PRACTICE BANK 1-4, 8-15

The nurse is teaching a Lamaze class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?

"ITS COMMON FOR WOMEN WITH POSTPARTUM DEPRESSION TO HAVE DELUSIONS ABOUT THE INFANT" Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression.

A client tells a nurse about an Internet site that claims bupropion hydrochloride (Wellbutrin, Zyban) was taken off the market because it caused seizures. What would be an appropriate response by the nurse?

"THERE WERE PROBS AND THE RECOMMENDED DOSE IS CHANGED" Bupropion hydrochloride was introduced in the United States in 1985 and was then withdrawn because of the occurrence of seizures in some clients taking the medication. The medication was reintroduced in 1989 with specific recommendations regarding dosage, i.e., a single dose should be no more than 150 mg and each dose should be separated by six hours, in order to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher doses.

An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider?

(DIGOXIN) LANOXIN Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.

The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.)

-ADJUST THE HEIGHT OF THE BED FOR CAREGIVER\ -MOVE THE HEAD OF THE BED INTO A FLAT POSITION -USE A FRICTION USING DEVICE The algorithm for safe client handling and repositioning a client from side-to-side or up in bed states: use 2 to 3 caregivers for a client who can partially assist and who weighs less than 200 pounds, use a friction-reducing device, move the bed so that it's flat and at a comfortable height for the caregivers. The client should not be pulled from the head of the bed. There really is no safe method to manually lift another adult.

The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.)

-NO SHOWERING OR 48 HRS AFTER SURGERY -SOME SHOULDER DISCOMFORT CAN BE EXPECTED -RESTRICT DIET TO BLAND, EASILY DIGESTIBLE FOOD FOR A FEW DAYS -USE 2 TBLSPOONS OF MILK OF MOM IF NO BM 3 DAYS POST SURGERY Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days.

The medication benztropine mesylate (Cogentin) is ordered; the nurse incorrectly administers carvedilol (Coreg) to the client. What actions should the nurse take to report this medication error? (Select all that apply.)

-NOTIFY THE CHARGE NURSE -DOCUMENT THE ADMIN OF CARVEDILOL -MONITOR ADN DOC THE PTS BP -NOTIFY THE HEALTH CARE PROVIDER A medication error requires factual documentation of the medication given and any effects of that medication. The health care provider must be notified; this will provide an opportunity for a counteracting drug to be prescribed. Notifying the charge nurse will provide an opportunity to discuss the factors contributing to the error and hopefully prevent future errors. The nurse will complete an incident report. Typically the client is not informed of the error unless adverse effects require immediate intervention.

The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client AVOID (Select all that apply.)

-ORANGES -MARINATED CAULFLAOWER AND BROCCOLLI -GRILLED SIRLOIN STEAK Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test.

A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care?

ACTIVITY INTOLERANCE RELATED TO AN IMBALANCE OF OXYGEN SUPPLY AND DEMAND The primary problem resulting from a decreased cardiac output in heart failure is activity intolerance. Dyspnea and fatigue are common, worsening as the heart function worsens; therefore, changes in activity tolerance are important indicators of problems with or improvement in the heart's condition. This option is the only nursing diagnosis that addresses both the cardiac and pulmonary aspects of the question.

A nurse is preparing to take a toddler's blood pressure for the first time. Which action should the nurse perform first?

ALLOW THE CHILD TO HANDLE THE EQUIPMENT BEFORE APPLYING THE CUFF The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful. This is the best and most age-appropriate response.

A client who is diagnosed with Parkinson's disease spends over one hour dressing for scheduled therapies. Based on this finding, which is the most appropriate intervention by the nurse?

ALLOW THE PT TIME NEEDED TO DRESS Clients with diagnosed Parkinson's disease often wish to take care of themselves. They become very upset when hurried and then are unable to manage at all. Any form of hurrying the client will result in a very upset and non-functioning client. Ask: Can a client with diagnosed Parkinson's disease move more quickly? If not, two options are immediately eliminated. When presented with the question of what the "nurse" should do, do not select an answer that involves others (family).

The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent?

