Nursing 401 crit care

A nurse is caring for a 7-year-old child with severe burns who has extensive eschar formation on the arms. What is the priority nursing intervention?

Checking radial pulses

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client?

Maintain balance to improve stability

A child returns to his room after left-side cardiac catheterization. What is involved in the postprocedure nursing care?

Monitoring the insertion site for bleeding

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues?

Percussion

The nurse uses which principles of body mechanics when caring for immobilized clients?

Placing the feet apart to increase the stability of the body

The nurse is planning care for a middle-aged woman who has been admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. What should the nurse tell the client to expect in the immediate postoperative period?

Presence of a urinary catheter

How can a nurse best soothe a hospitalized infant who appears to be in pain?

Holding the infant

A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care?

Providing frequent rest periods

Which statement is true about the sleep pattern of preschoolers?

The average preschooler sleeps about 12 hours a night. By the age of five, children rarely take daytime naps except in cultures in which a siesta is the custom. Partial awakening followed by a normal return to sleep is frequent. About 30% of an infant's sleep time is in the rapid eye movement sleep (REM) cycle.

A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase?

"The client will maintain present muscle strength."

An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. What is the best response by the nurse?

"The energy that would have been expended on suckling is conserved."

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing?

-OH

An infant is to be discharged after surgery for pyloric stenosis. What instructions should the nurse give the parents?

"Hold the baby while continuing to feed a regular formula slowly and burp frequently."

The nurse is teaching the parents of an infant who will have frequent cast changes about cast care. What suggestion should be included in the teaching?

Assess the skin at the edges of the cast.

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score?

13

A nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. What is the volume of solution the nurse should prepare?

250 to 350 mL

A 12-year-old child is admitted to the hospital for observation after sustaining a head injury. Twelve hours after the injury the child has none of the signs or symptoms of a head injury. What is the nurse's priority intervention at this time

Assessing the level of consciousness every hour. Evidence of a subdural hemorrhage may take hours or days to develop; a diminishing level of consciousness is an early indication of neurological damage.

What is the maximum heart rate of a 16 year old

90...

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure?

All metal must be removed because the MRI emits a strong magnetic field[1][2]. All medications may not be necessary before the test. Prehydration is not necessary and may cause interruptions for client to void. The client should have the opportunity to void before going for the test.

When teaching an adolescent with type 1 diabetes about dietary management, what instruction should the nurse include?

An adolescent with type 1 diabetes must carry a source of simple sugar (e.g., glucose tablets, Insta-Glucose, sugar-containing candy such as LifeSavers) to rapidly counteract the effects of hypoglycemia. This should be followed by a complex carbohydrate and a protein. Stating that meals should be eaten at home is an unrealistic and unnatural instruction for an adolescent. Stating that foods should be weighed on a gram scale is an unnecessary and time-consuming procedure. The adolescent should be made to feel a part of the family; the recommended diet is nutritious and no different from that of the rest of the family.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first?

Assess the client's heart and lung sounds.

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?

Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurologic check is not necessary unless the client's neurologic status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.

Which would the nurse consider to be a potential respiratory system-related complication of surgery?

Atelectasis is a potential complication of the respiratory system that can occur after surgery. Hyperthermia is a potential neuromuscular complication. Wound dehiscence is a potential skin complication. Hypovolemic shock is a cardiovascular complication that can occur after surgery

Which joint permits movement in any direction?

Ball-and-socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement.

An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube?

Before each feeding

A client remains depressed even after an 8-week trial on several antidepressant medications. A decision to initiate electroconvulsive therapy (ECT) is being considered by the treatment team. Which condition is a contraindication to ECT?

Brain tumor

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first?

Check the client's pedal pulses.

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention?

Check the compatibility of the medication and the continuous IV solution.

A preschool-aged child with leukemia who is undergoing chemotherapy is susceptible to rectal ulcerations. What should the nurse recommend to the parents that will lessen the severity of this problem?

Clean the child's perianal area after each bowel movement.

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis?

Comfort

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client?

Control of pain

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia?

Deficiency of thiamine

What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration?

Depressed anterior fontanel

A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention should the nurse emphasize?

Giving small amounts of clear liquids frequently to prevent dehydration

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. What should the nurse do to promote psychologic adjustment and early function immediatelyafter surgery?

Help the client adjust to the temporary prosthesis.

What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea?

Improvement of fluid balance

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest?

It decreases the potential for further dislodgment of emboli.

A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about postprocedure interventions that protect the catheter insertion site. What should the nurse inform the client of regarding the leg used for catheter insertion?

It should be kept extended while on bed rest.

The nurse is teaching crutch-walking to a 12-year-old adolescent. What does the child do that indicates the need for more teaching?

Looks down when placing the crutches

A nurse teaches the mother of a 2-year-old child who has celiac disease which foods to avoid. Which foods identified by the mother indicate that she understands the teaching?

Macaroni and cheese

A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure?

Pain at the insertion site

What change is seen when a child enters from a stage of toddlerhood to the stage of preschooler?

Preschoolers desire to extend their bedtimes. They show hyperactivity during sleeping hours. Preschoolers have sleep disturbances instead of sleeping soundly. Daytime naps are infrequent in preschoolers. Preschoolers sleep around 12 hours each night.

A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve?

Preventing pressure on peripheral blood vessels

What must the nurse do to determine a client's pulse pressure?

Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.

What procedure should a nurse use when elevating the head of an infant in a spica cast?

Raising the entire mattress at the head of the crib

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

Relieve the client's discomfort.

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?

Returning the aspirate and subtracting the amount of the aspirate from the feeding

Which surgery is used to treat excessive wrinkling or sagging of facial skin?

Rhytidectomy is the removal of excess skin and tissue from the face; this is the surgery used to treat wrinkling or sagging of facial skin. Rhinoplasty is the removal of excessive tissue or cartilage from the nose. Dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars. Blepharoplasty is the removal of bulging fat in the periorbital area; this is used to treat bags under the eyes.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position?

Right side-lying

An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?

Say the child's name and touch the child's arm before starting care.

The nurse is reviewing the amount of drainage on the dressing of a client after discharge from the postanesthesia care unit (PACU). On which area should the nurse focus for this assessment?

Surgical incision site

What can a nurse do to help confirm a suspected diagnosis of intestinal infestation with pinworms in a 6-year-old child?

Teach the mother the procedure for an anal cellophane tape test

What is the most common teratogenic effect associated with thalidomide?

Thalidomide is a teratogen that may cause shortened limbs and limb deformities. Growth delay, neural tube defects, and cleft lip with cleft palate are not associated with thalidomide use.

What is the minimum heart rate of a 14 year old?

The minimum heart rate of a 14 year old is 60 beats per minute.

What is the average optimal blood pressure of an adolescent?

The optimal blood pressure of an adolescent is 110/65 mm Hg. The average optimal blood pressure in an infant is 85/54 mm Hg. The average optimal pressure in a toddler is 95/65 mm Hg. The average optimal blood pressure seen in children between the ages of 6 and 13 is 105/65 mm Hg.

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?

This limits muscle contractions that may force causative organisms into the bloodstream.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

penne pasta, spinach, banana, and decaffeinated iced tea

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow?

The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

The stockings should be applied before getting out of bed.

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?

This is a positive Babinski sign[1][2][3]; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion is inaccurate"; a Babinski is not caused by intentional movement. Active range of motion is a type of exercise, not reflex.

A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy?

Two hours after feedings

A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid?

Uric acid stones are controlled by a low-purine diet. Foods high in purine, such as organ meats and extracts, should be avoided. Milk should be avoided with calcium, not uric acid, stones. Cheese or animal protein should be avoided with cystine, not uric acid, stones. Vegetables do not have to be avoided.

A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy dry skin? What is the best response by the nurse?

Use a moisturizer on the skin daily to help reduce itching.

