Nurs 4 - Nursing Process: Nursing diagnosis (EAQ's)

A client is in the intensive care unit. The nurse observing the telemetry monitor identifies flattening T waves and peaked P waves. What problem should the nurse consider based on these ECG changes? 1 Hypokalemia 2 Hypocalcemia 3 Hyponatremia 4 Hypomagnesemia

1 - Hypokalemia Flattened or inverted T waves, peaked P waves, depressed ST segments, and elevated U waves are associated with hypokalemia. Prolongation of the QT interval may indicate hypocalcemia. Hyponatremia is not reflected in the heart's electrical conduction. Although flattening of T waves may occur with hypomagnesemia, the ST segment may be shortened, and the PR and QRS intervals may be prolonged.

An Rh-negative mother who gave birth at 10:30 AM on January 7 should receive her Rh immune globulin injection no later than when? 1 10:30 PM on January 11 2 10:30 PM on January 11 3 10:30 AM on January 10 4 10:30 PM on January 10

3 - 10:30 AM on January 10 Rh immune globulin needs to be administered within 72 hours of delivery. Administration at 10:30 PM on January 10 or at any time on January 11 is too late.

Which sleep disorders are examples of dyssomnias? Select all that apply. 1 Insomnia 2 Nightmares 3 Sleep terrors 4 Restless leg syndrome 5 Obstructive sleep apnea

1 - Insomnia 4 - Restless leg syndrome 5 - Obstructive sleep apnea Insomnia, restless leg syndrome, and obstructive sleep apnea are examples of dyssomnias. Nightmares and sleep terrors are examples of parasomnias.

A nurse is preparing a teaching plan for the parents of a child with celiac disease. What information on the basic problem in celiac disease does the nurse include? 1 Green stools 2 Intolerance of gluten 3 Absence of intestinal villi 4 Susceptibility to severe dehydration

2 - Intolerance of gluten Celiac disease is an immunological small intestine enteropathy characterized by the inability to metabolize the gliadin component of gluten found in grains such as wheat, barley, rye, and oats; this results in excessive glutamine that is toxic to the mucosal cells. The stools are fatty and yellow. The intestinal villi are present but will atrophy if exposed to foods containing gluten. Fluid balance is not the basic problem with celiac disease; however, dehydration may occur in celiac crisis.

While in the playroom of a pediatric unit the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. What does the nurse conclude about this behavioral interaction? 1 It is a typical expression of toddlers' social development. 2 This is an example of antisocial behavior found in some children. 3 It is a lack of parental role models to demonstrate acceptable behavior. 4 This is an illustration of separation anxiety typical of hospitalized toddlers.

1 - It is a typical expression of toddlers' social development. As part of the socialization process, toddlers enjoy playing beside other children (parallel play); they are not developmentally ready for interactive (cooperative) play, which begins in the preschool years. This is not antisocial behavior; it is a misinterpretation of parallel play that is typical of toddlers' behavior. This is not an example of an ineffective parental role model; it is a misinterpretation of parallel play that is typical of toddlers' behavior. There are no data to indicate that the children are experiencing separation anxiety.

A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse? 1 The child is trying to assert independence. 2 The child is eager to resume regular play activities. 3 The child is unsure of the difference between yes and no. 4 The child is confused as a result of increased intracranial pressure.

1 - The child is trying to assert independence. The toddler is exhibiting typical behavior for this developmental level; most toddlers will say no as a means of asserting their independence. Although the child may be eager to resume playing, the behavior described is related to the child's assertion of autonomy. Although toddlers who are attempting to assert independence will say no even when they mean yes, they do understand the difference. This child's behavior does not indicate confusion; it is typical of 2-year-old children, who will say no to most things as a means of asserting their independence.

Which feature is characteristic of a risk nursing diagnosis? 1 The diagnosis does not have related factors. 2 The diagnosis can be used in any health state. 3 The defining characteristics support the diagnostic judgment. 4 The defining characteristics are supported by a client's readiness.