ALTERED BODY IMAGE Hospitalized adolescents may see all of these issues as a concern when they are hospitalized. However, the major threat is the fear of an altered body image because of the emphasis on physical appearance during this developmental phase.

The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?

AN OPEN WOUND ON THE HELL WITH MINIMAL DISCOMFORT When findings of infection occur in their feet, older clients who have either type of diabetes and/or arterial vascular disease should seek health care quickly and continue treatment until the infection is resolved. Foot wounds in diabetics can take months or even years to heal, even with appropriate treatment. Without treatment, serious infection, gangrene, limb loss and even death from septic shock may result. Peripheral neuropathy is common in prolonged diabetes with diminished sensation in the feet and legs in these clients and increased risk of injury. Even though perineal area complaints would need to have further evaluation, the problem is not the highest priority. Insomnia is not a manifestation of type 2 diabetes. The other option is a distractor that is unrelated to the diabetes.

A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?

ASSESS THE APICAL PULSE COUNTING FOR A FULL 60 SECONDS It is the nurse's responsibility to take the client's apical pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute, as bradycardia is a finding in digoxin toxicity.

A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?

BALLOONS Allergy to balloons often indicates a latex allergy. All personnel during and after surgery that are in contact with the child will need to be aware of this condition. The need to use non-latex gloves or equipment without latex components should be noted on the chart.

The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet?

BALANCED HIGH CAL DIET WITH EXTRA FAT SALT PROTEIN AND CALCIUM********** A child with cystic fibrosis needs a well-balanced, high calorie diet that includes extra fat, salt, and protein. Children with CF are at risk for osteoporosis, which is why they need full fat dairy products. Carbohydrate counting is recommended for children with diabetes. Foods low in sodium, potassium and phosphorus are tips for people with chronic kidney disease. A gluten-free diet is the only treatment for celiac disease.

A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs?

BEE, ONE HALF CUP OF LIMA BEANS, GLASS OF SKIM MILK 3/4 CUP OF STRAWBERRIES Beef and beans are an excellent source of protein, as is skim milk. Strawberries are a good source of vitamin C.

The nurse is collecting data from an adult client who is on long-term glucocorticoid therapy. Which finding should the nurse expect to observe?

BUFFALO HUMP Cushing's syndrome occurs when a client has received a high enough dose of glucocorticoid therapy for a long period of time. The findings of Cushing's syndrome include an abnormal fat distribution that results in a moon-shaped face, dorsocervical and supraclavicular fat pads (the buffalo hump) and truncal obesity with slender limbs. To help answer this question, remember that jaundice is typically related to problems with the liver and peripheral edema is usually caused by some cardiovascular or lymphatic problem; these options can be eliminated. Although the remaining two options involve an increase somewhere in the body, there are many things that can contribute to increased muscle mass. By process of elimination, you are left with "buffalo hump."

The unlicensed assistive person (UAP) completed an orientation program one week ago. During the first day working on the unit, which question should the nurse ask to best assess competency?

CAN I REVIEW YOUR SKILLS CHECKLIST The nurse needs to know that new UAP has competence in certain tasks. One way to do this is to review documented skills as listed by the agency. The other options are more specific and are more subjective because they refer to feelings or preferences.

A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding?

CANNOT STAND ON ONE FOOT At this age, gross motor development allows a child to balance on one foot. A child who is 3 years old should be able to hop, ride a tricycle and throw a ball (but they would have trouble catching it). Most young children with fetal alcohol syndrome, for example, show delays in motor skill development (both fine and gross motor).

A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents?

CHECK FREQUENTLY FOR SWELLING IN THE BABIES FEET Notice that only two of the options focus on cast care. Of those two options, the crossbar on the cast should never be used to lift or move the child. The parents of a child in an initial hip spica cast must check for circulatory impairment. The nurse should reinforce the importance of observing the extremities for swelling, discoloration, movement and sensation. Remember to look for the six Ps of impaired tissue perfusion: pain, paresthesia, pallor, pulselessness, paralysis and poikilothermia (coolness). Sometimes blowing cold air (never warm or hot) from a hand-held hair dryer into the cast can help with itching, but care should be taken never to insert anything into the cast.

BUPRIPION( WELLBUTRIN) to treat??