What should the nurse do to prevent thrombus formation after most surgeries?

walk

Which category of drugs carries fetal risk in humans?

X

A nurse is caring for a client who had major abdominal surgery one day ago. What factor increases the risk of this client developing a wound dehiscence?

being overweight

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy?

bleeding

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question?

cells

A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention?

check pulses

A 3-year-old is placed in a bilateral hip spica cast for the treatment of developmental dysplasia of the hip. The nurse should teach the parents to monitor their child and report to the practitioner the occurrence of what?

numbness

After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses with the client the procedure and what to expect after the removal. Which statement by the client indicates teaching by the nurse is understood?

"I probably will experience some burning on urination."

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?

"I'll start to have symptoms when I drink less fluid."

The parents of a 2-year-old child are watching the nurse administer the Denver II Developmental Screening Test to their child. They ask, "Why did you make our child draw on paper? We don't let our child draw at home." What is the best response by the nurse?

"It lets us test the child's ability to perform tasks requiring the hands."

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges?

"Put an ice pack on the affected area."

A client with malignant hot nodules of the thyroid gland has a thyroidectomy. What is the nurse's priority action immediately postoperative?

A deviated trachea is an imminent sign of airway compromise which requires immediate intervention. The client is at high risk for bleeding within the first 24 hours postoperative. Bleeding can accumulate at the incision site as well as in the neck causing tracheal compression with swelling that may compromise the client's ability to breath. Checking for bleeding may alert the nurse of an increasing risk of airway compromise. Pain management and breathing exercises are standard postoperative interventions.

Which test would the client undergo to receive a diagnosis of systemic lupus erythematosus?

A direct immunofluorescence test is used in the diagnosis of systemic lupus erythematosus. The patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions. An indirect immunofluorescence test is performed on a blood sample.

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information?

A low calcium intake is recommended. Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout.

A gavage feeding is prescribed for an infant. How does the nurse determine the length of tube needed to reach the stomach?

A measurement is made from nose to earlobe and then to the epigastric area.

A home care nurse is visiting a client who had a below-the-knee amputation. Which client statement indicates to the nurse that further teaching is needed?

A pillow may promote a flexion contracture of the hip and knee and may interfere with use of a prosthesis and ambulation. The response "When I sit in a chair, I put my legs out straight on an ottoman" expresses an action that prevents pooling of blood and edema in the extremities. The response "I apply a firm, even bandage around the end of my affected leg every day" explains an activity that prevents edema and promotes residual limb shrinkage. Pressing the end of the affected leg against a soft surface several times during the day prepares the residual limb for weight-bearing and for use of a prosthesis.

Which diagnostic test is being performed in this figure?

A pulse oximeter uses a wave of infrared light via a sensor placed on the client's finger, toe, nose, earlobe, or forehead to identify hemoglobin saturation with oxygen. In this figure, the instrument is attached to the client's finger. Capnometry and capnography are methods that measure the amount of carbon dioxide present in exhaled air, an indirect measurement of arterial carbon dioxide levels. Pulmonary function tests (PFTs) assess lung function and breathing problems. In this procedure, the client is asked to breathe only through the mouth, and a nose clip may be used to prevent air from escaping through the nose.

Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin?

An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction occurs.

Which drug used to treat acne has a bleaching effect?

Benzoyl peroxide has a bleaching effect on sheets, bedclothes, and towels. Isotretinoin is associated with photosensitivity, nasal irritation, dry skin and mucous membrane. Minocycline and tetracycline are systemic antibiotics that may cause photosensitivity reactions, vaginal candidiasis, and gastrointestinal upset.

What is the concentration of estradiol in the blood during the follicular phase of the menstrual cycle?

In the follicular phase of the menstrual cycle, 20-150 pg/mL of estradiol is released. Therefore 130 pg/mL of estradiol would be its concentration during the follicular phase of the menstrual cycle. Concentrations of 159, 165, and 171 pg/mL are greater than the reference range.

An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

A 7-year-old child is admitted for surgery. What is the priority nursing action?

Inspecting the child's mouth for loose teeth and reporting the findings

After an open reduction and internal fixation of a fractured hip, the nurse is helping a client to get out of bed into a chair. What should the nurse do to best accomplish this transfer?

Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair.

What is the priority nursing action in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance

Which interventions should the nurse perform when caring for an actively dying client? Select all that apply.

Reassure the client and family. Manage the client's symptoms.

A 4-year-old child with Wilms tumor undergoes nephrectomy. What essential information should the nurse plan to teach the parents?

Recognize the signs of urinary tract infection.

Which emergency response team helps set up shelters for victims who lost their homes due to a disaster?

Red cross

A client on a 2-gram sodium diet states, "I never add salt to my food when I cook. I just need help selecting low-sodium foods." After receiving dietary education, the client creates sample menus. Which meal selection will cause the nurse to intervene?

Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema?

daily weight

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss?

daily weights

The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition?

downs

While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention?

edema

A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition?

Asking the parents to visit at mealtimes

Which radiographic test is used to view the entire skeleton?

A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems, primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?

A rise in the level of formula within the tube indicates a full stomach. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A rapid inflow is the result of positioning the container too high or using a feeding tube with too large a lumen. Epigastric tenderness is not necessarily caused by a full stomach.

What surgical procedure is shown in the following picture?

A thoracentesis is a diagnostic procedure used to obtain a specimen of pleural fluid for diagnosis, to remove pleural fluid, or to instill medication. A mediastinoscopy involves a scope inserted through a small incision in the suprasternal notch advanced into the mediastinum to inspect and biopsy lymph nodes. A transbronchial biopsy involves passing forceps through a bronchoscope to obtain a specimen that can be studied to differentiate between the infection and rejection in lung transplant recipients. Computed tomography is used to diagnose lesions that are difficult to assess via conventional X-ray studies.

What is the most important nursing action when measuring a client's pulmonary capillary wedge pressure (PCWP)?

Deflate the balloon as soon as the PCWP is measured.

A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include?

Encouraging continuation of breastfeeding

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention?

Evaluating the client's ability to care for the ileostomy

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan which intervention?

Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychologic adjustment, but does not address the client's concerns at this time. Having a member of the family stay and give the client support should be permitted if requested by the client or family, but does not address the concerns voiced by the client.

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first?

The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour time period for the test is not necessary; voided specimens are acceptable. Straining the urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent?

The hyperextension required in swimming helps strengthen back muscles and necessitates deeper respirations, both of which are necessary before surgery and before wearing a brace or cast. The other options involve twisting the back muscles, which is not therapeutic for a child with this condition.

What does the nurse educate the mother of a toddler to do in order to promote safety?

The nurse educates the mother of a toddler to remove plastic grocery or other bags from from the house to reduce the risk of suffocation. The nurse should instruct the mother not to fill the crib with stuffed toys as there is an increased risk of suffocation. Putting pacifiers around the neck of the child attached with a string increases the risk of choking. The nurse should tell the mother to place a newborn on his or her back to sleep; it reduces the risk of sudden infant death syndrome.

Which statement is applicable to Watson's theory of transpersonal caring?

Watson's theory of transpersonal caring defines the outcome of nursing activity in relation to the humanistic aspects of life. The Roy adaptation model views the client as an adaptive system. The Neuman systems model is based on stress and the client's reaction to the stressor. Leininger's theory focuses on cultural diversity; the goal of nursing care should be to provide the client with culturally specific nursing care.

A nurse is assessing the urine of a client with a urinary tract infection. Which assessment finding is consistent with a urinary tract infection?

cloudy

A nurse is caring for a 6-year-old child with sickle cell anemia. What is the priority nursing intervention to prevent thrombus formation?

fluids

A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest?

get warm

The primary healthcare provider prescribes one unit of packed red blood cells to be administered to the client who suffered a hip fracture. Several minutes after the start of the infusion, the client reports itching. Upon further assessment, the nurse observes hives on the client's chest. Which action should the nurse take next?

stop it

Which pulse site is used to perform Allen's test?

ulnar

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management?

