

3. Recalculating the infant's Apgar score 5 minutes after birth Rationale The nurse calculates the infant's Apgar score at 1 and 5 minutes after birth for rapid evaluation of early cardiopulmonary adaptation. If the score is between 8 and 10, no intervention is needed except for support of the infant's spontaneous efforts. If the score is between 4 and 7, the nurse gently stimulates the infant by rubbing his or her back and administers oxygen to the infant. A score between 0 and 3 indicates the need for resuscitation.

A 6-year-old child is brought to the school nurse's office because the child is complaining of abdominal pain. During assessment of the child, the nurse notes the presence of bruises on the child's abdomen and back, as well as several cigarette burns, and suspects child abuse. Which priority action should the nurse plan to take? 1. Documenting the bruises 2. Asking the child how long his parents have been abusing him 3. Removing the child from the abusive situation to prevent further injury 4. Calling the parents to ask them how the child sustained the bruises and burn marks

3. Removing the child from the abusive situation to prevent further injury Rationale In a case of suspected child abuse, removing the child from the abusive situation to prevent further injury is the priority. Also, every case of suspected child abuse must be reported to local authorities. The nurse would also provide accurate and thorough documentation of the child's bruises, but this is not the priority action. Asking the child how long he has been abused is inappropriate and may instill fear in the child. Determining how long the parents have been abusing the child is not the priority; neither is confronting the parents. Confrontation may anger the parents (if they are in fact the abusers), and they may take the child home before safety interventions can be initiated, putting the child at risk for further injury, especially if the parents believe that the child has told someone that he is the victim of abuse.

A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. 1. Perform the exercise while urinating. 2. Perform the exercise once only after urinating. 3. Repeat the contraction-relaxation cycle 30 times a day. 4. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. 5. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.

3. Repeat the contraction-relaxation cycle 30 times a day. 4. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. Rationale Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.

Janice comes to the clinic for her 39-week visit. (Refer to Janice's record by clicking "Chart" below.) Based on the data recorded (refer to medical record), the nurse concludes that one condition may be a problem. What is it? Blood pressure 162/110 mm Hg Temperature: 98.4° F Pulse 92 beats/min Respirations 14 breaths/min "I've had a headache for the last few days." "My vision seems blurry lately." "I've had to take off my rings because my fingers are swollen." Urine dipstick: proteinuria +2; glucose negative Bilateral ankle edema, +2 Edema of face and fingers Fundal height 38.5 cm Fetal heart tones (FHTs): 140 beats/min Deep tendon reflexes: 2+ 1. Eclampsia 2. Mild preeclampsia 3. Severe preeclampsia 4. Chronic hypertension

3. Severe preeclampsia Rationale A client experiencing severe preeclampsia will have a blood pressure of 160/110 mm Hg or higher on two separate occasions and will have 2+ to 3+ proteinuria on dipstick testing. Headaches, blurred vision, and facial and finger edema may also be present. Chronic hypertension would have been detected before pregnancy or before 20 weeks of gestation. Mild preeclampsia presents with a blood pressure of 140/90 mm Hg, minimal or no headache, no vision problems, and proteinuria of less than 2+ on dipstick testing. Eclampsia is an emergency that is characterized by seizure activity and sometimes coma.

After checking Penny again, the obstetrician decides to perform rupture of the membranes (ROM). Penny is told that she will need to empty her bladder first and then remain in bed after the procedure. Which of these assessment findings after ROM indicate that the amniotic fluid is normal? Select all that apply. 1. Strong odor 2. Thick and cloudy 3. Watery consistency 4. Greenish-brown color 5. Pale and straw colored

3. Watery consistency 5. Pale and straw colored Rationale Normal amniotic fluid is pale or straw-colored and of a watery consistency, without a strong odor. Thick, cloudy amniotic fluid or a strong odor might indicate an intrauterine infection. Greenish-brown fluid reflects the presence of meconium and may indicate that the fetus has had a hypoxic episode.

Because maintaining a constant hormone level is important for effectiveness, the woman using oral contraceptive must take a pill at the same time each day. Unless a woman begins the pills during the first 7 days of the menstrual cycle, she should use another contraceptive method during the first week of the first cycle until blood hormone levels are established. If the woman misses a pill, she should take it as soon she remembers. If the woman misses a period and thinks that she might be pregnant, she should stop taking the pill and have a pregnancy test immediately. 1. She will need to have yearly liver function studies. 2. She will need to have a yearly cardiovascular test for 2 years and one every other year thereafter. 3. She will need to have a yearly pelvic and breast examination, Papanicolaou (Pap) smear, and blood pressure measurement. 4. She will need to have a pelvic and breast examination and Pap smear every 2 years, but her blood pressure should be checked every 6 months.

3. She will need to have a yearly pelvic and breast examination, Papanicolaou (Pap) smear, and blood pressure measurement. Rationale A woman who takes oral contraceptives should have a yearly pelvic and breast examination, Pap smear, and blood pressure measurement. Cardiovascular tests and liver function studies are not necessary.

The nurse is conducting a group therapy session. One client with mania talks constantly, dominating the session and her behavior is disrupting group interaction. The nurse should take which initial action? 1. Ask the client to leave the group session 2. Ask another nurse to escort the client out of the group session 3. Tell the client she needs to allow other clients in the group to talk 4. Tell the client that she will not be allowed to attend future group sessions

3. Tell the client she needs to allow other clients in the group to talk Rationale A manic client may be extremely talkative, dominating group meetings or therapy sessions. If this occurs, the nurse should initially set limits on the client's behavior. It is inappropriate initially to ask the client to leave the session or to ask another person to escort the client from the session, which could agitate the client and further escalate the client's behavior. Telling the client that she will not be allowed to attend future group sessions is also an inappropriate initial action. It violates a client's right to receive treatment and is a threatening action.

Claudia, pacing back and forth across the lounge, begins to yell at a client named Charles. She tells Charles that she will hit him if he doesn't start paying attention to her. What is the appropriate response by the nurse who witnesses the incident? 1. Telling Claudia to leave the lounge 2. Escorting Charles from the lounge 3. Telling Claudia, "Claudia, do not yell at Charles or hit him. If you can't control yourself, we'll help you." 4. Telling Claudia, "Claudia, your behavior is inappropriate. If you don't stop yelling, we're going to have to restrain you and put you in seclusion."

3. Telling Claudia, "Claudia, do not yell at Charles or hit him. If you can't control yourself, we'll help you." Rationale The nurse must set limits on Claudia's behavior in simple, clear, and concrete terms and provide Claudia with reassurance that she will be given assistance if she is unable to control her behavior. Escorting Charles from the lounge is inappropriate; another client should not be expected to leave the lounge because of Claudia's behavior. Telling Claudia to leave the lounge and making threats or putting pressure on Claudia may escalate her behavior; additionally, these options are inappropriate and violate the client's rights.

Michael tells the nurse that he is much too nervous about having surgery and that he has changed his mind: He does not want the surgery. Which action should the nurse take? 1. Telling Michael that he is contracted to having the surgery since signing the informed consent 2. Telling Michael that there is nothing to be nervous about because such surgical procedures are performed every day 3. Telling Michael that he has a right to change his mind and informing him of the consequences of not having the surgery 4. Telling Michael that it is his choice but that his surgeon will be very upset because the cancellation will cause a disruption in the operating room schedule

3. Telling Michael that he has a right to change his mind and informing him of the consequences of not having the surgery Rationale The client has a right to make health care decisions and to change his mind in regard to treatment even if he has signed the informed consent. However, the client must be informed of the harmful consequences of refusing the treatment or procedure. If the client persists in refusing the treatment or procedure, the health care provider is notified, and the rejection should be documented, signed, and witnessed. Telling Michael that there is nothing to be nervous about or that he will upset the operating room schedule avoids his feelings and concerns and is inappropriate and nontherapeutic.

A nurse is preparing to work as a volunteer at a seafood festival, in charge of the first aid tent. What does the nurse understand about her work as a volunteer? Select all that apply. 1. That she will not be provided legal immunity under the state's Good Samaritan law 2. That she must have professional liability insurance, because the Good Samaritan law will not apply 3. That Good Samaritan laws vary by state, and she must be aware of the law in the state in which she is volunteering 4. That she will be covered by the Good Samaritan law as long as she provides nursing care within acceptable standards 5. That she will not be covered by the Good Samaritan law, because it applies only to accidents that occur on highways

3. That Good Samaritan laws vary by state, and she must be aware of the law in the state in which she is volunteering 4. That she will be covered by the Good Samaritan law as long as she provides nursing care within acceptable standards Rationale Good Samaritan laws are passed by state legislatures. Because these laws vary by state, the nurse must be aware of the law in the state in which she is volunteering. Such laws encourage health care professionals to assist in emergency situations without fear of being sued for the care they provide. The law limits liability and offers legal immunity for people helping in an emergency, provided that they render reasonable care. Immunity from lawsuit applies only when all conditions of the state law are met (e.g., the health care provider receives no compensation for the care provided and the care given is not intentionally negligent). All nurses are encouraged to obtain their own professional liability insurance; if the nurse does have his or her own professional liability insurance the Good Samaritan law will still apply.