DEPRESSION (ALSO SMOKING CESSATION) has bitter taste!

The nurse is reinforcing information about the side effects of fluoxetine (Prozac, Sarafem) to a client. Which group of findings should be included?

DIARRHEA, DRY MOUTH, WEIGH TLOSS, REDUCED LIBIDO Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). it is used to treat depression, obsessive-compulsive disorder, some eating disorders and panic attacks. Commonly reported side effects include diarrhea, dry mouth, weight loss and reduced libido.

A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude?

DISCRIMINATION Prejudice is a hostile ATTITUDE toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs or opinions about an individual, group or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. If you are not sure of the correct answer, look at the words in quotation in the question and ask yourself: Does this nurse's statement sound like discrimination (a behavior or action) or prejudice (attitude)?

A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test?

DO NTO EAT OR DRINK ANYTHING BUT WATER 12 HRS BEFORE THE BLOOD TEST The client should fast (no fluids or foods, except for water) for 8 to 12 hours prior to sample collection for serum lipid levels (cholesterol, triglycerides, HDL, LDL).

A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate?

DRY NON PRODUCTIVE COUGH******* Noisy respirations and a dry nonproductive cough are usually the first respiratory findings to appear in a newly diagnosed cystic fibrosis client. Because the question relates to a respiratory condition, you should select a respiratory option (and there is only one option related to the respiratory system).

The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?

DRY OFF THE INFANT WITH A WARM BLANKET OR TOWEL The priority interventions are in recovering a normal newborn. Maintaining the infant's temperature by drying, warming, and removing any wet blankets or towels are the priority interventions. All interventions are correct, but warming and drying would be the priority.

nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care?

ENCOURAGE THE PARENTS TO ENROLL IN A CHILD CARDIOPULMONARY RESUCITATION CLASS While all suggestions are appropriate, the priority education focus of the parents/caregivers should include techniques of CPR in order to provide for emergency care for their child. When all the options are correct, you need to decide which option is the most important and most closely associated with the client or problem. You will also note that three of the options deal with play, the caregivers, and the parents/toddler respectively. Only the correct response relates to heart activity (CPR).

A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse?

EXPLAIN TO THE PARENT THAT THIS BEHAIVIOR IS EXPECTED During normal development, fear of strangers becomes prominent beginning around age 6 to 8 months. Such behaviors include clinging to parent, crying and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool.

A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)?

FALLS FORWARD WHEN SITTING Sitting without support is normal for infants between seven to nine months of age. You will note that the question implies there is a problem. As you read each answer, ask yourself if the behavior is normal for an 8 month-old child. You will also note that there are two options with neurologic components and two options focusing on musculoskeletal development. Because the nervous system would be a priority over the musculoskeletal system, you should then identify the 8 month-old who cannot sit up as the abnormal condition.

A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus?

FLUID INTAKE OF AT LEAST 3000ML PER DAY Gout is a very painful condition in which uric acid crystals collect in a joint causing severe pain and inflammation. Fluid intake should be increased in the client with gout to prevent kidney stones from precipitation of urate in the kidneys. The diet should be low in purines to prevent uric acid formation. NSAIDs, such as ibuprofen or naproxen, are often prescribed to reduce inflammation and pain. If compresses are used, they would be warm, not hot.

The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first?

GENTLY IRRIGATE THE TUBE WITH STERILE NORMAL SALINE The RN will assess the position and patency of the NG tube, as well as the color and amount of gastric drainage. The RN can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or if repositioning the tube is needed, the RN must call the surgeon. The NG tube inserted in surgery should not be repositioned by a nurse because of the risk of disrupting any internal sutures. It would be contraindicated to increase the suction.

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client?

GOOD MORNING YOU ARE IN THE HOSPITAL I AM YOURE NURSE ELAINE JONES The best statement is one that provides information in a short and direct manner. Nurses should simply establishes the time, location and state their name. With reality orientation, nurses should be brief and to the point; you will note that each statement uses five or fewer words. These types of statements will enhance recall and memory. For clients who are confused, it's best not to engage in a guessing game and ask if they know where they are, or why they are in the hospital.