Divide food into four to six meals a day

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do?

Divide the daily caloric intake into six smaller meals

A nurse performs full range-of-motion exercises on a client's extremities. When putting an ankle through range-of-motion exercises, what must the nurse perform?

Dorsiflexion, plantar flexion, eversion, and inversion

An infant has been admitted with failure to thrive (FTT). The nurse knows that more education is needed when one of the parents makes what statement?

Doubling the amount of water in the formula reduces the baby's caloric intake. Holding the head up, burping the baby, and making sure that formula is in the nipple are all ways to increase caloric intake and reduce the chance of postfeeding vomiting due to air swallowing.

A nurse teaches a client who has had a thyroidectomy for thyroid cancer to observe for signs of surgically induced hypothyroidism. What should be included in the teaching plan? Select all that apply.

Dry skin is a response to hypothyroidism that is related to the associated decreased metabolic rate. Lethargy and sensitivity to cold are symptoms related to hypothyroidism that are associated with a decreased metabolic rate. Insomnia and tachycardia are related to hyperthyroidism, not hypothyroidism.

When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. When teaching when to call the primary healthcare provider, what statement made by the client shows that teaching was effective?

Dry, sparse hair and cold intolerance are characteristic responses to low serum thyroxine. Muscle cramping is associated with hypocalcemia. Low thyroxine levels reduce the metabolic rate, resulting in fatigue, but do not increase the pulse rate. Low thyroxine levels reduce the metabolic rate, resulting in weight gain and bradycardia, not tachycardia.

The mother of a 5-year-old child recovering from varicella (chickenpox) calls the nurse in the pediatric clinic, asking how the child's itching can be relieved. What is the best response by the nurse?

Drying the lesions relieves the itching (pruritus). Patting the lesions will not disturb them, and calamine lotion is an effective drying agent. Mittens may minimize injury caused by scratching but will not relieve pruritus. An antibiotic ointment prevents secondary infection but does not relieve the itching because it does not have a drying effect. An antibiotic requires a practitioner's order. Dressings may disrupt the vesicles and lead to scar formation.

Which second-generation antidepressant can worsen uncontrolled angle closure glaucoma?

Duloxetine can worsen uncontrolled angle-closure glaucoma. Trazodone is contraindicated in clients with a known drug allergy. Bupropion is contraindicated for clients with seizures. Mirtazapine is contraindicated in cases of known drug allergy and concurrent use of monoamine oxidase inhibitors.

The nurse is providing postoperative care to a client who had surgery in which a hip prosthesis was inserted. An abductor splint is in place. When should the nurse remove the splint?

During the client's skin care and physical therapy

Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs?

Emphysema is a condition in which a dysregulation of lung proteases may lead to the collapse of the walls of the bronchioles and alveolar air sacs. Asthma is a condition that involves a reversible airflow obstruction in the airways. In chronic bronchitis, infections or bronchial irritants cause increased secretions, edema, bronchospasm, and impaired mucociliary clearance. Centriacinar or centrilobular emphysema affect the respiratory bronchioles most severely.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement?

Encourage the family to bring in special foods preferred in their culture.

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care?

Head of the bed remains elevated after the feeding.

A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?

Hemorrhage

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs?

High in protein and vitamin C

An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress?

Increased eosinophil level

Which tocolytic agent inhibits prostaglandin activity and is given along with sucralfate to help manage preterm labor?

Indomethacin is a nonsteroidal antiinflammatory agent that may cause gastric irritation so sucralfate is administered along with this drug. Nifidipine is a calcium channel blocker used to manage preterm labor. Calcium gluconate is used to reverse magnesium sulfate toxicity. Magnesium sulfate is used to manage preterm labor and pregnancy-induced hypertension.

Intestinal infestation with Enterobius vermicularis (pinworm) is suspected in a 6-year-old child. The nurse asks the parents to assist in confirming the child's diagnosis. What does the nurse instruct the parents to do?

Perform an anal cellophane tape test early in the morning.

Why is Phalen's test performed in a client?

Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time?

Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

A client at 42 weeks' gestation is admitted for a nonstress test. The nurse concludes that this test is being done because of what possible complication related to a prolonged pregnancy?

Placental insufficiency

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever?

Positive antistreptolysin titer

A nurse advises a mother to teach her child to swim under guided supervision. Which age group of the child is the nurse referring to?

Preschoolers should be taught to swim, but under supervision. Learning to swim is a useful skill that can someday save a child's life. The mother of a toddler should be instructed to place window guards on all windows and never leave a child alone in the bathroom, tub, or near any water source. Adolescents should be taught about the effects of using alcohol and drugs and referred to community and school-sponsored activities. The mother of a school-age child should be taught about the safe use of equipment for play and work and proper bicycle safety.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding?

There is less chance of aspiration.

An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?

Using modified techniques for feeding

A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response?

Vascular spasms In an attempt to stop the bleeding, adjacent arteries constrict (vasospasm); this in turn contributes to the ischemia responsible for the neurologic deficits. The volume of blood loss is not great enough to significantly alter the oxygen-carrying capability of the remaining blood supply. Although prolonged ischemia may cause necrosis, many of the manifestations of cerebral ischemia are reversed as pressure diminishes, and there may be no permanent damage. Severe electrolyte imbalance may cause generalized weakness; however, hemiparesis and aphasia are not the result of electrolyte loss.

What is the priority nursing responsibility in the care of a young toddler after a circumcision?

Watching for bleeding around the penis

While caring for a client who had an open reduction and internal fixation of the hip, the nurse encourages active leg and foot exercises of the unaffected leg every 2 hours. What does the nurse explain that these exercises will help to do?

clots

When assessing the laboratory values of a client with type 2 diabetes, what would the nurse expect the results to reveal?

Urine negative for ketones and positive glucose in the blood

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be?

Perform a complete pain assessment.

What is the recommended size of the urinary catheter that can be used in a 3-year-old child?

8 to 10 Fr

Which surgical procedure is appropriate for the removal of a vocal cord due to laryngeal cancer?

A cordectomy is a surgical procedure performed in clients with laryngeal cancer; this surgery involves the removal of a vocal cord. A tracheotomy is a surgical incision in the trachea for the purpose of establishing an airway. A total laryngectomy is a surgical procedure in which the entire larynx, hyoid bone, strap muscles, and one or two tracheal rings are removed. A nodal neck dissection is also done in a total laryngectomy if the nodes are involved. An oropharyngeal resection is a surgical procedure performed to treat cancer of the oropharynx.

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). What does the nurse expect to find?

A decrease in CD4 T cells

Which type of cast will the nurse be caring for in a child with a fractured femur?

A hip spica cast is now mainly used for femur fractures in children. A cylinder cast is used for knee fractures because it extends from the groin to the malleoli of the ankle. A prefabricated knee splint is a commonly used cast for lower extremity injuries. A Robert Jones dressing is composed of bulky padding materials, splints, and elastic wrap or stockinette used for lower extremity injuries.

The client's pituitary gland must be removed. Which surgery will the client undergo?

A hypophysectomy is the surgical removal of the pituitary gland or its tumor. A mastectomy is the surgical removal of breast tissue. A prostatectomy is the surgical removal of the prostate gland. A thyroidectomy is the surgical removal of the thyroid gland.

Which test helps to identify fibroids, tumors, and fistulas while performing a reproductive tract examination?

A hysterosalpingogram is an X-ray used to evaluate tubal anatomy and patency and used to identify uterine problems such as fibroids, tumors, and fistulas. A mammography is an X-ray of the soft tissue of the breast. An ultrasonography (US) is a technique used to assess fibroids, cysts, and masses. Computer tomography is used to detect and evaluate masses and identify lymphatic enlargement from metastasis.

Which retrograde procedure involves the examination of the ureters and the renal pelvises?