1 - The diagnosis does not have related factors. A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.

A 37-year-old woman is admitted to the unit with severe menorrhagia. During assessment the nurse learns that she has a history of fibroids, menorrhagia, pelvic pain, and depression. The client has been undergoing hormone therapy in hopes of easing the symptoms and reducing the size of the fibroids, without success. The lab reports hemoglobin and hematocrit readings of 6.8 g/dL (68 mmol/l) and 20.2 (20%), respectively. The client begins to sob and cries, "I don't know what to do—my primary healthcare provider is recommending a hysterectomy, but I haven't had children yet!" What is the best response by the nurse? 1 "There are so many children up for adoption, looking for a mother." 2 "This must be so difficult for you. Children are really important to you?" 3 "You really have no choice but to follow the recommendation; the primary healthcare provider is right." 4 "Believe me when I tell you that kids are so difficult to raise—you're better off without them."

2 - "This must be so difficult for you. Children are really important to you?" Validating the client's feelings and including an open-ended question will encourage further expression. Previous problems and health conditions could later be included in the conversation to help the client make the best decision. Adoption is certainly an option for this person, but this is not what she needs to hear at this time. This statement also closes down communication. The client does have a choice, and telling her that she does not could preclude further communication and cause anger and defensiveness. Telling the client that she's better off without children is not what the client needs to hear, especially when she is facing an operation that could end her chance of giving birth to children.

Which statement best describes a diagnostic label? 1 It is a condition that responds to nursing interventions. 2 It describes the essence of the client's response to health conditions. 3 It describes the characteristics of the client's response to health conditions. 4 It is identified from the client's assessment data and associated with the diagnosis.

2 - It describes the essence of the client's response to health conditions. A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.

The nurse is counseling a woman who has just been identified as having a multiple gestation. Why does the nurse consider this pregnancy high risk? 1 Postpartum hemorrhage is an expected complication. 2 Perinatal mortality is two to three times more likely in multiple than in single births. 3 Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. 4 Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

2 - Perinatal mortality is two to three times more likely in multiple than in single births. Perinatal morbidity and mortality rates are higher with multiple-gestation pregnancies, because the greater metabolic demands and the possibility of malpositioning of one or more fetuses increases the risk for complications. Although postpartum hemorrhage does occur more frequently after multiple births, it is not an expected occurrence. Adjustment to a multiple gestation and birth is individual; the time needed for adjustment does not place the pregnancy at high risk. Maternal mortality during the prenatal period is not increased in the presence of a multiple gestation.

An executive busy at work receives a phone call from a friend relating bad news. The executive makes a conscious effort to put this information out of mind and continues to work at the task at hand. The next day executive remembers that the friend telephoned but is unable to recall the message. Which defense mechanism does this behavior represent? 1 Regression 2 Suppression 3 Reaction formation 4 Passive aggression

2 - Suppression Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression is the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn? 1 A 55-year-old client who had a mastectomy and is very anxious about her body image 2 An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking 3 A 56-year-old client who had a heart attack last week and is requesting information about exercise 4 A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

3 - A 56-year-old client who had a heart attack last week and is requesting information about exercise A client who is requesting information is indicating a readiness to learn. When a nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse should encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

The mother of a preschool-age child tells the school nurse that her husband is dying of cancer and that she is worried about how her child will cope. As part of their discussion, what does the school nurse include that preschool-age children view death as? 1 Universal 2 Irreversible 3 A form of sleep 4 A frightening ghost

3 - A form of sleep Between the ages of 3 and 5 years death is viewed as a departure or sleep and as reversible. The universality and irreversibility of death are concepts held by children starting at 8 to 9 years of age. The early school-age child of 6 or 7 years personifies death, possibly envisioning it as a ghost, and sees it as horrible and frightening; this is consistent with the concrete thinking present at this age.