A pregnant client comes to the clinic for a first visit. A nurse gathers data about her obstetric history, which includes: three year-old twins at home and a miscarriage at 12-weeks gestation 10 years ago. Which documentation should the nurse make?

GRAVIDA 3 PARA 1 Gravida is the number of pregnancies and parity or para is the number of pregnancies that reach viability (which is considered 20 weeks). This woman is now pregnant. She has also had two prior pregnancies, with one of those pregnancies reaching viability (the twins). Remember to simply count the number of pregnancies, as well as the number of pregnancies that reached viability; avoid confusing twins or multiple births with the number of viable births. If asked to document information using the five number system, it would be: 3-1-0-1-2 (gravida, term pregnancies, preterm, abortions, living children).

The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach?

HELP THE MOTHER UNDERSTAND THAT THIS IS A NORMAL RESPONSE TO HOSPITALIZATION The protest phase of separation anxiety is a normal response for a child this age. Separation anxiety is at its peak during toddler years of 12 to 36 months.

The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse?

HEMATEMESIS Vomiting of blood may indicate hemorrhage, especially from esophageal varices. This condition can be life-threatening, requiring immediate intervention.

A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)?

I HAVE BEEN EXPOSED TO MYOBACTERIUM TUBERCULOSIS The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests, such as a chest x-ray, are needed to determine if active tuberculosis is present.

A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best?

I KNOW YOU BELIEVE YOU HAVE AN INCURABLE DISEASE The correct response is one that does not challenge the client's delusional system and provides some reassurance of a desire to help the client. The comment does not confirm the client's comment but simply reflects that the nurse has listened and heard the comment.

The nurse is reinforcing information about recognizing the findings of digoxin toxicity. Which statement made by the client is correct and indicates no need for further teaching?

I WILL REPORT A SLOWER PULSE A slow heart rate is related to increased cardiac output and an intended effect of digoxin. No reporting of heart rate is needed unless the pulse rate is: less than 60 BPM in adults, less than 70 BPM in children or less than 90 BPM in infants. The other statements may indicate a potential digoxin toxicity.

A child is admitted to the unit with findings of nasal congestion and cough with periods of cyanosis and dehydration. The suspected diagnosis is pertussis (whooping cough). What is the priority nursing intervention for this child?

IMPLEMENT DROPLET PRECAUTIONS ALONG WITH STANDARD PRECAUTIONS Although all the responses are correct actions, it is most important to implement strict droplet precautions in addition to standard precautions because pertussis is spread via close contact. Therapeutic management focuses on providing respiratory support and eradicating the bacterial infection (macrolides, such as erythromycin, are the drug of choice). Fluids are encouraged to help thin secretions. Monitoring heart rate and oxygen saturation, especially during coughing paroxysms, is indicated.

A nursing student asks the practical nurse (PN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize?

INCREASE IN HEALTH CARE SPENDING THATS GORWING FASTER THAN THE ECONOMY One of the most significant reasons for health reform is the need to control costs. Health care spending continues to grow at a faster rate than the economy. Other reasons contributing to increased health care spending includes a decrease in the number of people with health care insurance and decreased competition in both insurer and provider markets. End-of-life care is expensive, but it is too narrow a focus to be the correct response.

A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need?

INDEPENDANCE Negativism is typical of toddlers. Think of the phrase: "No, me do it" when answering this question. Independence and autonomy versus shame and doubt are the developmental tasks of toddlerhood.

A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments?

IT CAN HELP IDENTIFY POTENTIAL NEUROLOGICAL DEFECTS******* AFP is a substance made in the liver of the fetus. A fetus with neural tube defects, such as spina bifida and anencephaly, loses AFP to the amniotic fluid and, consequently, to maternal blood. The blood test is performed between the 15 and 17 weeks of pregnancy and can be used as part of a screening test to find chromosomal problems, such as Down sydrome.

A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?

LISTENING QUIETLY WITHOUT COMMENTA young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?

The nurse is caring for a client who is experiencing a panic attack. Which action would be the nurse's primary intervention for the client?

MAINTAIN SAFETY OF THE PT Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. A panic attack is suspected when clients have the feeling that something bad will happen or when they experience a feeling of doom.