A pyelogram is a retrograde examination of the ureters and the pelvis of both kidneys. A cystogram is a retrograde examination of the bladder. An urethrogram is a retrograde examination of the urethra. A voiding cystourethrogram is used to determine whether urine is flowing backward into the urethra.

The nurse is caring for a client with a possible pulmonary embolism (PE). Which diagnostic test should the nurse initially anticipate will be prescribed for this client because it is the evidence-based gold standard for a PE diagnosis?

A spiral (helical) computed tomographic angiography (CTA) is considered the gold standard for a pulmonary embolism (PE) medical diagnosis. The spiral CTA also has the added advantage of diagnosing other pulmonary abnormalities. A pulmonary angiography is still used as a PE diagnostic test, usually if the client also has coronary disease and invasive treatment (i.e., angioplasty) may become necessary; however, it is no longer the gold standard because it is expensive and invasive, and the spiral CTA has excellent accuracy and better accessibility. Ventilation/perfusion (V/Q) scans are currently used only in certain circumstances such as when the client has contrast dye allergy. D-dimer and arterial blood gas (ABG) laboratory tests are typically prescribed for a client with a possible PE; however, these tests are not specific or sensitive enough to be used alone to make the PE diagnosis. An ABG is used to evaluate the client's oxygenation status during medical diagnosis and treatment to determine if additional emergency treatment is needed, such as intubation and mechanical ventilation. A D-dimer simply reveals the presence or absence of fibrin split products which occur when a blood clot degrades or breaks down; however, about half of clients with a PE still test negative (a normal result) and several other conditions can produce a positive D-dimer result.

A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child?

Abduction will enable the head of the femur to fit into the acetabulum, thereby correcting the dysplasia. Flexion causes the head of the femur to move away from the acetabulum. Extension causes the head of the femur to move away from the acetabulum. Adduction causes the head of the femur to move away from the acetabulum.

What is the most common cause of death among adolescents?

Accidents are the most common cause of death in adolescents; approximately 74% of all adolescent deaths are caused by accidents. Suicide is the third leading cause of death in adolescents. Homicide is the second leading cause of death in adolescents. Death by substance abuse affects 30% of adolescents.

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do?

Administer the prescribed antiemetic

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include?

Administering cleansing enemas and then neomycin

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response?

After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome?

Allows excess tissue fluid to be excreted

A child is found to be allergic to dust. The nurse is preparing a teaching plan for the parents. What should the nurse include in the plan?

Although dust cannot be avoided completely, use of a damp cloth helps eliminate the quantity of airborne particles that might be inhaled. Hiring professional housecleaners is unnecessary and unrealistic. There are ways to limit the quantity of airborne particles. Redecorating will not eliminate dust; it is part of our environment.

Which diagnostic scan is used to detect diffuse or localized muscle weakness?

An electromyography is performed to detect diffuse or localized muscle weakness by determining the electric potential generated in an individual. Arthroscopy is used for the direct visualization of ligaments, menisci, and articular surfaces of a joint. A radiography is performed to detect bone density, alignment, swelling, and intactness of a joint. A myelography is performed to visualize the vertebral column, intervertebral discs, spinal nerve roots, and blood vessels.

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend?

Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.

A parent of a healthy 8-month-old infant asks a nurse which pureed foods and type of milk are most appropriate at this age. What should the nurse suggest?

Applesauce, carrots, chicken, and formula are easily digested foods that should be introduced by 6 months of age; breast milk or formula, rather than cow's milk, is recommended for the first year of life. Ham is too high in fat and sodium for an infant younger than 1 year.

Which diagnostic test is used for the direct visualization of ligaments, menisci, and articular surfaces of joints?

Arthroscopy is a diagnostic test that uses an arthroscope to directly visualize the ligaments, menisci, and articular surfaces of a joint. A muscle biopsy is conducted to diagnose atrophy and inflammation. An ultrasonography is used to view soft tissue disorders, traumatic joint injuries, and osteomyelitis. An electromyography may be performed to evaluate diffuse or localized muscle weakness.

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take?

Assess the pulses distal to the dressing.

After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action?

Assessment, the first step of the nursing process, is the priority because it influences all future interventions. The infant's respiratory status and vital signs should be assessed before a sedative is administered. Although it is important to attach the nasogastric tube to a suction device, this may be done after the infant's status has been assessed. Although it is important to connect the intravenous line to a pump, this may also be done after the infant's status has been assessed.

Pulse oximetry is prescribed for an adolescent. What should the nurse do to ensure accuracy of the pulse oximeter reading?

Attach the probe to a finger or earlobe.

An infant with a diaphragmatic hernia undergoes corrective surgery. What nursing assessment indicates that the infant's respiratory condition has improved?

Auscultation of breath sounds bilaterally

A nurse is obtaining a health history from the parents of a preschooler with celiac disease. What characteristic does the nurse expect when the parents describe their child's stools?

Children with celiac disease have a gluten-induced enteropathy and are unable to absorb fats from the intestinal tract, resulting in the typical characteristics of their stools. The stools are large and fatty or frothy, not mucoid. Although the stools are large and frothy, they are pale because of their high fat content. The stools are large and foul-smelling and have little color.

The nurse prepares to discharge a newborn from the hospital. Which placement of the infant by the father indicates an understanding of the nurse's education regarding car seat safety?

Children younger than 2 years should be placed in a rear-facing car seat secured in the back seat. Placing young children in the front seat is dangerous and could even be fatal if the air bag deploys. Once the child weighs 35 to 40 lb (15.9 to 18.1 kg), a front-facing car seat may be used. Children should sit in the back seat until they are 13 years old.

A 10-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage?

Corn, chicken, rice, apples, and milk are permitted on the low-sodium, low-potassium diet that the child should be following. Bananas and potatoes are high in potassium, and pretzels are high in sodium. Only the peaches are low in sodium, and all but the butter are fairly high in potassium. Processed foods are high in sodium and fairly high in potassium.

Which urodynamic study provides information on bladder capacity, bladder pressure, and voiding reflexes?

Cystometrography (CMG) is an urodynamic study that provides information on bladder capacity, bladder pressure, and voiding reflexes. Radiography is a diagnostic test for clients with disorders of kidney and urinary system to screen for the presence of two kidneys, to measure kidney size, and to detect gross obstruction in kidneys or urinary tract. Renal arteriography is a diagnostic study used to determine renal blood vessel size and abnormalities. Electromyography (EMG) is an urodynamic study used to test the strength of perineal muscles in voiding.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse's priority?

Determining proper typing and crossmatching of blood

On a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question?

Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Both cloth and disposable diapers can cause diaper dermatitis if they are not changed frequently. An increased pH (i.e., alkaline) of the urine can contribute to diaper dermatitis. A change in diet may contribute, but there is no evidence that this is directly related.

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?

Encourages a normal walking pattern Without a prosthesis, a walker or crutches are necessary, and these require readjustment of weight bearing on one leg. Early use of a prosthesis does not affect the incidence of phantom limb pain, which occurs in about 10% of clients with amputations. Early use of a prosthesis has no effect on wound infection. Although true, fitting of the prosthesis before discharge is not the major purpose; a prosthesis can be fitted easily after discharge when the residual limb has healed completely and is no longer edematous.

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?

Endocarditis

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family?

Enhances the quality of the client's life

How does exercise help relieve menstrual discomfort in adolescents? Select all that apply.

Exercise helps to relieve menstrual discomfort through increased vasodilation followed by a subsequent decrease in ischemia. Exercise reduces congestion in the pelvis and minimizes the discomfort in the pelvis. Exercise promotes the release of endogenous opiates and suppresses prostaglandin production.

After her baby undergoes corrective surgery for hypertrophic pyloric stenosis, the mother is asked to offer the first feeding. The infant sucks it eagerly and vomits immediately. What is the nurse's explanation to the mother?