A client with a diagnosis of severe depression is being treated in an inpatient mental health unit. Which observation by the nurse indicates an increased risk for suicide? 1. The client is pacing the hallway. 2. The client is sitting in her room, wringing her hands. 3. The client gives her handmade sweater to her roommate. 4. The client is sitting alone in the corner of the clients' lounge.

3. The client gives her handmade sweater to her roommate. Rationale The nurse must be alert for clues indicating a risk for suicide in the client with depression. Behavioral changes, especially those that occur when the depression lifts and the client has more energy available with which to carry out a suicide plan, may indicate such a risk. Signs include giving away prized personal possessions, writing farewell notes, making out a will, and putting personal affairs in order. Pacing the hallway, wringing the hands, and sitting alone are all behaviors that may be noted in a client with depression, and although they cannot be ignored, they are not direct signs of an increased risk for suicide.

The nurse in a mental health clinic is interviewing a client who was referred to the clinic by the client's primary health care provider. Which finding indicates to the nurse that the client needs assistance to restore and maintain mental health? 1. The client has a positive self-concept. 2. The client identifies strengths and uses these for goal attainment. 3. The client has a distorted view of the world and communicates inappropriately. 4. The client identifies coping mechanisms used to successfully cope with threats to the self.

3. The client has a distorted view of the world and communicates inappropriately. Rationale A client who experiences a disturbance in homeostasis as a result of a threat to the self and experiences an alteration in reality may come to have a distorted view of the world and may communicate inappropriately and inadequately. This psychic discomfort felt by the individual may be manifested through various mental health problems such as adjustment disorders, psychophysiological manifestations, psychotic disorders, and behaviors indicative of sensory deprivation. The remaining options are all healthy mental health behaviors.

During a conversation with a nurse, an older client states, "I'm so dissatisfied with my life — it's just been one disappointment after another." Using Erik Erikson's theory of psychosocial development, which interpretation of the client's statement does the nurse make? 1. The client has fulfilled his life's goals. 2. The client is looking back over his life and accepting what has occurred. 3. The client is demonstrating unsuccessful resolution of the crisis associated with this developmental stage. 4. The client is demonstrating successful resolution of the crisis associated with the developmental stage by verbalizing what has occurred during his life.

3. The client is demonstrating unsuccessful resolution of the crisis associated with this developmental stage. Rationale According to Erikson, all individuals pass through eight psychosocial stages over the course of a lifetime. Each stage represents a crisis in which the goal is to integrate physical, maturation, and psychosocial demands. In later adulthood, the psychosocial crisis is integrity versus despair. The task during this stage is to look back over one's life and accept its meaning. A sense of integrity and fulfillment indicates successful resolution of the crisis. Dissatisfaction with life indicates unsuccessful resolution of the crisis.

A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? 1. The procedure will take about 2 hours. 2. The obstetrician will locate the fetus with the use of the Leopold maneuvers. 3. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. 4. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.

3. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Rationale Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.

Lian is given a prescription for diclofenac. After reviewing Lian's medical record (click "Chart" below), what concerns should the nurse have?" 1. There are no concerns with these prescriptions as they are written. 2. The diclofenac and the irbesartan should be taken at least 2 hours apart. 3. The ginseng may cause bleeding problems if it is taken with the diclofenac. 4. The new prescription for diclofenac may interact with the calcium-vitamin D supplement, reducing the effectiveness of the diclofenac.

3. The ginseng may cause bleeding problems if it is taken with the diclofenac. Rationale The diclofenac, an NSAID, may interact with herbal preparations such as ginseng, with a resulting increase in antiplatelet action, which could lead to increased bleeding tendencies. Whenever a client is taking an herbal product, the prescriber must be notified so that he or she may evaluate the potential for herb-drug interactions. The statements in the other options are incorrect.

After eating lunch, Margaret gets out of bed and walks to the bathroom. On her way back from the bathroom she becomes lightheaded and grabs at the overbed table, which rolls into the wall, causing Margaret to fall to the floor. The nurse rushes into the room on hearing the noise and finds Margaret lying on the floor. The nurse takes Margaret's vital signs and assesses Margaret for injuries. After determining that Margaret has sustained no further injuries, the nurse assists Margaret back into bed. Which statement indicates negligence on the part of the nurse with regard to Margaret's fall? 1. Margaret did not call for assistance to get out of bed. 2. The nurse placed Margaret's call bell within her reach. 3. The nurse did not instruct Margaret in how to use the call bell. 4. The nurse instructed Margaret to call for assistance to get out of bed

3. The nurse did not instruct Margaret in how to use the call bell. Rationale Negligence, conduct that falls below the standard of care, includes acts of commission as well as acts of omission. If a nurse gives care or fails to give care that does not meet standards, he or she may be held liable for negligence. If a nurse does not instruct a client in how to use a call bell, the client cannot call the nurse for assistance. The nurse must instruct the client in the use of the call bell, place the call bell within reach, and instruct the client to call for assistance to get out of bed.

Later that evening, a newly hired nurse comes to the emergency department and states to the nurse caring for Angela, "I've been assigned to work here, but I don't have a computer password yet. May I use yours?" How should the nurse respond? Select all that apply. 1. The nurse gives the new nurse the password, then changes it at the end of the shift. 2. The nurse gives the new nurse the password and asks her not to give it to anyone else. 3. The nurse states, "No, I can't give you my password. It's against our hospital policy to share passwords." 4. The nurse states, "I can't give my password to you, but I'll open the client records for you so that you can enter your own data." 5. The nurse states, "Let's call the information technology department and see what they can do about getting a password for you."

3. The nurse states, "No, I can't give you my password. It's against our hospital policy to share passwords." 5. The nurse states, "Let's call the information technology department and see what they can do about getting a password for you." Rationale Passwords are essential for keeping client information confidential. One's password should not be known to anyone but the user and the information systems administrator. Passwords for health care agency computer systems should not be shared with anyone else, under any circumstances. The nurse should help the new employee obtain a new password within the guidelines of the health care facility.

A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? 1. She should cover the discoloration with makeup. 2. She should come to the clinic immediately to be checked. 3. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. 4. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen.

3. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. Rationale Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.

Hospice care has been initiated for Louis, and he is being provided with several daytime services. His condition is deteriorating. During the night, Laura notices that Louis' breathing pattern has changed, and she calls the hospice nurse. The nurse comes quickly to assess Louis and notes periods of apnea alternating with periods of deep, rapid breathing. What is the appropriate explanation for the nurse to give to Laura? 1. Louis probably has some sinus congestion. 2. This type of breathing is a sign of pneumonia. 3. This type of breathing is a sign of approaching death. 4. Louis needs to be turned and repositioned more frequently.

3. This type of breathing is a sign of approaching death. Rationale An abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing is a physical manifestation of approaching death. Sinus congestion, pneumonia, and the need for more frequent repositioning are not associated with this type of breathing.

Which of the following tasks should the nurse assign to a nursing assistant? Select all that apply. 1. A colostomy irrigation 2. A continuous tube feeding 3. Urine specimen collections 4. Stool specimen collections 5. Ambulating a client who is unsteady 6. Feeding a client who has difficulty swallowing food and fluids

3. Urine specimen collections 4. Stool specimen collections 5. Ambulating a client who is unsteady Rationale The nurse must keep in mind the skills of the health care team member and the needs of the client to make the most appropriate assignment. In this case, the appropriate tasks for a nursing assistant would be to collect urine and stool specimens and to ambulate the client who is unsteady. The nursing assistant is trained to perform these activities. Colostomy irrigation and tube feedings are not performed by unlicensed personnel. The client having difficulty swallowing food and fluids is at risk for aspiration.

A nurse has just assisted in the delivery of a newborn infant and is preparing to help deliver the placenta. For which sign of placental separation does the nurse monitor the woman? 1. A soft, boggy fundus 2. Shortening of the umbilical cord 3. Vaginal fullness on examination 4. Assumption of a discoid shape by the uterus

3. Vaginal fullness on examination Rationale Signs of placental separation include a firmly contracting fundus; a change in the uterus from a discoid to a globular shape, which occurs as the placenta moves into the lower uterine segment; a sudden gush of dark blood from the introitus; apparent lengthening of the umbilical cord as the placenta descends to the introitus; the presence of vaginal fullness (placenta) on vaginal or rectal examination; and the presence of fetal membranes at the introitus.

Joseph has been undergoing therapy, and suicide precautions have been discontinued. Joseph asks the nurse about being discharged from the mental health unit. What information does the nurse keep in mind as he responds to Joseph? 1. Administrative approval is required before discharge. 2. Because of his admission status, Joseph may not request discharge. 3. Voluntarily admitted clients have the right to request and be granted release from the mental health unit. 4. Discharge will not be considered unless Joseph is able to move in with a relative or friend who can stay with Joseph full time for at least 1 month.