A 14-month-old child is admitted to the pediatric hospital with a fractured right femur. The child is placed in Bryant traction. When the parents see the child for the first time in traction, they are surprised to see both legs in traction and ask why. What information should the nurse share about Bryant traction? 1 Putting both legs in traction keeps one leg from becoming longer than the other. 2 Putting both legs in traction keeps the baby from turning over in bed and breaking his leg again. 3 As a means of ensuring countertraction, both legs are placed in traction, and the buttocks are suspended off the bed. 4 When the leg was x-rayed, the healthcare practitioner apparently discovered that the other leg was broken as well.

3 - As a means of ensuring countertraction, both legs are placed in traction, and the buttocks are suspended off the bed. In young infants the body weight doesn't provide adequate countertraction to overcome the spasm of the muscles. With both legs in traction and the buttocks suspended off the bed, countertraction is sufficient to realign the femur. Putting both legs in traction does not keep the child from having one leg longer than the other. A bed jacket could keep the child from turning over in bed; keeping the baby from turning over in bed is not the reason for putting both legs in traction. This type of traction can be used for one fractured femur; it is not reserved for bilateral fractures.

A nurse assesses a 35-year-old multiparous client who is scheduled for a tubal ligation to determine her emotional response to the planned procedure. What factor in the client's history will contribute most to the healthy resolution of any emotional problem associated with sterilization? 1 Belief that surgery will relieve her monthly dysmenorrhea 2 Knowledge that her partner does not want to have any more children 3 Feeling that her family is complete and she now has the children that were planned 4 Recovery from her previous complicated birth and does not want to experience another birth

3 - Feeling that her family is complete and she now has the children that were planned Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should have no effect on dysmenorrhea. The decision for sterilization should not be made by others, only by the woman herself. Decisions regarding sterilization should not be made when the client is under stress.

A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? 1 Crepitus 2 Sinusitis 3 Fracture of the nose 4 Upper respiratory tract infection

3 - Fracture of the nose Fractures of the nose often result from injuries received during falls, sports activities, car crashes, or physical assaults. Nose fractures may lead to difficulty in breathing. Crepitus is crackling of the skin on palpitation. Sinusitis is an inflammation of the tissues lining the sinuses. In an upper respiratory tract infection, a stuffy nose and itching results in difficulty breathing. However, pain may not be present.

What is the cause of milk anemia in toddlers? 1 Drinking skim milk 2 Drinking whole milk 3 Increased milk intake 4 Increased intake of fruits

3 - Increased milk intake Toddlers who consume more than 24 ounces of milk daily in place of other foods sometimes develop milk anemia because milk is a poor source of iron. Children are usually not offered low-fat or skim milk until age 2 because they need the fat for satisfactory physical and intellectual growth. Toddlers need to drink whole milk until the age of 2 years to make sure that there is adequate intake of fatty acids necessary for brain and neurological development. Other solid food items are necessary for healthy growth and development in toddlers.

A nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. What condition does this medication prevent? 1 Herpetic ophthalmia 2 Retinopathy of prematurity 3 Ophthalmia neonatorum 4 Hemorrhagic conjunctivitis

3 - Ophthalmia neonatorum Ophthalmia neonatorum is caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate's eyes. Herpes affects the neonate systemically. Retinopathy of prematurity (formerly retrolental fibroplasia) occurs as a result of prolonged exposure to a too-high oxygen concentration. Hemorrhagic conjunctivitis is usually caused by rapid expulsion of the fetus's head from the vagina.

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? 1 True labor 2 Placenta previa 3 Partial abruptio placentae 4 Abdominal muscular injury

3 - Partial abruptio placentae Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain.

3 - The nurse asks the client to explain the surgery. The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

Which critical thinking skill does the nurse associate with the concept of maturity? 1 Eagerness to acquire knowledge 2 Being tolerant of different views 3 Trust in own reasoning processes 4 Ability to reflect on own judgments

4 - Ability to reflect on own judgments Maturity is the ability of a critical thinker to reflect on his or her own judgments. A critical thinker realizes that multiple solutions are acceptable. Inquisitiveness is the eagerness to acquire knowledge. A critical thinker is considered open-minded if he or she respects the right of others to have different opinions and is tolerant of different views. The critical thinker possesses self-confidence and trusts in his or her own reasoning process.