Explaining that the first postoperative feeding usually induces vomiting provides correct information while supporting the anxious parent. Vomiting is not caused by mucus accumulation. Questioning the mother's feeding technique may cause guilt; although the feeding technique may need to be changed, discussing it at this time is inappropriate. When the vomiting subsides, the feeding is continued.

Which is the priority nursing intervention in order to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination?

Explaining the procedure and maintaining eye contact while touching the client gently will help the client relax and will lessen discomfort. Distracting the client by asking her preference regarding the sex of her infant may distract the client; however, this will not produce relaxation. The client may become more anxious if the procedure is hurried. Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath may make the client more anxious; holding the breath causes tightening of the perineum.

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?

Feeling of heaviness in both legs

Which pulmonary function test provides a more sensitive index of obstruction in smaller airways?

Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.

During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse?

Frequent diaper changes with cleansing are needed.

After surgery for a myelomeningocele, an infant is being fed by means of gavage. When checking placement of the feeding tube, the nurse is unable to hear the air injected because of noisy breath sounds. What should the nurse do next?

Gastric returns indicate correct placement of the feeding tube. Further assessment is necessary before the provider is notified. Advancing the tube even 1 cm may cause undue trauma, regardless of where the tube is located. Inserting even a small amount of formula is unsafe until correct placement is verified; formula may enter the lungs if the tube is not in the stomach.

What will the nurse expect diagnostic studies of a client with Cushing syndrome to indicate?

High levels of 17-ketosteroids in a 24-hour urine test is a urinary metabolite of steroid hormones that are excreted in large amounts in hyperaldosteronism. With aldosterone hypersecretion, sodium is retained and potassium is excreted, resulting in hypernatremia and hypokalemia. With Cushing syndrome, the eosinophil count is decreased, not increased. ACTH levels usually are high in Cushing syndrome.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?

High osmolarity of the feedings

The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response?

Holding may meet needs and reduce tension on the suture line.

What is the maximum recommended length for enema tube insertion in an adolescent?

In adolescents, the maximum length for insertion of an enema tube is 10 cm.

Which does the nurse understand related to negative pressure wound therapy? Select all that apply.

In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.

A nurse needs to perform a postural drainage of both lung apices in a 4-year old child. In what position should the nurse place the child?

In order to perform a postural drainage in a 4-year-old child, the nurse should place the child sitting on the nurse's lap, leaning forward against a pillow. In order to perform a postural drainage of the apical segments of adults, the client should sit on the side of the bed. In order to perform a right upper lobe drainage in an adult, the client should be the supine position with the head elevated. In order to perform a drainage of both lower lobes in an adult, the client should lie supine in Trendelenburg position.

A 5-year-old child is admitted to the pediatric intensive care unit with a diagnosis of acute asthma. A blood sample is obtained to measure the child's arterial blood gases. What finding does the nurse expect?

Increased carbon dioxide level

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment?

Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do?

Keep a record of the day's activities.

A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema?

L. Sims

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation?

Leaving a dim light on in the client's room at night

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation?

Length of time this problem has existed

Which urinalysis finding indicates a urinary tract infection?

Leukoesterases are released by white blood cells as a response to an infection or inflammation. Therefore, the presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching?

Low-fat meals should be eaten to prevent interference with your fat digestion mechanism.

Which diagnostic test may be used to distinguish vascular from nonvascular structures?

Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate?

Metabolic alkalosis

When planning discharge teaching for the parents of a child with asthma, what information should the nurse include?

Minimize exertion and exposure to cold.

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment?

Moderate protein Because the liver is unable to detoxify ammonia to urea and the client is experiencing impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no protein restrictions are not required because clients need protein for healing. High protein is contraindicated in hepatic encephalopathy.

A client is diagnosed with psoriasis, and the nurse is providing health teaching concerning skin care at home. Which recommendation does the nurse include in the teaching?

Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, allowing the trapped water to hydrate the stratum corneum. Excessive exposure to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease, and affected areas do not need to be covered when in contact with others.

Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery?

Monitoring for increasing intracranial pressure

A nurse in the pediatric clinic is testing a 4-year-old child with recurrent otitis media for signs of hearing loss. The child's parent asks what can be done if there is a hearing loss. The nurse responds that the most common treatment is what?

Myringotomy is surgical incision of the eardrum to permit drainage of infected middle ear fluid and thus improve hearing. Removal of the adenoids will not relieve the pressure from inflamed ears. Antibiotics are administered systemically, not locally, if needed. Systemic antibiotics, not steroids, are prescribed; a myringotomy is performed if antibiotics are ineffective.

A client with pain and paresthesia of the left leg is scheduled for an electromyogram. What should the nurse discuss with the client before the test is performed?

Needles will be inserted into the affected muscles during the test.

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse's action be to confirm that the membranes have ruptured?

Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color in the presence of urine. Temperature assessment is not specific to ruptured membranes at this time; vital signs are part of the initial assessment. Although this may be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic fluid. Inspecting the vagina for leaking fluid will not confirm rupture of the membranes.

Which nursing theory focuses on the client's self-care needs?

Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication?

Pain medication is required, along with intensive supportive nursing care. To the client the pain is real, requiring pain medication; addiction is not a concern at this time. Explaining that the pain is psychological in origin does not help relieve the pain; medication and emotional support are required. The pain may not recede within a few days; pain medication should be administered.

A young child is admitted to the pediatric unit with a diagnosis of Wilms tumor. Considering the unique needs of a child with this diagnosis, what statement should be on a sign placed by the nurse at the child's bedside?

Palpation increases the risk of tumor rupture and is contraindicated. There is no data to indicate that surgery is scheduled; therefore, there is no reason to maintain nothing-by-mouth (NPO) status. There is no contraindication to intravenous medication. Recording of intake and output may or may not be instituted; it is not specific to children with Wilms tumor.

Which parameter should the nurse consider while assessing the psychologic status of a client with acquired immune deficiency syndrome (AIDS)?

Presence of anxiety should be considered while assessing the psychologic status of a client with AIDS. Sleep patterns and severity of pain are related to the assessment of activity and rest, a physical status. Cognitive changes are related to the assessment of neurologic status.

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI?

Prevent the development of clots in the bladder.

Which statement is true regarding the Hering-Breuer reflex?

Prevents overdistension of the lungs

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?

Previous experience and cultural values

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?

Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client?

Protect the abdominal skin from bile drainage

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?

Provide the client with comfort measures used for women in labor.

A nurse is caring for a school-aged child with type 1 diabetes. There have been problems maintaining euglycemia. What laboratory test does the nurse expect to be prescribed that will reveal the effectiveness of the diabetic regimen over time?

Rationale The glycosylated hemoglobin test provides an accurate long-term index of the average blood glucose level for the 100 to 120 days before the test; the test is not affected by short-term variations. A result of less than 8% for this child indicates that the diabetic regimen is effective. Serum glucose reflects short-term (hours) variations in blood glucose. Glucose tolerance reveals carbohydrate metabolism in response to a glucose load. Fasting blood sugar is a screening test to rule out diabetes mellitus.

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first?

Record the observation and continue to monitor the drainage from the tube.

A client has a hiatal hernia. The client is 5 feet 3 inches tall (163 cm) and weighs 160 pounds (72.6 kg). Which information should the nurse include when discussing prevention of esophageal reflux?

Reduce your caloric intake to foster weight reduction.

A client with type 1 diabetes is admitted to the hospital for major surgery. Before surgery, the client's insulin requirements are elevated but well controlled. What insulin requirements will the nurse anticipate for this client postoperatively?

Remain elevated

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?

Removing the catheter within 24 hours

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO 2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition?

Respiratory acidosis

A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding?

Rinse the suture line.

A nurse is teaching a school-aged child with juvenile idiopathic arthritis (JIA) activities to prevent the loss of joint function. What should the nurse caution the child to avoid?

Sedentary activities

What is a common characteristic of Sjögren's syndrome (SS)?