3. Voluntarily admitted clients have the right to request and be granted release from the mental health unit. Rationale Voluntarily admitted clients have the right to request and be granted release from the mental health unit. Administrative approval is not required. Asking Joseph to move in with a relative or friend who will stay with him on a full-time basis for at least 1 month is incorrect and unrealistic.

The nurse is planning activities for a client, hospitalized in the mental health unit, who is experiencing a moderate level of anxiety. Once the nurse has conducted a physical assessment, which activity is most appropriate for the client? 1. Painting 2. Drawing 3. Walking 4. Board games

3. Walking Rationale Interventions for the client with moderate anxiety include providing outlets through which to work off excess energy and direct the client's attention outward. Physical activity can provide relief of built-up tension, increase muscle tone, and increase release of endorphins. Such activities include walking, table tennis, dancing, and exercising. Painting, drawing, and board games are sedentary activities.

A nurse who has just assisted in the delivery of a newborn infant is providing initial care to the infant. Which action should the nurse take to prevent heat loss by way of conduction in the infant? 1. Keeping the infant away from drafty areas 2. Keeping the infant away from cold windows 3. Warming the hands before touching the infant 4. Drying the infant as soon as possible after birth

3. Warming the hands before touching the infant Rationale Conduction of heat away from the body occurs when a newborn comes in direct contact with an object that is cooler than his or her skin. Placing an infant on a cold surface or touching the newborn with cold hands or a cold stethoscope causes this type of heat loss. Convective heat loss occurs when heat is transferred to air surrounding the infant. Keeping the infant out of drafts and maintaining warm environmental temperatures help prevent this type of heat loss. Radiation is the transfer of heat to cooler objects that are not in direct contact with the infant. An infant placed near a cold window loses heat by way of radiation. Heat loss by way of evaporation occurs when a wet surface is exposed to air. Drying the infant as soon as possible after birth and after bathing prevents this type of heat loss.

The nurse is performing an assessment of an African-American client who is being seen in the clinic for the first time. Which question should the nurse ask to elicit information on a health risk associated with this cultural group? 1. "Does anyone in your family have arthritis?" 2. "Does anyone in your family have thalassemia?" 3. "Does anyone in your family have tuberculosis?" 4. "Does anyone in your family have high blood pressure?"

4. "Does anyone in your family have high blood pressure?" Rationale The incidence of hypertension varies significantly among races and cultural groups. Hypertension is more prevalent among African Americans than among whites. Other health risks in this group include sickle cell anemia, hypertension, heart disease, cancer, lactose intolerance, diabetes mellitus, and obesity. Arthritis, thalassemia, and tuberculosis are not health risks for the African-American client.

Lynn Ann decides to have the surgery to remove the pancreatic mass, and the surgery is performed by Dr. Donlon. Lynn Ann is told that the mass was malignant but that it was encapsulated, there was no evidence of local invasion or metastasis, and that she will not need to undergo chemotherapy. Dianne comes to the hospital to visit, approaches Lynn Ann's nurse, and asks about the outcome of the surgery. How should the nurse respond to Lynn Ann's sister? 1. "Everything went great. Lynn Ann has a very good prognosis." 2. "Let's go into the conference room. I don't want to talk about Lynn Ann here in the hallway." 3. "You're a nurse! You know the rules! I can't discuss Lynn Ann's condition with you!" 4. "Dr. Donlon has explained everything to Lynn Ann. You'll need to talk to Lynn Ann about her status."

4. "Dr. Donlon has explained everything to Lynn Ann. You'll need to talk to Lynn Ann about her status." Rationale The client has the right to privacy, and the nurse must protect the client's privacy as much as possible. The nurse should not discuss any information with anyone but Lynn Ann herself about Lynn Ann's diagnosis. Doing otherwise would violate the client's right to privacy. Therefore the correct response is to explain that any information about Lynn Ann's condition will have to be obtained from Lynn Ann.

The nurse, performing an assessment of a client, asks about the use of substances such as alcohol and drugs. The client tells the nurse that he has been using alcohol for a long time. Which question should the nurse ask to determine whether the client is physically dependent on alcohol? 1. "Do people criticize your drinking?" 2. "Have you ever felt guilty about drinking?" 3. "Have you ever felt as though you should try to cut down on your drinking?" 4. "Have you noticed that you have had to drink increasing amounts of alcohol?"

4. "Have you noticed that you have had to drink increasing amounts of alcohol?" Rationale Tolerance is a need for increasing amounts of the substance to achieve the desired effect. It is a sign that the person is physically dependent on the substance. To determine whether the client is physically dependent on a substance, the nurse would ask the client whether he has noticed the need to drink increasing amounts of alcohol. The questions in the other options are related to a psychological dependence on alcohol.

After his initial withdrawal phase, interventions to maintain abstinence, among them treatment with disulfiram, are planned for Carl. Carl is willing to comply with this therapy, and so the nurse teaches him about the medication. Which statement by Carl indicates that he has a need for further teaching about the medication and maintaining abstinence? 1. "I need to avoid any food that is prepared with vinegar." 2. "Attending Alcoholic Anonymous meeting will be very helpful." 3. "If I drink alcohol while I'm taking this medication, I'll get really sick." 4. "I need to take this medication as soon as I feel the urge to have a drink of alcohol."

4. "I need to take this medication as soon as I feel the urge to have a drink of alcohol." Rationale Disulfiram interrupts the metabolism of alcohol, causing a buildup of a toxic substance in the body if the client uses alcohol in any form. Therefore all alcohol-containing preparations, including such items as cough medicines, rubbing compounds, vinegar, aftershave lotions, and some mouthwashes, must be avoided. The medication must be taken daily. If the client consumes alcohol while taking the medication, a disulfiram-alcohol reaction will occur. Features of this reaction include facial flushing, sweating, throbbing headache, neck pain, nausea and vomiting, hypotension, tachycardia, and respiratory distress. The client should attend a support group such as Alcoholics Anonymous to help maintain abstinence from alcohol.

Louise calls the firm's nurse's office and schedules an appointment. She tells the nurse that she is feeling tired and stressed and that she is experiencing palpitations every time one of the lawyers places a document on her desk. Louise tells the nurse that she has heard that taking ginseng will relieve the stress and asks whether it is safe to take. How should the nurse respond to Louise? 1. "Many reports indicate that ginseng reduces stress." 2. "Ginseng is a natural herbal substance and is safe to take." 3. "It's a good idea to try ginseng, because it is so important to keep the stress level down to prevent illness." 4. "It's best to consult a health care provider regarding the use of ginseng, because it may not be appropriate for you.

4. "It's best to consult a health care provider regarding the use of ginseng, because it may not be appropriate for you. Rationale Herbal substances that have been used to relieve anxiety and stress include ginseng, St. John's wort, and kava. Contraindications to the use of these substances do exist. The client should be warned of this fact and advised to consult a health care provider regarding the use of herbal substances. Therefore the other responses are inappropriate.

During the 30-week follow-up visit, the nurse assesses Janice and asks, "How are you feeling these days?" Which of these statements from Janice would indicate that further assessment is needed? Select all that apply. 1. "I spend so much time going to the bathroom!" 2. "I haven't been sleeping well for several days." 3. "I've noticed that I get out of breath after I vacuum the floors." 4. "Since yesterday I've noticed that the baby isn't moving as much." 5. "I've noticed that my fingers and face have been swollen when I wake up in the morning."

4. "Since yesterday I've noticed that the baby isn't moving as much." 5. "I've noticed that my fingers and face have been swollen when I wake up in the morning." Rationale During the second and third trimesters of pregnancy, certain signs and symptoms may indicate complications. Any change in the pattern or frequency of fetal movements should be investigated immediately to detect or rule out fetal jeopardy. Swelling of the face or fingers may indicate a hypertensive condition or preeclampsia. Discomforts that are expected during this trimester of pregnancy include insomnia, frequent urination (caused by impingement of the enlarging uterus on the bladder, resulting in reduced bladder capacity), and shortness of breath (resulting from limitation of diaphragm movement by the enlarging uterus).

An employee from the dietary department is stocking the kitchen of a mental health unit. A client who is nearby says to the nurse, "The terrorists are here, and they're out to get me! They're putting anthrax in the sugar containers!" Which response should the nurse give to the client? 1. "There aren't any terrorists in the kitchen." 2. "No one is trying to hurt you. It's all in your mind." 3. "You will scare the other clients if they hear you talking that way." 4. "The person you saw is from the dietary department. He's here to stock the unit kitchen with food."

4. "The person you saw is from the dietary department. He's here to stock the unit kitchen with food." Rationale When dealing with a client experiencing a delusion, the nurse should be open, honest, and reliable in interactions to ease the client's suspicion. The nurse should also present reality to the client. The nurse should avoid arguing about the content of the delusion, instead focusing on the feelings the delusion generates in the client. The nurse should not dwell on the delusion but instead should focus conversation on more reality-based topics.