A client returns from the operating room after a right orchiectomy.(REMOVAL OF TESTES) What is the priority nursing intervention during the immediate postoperative period?

MANAGE POST OP PAIN Due to the location of the incision, pain management is the priority. Bladder spasms are more related to postoperative prostate surgery than testes removal.

A client diagnosed with heart failure is prescribed oral digoxin (Lanoxin). What is the priority nursing action for this medication?

MEASURE APICAL PULSE PRIOR TO ADMINISTRATION Digoxin decreases conduction velocity through the AV node and prolongs the refractory period. The nurse should withhold the dose and notify the health care provide if the apical heart rate is less than 60 BPM (in the adult); the apical pulse should be taken for 1 full minute. The RN should monitor the ECG throughout and periodically monitor BP for clients receiving IV digoxin, but this is not required for the oral form of the medication. The nurse should monitor intake and output, but this is not a priority action.

The client is prescribed a nitroglycerine patch. When asked by the client, which response by the nurse reinforces the best reason for not wearing a nitroglycerin patch for more than 12 hours each day

MEDICATION TOLERANCE Nitroglycerin patches may not work as intended when they are used continuously. To prevent tolerance to the medication, clients are instructed to wear a patch for only 12 to 14 hours each day. Some of the more common side effects of wearing a nitroglycerin patch may include headache, dizziness, lightheadedness, nausea, redness or irritation of the skin that was covered by the patch and flushing.

A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?

NAUSEA AND VOMITING Some of the earliest signs of salicylate toxicity include nausea, vomiting, diaphoresis and tinnitus. Other findings include hyperventilation, tachycardia and hyperactivity. As toxicity progresses, there may be agitation, delirium, hallucinations, convulsions, lethargy and stupor. With the large ingestion of the aspirin, which is an acid, the temperature may rise from the severe acidosis that increases metabolic rate. Hyperventilation may be present from the attempt of the body to rid the acid via carbon dioxide.

A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client?

NON REBREATHER MASK When a tight seal is achieved using a non-rebreather mask, up to 100% of oxygen is available. The venturi mask, partial rebreather mask and simple mask cannot deliver oxygen concentrations as high as the non-rebreather mask. If you are unsure of the correct response, you should know that because the question is asking for the highest concentration of oxygen delivery, it would be unlikely that something with the words "partial" and "simple" would be correct, so you can eliminate those options. A Venturi mask can deliver a fixed concentration of oxygen, but in increments no higher than 40%.

The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective?

OFER THE CLIENT FREQUENT OPPERTUNITIES TO INTERACT WITH THE NURSE The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships within safe realms. To offer frequent interactions initiates the development of relationship skills.

WHAT IS POIKILOTHERMIA?

ONE OF THE 6 ps OF IMPAIRED TISSUE PERFUSION poikilothermia is COOLNESS

A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use?

OPEN THE BOTTOM OF THE POUCH TO ALLOW THE FLATULUS TO BE EXPELLED The only correct way to vent the flatus from a one-piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and then close the bottom of the pouch. Because the colostomy is at the sigmoid level, the stool will most likely be formed stool. Sometimes the bags will have a charcoal filter in the top where flatus can be expelled on a constant basis with minimal odor. Piercing the ostomy pouch is never an option because it could allow stool to leak from the pouch. Although ambulation will help to reduce flatus, this does not address the flatus currently in the pouch.

A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate?

PALE MUCOSA INSIDE THE MOUTH In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing child with mild to severe tachycardia. The skin may have a waxy appearance. Anemia that is severe can cause a lack oxygen to the body, causing the skin color to become an ashen, dusky gray instead of the classic skin color of cyanosis with oxygen deficiency. The hemoglobin level would be low rather than high in anemia.

A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure?

PLACE THE HANDs OR A FOLDED BLANKET UNDER THE HEAD OF THE CHILD The priority during seizure activity is to protect the child from physical injury. Place a pillow, folded blanket or the hands under the child's head to prevent concussion or further head trauma. The other body parts are at less risk for injury.

A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose?

PROTECT THE EGO ANS DIMINSH ANXIETY Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect the presence of stressful situations. Healthy reactions that use both types of defense mechanisms are those in which clients admit that they are feeling various emotions.