Sjögren's syndrome (SS) is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of Sjögren's syndrome (SS).

The nurse provides a list of appropriate food choices to a client with newly diagnosed diabetes. The client reviews the list and says, "I do not like and refuse to eat asparagus, broccoli, and mushrooms." In response, the nurse teaches the client about the food exchange list. The nurse evaluates that teaching was effective when the client states, "Instead of asparagus, broccoli, and mushrooms, I will eat which foods?"

String beans, beets, and carrots are in the vegetable exchange, as are asparagus, broccoli, and mushrooms. Corn, lima beans, dried peas, baked beans, potatoes, or parsnips are starchy vegetables and are listed as bread exchanges. Corn muffins, corn chips, or pretzels are from the bread exchange list.

The nurse is providing discharge instructions to the parents of a child who has undergone surgical correction of hypospadias. What is the priority information for the nurse to include?

Teaching parents how to care for the catheterization system

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?

The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO 2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.

Which joint helps in the gliding movement of the wrist?

The biaxial joint helps in the gliding movement of the wrist. Pivot joints permit rotation in the radioulnar area. Hinge joints allow for flexion and extension. Ball and socket joints permit movement in the shoulders and hips.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?

The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

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?

The client may have atrial fibrillation.

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

The client usually is instructed to press the end of the residual limb against a pillow to toughen the limb for weight bearing; this process is begun by pushing the residual limb against increasingly harder surfaces. Abduction of the residual limb does not maintain functional alignment and should be avoided; it does not prepare the end of the residual limb for a prosthesis. Dangling the residual limb does not help prepare it for a prosthesis and may impede venous return, which prolongs healing. Soaking the residual limb in warm water twice a day may macerate the residual limb and hinder the use of a prosthesis.

A nurse is performing range-of-motion exercises with a client who had a cerebrovascular accident (CVA). The nurse places the client's hand in the position exhibited in the picture. What is the term for this position?

The fingers are flared out in the extended, abducted position. The fingers are neither bent nor flexed. The fingers are abducted, not adducted, from the midline of the hand. Circumduction is a circular movement of a limb that occurs at a ball-and-socket joint. The shoulder and hip joints, not the wrist or fingers, can be moved in this way.

A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program?

The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

Which client's urine specific gravity level is abnormal?

The normal specific gravity of urine lies between 1.005 and 1.030. A specific gravity value of 1.041 is higher than the normal range; therefore, it's abnormal. The specific gravity values of urine such as 1.006, 1.012, and 1.028 lie in the normal range.

The nurse is performing a physical examination of a client by placing the left hand on the back and supporting the client's right side between the rib cage and the iliac crest. Which physical assessment maneuver is the nurse performing on this client?

The physical assessment involves inspection, palpation, percussion, and auscultation. During palpation of the right kidney, the nurse places the left hand behind and supports the client's right side between the ribcage and the iliac crest. During an inspection, the nurse assesses the client for changes in skin, abdomen, weight, face, and extremities. During percussion, the nurse strikes the fist of one hand against the dorsal surface of the other hand, which is placed flat along the post costovertebral angle (CVA) margin. While performing auscultation, the nurse uses the bell of the stethoscope over both CVAs and in the upper abdominal quadrants.

Which part of the nephron secretes creatinine required for elimination?

The proximal tubule of the nephron secretes creatinine and hydrogen ions. It also reabsorbs water and electrolytes. The glomerulus filters the blood selectively. The ascending loop of Henle reabsorbs sodium and chloride, whereas the descending loop of Henle concentrates the filtrate. The collecting duct reabsorbs water.

A terminally ill client has died in the hospital and it is time to inform the client's family members. The nurse is unsure how to console the family members. Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family?

The social worker on the interprofessional team helps the family members prepare for the client's death and also during the grief and bereavement process. Therefore, the nurse involves the social worker in consoling the family members in this situation. The primary health care provider and pharmacist may not be involved in consoling the family members after the client's death, nor may the occupational therapist be involved at this stage.

Which diagnostic study is used to investigate the cause of an inflamed joint and determines a client's response to antiinflammatory drug therapy?

Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface. Therefore it is used to investigate the cause of an inflamed joint and in determining the client's response to antiinflammatory drug therapy. Plethysmography is used to record variations in volume and pressure of blood passing through tissues. Duplex venous Doppler records blood flow abnormalities to the lower extremities, which helps to detect deep vein thrombosis. Somatosensory evoked potential is used to identify subtle dysfunction of lower motor neuron and primary muscle disease.

Which treatment is beneficial for a client with muscle spasm?

Thermotherapy, the use of heat therapy, eases pain and muscle contraction; therefore it is useful in treating muscle spasms. Muscle massage stimulates muscle tissue contraction and may worsen a muscle spasm. Frequent position changes are beneficial for a client with contracture. A muscle-strengthening exercise regimen is beneficial for a client with muscle atrophy.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices?

They help the venous blood return to the heart.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful?

Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.

What step should the nurse undertake during the administration of eardrops in children ages 1 to 3 years?

To administer ear drops to a toddler, pull the auricle down and back. The cotton ball is placed in the outermost part of the ear canal. The toddler is kept in the side-lying position for 2 to 3 minutes. The dropper is held 1 cm above the ear canal for the instillation of drops.

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision.

The parents of a 6-year-old child with celiac disease tell the school nurse that their child becomes dejected because she is not able to eat snack foods like the rest of her class and friends. What snack can the nurse recommend that is safe for the child to eat?

Tortilla chips

A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The primary healthcare provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the primary healthcare provider to prescribe to confirm this diagnosis?

Urinalysis and urine culture and sensitivity

An infant with the diagnosis of exstrophy of the bladder undergoes surgery to close the defect. What must the nurse include in the discharge teaching for the parents?

Urinary tract infections are a major concern and must be treated early. Rubber pants promote infection because they hold moisture close to the body; a warm, moist environment promotes the growth of pathogens. Sponge baths are given to prevent infection from bathwater. The amount of urine produced or excreted is not affected by positioning.

Which food should the nurse recommend for a toddler-age client who is at risk for developing rickets?

Yogurt

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow?

add NaCl

What does the A of the mnemonic "ABCDE" of primary nursing survey stand for?

airway

Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item?

apples

The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply.

e GCS[1][2] is a common way of determining and documenting level of consciousness that scores verbal response, motor response, and eye-opening response. The lowest score is 3, which indicates a totally unresponsive client; a normal GCS score is 15. Pupillary and cognitive responses are not part of the GCS assessment.

A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid?

wheat and oats

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective?

"Before I start the procedure, I will measure the residual volume."

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene?

"Clients with decreased sensory perception of touch should be carefully monitored for infection." Decreased sensory perception is a neurological change associated with aging. Clients with this change should be instructed to reduce the risks associated with falling. Therefore, the nurse should intervene to correct this misconception. All the other statements are correct and require no follow up. Clients with an increased risk for infections due to structural deterioration of microglia should be monitored for infections. Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts to facilitate retention of information. This would help the client to learn new information and recall it when needed. Clients with slower processing time should be provided with sufficient time to respond to questions or directions. Allowing adequate time for processing helps differentiate normal findings from neurologic deterioration. Clients with decreased coordination should be instructed to hold handrails when ambulating to provide support and prevent falls.

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

A score of 8 or below indicates coma. The Glasgow Coma Scale is used to assess the extent of neurologic damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. To achieve the ratings of 9, 12, or 15 the client must be exhibiting some meaningful responses.

A nurse is performing a neurologic assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of the client?

A tongue depressor is used to depress the tongue to observe the pharynx and larynx, and to assess soft palate symmetry and the presence of the gag reflex; the information obtained provides data about cranial nerve X (vagus). A tuning fork is used to assess cranial nerve VIII (auditory). An ophthalmoscope is used to assess cranial nerve II (optic). Cotton and a straight pin are used to assess sensory function: light touch and pain.