Lynn Ann schedules an appointment with another health care provider, Dr. Anna Donlon, to obtain a second opinion. Dr. Donlon tells Lynn Ann that biopsy is unnecessary at this time because she will need extensive abdominal surgery to remove the mass, regardless of whether it is benign or malignant. After Dr. Donlon leaves the examining room, Lynn Ann says to the nurse, "I can't believe that I need surgery — I feel fine! Lately I've read quite a bit about herbal products and alternative therapies, and I think I should give that a try before I have the surgery. What do you think?" Which response by the nurse is appropriate? 1. "I have so many people ask me about alternative therapy. Personally, I don't think that it works." 2. "You'd better not try that stuff if you plan to have Dr. Donlon treat you. She's totally against using that stuff." 3. "How much have you read? Did you read about the adverse effects of these herbal products? If you had, you wouldn't use them." 4. "We have an alternative therapy department here at the clinic. It is important to be well informed about the available therapies and how they are believed to work. Would you like the phone number so that you can schedule an appointment?"

4. "We have an alternative therapy department here at the clinic. It is important to be well informed about the available therapies and how they are believed to work. Would you like the phone number so that you can schedule an appointment?" Rationale The client has the right to be informed about treatment options. If the client requests information about a treatment option, the nurse must help the client obtain that information. The nurse should not give his or her opinion to the client. The incorrect options are nontherapeutic responses.

A client is found to have post-traumatic stress disorder (PTSD) after witnessing a terrorist attack and seeing several people jump to their deaths from a burning building. The client, who is undergoing counseling, says to the nurse, "Those people who jumped were my friends and coworkers. The only reason I wasn't there is that it was my turn to get the coffee and doughnuts for everyone that morning. If I hadn't gone, I would have been with them. Maybe I could have helped." Which response should the nurse give to the client? 1. "You just weren't meant to be there." 2. "It was a horrible attack, and there wasn't anything anyone could do." 3. "You need to think about the families of the victims and what they are dealing with." 4. "You are not responsible for the attack but are responsible for learning how to cope with the trauma."

4. "You are not responsible for the attack but are responsible for learning how to cope with the trauma." Rationale PTSD is precipitated by a specific overwhelming and devastating event. A positive outcome for the client is that the client will cope effectively with thoughts and feelings associated with the traumatic event. To help reduce the client's feelings of powerlessness and guilt, the nurse should note that the client was not responsible for the event. Stating that it was a horrible attack or that the client wasn't meant to be there does not help the client interpret the event or develop coping skills. Thinking about the families of victims and how they are dealing avoids addressing the client's thoughts and feelings.

Laura calls her daughter and son to inform them that Louis does not have much time left. The daughter comes quickly to her parents' house, and Louis dies shortly thereafter. The daughter, who is crying, says to the hospice nurse, "It's all my fault. If I hadn't refused to have that test 10 years ago, I could have donated a kidney, and my father would still be alive. It's all my fault!" Which response by the nurse is appropriate? 1. "It's not your fault! You have to stop thinking that way." 2. "You shouldn't feel so guilty. Your brother also refused to have anything to do with being a donor." 3. "Probably so — but, then again, a lot has changed in 10 years. Ten years ago, there was more risk involved in the procedure." 4. "You made the best decision at the time. Let's talk about what makes you feel as though your father's death is your fault."

4. "You made the best decision at the time. Let's talk about what makes you feel as though your father's death is your fault." Rationale The correct option involves the therapeutic communication technique of paraphrasing. It is open ended as well, making it therapeutic. The nurse provides support, restates the daughter's message, and provides the daughter an opportunity to express her feelings. "It is not your fault" is an aggressive response and is a communication block because it does not encourage the daughter to express her feelings. Addressing guilt and change are incorrect because they reinforce the daughter's belief that she is responsible for her father's death.

Carol is assigning clients to her team members. Which client should Carol assign to the nursing assistant? 1. A client scheduled for a colonoscopy 2. A client with an arteriovenous fistula in the right arm who is scheduled for hemodialysis 3. A client who is stable but was treated with furosemide and oxygen therapy during the night for pulmonary edema 4. A client who requires frequent ambulation with a walker and must be encouraged to maintain her independence in carrying out activities of daily living

4. A client who requires frequent ambulation with a walker and must be encouraged to maintain her independence in carrying out activities of daily living Rationale When assigning clients to nursing staff, the nurse must match the task to the delegatee in keeping with the state's nurse practice act and the health care institution's descriptions of various jobs. A client who requires frequent ambulation and encouragement to carry oug activities of daily living may be attended to by the nursing assistant. The client scheduled for a colonsoscopy will require preparation for the procedure in addition to frequent observation after the colonoscopy. The client with an arteriovenous fistula will require predialysis procedures and assessment of the fistula for patency. The client with pulmonary edema who was treated with furosemide and oxygen therapy and is in stable condition will still require frequent assessments.

A nurse planning client assignments for the day has an LPN and a nursing assistant on the nursing team. Which client should the nurse assign to the LPN? 1. A client who is scheduled for an electrocardiogram and a chest radiograph 2. A client with stable congestive heart failure who has early-stage Alzheimer disease 3. A client who has been treated for dehydration who is weak and requires assistance with bathing 4. A client with emphysema who is receiving oxygen at a rate of 2 L/min by nasal cannula and becomes dyspneic on exertion

4. A client with emphysema who is receiving oxygen at a rate of 2 L/min by nasal cannula and becomes dyspneic on exertion Rationale The nurse would most appropriately assign the client with emphysema to the licensed practical nurse. This client has an airway problem and has the highest priority needs of the clients presented in the options. The client who has been scheduled for testing, the client who needs assistance with daily needs, and the client who has early stage Alzheimer's disease in addition to a stable cardiac problem can appropriately be cared for by the nursing assistant.

A client who is hospitalized in a mental health unit has become argumentative and agitated, pacing the hallway. He suddenly begins to glare at another client and makes verbal threats. Which action should the nurse take? 1. Telling the client that if he continues to make threats, he will be placed in seclusion 2. Approaching the client, putting an arm around his waist, and asking what is bothering him 3. Obtaining assistance from other members of the nursing staff and taking the client to his room 4. Acknowledging the client's anger and providing the client options for dealing with his behavior

4. Acknowledging the client's anger and providing the client options for dealing with his behavior Rationale To deescalate angry behavior, the nurse first ensures the safety of the client, other clients, and self. The nurse should acknowledge the client's anger, determine the client's need, and provide options to deal with the behavior. The nurse should also make the client aware of the consequences of his anger and violence. Threatening the client is a violation of his rights. The nurse should maintain a large personal space, use a nonaggressive posture, and avoid touching the client. The other options are incorrect.

The nurse is describing high-risk therapies to a client. Which modalities does the nurse include in the discussion? Select all that apply. 1. Prayer 2. Touch 3. Meditation 4. Acupuncture 5. Rectal irrigation 6. Medicinal herbs

4. Acupuncture 5. Rectal irrigation 6. Medicinal herbs Rationale Acupuncture, medicinal herbs, and detoxification methods such as rectal irrigation, all invasive therapies, are considered high risk. Low-risk therapies are those that have no adverse effects and may be employed by the nurse who has training and experience in their use. These therapies include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures such as prayer.

What does the nurse understand with regard to a DNR order? 1. The DNR order is applicable for the length of the client's hospitalization. 2. The health care provider is the person who is primarily responsible for making the decision regarding a DNR order. 3. A DNR order indicates that no resuscitative measures at all, including the administration of medication, should be instituted. 4. Agency and/or state guidelines must be followed with regard to notification of the client or family about consideration of a DNR order.

4. Agency and/or state guidelines must be followed with regard to notification of the client or family about consideration of a DNR order. Ratioanle A DNR order is written by a health care provider when a client has indicated a desire to be allowed to die if he or she stops breathing or his or her heart stops beating. Agency and state guidelines must be followed with regard to notification of the client or family about consideration of a DNR order. The DNR order must be reviewed on a regular basis in accordance with agency and state policy and must be clearly defined so that other treatment, not refused by the client, will be continued.

Three months later, Marilyn visits the health care provider's office because of ear pain. The health care provider's assessment and prescription are shown in Marilyn's health record (click "Chart" below). Based on these prescriptions, what should the nurse teach Marilyn at this time? 1. The vitamins should not be taken while Marilyn is taking the antibiotic. 2. The oral contraceptive should be stopped until the antibiotic prescription is finished. 3. The oral contraception should be stopped while Marilyn is taking the pseudoephedrine for nasal congestion. 4. An alternate form of birth control will be needed while Marilyn is taking the ampicillin and for at least 1 month afterward.

4. An alternate form of birth control will be needed while Marilyn is taking the ampicillin and for at least 1 month afterward. Rationale Several medications, including penicillin antibiotics, can reduce the effectiveness of oral contraceptives, which may in turn result in unintended pregnancy. Marilyn should use an alternate form of birth control while taking the ampicillin and for at least 1 month afterward, but the oral contraceptive should not be stopped. Vitamins and pseudoephedrine do not interact with oral contraceptives.