A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization?

PROTECTION FROM HARM TO SELF AND OTHERS Involuntary hospitalization may be required for clients considered dangerous to self or others, or for individuals who are considered severely disabled by their illness. Remember that safety is always a priority. Although one of the goals of hospitalization is to restore maximum independent living as quickly as possible, this the reason why a person is involuntarily hospitalized.

A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach?

Placing the spoon in the client's hand and stating "Use the spoon to eat your food." By placing the spoon in the client's hand while giving basic instructions to the client identifies a need for adaptive behavior with instruction and a verbal expectation. This response is the most client-centered and therapeutic for the autistic child. Punitive responses should always be eliminated ("I believe you know better than to eat with your hands" and "You can't have any more food until...").

A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents?

REPORT A PERSISTENT COUGH TO THE HEALTH CARE PROVIDER Persistent coughing should be reported to the health care provider because this may indicate bleeding.

The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred?

REPORTED BEHAIVIORAL CHANGES If a client alters any behaviors, such as smoking, drinking alcohol and stress management, this would suggest that learning has occurred.

An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus?

RESPIRATORY FUNCTION Spinal injury at the C-2 level results in quadriplegia, with compromise of the neurologic control of breathing. Clients with this type of injury require mechanical ventilation to support their breathing. While the client will experience all of the problems identified, respiratory function is the highest priority.

The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus?

RESTORE YIN AND YANG The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus?

A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?

RHONCHI Pneumonia causes a marked increase in interstitial and alveolar fluid, producing secretions in the airway, or discolored sputum. Rhonchi are low-pitched, snore-like sounds caused by airway secretions. These abnormal sounds occur in pneumonia and, as the illness subsides, they should disappear, demonstrating the effectiveness of the antibiotic therapy. Friction rubs, diminished sounds, and wheezes are not typically associated with pneumonia. If the lung sounds and other findings were not improving or were getting worse after two to three days of antibiotic therapy, the provider should be notified, as an alternative antibiotic may be needed to treat the organism responsible for the infection.

A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age?

RIDING A TRICYCLE Coordination is gained through large muscle use. A 3 year-old child has the ability to ride a tricycle, hop and stand on one foot. The other activities would more typically be found in preschoolers.

The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?

RIGHT AFTER THE PERIOD WHEN YOUR BREASTS ARE LESS TENDER The best time for a breast self exam (BSE) is at the end of the menstrual cycle, when the breasts are no longer swollen and tender from hormone elevation. BSE is to be avoided during the first two days of the menses.

A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?

RISK FOR INFECTION Membranes that ruptured more than 24 hours prior to birth greatly increase the risk of infection to both the mother and the newborn. You will notice that the three incorrect options are more acute in focus and would probably occur well before 36 hours postpartum.

A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display?

SIT WITHOUT SUPPORT The age that a normal child develops the ability to sit steadily without support is from seven to eight months.

A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take?

SLEEP WITH THE HEAD PROPPED ON SEVERAL PILLOWS Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best minimized by sleeping in a semi-upright position, eating small frequent meals, or eating at least three hours before sleeping. Drinking plenty of water will help with digestion but drinking too much water at one time may actually worsen heartburn symptoms. Medications need to be approved by the health care provider.

A nurse is collecting data about the motor function of a client with a history of acute head injury. What technique should the nurse use?

SQUEEZE THE TRAPEZIUS MUSCLE FIRMLY If there is no spontaneous movement in an unconscious client, the nurse can provide central pain stimulation to assess motor function. Squeezing the trapezius is the preferred method; the nurse can also gently pinch the earlobe or apply supraorbital pressure. Although rubbing the sternum with the knuckles can be used, this technique can cause bruising and is no longer recommended. Shaking an extremity is inappropriate.

The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications?

THE NURSE PRACTICE ACT OF THE STATE IN WHICH THE PRACTICE TAKES PLACE A state's nurse practice act will provide the scope of practice conditions regarding IV therapy. What LPNs can and cannot do with respect to intravenous medications and treatments varies from state to state. A policy manual cannot direct nurses to perform skills that are above and beyond their scope of practice. The ANA is a professional organization representing the interests of nurses.