After a hurricane, the nurse is assessing the response of a client to stimuli on the Glasgow Coma Scale (GCS) as a part of the primary survey. The nurse observes that the client opens his eyes when his name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus. What is the Glasgow coma score for this client?

11 Glasgow scale (GCS) is used by the nurse to conduct neurologic assessment as a part of primary survey. It is performed to determine the client's response to verbal and/or painful stimuli in order to assess the level of consciousness and degree of disability. A score of 3 is given when the client opens the eyes when the name is stated. If disorganized use of words is present, a score of 3 is given. A score of 5 is given when there is a lack of obedience but attempts to remove the offending stimulus. Therefore the client's GCS score would be 3+3+5= 11.

The mother of a 4-month-old infant weighing 11 lb (5 kg) asks the nurse how much formula is required per day now that her baby has been weaned from the breast. The recommended caloric intake is 108 kcal/kg, and the formula contains 20 kcal/oz (20 kcal/30 mL). How much formula should the nurse tell the mother to give to her infant each day?

27 oz

What are the reasons for performing a lumbar puncture on a client? Select all that apply.

4. Reading cerebrospinal fluid pressure5. Injecting contrast medium for diagnostic studyA lumbar puncture is the insertion of a spinal needle into the subarachnoid space between the third and fourth lumbar vertebrae; it can be used to obtain cerebrospinal fluid readings with a manometer. Using a lumbar puncture, contrast medium or air is injected for diagnostic study. Evoked potentials measure the electrical signals to the brain generated by sound, light, or touch, and are used to confirm neurologic conditions like spinal cord injuries and multiple sclerosis. Evoked potentials are also used to assess sensory nerve problems. Cerebral blood flow evaluation is used to measure blood flow in many areas using radioactive substances.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare?

500 - 750 ml

A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying?

Offer a pacifier

A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication?

Place the pill under the tongue and let it dissolve.

A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse?

The nurse must determine whether the infant is eating solid foods and receiving vitamin and mineral supplements. Although orange juice contains vitamin C, it is too high in simple sugars and contains insufficient amounts of iron, calcium, and other essential vitamins and minerals. It is inappropriate to comment on the infant's weight; it is also insufficient to comment on just one aspect of the infant's dietary history. Asking why the infant is only drinking orange juice is a judgmental and accusatory question; again, it is insufficient to comment on just one aspect of the infant's diet history.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet?

Wheat, Oats, Rye

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump?

check residual

A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do?

Sit on the edge of the bed so they can hold the client upright.

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant

Supine, with the head elevated about 45 degrees

The student nurse is performing a rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse. Which parameters should the student nurse consider for proper assessment? Select all that apply.

The disability examination provides a rapid baseline assessment of neurologic status. It helps to evaluate level of consciousness by the "AVPU" mnemonic, which also helps to assess the responsiveness to pain and voice. Level of anxiety is not assessed by a disability mnemonic. Body temperature and evidence of assault are assessed in a primary survey of exposure.

A primary healthcare provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide to the client about the need to follow this diet?

Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."

A nurse is assessing the level of consciousness of four different clients. Which client would have the lowest neurologic function?

GCS again

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse bestassess the client's pain level?

Using Wong's "Pain Faces"

A child is brought to the emergency department after sustaining a blow to the head while playing football after school. The nurse performs a neurologic assessment to determine whether the child has an acute head injury. What should the nurse assess first?

A declining level of consciousness (LOC) reflects increased intracranial pressure precipitated by injury to the brain. Ocular signs and muscle strength are less indicative of increased intracranial pressure than is a reduced LOC. Injuries to the scalp do not cause increased intracranial pressure because they are outside the cranium.

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?

Abnormal upper arm extension receives a rate of 2 because it is characteristic of decerebrate (extension) posturing. Greater injury leads to less purposeful movement. Decerebrate posturing indicates severe brain injury; the only more serious response is total lack of response. Flexing, characteristic of decorticate (flexion) posturing associated with severe brain injury, receives a rate of 3. Localizing receives a rate of 5. The inability to withdraw from a painful stimulus indicates the greatest neurologic impairment. Withdrawing receives a

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question?

Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr. Because one-half NS is a hypotonic solution, it is contraindicated. It would actually compound the issue instead of correcting the hyponatremia. Treatment for hyponatremia can include restricting fluid intake and increasing sodium intake either via oral intake or, in severe cases, intravenous fluids. The presence of hyponatremia, as well as correction of hyponatremia if done too quickly, can cause fluid shifts in the brain, resulting in altered mental status. Therefore it is important for the nurse to assess for neurologic changes.

The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet?

Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action?

Auscultate the lungs to evaluate breath sounds. The most significant and life-threatening complication of insertion of a subclavian catheter is a pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the lung; a client's respiratory status always is the priority. Although a chest x-ray may be done before TPN is begun, it is not the priority immediately after insertion of the catheter. A baseline blood glucose level should be obtained before insertion of the catheter. After TPN is started, routine monitoring of blood glucose levels is important. Although assessing for a neurologic deficit should be done eventually, it is not the priority at this time.

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority?

Checking that a bag-valve mask is available during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important but not of primary urgency; the respiratory status is the priority. Verifying that the family has been notified of the transfer is important but not of primary urgency; the respiratory status is the priority.

Non-weight bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, what is the most important activity the nurse should teach the client?

Exercise the triceps, finger flexors, and elbow extensors.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first?

Gather more data from the night nurse about the technique used

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking?

Get swoll

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli?

Green beans

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning?

Green vegetables

A nurse is caring for a female client during the manic phase of bipolar disorder. What should the nurse do to help the client with personal hygiene?

Guide her to dress appropriately in her own clothing.

On a routine visit to the well-child clinic, the parents of a 3-year-old child tell the nurse that their child is a "picky" eater and express concern about their child's nutritional status. What should the nurse suggest to help the parents meet the child's nutritional requirements?

Including some of the foods the child prefers in every meal

A group of clients is admitted with neurologic injury after hiking at high altitude. The nurse is assessing using the "AVPU" mnemonic. Which type of emergency assessment is the nurse performing?

Disability assessment is a part of the primary survey that is done to assess the level of consciousness that may occur due to a neurologic injury. In the mnemonic " AVPU," A indicates alert, V indicates response to voice, P stands for response to pain, and U indicates unresponsive. Exposure assessment is one of the priorities of a primary survey, which involves removing clothing for a complete assessment and preventing hypothermia using heat devices. Breathing assessment involves checking breath sounds and respiratory effort. Circulation assessment is performed in a primary survey to monitor blood pressure and pulse.

For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal?

Irritability Tachycardia Increasing anxiety Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia is one of the early sign of withdrawal; it results from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they usually do not occur before 48 to 72 hours of abstinence. Fever and diaphoresis are later signs of withdrawal that may be seen during alcohol withdrawal delirium; they result from autonomic overactivity.

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?

Lack of mineralocorticoids ( aldosterone) leads to loss of sodium ions in the urine and subsequent hyponatremia. Potassium intake is not encouraged; hyperkalemia is a problem because of insufficient mineralocorticoids. Increasing protein is needed to heal the adrenal tissue and thus cure the disease caused by idiopathic atrophy of the adrenal cortex; tissue repair of the gland is not possible. Vitamins are not directly energy-producing; nor will they help the client gain weight.

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed?

Maintaining a patent airway The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurologic assessment for mental status, sensory level, and motor function, which holds a medium priority.

The nurse is conducting a neurologic assessment on a client brought to the emergency room after a motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward and inward. The nurse recognizes that this response represents an injury to what part of the brain?

Midbrain Decorticate posturing[1][2][3] is a sign of significant deterioration in a client's neurologic status and is manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion, alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses in the above listed areas.