During a discussion of her osteoarthritis, Lian mentions to the nurse that she must take steps "to balance my yin and yang" for the treatment to be successful. Which statement best explains this belief? 1. This imbalance is caused by a spell cast by the "evil eye." 2. Illness is a result of divine punishment for a person's sins. 3. Illness is caused by hot and cold imbalance, such as prolonged exposure to heat or cold. 4. An imbalance in these two forces will result in illness; balance maintains and improves health.

4. An imbalance in these two forces will result in illness; balance maintains and improves health Rationale In traditional Asian philosophy, it is believed that a balance between the life forces of yin and yang maintains and enhances health and that illness results when these forces are imbalanced. Belief in the "evil eye" — a condition that results when an individual has cast a spell on another person by looking at but not touching the person — is held by many Hispanic and Latino Americans. A view of illness as a divine punishment for a person's sins is a belief held by some African Americans. The theory that hot and cold imbalance causes illness is another belief often held by Hispanic and Latino Americans.

A student nurse who has been assigned to care for a client on a medical unit arrives at the unit and asks the nurse in charge for the client's medical record so that she may review it. Which action should the charge nurse take? 1. Making a copy of the record for the student 2. Giving the student the client's medical record 3. Sitting with the student while the student reviews the record 4. Asking the client for permission for the student to review the medical record

4. Asking the client for permission for the student to review the medical record Rationale A client's medical record is confidential. Only staff members directly involved in a client's care have legitimate access to a client's record. Any other individual must obtain permission from the client to review the record. Medical records should not be copied. If it is necessary to copy a record, the client must give permission.

A female client is brought to the emergency department by a neighbor after experiencing sudden paralysis in both arms. On assessing the client, the nurse discovers that the paralysis developed 2 days after the client's husband told her that he wanted a divorce. The client verbalizes concern about her condition because she is a computer programmer and needs her hands to perform her work. Which action should the nurse undertake first? 1. Requesting a psychiatric consult 2. Contacting the crisis intervention team 3. Conducting a thorough mental-health assessment 4. Assessing the client for any physical basis for the paralysis

4. Assessing the client for any physical basis for the paralysis Rationale A conversion disorder is a somatic symptom disorder in which a physical symptom appears when no organic cause exists. The most common conversion symptoms are blindness, deafness, paralysis, and inability to talk. Symptoms are not intentionally produced by the client and are directly related to conflict and increasing anxiety. This type of illness should never be dismissed as psychosomatic, and the nurse should initially plan to carefully assess the client to help rule out an organic cause for the paralysis. Requesting a psychiatric consult, contacting the crisis intervention team, and conducting a mental health assessment may be components of treatment, but they are not the first considerations.

That evening, during an assessment, the nurse finds that Annie's uterine fundus is above the umbilicus and to the left of the midline of the abdomen. What action by the nurse is a priority? 1. Performing fundal massage 2. Performing a sterile urinary catheterization 3. Assessing the lochia on Annie's perineal pad 4. Assisting Annie to the bathroom to help her void

4. Assisting Annie to the bathroom to help her void Rationale A full bladder causes the uterus to be displaced above the level of the umbilicus and off to one side of the midline of the abdomen. It may also lead to uterine atony, because it prevents the uterus from contracting normally. The priority nursing intervention is to assist the woman in emptying her bladder as soon as possible, either by taking her to the bathroom or offering a bedpan if she is not ambulatory. Fundal massage should be performed, if the fundus is boggy, once the bladder has been emptied. Catheterization is done only if the woman is unable to void after measures have been taken to encourage urination. Assessing the lochia does not address the problem.

A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? 1. Checking the woman's blood pressure 2. Calling the obstetrician to the examining room 3. Placing a cool cloth on the woman's forehead 4. Assisting the client into a lateral recumbent position

4. Assisting the client into a lateral recumbent position Rationale When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.

Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? 1. The result of the Rh factor screen is normal. 2. Because the Rh factor is not present, no additional testing is necessary. 3. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. 4. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.

4. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation. Rationale If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.

A nurse prepares to teach a pregnant woman to perform tailor-sitting exercises. Which instruction should the nurse provide to the client? 1. Lie flat on the back and place both feet against a wall. 2. Position self on the hands and knees and arch the back five times in a 30-second period. 3. Sit with the legs straight, press the knees toward the floor, and hold the position for 10 seconds. 4. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes

4. Bend the knees, place the soles together, use the thigh muscles to press the knees to the floor, and hold the position for 5 to 15 minutes Rationale Tailor-sitting exercises are useful in alleviating heartburn and shortness of breath or dyspnea. The woman sits on the floor, bends her knees, places the soles together, uses her thigh muscles to press the knees to the floor, and holds the position for 5 to 15 minutes. The other options are incorrect descriptions of this exercise.

A nurse is setting up an intravenous pump that will be used for a client who will be receiving a continuous intravenous infusion of normal saline solution containing heparin. As the nurse prepares to plug the pump's electrical cord into the wall socket, she notes that no socket is available because of other medical equipment being used in the room. Which action by the nurse is most appropriate? 1. Allowing the pump to run in battery mode 2. Obtaining an extension cord from the nurses' lounge 3. Moving the client into the hallway, near a wall socket 4. Calling the hospital's electrical department for assistance

4. Calling the hospital's electrical department for assistance Rationale The nurse would most appropriately contact the hospital's electrical department for assistance in safely setting up electrical equipment. Safety-type extension cords are used only if necessary, and although this may be an option, it is not the most appropriate one. Electrical outlets should not be overloaded, because this presents an electrical hazard. The nurse would not allow the pump to run on its battery for an extended period. It is inappropriate to place a client in a hallway. This would constitute an invasion of the client's privacy.

A 16-year-old boy is brought to the emergency department by ambulance. The mother of the client tells the nurse that she called the ambulance because her son's behavior was bizarre and violent and because he was having hallucinations. The mother says that she is concerned because her son has been "hanging out with the wrong crowd" and she suspects that he has been "sniffing cocaine." During the assessment, which sign of cocaine intoxication should the nurse expect to note? 1. Lethargy 2. Bradycardia 3. Hypotension 4. Dilated pupils

4. Dilated pupils Rationale Signs of cocaine intoxication include dilated pupils, tachycardia, hypertension, nausea and vomiting, and insomnia. Other effects include euphoria, impairment of judgment and social or occupational function, paranoia, delusions, and hallucinations, as well as the potential for violence.

Which intervention does the nurse immediately implement for James Nicholas on the basis of his 1-minute Apgar score? 1. None 2. Preparing for neonatal resuscitation 3. Supporting spontaneous respiratory efforts 4. Gently stimulating the infant by rubbing his back and administering oxygen

4. Gently stimulating the infant by rubbing his back and administering oxygen Rationale The Apgar scoring method is used for quick evaluation of the newborn infant's cardiorespiratory adaptation after birth. A 1-minute score of 4 to 7 means that the nurse should take measures to stimulate the infant, such as gently rubbing the infant's back, while administering oxygen. Resuscitation is necessary for scores of 0 to 3. For Apgar scores of 8 to 10, no action is needed except for continued observation and support of the infant's own spontaneous efforts.

You quickly obtain a fire extinguisher to extinguish the fire and pull the pin on the extinguisher. What is your next action? 1. Squeezing the handle to activate the extinguisher 2. Squeezing the handle and aiming at the center of the flames 3. Holding the fire extinguisher at waist level and aiming the nozzle at the top of the flames 4. Holding the hose in one hand and the handle in the other, then aiming the nozzle at the base of the flames

4. Holding the hose in one hand and the handle in the other, then aiming the nozzle at the base of the flames Rationale The nurse's first action would be to pull the pin on the fire extinguisher. The nozzle of the extinguisher is then aimed at the base of the fire, not at the top of the flames. The handle is squeezed and the nozzle swept from side to side over the fire.

After the admission assessment, the nurse reviews Margaret's medical record and notes that the health care provider has written prescriptions. Which prescription should the nurse question? 1. Chest x-ray today 2. Incentive spirometry every hour 3. Out of bed to chair with assistance only 4. Ibuprofen 400 mg every 4 hours prn

4. Ibuprofen 400 mg every 4 hours prn Rationale The components of a medication prescription, in addition to the date and time at which the prescription was written, are the name, dosage, and route and frequency of administration of any medication and the health care provider's signature. The nurse would question "Ibuprofen 400 mg q4h prn" because it does not indicate a route of administration. The other prescriptions are complete.