The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority?

THE WET CAST SHOULD BE HANDLED WITH THE PALMS OF HANDS FOR 48-72 HRS Handle cast with palms of the hands and lift at two points of the extremity. This will prevent stress at the injury site and indentations that cause pressure areas on the cast. The other options are correct actions, but are not the most important.

The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development?

THINKS LOGICALLY TO ORGANIZE FACTS******* According to Piaget, the child is in the concrete operational stage and is capable of mature thought when allowed to manipulate and organize objects or thoughts. School-age children tend to focus on "rules," which helps to organize facts. The other options are either too advanced or not advanced enough.

The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis ( collapse of expanded lung)?

TURN COUGH AND BREATHE DEEPLY Deep air excursion by turning, coughing and deep breathing will expand the lungs and stimulate surfactant production. This is the best way to prevent atelectasis. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in prevention of atelectasis following surgery. However, they are not the priority.

The nurse is reviewing the history of a pregnant woman. Which factor should the nurse recognize as a priority contraindication for breastfeeding?

USES COCAINE ON WEEKENDS Binge use of cocaine can be just as harmful to the breast-fed newborn as regular (daily) use of cocaine. Alcohol is also contraindicated. However, between the two substances, cocaine is the more dangerous.

In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect?

VAGINAL LACERATIONS Continuous bleeding in the absence of a boggy fundus indicates undetected vaginal tract lacerations. If you are not sure about the correct response, re-read the responses and you should note that three of the (incorrect) options would result in excessive bleeding, and not a "trickle."

A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome?

VARICELLA Varicella (chicken pox), influenza and the cold virus are viral illnesses that have been identified as increasing the risk for Reye's syndrome in children, particularly when aspirin has been used. Rubeola, meningitis, and hepatitis are not recognized as precursors to Reye's syndrome. The combination of a viral infection and the administration of aspirin to children from birth to 19 years of age can result in the development of Reye's syndrome; therefore, aspirin should be avoided during these ages.

A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client?

WASH HANDS THOROUGHLY BEFORE AND AFFTER ANY PT CONTACT Salmonella is usually transmitted to humans by eating food contaminated with animal feces. Thorough hand washing can help prevent the spread of Salmonella. Note that the question asks for the primary action. Also note that it does not state a geographic location, such as in a home or in an acute care agency.

A nurse is caring for a client diagnosed with obesity and osteoarthritis of the knees. During reinforcement of the teaching given by the registered nurse (RN), the practical nurse (PN) should know that which health practice should have the greatest benefit on the client's outcome?

WEIGHT REDUCTION A major contributor to the development of osteoarthritis is excess body weight, due to the ongoing stress placed on joints. Weight reduction can play a key role in promoting the client's long-term health and mobility. Leg elevation is not indicated in osteoarthritis of knees. Joint braces are not a treatment for osteoarthritis. Anti-inflammatory medications play a role in reducing inflammation and pain, but they will not address the cause of the problem.

The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?

WHEN IT IS 1/3 TO 1/2 FULL If the pouch becomes more than half full, it could put pressure on the seal, causing a leak. The pouch may also detach, causing the contents to spill. This will not only irritate the skin but also embarrass the client.

The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond?

YOU SEEM UPSET TELL ME ABOUT HWO YOU ARE FEELING A nonjudgmental, open-ended response facilitates dialogue between the client and nurse. The correct response is the more general, client-centered option. This type of comment facilitates the flow of communication.

A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond?

YOU SOUND ANGRY RIGHT NOW The nurse recognizes and identifies the underlying emotion with a matter-of-fact attitude. In similar situations of emotional outbursts, the action by the nurse should be to focus on the client's feelings before the client's behavior.

A female client admitted for a breast biopsy says tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." What would be the most appropriate response to this statement?

YOU SOUND WORRIED THAT THE SURGERY MIGHT CHANGE YOUR RELATIONSHIP WITH YOURE PARTNER The best response is one that encourages further discussion by making an observation, without focusing on an area that the nurse feels is a problem. The client has the control to direct the focus of the conversation. One incorrect response - elicits a "yes" or "no" answer which blocks rather than supports further discussion. Another incorrect response is confrontational and requires an explanation of a specific focus, rather than prompting client contol of topic. The third incorrect response offers false reassurance and does not engage the client in further discussion.