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? 1 Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history 2 Assess vital signs, obtain a history, and arrange for emergency x-ray films 3 Conduct a thorough physical assessment, assess vital signs, and cover open wounds 4 Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

4 - Assess vital signs, control accessible bleeding, and determine the presence of critical injuries A thorough physical assessment is too time-consuming initially; open wounds can be covered at a later time. Initial rapid assessment will determine priorities of care and subsequent actions. IV therapy and transfusions will be prescribed, but baseline data are needed to assess the client's present condition and the significance of future responses. Although important, obtaining a history and x-ray films can be postponed until bleeding is controlled and injuries are assessed.

A 47-year-old client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse that she has been experiencing hot flashes and that her periods have been occurring at longer, less regular intervals, with a scanty flow. What does the nurse conclude is the most likely cause of these changes? 1 Uterine cancer 2 Lack of estrogen 3 Early cervical carcinoma 4 Expected menopausal changes

4 - Expected menopausal changes The adaptations described, along with the client's age, suggest that the client is experiencing menopause. Irregular spotting and bleeding occur with uterine cancer and are not associated with the menstrual cycle. Estrogen is reduced, not eliminated, during and after menopause; the adrenal glands produce a small amount of estrogen throughout life. Early cervical cancer is asymptomatic; an irregular bloody vaginal discharge is a late sign of cervical cancer.

The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? 1 NANDA-I label, related factor, and etiologies 2 NANDA-I label, risk factor, and nursing interventions 3 NANDA-I label, related factor, and nursing interventions 4 NANDA-I label, related factor, and defining characteristics

4 - NANDA-I label, related factor, and defining characteristics The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions.

What does the nurse explain to a client that a positive diagnosis for human immunodeficiency virus (HIV) infection is based on? 1 Performance of high-risk sexual behaviors 2 Evidence of extreme weight loss and high fever 3 Identification of an associated opportunistic infection 4 Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests

4 - Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests Positive ELISA and Western blot tests confirm the presence of HIV antibodies that occur in response to the presence of the HIV. Performance of high-risk sexual behaviors places someone at risk but does not constitute a positive diagnosis. Evidence of extreme weight loss and high fever do not confirm the presence of HIV; these adaptations are related to many disorders, not just HIV infection. The diagnosis of just an opportunistic infection is not sufficient to confirm the diagnosis of HIV. An opportunistic infection (included in the Centers for Disease Control and Prevention surveillance case definition for acquired immunodeficiency syndrome [AIDS]) in the presence of HIV antibodies indicates that the individual has AIDS.

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? 1 The client's heart may be beating faster temporarily. 2 The nurse may not know how to take an accurate pulse. 3 The radial pulse site may be surrounded by too much subcutaneous fat. 4 The client may have atrial fibrillation.

4 - The client may have atrial fibrillation. Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia, not a pulse deficit. It is unlikely the nurse does not know how to take a pulse accurately; nurses are trained in assessment. If a pulse deficit identified at a pulse site is attributed to the presence of excessive subcutaneous fat, the nurse should obtain the peripheral pulse at a different site.

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1 All nursing functions will be completed by discharge. 2 All invasive intravenous lines will remain patent. 3 The client will remain awake, alert, and oriented at all times. 4 The client will be free of signs and symptoms of infection by discharge.

4 - The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

Which statement is true for collaborative problems in a client receiving healthcare? 1 They are the identification of a disease condition. 2 They include problems treated primarily by nurses. 3 They are identified by the primary healthcare provider. 4 They are identified by the nurse during the nursing diagnosis stage.

4 - They are identified by the nurse during the nursing diagnosis stage. The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.