A nurse assigned to care for a client with chronic obstructive pulmonary disease (COPD) reviews the client's care plan. Which of the following should the nurse identify as a priority concern for the client? 1. Weight gain related to an increase in appetite 2. Loneliness related to a lack of support systems 3. Fear related to the outcome of the disease process 4. Inability to clear respiratory tract because of excessive mucus production

4. Inability to clear respiratory tract because of excessive mucus production Rationale Maintaining a patent airway is always the first priority. Loneliness and fear involve psychosocial needs and would be considered after physiological needs are addressed. The client with COPD is most likely to experience a decrease in nutrition due to the increased metabolic effects that occur.

The nurse is performing an assessment of a client who is an alcoholic. During the assessment, the client preaches about the evils of drinking. Which adaptive defense mechanism should the nurse recognize in the client's behavior? 1. Projection 2. Identification 3. Rationalization 4. Reaction formation

4. Reaction formation Rationale Reaction formation is the development of conscious attitudes and behaviors and the acting out of behaviors that may conflict with what one really feels. The client's proclamations about the evils of drinking are an example of this adaptive defense mechanism. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Identification is an unconscio us attempt to change oneself to resemble an admired person. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior.

A client admitted to the mental health unit has a diagnosis of moderate depression. The nurse, formulating a nursing care plan, is concerned about the client's nutritional status. Which nursing interventions should be included in the care plan? Select all that apply. 1. Weighing the client daily 2. Filling out the menu for the client 3. Restricting visitors during mealtimes 4. Including the dietitian in meal planning 5. Providing small high-calorie, high-protein snacks throughout the day

4. Including the dietitian in meal planning 5. Providing small high-calorie, high-protein snacks throughout the day Rationale The client with depression experiences anorexia, and poor nutrition puts the client at risk for illness, so maintaining adequate nutrition is crucial. The nurse should involve the dietitian in meal planning to ensure that the client is obtaining adequate nutrients. The client should be asked about food dislikes and provided with the opportunity to fill out the menu, because the client is more likely to eat foods he or she has selected. Small high-calorie, high-protein snacks and fluids should be offered frequently throughout the day and evening. Frequent small snacks are more easily tolerated than large plates of food when a client is anorexic. The client is weighed weekly (not daily) to monitor the nutritional status. Weighing the client daily is unnecessary. When possible, the nurse should encourage family or friends to remain with the client during meals. This intervention reinforces the idea that someone cares, may increase the client's self-esteem, and may serve as an incentive to eat.

A woman who has just delivered a baby asks the nurse when she may resume sexual intercourse. Which response should the nurse give to the client? 1. Intercourse may be resumed at any time after delivery. 2. Intercourse may not be resumed until menstruation returns. 3. Intercourse may not be resumed until after the 6-week checkup with the obstetrician. 4. Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed

4. Intercourse may be resumed 2 to 4 weeks after delivery, once bleeding has stopped and the episiotomy has healed Rationale The woman who has just given birth should be told that she may safely resume sexual intercourse by the second to fourth week after delivery, when bleeding has stopped and the episiotomy has healed. The other options are incorrect.

Newborn James Nicholas is taken to the nursery for assessment and placed in the infant warmer while he is cleansed. His vital signs are stable, and he settles easily. Before taking the infant back to his mother, the nurse administers an injection of vitamin K. Which injection route and site are appropriate? 1. Intravenous 2. Subcutaneous, upper arm 3. Intramuscular, dorsogluteal muscle 4. Intramuscular, vastus lateralis muscle

4. Intramuscular, vastus lateralis muscle Rationale Vitamin K, when administered for the prevention of hemorrhagic disease in the newborn, is given intramuscularly in the vastus lateralis. It is never given as a subcutaneous injection, and intravenous vitamin K is only used in special situations, such as for a preterm infant who does not have any muscle mass to support injections. The dorsogluteal muscle is very small and poorly developed in newborns, and the sciatic nerve is much more prominent at this age. Additionally, the deltoid muscle of a newborn does not have enough mass for an injection.

A nurse employed in the emergency department (ED) cares for a male client who has sustained a gunshot wound, but the client dies in the ED. The client, who was having a romantic affair with a married woman, was shot by the woman's husband. The nurse tells a neighbor about the incident and the affair and also reports to the neighbor that the woman's husband was arrested by the police for murder. What offense has the nurse committed by sharing this information with the neighbor? 1. Libel 2. Fraud 3. Assault 4. Invasion of privacy

4. Invasion of privacy Rationale The client has the right to be free of unwanted intrusion into his or her personal affairs. Invasion of privacy includes violation of confidentiality, intrusion on private client or family matters, and sharing of client information with unauthorized persons. Defamation (libel or slander) occurs when a person makes false statements that result in damage to an individual's reputation. Fraud is a deliberate deception intended to produce unlawful gain. Assault occurs when a person puts another person in fear of harmful or offensive contact.

A client with claustrophobia is seen in the mental health clinic and is told that one treatment for the disorder is systematic desensitization. When the client asks the nurse to describe the treatment, what information does the nurse provide? 1. It involves focus on the consequence of a behavior. 2. A stimulus attractive to the client is paired with an unpleasant experience. 3. The therapist will perform certain behaviors, and the client will imitate the behaviors. 4. It involves exposure to the phobic situation, starting with short periods and gradually increasing, until the fear has ceased.

4. It involves exposure to the phobic situation, starting with short periods and gradually increasing, until the fear has ceased. Rationale Focus on the subject of the question, systemic desensitization. In this type of therapy, incrementally increasing exposure to a feared stimulus is paired with an increasing level of relaxation, helping reduce the intensity of fear to a more tolerable level. Operant conditioning is the manipulation of selected reinforcers to elicit and strengthen desired behavioral responses; the reinforcer refers to the consequence of the behavior, which is defined as anything that increases the occurrence of a behavior. Aversion therapy is a form of behavioral therapy in which negative reinforcement is used to change behavior; for example, a stimulus attractive to the client is paired with an unpleasant event in the hope of endowing the stimulus with negative properties, thereby dissuading the behavior. Modeling is a type of behavioral therapy in which the therapist acts as a role model for specific identified behaviors so that the client learns through imitation.

Two police officers arrive at the emergency department with a client who was been displaying violent behavior in a local park. The police report to the nurse that they tried unsuccessfully to reason with the client and that the client continued to direct violent behaviors at other individuals in the park. After a thorough psychosocial assessment of the client, the health care provider determines that the client requires emergency involuntary admission to the mental health facility. What determination does the nurse make with regard to this type of admission? 1. It requires the client's consent. 2. It abrogates the client's right to informed consent. 3. It is normally sought by the client or the client's guardian. 4. It is necessary for a client who is a danger to self or others.

4. It is necessary for a client who is a danger to self or others. Rationale Involuntary admission is made without the client's consent. Generally involuntary admission is necessary when the client is a danger to self or others, is in need of psychiatric treatment, or is unable to meet his or her own needs. Voluntary admission is usually sought by the client or by the cli ent's guardian. Clients who are involuntarily admitted do not lose their right to informed consent.

Madeleine expresses concern to the nurse about the need for having one of her daughters act as a spokeswoman in the event of an emergency should additional decisions need to be made. What should the nurse tell Madeleine? 1. Once the living will is in place, there is no need for a spokesperson. 2. The health care provider will keep Madeleine's family informed in the event of an emergency. 3. As long as she has shared her wishes with her daughter, there is no need for a spokesperson. 4. Madeleine may appoint a person to carry out her wishes or to make decisions on her behalf if and when she is no longer able to do so.

4. Madeleine may appoint a person to carry out her wishes or to make decisions on her behalf if and when she is no longer able to do so. Rationale A durable power of attorney for health care is a legal document that appoints a person (health care proxy) chosen by the client to carry out his or her wishes as expressed in the advance directive or to make decisions on the client's behalf if and when he or she is no longer able to do so. It is the health care provider's responsibility to keep the client's family informed about the client's condition in an emergency, but this option is unrelated to the subject of the question. The need for a spokesperson maybe still be necessary even if a living will is in place.

Penny's labor is progressing slowly because her contractions are inadequate, so the obstetrician prescribes intravenous oxytocin to augment labor. While the oxytocin is being administered, the nurse, monitoring Penny closely, notes that her contractions are occurring every 3 minutes and are lasting 60 seconds. Which action should the nurse take? 1. Contact the obstetrician 2. Stop the oxytocin infusion 3. Transport Penny to the delivery room 4. Maintain the current dosage of oxytocin

4. Maintain the current dosage of oxytocin Rationale Oxytocin, a hormone naturally produced by the posterior pituitary gland, stimulates uterine contractions and may be used to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions. The nurse monitors the client closely and maintains the dosage if the intensity of contractions results in intrauterine pressure of 40 to 90 mm Hg (as shown by an internal monitor), if the duration of contractions is 40 to 90 seconds, if the contractions come at 2- to 3-minute intervals, or if cervical dilation of 1 cm/hr occurs in the active stage. Oxytocin is stopped if uterine hyperstimulation or a nonreassuring pattern of fetal heart rate occurs. There is no need to contact the obstetrician at this time or to transport Penny to the delivery room, because she is still progressing through the first stage of labor.