After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment

Motor function is part of a neurologic assessment and provides information about cerebral function. Blood pressure and temperature are not direct measures of neurologic status. Head circumference provides information as to skeletal development and brain growth, not neurologic data. A change in head circumference as a result of increased intracranial pressure is not expected in a 4-year-old whose cranial bones are fused.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what?

No cortical functioning with some reflex breathing A client who is declared as being brain dead has no function of the cerebral cortex and a flat electroencephalogram (EEG). The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. No spontaneous reflexes, shallow and slow breathing, and deep tendon reflexes only and no independent breathing do not fit the definition of brain dead.

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply.

Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a client who is about to die and is receiving end-of-life care. End-of-life care comprises measures to make the client as comfortable as possible. It may include measures such as regular oral care and repositioning.

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement?

Placing the prescribed as-needed warm, wet compress on the elbow

A nurse educates a group of parents about how to teach their children to safely cross roads and walk in parking lots. Which age group of the children is the nurse referring to?

Preschoolers should be taught how to cross roads and walk in parking lots. Parents of toddlers should be instructed to place window guards on all windows and to never leave a child alone in the bathroom, tub, or near any water source. Adolescents should be taught about the effects of using alcohol and drugs and referred to community and school-sponsored activities. School-aged child should be taught about the safe use of equipment for play and work as well as proper bicycle safety.

A nurse is teaching the parents of an infant with cerebral palsy how to provide optimal care. What should the nurse include in the teaching?

Preserving muscle tone to prevent joint contractures

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours?

Prevent pressure ulcers

A client has undergone hypophysectomy. Which action would the nurse consider to be most appropriate during postoperative care to prevent a cerebrospinal fluid (CSF) leak?

Prohibiting coughing or sneezing Hypophysectomy is the surgical removal of the pituitary gland and tumor for the treatment of hyperpituitarism. Coughing and sneezing should be avoided because this may lead to increased pressure in the incision area and CSF leak. Performing deep-breathing exercises would help in preventing pulmonary problems. Nasal drainage should be assessed to determine the leakage of CSF. Neurologic status of the client should be monitored to determine intracranial pressure.

What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone

Providing frequent oral care Instituting fall risk precautions Monitoring for and reporting neurologic changes The excess production of antidiuretic hormone associated with SIADH leads to increased water reabsorption by the kidneys. Increased water reabsorption results in decreased urinary output, increased intravascular fluid volume, serum hypoosmolality, and dilutional hyponatremia. Because treatment includes restricting fluids, frequent oral care is provided to increase client comfort. Fall risk precautions are instituted to protect the client from injury that might occur as a result of neurologic changes associated with declining serum sodium. The nurse monitors for and reports changes in neurologic status resulting from cerebral edema and hyponatremia. Immediate treatment goals are to restore normal fluid balance and normal serum osmolality. Fluids are restricted to no more than 1000 mL and to no more than 500 mL for the client with severe hyponatremia. Treatment of SIADH includes placing the bed flat or elevating the head of the bed no more than 10 degrees. This position promotes venous return to the heart, which increases left ventricular filling pressure. Increasing left ventricular filling pressure stimulates osmoreceptors to send a message to the pituitary (via the hypothalamus) that antidiuretic hormone release should be decreased.

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?

Push-ups to strengthen arm muscles Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair, so the nurse should teach the client how to do wheelchair push-ups safely. Equilibrium is not a problem. The client does not have neurologic control of the other activities.

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?

Rationale The three areas of assessment to determine the level of consciousness using the Glasgow Coma Scale are motor response to verbal commands, eye opening in response to speech, and verbal response to speech. Assessing breathing patterns, deep tendon reflexes, and eye accommodation are not included in the Glasgow Coma Scale.

An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the healthcare provider will most likely prescribe?

Resume small, easily digested feedings gradually

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer?

Sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day.

A nurse is assessing sudden changes in the neurologic status of different clients after an earthquake. Which client should require endotracheal intubation and mechanical ventilation?

The Glasgow Coma Scale (GCS) assigns a numeric score for each of the areas of the client's neurologic status. The lower the score of the GCS, the lower the client's neurologic function. Client 3 is opening the eyes on pain, so the score is 2. The client shows abnormal flexion motor response, which has a score of 3, and the verbal response is incomprehensible, scoring 2. Therefore, the total score is 2+3+2=7. A score equal to or below 8 indicates a need for endotracheal intubation and mechanical ventilation. Client 1 will have a GCS score of 12. Client 2 will have a GCS score of 13. Client 4 will have a GCS score of 9.

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

The Romberg test evaluates proprioception. A client is asked to close the eyes when standing. If balance is lost after the client's eyes are closed, a positive Romberg test suggests that there is a sensory cause. Fanning of toes when the sole of the foot is firmly stroked is a positive Babinski reflex that is indicative of corticospinal pathology in an adult. Dilation of pupils when focusing on an object in the distance is accommodation, a normal finding. Movement of eyes toward the opposite side when head is turned is the oculocephalic or oculovestibular reflex, a normal finding.

The nurse is reviewing the cerebrospinal fluid (CSF) laboratory findings of four neurologically compromised clients. Which client does the nurse suspect to have had a previous meningeal hemorrhage?

The brown color of the CSF indicates the client has had a meningeal hemorrhage. A yellow color of the CSF is due to the hemolysis of the red blood cells (RBC) that leads to increased production of bilirubin. An unclear or hazy appearance of the CSF indicates an elevated white blood cell count. A pink-red to orange color indicates the presence of RBCs.

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions?

The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

A client sustains a vertebral fracture at the T1 level and is admitted to the emergency department. During a detailed neurologic assessment, the nurse expects to identify which clinical manifestation?

The client will have normal biceps reflexes with a T1 injury. The nerves for arm innervation are at C4, which is above the injury level of T1. Diaphragm innervation is not affected by this injury; the diaphragm is innervated above C4. Innervation of muscles used to move the lower arms is not affected by this injury; these muscles are innervated above C7. Innervation for pain sensation of the hands is not affected by this injury; these nerves are innervated above C7.

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record?

The score is 8. The Glasgow Coma Scale[1][2] is a three-part neurologic assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma. Nine and 12 are too high a rating for the behaviors exhibited by the client. A rating of 15 indicates that the client is opening the eyes spontaneously, obeying commands, and fully oriented.

A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet?

Vitamin C plays an important role in tissue formation, and vitamin E is required to protect against the oxidative stress associated with pregnancy. Too much emphasis on fat-soluble vitamins may result in an inadequate intake of important water-soluble vitamins. Dietary fiber and oat bran and low-fat foods with essential fatty acids have no known effect on natural defenses.

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant?

Weak, rapid pulse

A nurse is preparing a 10-year-old child for a tonsillectomy and adenoidectomy to be performed later in the day. What information should the nurse share with the child?

What the child will experience before and after the procedure

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. Which is an expected response in a healthy adult?

Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.

A client who had a craniotomy is transferred to the intensive care unit from the postanesthesia care unit. Which nursing action is most important when caring for this client?

Yellow drainage may be cerebral spinal fluid, and bloody drainage is a sign of hemorrhage; either one should be reported to the healthcare provider immediately. Axillary temperatures are influenced by environmental conditions. Temperature evaluation must be accurate; therefore the rectal, not axillary, route is most appropriate. Oral temperatures are contraindicated for clients at risk for seizures. While deep breathing expands the lungs and mobilizes secretions to prevent respiratory complications, coughing can increase intracranial pressure and should be avoided. When necessary, secretions may be removed by suctioning because suctioning is less stressful than coughing and less likely to increase intracranial pressure. Administration of opioids and sedatives hinders accurate neurologic assessment because they depress the central nervous system.

When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include?

instilling artificial tears frequently lubricates the eye and prevents drying of the cornea. Irrigating the eye is inappropriate; eye irrigations are used to flush foreign matter from the eye. Checking the corneal reflex every hour can lead to corneal abrasion. Taping the eyelid open can cause corneal ulceration or injury.