The nurse examines Christyna and finds a variety of bruises on other parts of her body. The nurse documents these findings. Look at Christyna's medical record, shown below. Which area of bruising is considered atypical for a child of Christyna's age? Nursing Assessment: Skin Bruises noted in several areas: Left and right upper arms Left knee, across patella Middle of abdomen, toward the right lower quadrant Left shin Right elbow 1. Left shin 2. Right elbow 3. Left knee, across patella 4. Middle of abdomen, toward the right lower quadrant

4. Middle of abdomen, toward the right lower quadrant Rationale Once children start to walk, it is common for them to sustain bruises in areas over bony prominences on the front of the body, such as the knees, shins, and elbows, in accidents such as falling. However, bruising in atypical areas, such as the hands, feet, abdomen, and buttocks, is not common and should arouse concern in the examiner.

The nurse conducts an assessment of a 98-year-old client with end-stage cardiac disease who is dying. Which findings is a physical manifestation of approaching death? 1. Warm toes and feet 2. Increased heart rate 3. Increased blood pressure 4. Mottling around the knees

4. Mottling around the knees Rationale As death approaches, metabolism is reduced and the body's processes gradually slow until all functions have ended. With decreased oxygenation and altered circulation causing metabolic changes, the heart rate slows and weakens and blood pressure decreases progressively. Decreased circulation is especially noticeable in the skin. The extremities become pale, mottled, and cyanotic. The skin feels cool to touch, first in the feet and legs, then in the hands and arms, and finally in the torso. The skin would feel warm if an increased temperature resulting from an underlying disease process such as sepsis were present.

A pregnant woman expresses concern to the nurse about how her 10-year-old daughter will adapt to a newborn's introduction into the home. Which response should the nurse make to the woman? 1. Most children resent a "newcomer" to the home. 2. An only child always has difficulty when a new baby arrives. 3. She must provide a great deal of attention to the 10-year-old to help prevent resentment on the older child's part. 4. Older school-age children often enjoy taking responsibility for the care of a younger sibling.

4. Older school-age children often enjoy taking responsibility for the care of a younger sibling. Rationale Older school-age children often enjoy taking responsibility for the care of a younger sibling. The nurse would appropriately teach the pregnant woman measures to deal with adaptation to a new infant. The information in the other options is inaccurate.

Which precautions should the nurse take to prevent newborn abduction? Select all that apply. 1. Placing the newborn's crib close to the mother's door 2. Instructing the mother to carry the newborn to the nursery after feeding 3. Closing the hospital room door if the infant needs to be left unattended 4. Questioning unknown person(s) who are carrying large bags or packages 5. Ensuring that all health care personnel wear proper name (identification) badges

4. Questioning unknown person(s) who are carrying large bags or packages 5. Ensuring that all health care personnel wear proper name (identification) badges Rationale Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking a nurse to attend to the newborn if no one is available to watch the newborn (the newborn is never left unattended). The nurse should monitor the environment closely and question any suspicious or unknown person, especially one carrying a large bag or package that could contain an infant.

A male health care provider who has been making sexual comments to a female nurse for some time asks the nurse to help him collect equipment with which to perform a procedure on a client. While in the supply closet, he places his hands on the nurse and tells her that he would like to take her to dinner. Which action should the nurse take first to best deal with the unwanted sexual advances? 1. Calling the nursing supervisor and reporting the health care provider's behavior 2. Telling the health care provider that she will be filing a report regarding his behavior 3. Calling the American Medical Association (College of Nurses) and reporting the health care provider's behavior 4. Telling the health care provider that his behavior is making her uncomfortable and that he needs to stop it

4. Telling the health care provider that his behavior is making her uncomfortable and that he needs to stop it Rationale Sexual harassment is any unwelcome conduct of a sexual nature. A nurse who is being sexually harassed should start with the most direct measure and tell the harasser that the behavior is making him or her uncomfortable and that it must be stopped immediately. If this measure is not effective in ending the harassment, the nurse may file a complaint against the perpetrator. Reporting the health care provider's behavior is not the best measure to take first. The initial goal is to stop the behavior, not punish the perpetrator, and to maintain some type of harmonious relationship.

The physical therapist has suggested that Lian wear a wrist brace during the day. As she listens to the instructions, Lian nods but says nothing. How should the nurse interpret Lian's response to the physical therapist's instructions? 1. Lian does not understand the instructions. 2. Lian is indicating that she understands the instructions. 3. Lian is listening to the instructions but does not understand them. 4. The nurse cannot tell whether Lian understands the instructions and makes a mental note to clarify whether she understands.

4. The nurse cannot tell whether Lian understands the instructions and makes a mental note to clarify whether she understands. Rationale Asian clients value silence and often avoid indicating disagreement in public. In this situation, Lian's nodding may indicate that she hears the instructions, but she does not necessarily understand them. The best way for the nurse to ensure that Lian understands the instructions is to ask her directly. The nurse should not assume that instructions are understood by the client.

Julianne quickly grabs a bag containing the items she needs when responding to a disaster. She then drives to the scene of the accident. As Julianne plans to respond and help care for victims, what does she recall as the priority task? 1. Determining the community risks 2. Identifying specific responsibilities of various disaster response personnel 3. Initiating actions that will return the community to normal after the disaster 4. The physical health, safety, and mental health of both the victims and the members of the disaster response team

4. The physical health, safety, and mental health of both the victims and the members of the disaster response team Rationale FEMA identifies four disaster management phases: mitigation, preparedness, response, and recovery. In the mitigation phase, community hazards and community risk (actual and potential threats) for the occurrence of the disaster are identified. Actions or measures to prevent the occurrence of a disaster or reduce its damaging effects are also addressed. The preparedness phase involves planning for rescue, determining the need for resources, and identifying the specific responsibilities of various disaster response personnel. The response phase includes putting disaster planning services into action, including actions to save lives and prevent further damage. The primary concerns of this phase include safety and physical and mental health of both the victims and the members of the disaster response team. The recovery phase involves actions taken to return to normal after the disaster.

The nurse notes documentation in the record of a client in labor that the client is completely effaced. Based on this information, what conclusion should the nurse make? 1. The cervical os is completely dilated. 2. The client will require induction with the use of oxytocin. 3. Enlargement of the cervical canal that occurs during the first stage of labor is complete. 4. The shortening and thinning of the cervix that occurs during the first stage of labor is complete.

4. The shortening and thinning of the cervix that occurs during the first stage of labor is complete. Rationale Effacement is the shortening and thinning of the cervix that occurs during the first stage of labor. Dilation is the enlargement of cervical os and cervical canal during the first stage. When the cervical os is completely dilated, the client is prepared for the birth of the baby. Induction is the deliberate initiation of uterine contractions that stimulates labor. In this situation, induction is not necessary.

The nurse who is admitting Michael to the hospital reviews the medical record that was sent from the surgeon's office and checks the informed consent for surgery. Because Michael's signature on the consent form was witnessed by the nurse in the surgeon's office, the hospital nurse makes which determination? 1. The surgeon's nurse has explained the surgical procedure to Michael 2. Michael has an adequate understanding of the surgical procedure 3. All of Michael's questions about the surgical procedure have been answered 4. The surgeon's nurse was a witness to Michael's signature of the consent form

4. The surgeon's nurse was a witness to Michael's signature of the consent form Rationale The surgeon who performs the surgical procedure is responsible for explaining the procedure, as well as its risks, benefits, and possible alternatives, to the client. The nurse may be involved in the process of obtaining informed consent for medical procedures by witnessing the client's signature of the consent form after the surgeon has completed the informed consent process. This role is different from obtaining consent, for the nurse is either obtaining the client's signature (when the nurse becomes a witness to signature only) or watching the client sign the form in the presence of the surgeon. The nurse's signature on the consent form does not guarantee that the client has an adequate understanding of the surgical procedure or that he has had all of his questions answered.

The nurse caring for Joseph discusses the plan of care with the psychiatrist, who tells the nurse that Joseph would benefit from cognitive therapy. What information does the nurse provide to Joseph about this type of therapy? 1. Medication is the main treatment in this form of therapy. 2. A reward will be given to Joseph for every hour in which he does not have a suicidal thought. 3. The psychiatrist will function as a role model, helping Joseph learn to prevent thoughts of suicide. 4. Therapeutic techniques are designed to identify, reality-test, and correct distorted or dysfunctional beliefs.

4. Therapeutic techniques are designed to identify, reality-test, and correct distorted or dysfunctional beliefs. Rationale The therapeutic techniques of cognitive therapy are designed to identify, reality-test, and correct distorted conceptualizations and the dysfunctional beliefs underlying these cognitions. The client learns to master problems in situations he or she previously considered insurmountable by evaluating and correcting his or her thinking. Medication is not a primary component of cognitive therapy. In modeling, the psychiatrist or therapist acts as a role model for specific identified behaviors. In operant conditioning, a reward would be given for not having a suicidal thought.

Once the nurse has implemented treatment for Mrs. Valenti's dehydration, which ocurrence indicates the best expected outcome should the nurse be alert for?1. Thirst 2. Dry mucous membranes 3. Decrease in blood pressure 4. Urine output greater than 30 mL/hr

4. Urine output greater than 30 mL/hr Rationale The expected outcome for the client with deficient fluid volume is that adequate fluid volume and electrolyte balance will return, as evidenced by a urine output greater than 30 mL/hr, normal blood pressure, decreasing heart rate, consistent weight, and normal skin turgor. Thirst, dry mucous membranes, and a decrease in blood pressure are defining characteristics of deficient fluid volume.

One hour after delivery, the nurse checks Annie for postpartum bleeding. Which procedure is best for this purpose? 1. Assessing Annie's blood pressure 2. Visually assessing bleeding by checking Annie's perineal pad 3. Asking Annie how much bleeding she has had since the last check 4. Visually assessing bleeding by checking the linens under Annie's buttocks and the perineal pad

4. Visually assessing bleeding by checking the linens under Annie's buttocks and the perineal pad Rationale Estimating blood loss after delivery is important and can be done by visually examining the perineal pad. However, when the mother is supine, blood may flow between the buttocks and onto the linens beneath the mother, not onto the perineal pad. Therefore, it is also important to check the linens under the mother's buttocks for bleeding. The blood pressure may not change unless a significant amount of bleeding occurs. Asking Annie about the amount of bleeding is not a reliable means of assessment. Checking the bed linens and perineal pad provides a complete assessment of blood loss.

The nurse, monitoring Carl closely for early signs of alcohol withdrawal, understands that these early signs begin: within which time frame? 1. 3 days after the cessation of alcohol intake 2. 48 hours after the cessation of alcohol intake 3. 72 hours after the cessation of alcohol intake 4. Within a few hours of the cessation of alcohol intake

4. Within a few hours of the cessation of alcohol intake Rationale The early signs of alcohol withdrawal develop within a few hours after the client stops drinking or reduces alcohol intake. These signs peak after 24 to 48 hours and then rapidly disappear unless the withdrawal progresses to alcohol-withdrawal delirium.

A nurse is irrigating a client's abdominal wound when the client becomes agitated, grabs the bottle of saline solution that the nurse is using to perform the irrigation, and throws the bottle at the nurse. The nurse immediately calls for assistance. What action should the nurse take after a unlicensed assistive personnel (UAP) arrives? 1. Asking the unlicensed assistive personnel to check for a prescription for a sedative 2. Leaving the room and calling the health care provider for a prescription for a safety device 3. Stopping the wound irrigation and tells the client that she will complete the procedure when he calms down 4. Asking the UAP to apply a safety device to the clien

4. Asking to UAP to apply a safety device to the client Rationale A health care provider's prescription is necessary for the application of restraints to a client; however, in an emergency situation, if the client presents a risk for injury to self or others, a restraint may be applied. When the nurse must restrain a client in an emergency situation, a health care provider's prescription must be obtained as soon as possible thereafter. The nurse should restrain the client and complete the procedure, because leaving an abdominal wound unprotected presents a risk for infection. It is also inappropriate for the nurse to ask the UAP to check for a prescription for a sedative; this is the nurse's responsibility. Asking the UAP to leave the client's room places the nurse at risk for further injury by the client. Stopping the wound irrigation and telling the client that she will complete the procedure when he calms down is a nontherapeutic action and increases the client's risk for infection.

A client who has returned from the operating room after repair of a hip fracture is alert but confused, pulling at the IV catheter that has been inserted in her left arm. The nurse should apply which type of safety device to best keep the client from pulling out the IV line? Which type of restraint would be best for keeping the client from pulling out the IV line? 1. Belt 2. Wrist 3. Elbow 4. Mitten

4. Mittens Rationale A mitten restraint, a thumbless device that covers the client's hand, is used to restrain the hand, preventing the client from dislodging invasive equipment (e.g., an IV line). It allows greater movement than does a wrist restraint. A wrist restraint is used to immobilize an extremity but does not allow movement as a mitten restraint does. A belt restraint is wrapped around the client's waist and used to secure a client to the bed or stretcher. An elbow restraint, consisting of a fabric wrap with slots into which tongue blades are inserted, is wrapped around the elbow area to keep the joint from being flexed.

The nurse providing information to the wife of a client who abuses alcohol encourages the woman to attend an Al-Anon support group. The wife tells the nurse that she is embarrassed by her husband's behavior and that it would be difficult for her to face other people. Which response should the nurse give the woman to help alleviate her concerns? 1. The support group is always led by a nurse and health care provider. 2. She will not know any of the members of the support group. 3. She does not need to provide her name or any other identifying information to the group. 4. The members of the group have experienced or are experiencing the same problem she is facing

4. The members of the group have experienced or are experiencing the same problem she is facing Rationale Al-Anon is a support group for spouses and friends of alcoholics or addicts. Support groups are based on the premise that people who have experienced a particular problem are able to help others with the same problem. Although a nurse or other health care professional may be asked to speak at a support group meeting, the members of the group lead the group. The nurse cannot ensure that the wife will not know any of the members. Although the wife does not need to provide her name or any other identifying information to the group, this response is not helpful and will not alleviate the wife's concerns.

A client who is an alcoholic is brought to the hospital by his family because he has begun to exhibit signs of confusion and mental deterioration. After a physical examination, the health care provider determines that the client has Korsakoff syndrome. On the basis of this finding, what does the nurse expect the health care provider to prescribe? 1. Ginkgo biloba 2. A muscle relaxer 3. Antiviral medication 4.Thiamine (vitamin B1)

4.Thiamine (vitamin B1) Rationale Korsakoff syndrome, a secondary dementia caused by thiamine (vitamin B1) deficiency, is associated with prolonged heavy ingestion of alcohol. Along with progressive mental deterioration, Korsakoff syndrome is marked by peripheral neuropathy, cerebellar ataxia, confabulation, and myopathy. Ginkgo biloga, a muscle relaxer, and antiviral medications are not used to treat Korsakoff syndrome. Although ginkgo biloba has been used to improve cognitive function in some clients, it should be used with caution in clients who consume alcohol.

A nurse employed in an emergency department (ED) on the evening shift is assigned to triage arriving clients. Which client should the nurse designate as the highest priority? 1. A client who twisted her ankle in a fall while inline skating 2. A client with asthma who is not experiencing respiratory distress 3. A client with chest pain who says that he just ate pizza made with a very spicy sauce 4. A client with a minor laceration of the index finger, sustained while the client was cutting an eggplan

A client with chest pain who says that he just ate pizza made with a very spicy sauce Rationale In an ED, triage is used to classify clients on the basis of their need for care and establish priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Trauma, limb amputation, chemical splashes in the eyes, chest pain, severe respiratory distress, cardiac arrest, and acute neurological deficit are all classified as emergencies and are given top priority. Simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, and renal stones represent urgent needs, and clients with these conditions are given number-two priority. Conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and clients with these conditions are the number-three priority.

After the cesarean delivery, the obstetrician hands the newborn to the delivery room nurse. Prioritize the nurse's action in caring for the newborn in the order in which they would be performed. 1. Placing the newborn at the mother's breast 2. Wrapping the newborn in a warm blanket 3. Checking the newborn's temperature 4. Calculate the newborn's Apgar score

Calculate the newborns Apgar score Checking the newborn's temperature Wrapping the newborn in a warm blanket Placing the newborn at the mother breast

Things to remember (Foundation of Mental Health)

Mental illness is characterized by thought or behavior patterns that impair function and cause the affected individual distress. In a voluntary hospital admission, the client agrees to accept treatment. -An involuntary admission may be necessary when a person is mentally ill, is a danger to self or others, or is in need of psychiatric treatment or physical care. -The client who seeks voluntary admission has the right to request and receive release from the hospital. -The nurse should identify the religious and spiritual practices of the client and the client's cultural beliefs and values and incorporate these into the plan of care. -The phases of a therapeutic nurse-client relationship are the preinteraction phase, the orientation (or introductory) phase, the working phase, and the termination (or separation) phase. -Communication should be goal directed, involving therapeutic communication techniques. -The milieu is the physical and social environment in which an individual is undergoing treatment. -Behavioral therapy comprises a diverse range of approaches for dealing with maladaptive behavior. -Cognitive therapy is based on the principle that how individuals feel and behave is determined by how they think about the world and their place in it; their cognitions are based on the attitudes or assumptions developed from previous experiences. -Stages of group development are the initial stage, the working stage, and the termination stage. -Self-help or support groups are based on the premise that persons who have experienced a similar problem are able to help others with the same problem.

The nurse preparing to remove gloves, gown, mask, and eyewear worn during of a care of a client. Indicate in the order of priority, how should the nurse remove the contaminated items. Untie upper mask strings Remove Mask Remove eyewear Remove gown Untie lower mask strings Remove gloves

remove gloves remove eyewear remove gown untie lower mask strings untie upper mask strings remove mask