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is most important to ensure patency of the tube?

ADEQUATELY FLUSHING WITH SUFICIENT AMOUNTS OF WATER BEFORE AND AFTER USING THE TUBE Prior to using the tube, it must be checked to make sure it is free from obstruction and leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after use is the best way to ensure patency. Liquid medication preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the client to cough, which will speed up the removal of excessive air, but the tube still needs to be flushed with water before and after use.

A nurse is caring for a client who has been diagnosed with acute sickle cell vaso-occlusive crisis. Which intervention by the nurse would be most important?

ADMININSTER ANALGESIC TX AS ORDERED Pain is very severe in sickle cell crisis, and is a priority in care. The main objectives in the treatment of a sickle cell crisis is providing analgesics for pain, adequate hydration, oxygenation, bed rest, electrolyte and blood replacement, and antibiotics to treat any existing infection that could have contributed to the crisis. Because pain causes sympathetic stimulation, which results in vasoconstriction, pain management is the most important nursing action among the given choices. Clear liquids, bed rest and temperature control measures assist in reducing the ischemia associated with a sickle cell crisis. You will note that this is a specific question, requiring a specific answer. When deciding on which option to select, you should conclude that pain control should take priority over the other options.

The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse?

ADMINISTER PRN MEDICATION AS ORDERED In a client with a diagnosis of acute angina, chest pain means the heart is deprived of oxygen. The priority action would be to give the prescribed pain medication, which will improve oxygenation to the heart. Detailed assessment of the pain, lab tests and ECG can be done once the medication is given. Mostly likely this client would also have a standing order for nitroglycerin.

A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point?

ADMINISTRATON OF A THYROID PROBLEM WILL PREVENT PROBLEMS You will notice that only one option (the correct response) includes the word "thyroid." Associate this with the content of this question, which is hypothyroidism. This option also addresses replacing something that is missing (hypo) making it a "treatment" for the content of this question. Early identification and lifetime treatment with hormone replacement therapy (levothyroxine) corrects this condition.

A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client?

AIRBORNE Airborne precautions include an OSHA mandated/NIOSH certified respirator, negative pressure in a private room with the door closed or a semiprivate room with both clients diagnosed with the same disease (called cohorts), and limited movements or transport of the client. If these clients have to leave the room, they must wear a mask. A tight fitting, high-efficiency mask, such as the particulate HEPA filtered respirator mask, is required when caring for clients who have suspected communicable disease of the airborne variety. Active TB, measles and chicken pox require airborne precautions. Droplet precautions are used for influenza, whooping cough and mumps. Contact precautions are for active HSV lesions, VRE, MRSA, lice, scabies, RSV and impetigo.

When reinforcing teaching about a new prescription for NORTRYPTILINE (PAMELOR) to a client diagnosed with depression. What information should the nurse emphasize?

ALCOHOL USE IS TO BE AVOIDED Alcohol potentiates the action of tricyclic, as well as other, antidepressants. If the medication is unknown, focus on what is known. The client has been diagnosed with depression and is likely on an antidepressant. Then think about what you know about antidepressants and each of the options. Select the response with "alcohol" because this is the more common substance to avoid with most medications.

A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse?

I WILLPUT MY RIGHT LEG THROUHG A FULL RANGE IN MOTION To prevent arterial occlusion after arterial revascularization, the nurse should have the client avoid full range of motion. This prevents stress or kinking of the grafts. A throbbing pain may indicate that the blood supply is increasing in the surgical area and this is a desired effect. Smoking causes vasoconstriction and will contribute to occlusion. Coughing and deep breathing are important after any surgery.

Lactulose (Kristalose, Chronulac) has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?

INCREASED ABILITY TO CONCENTRATE Lactulose is used to treat constipation (it's a cathartic). It is used to treat or prevent complications of liver disease, such as hepatic encephalopathy. In liver disease, ammonia builds up in the blood; lactulose works by reducing the amount of ammonia in the blood. Early symptoms of hepatic encephalopathy include confusion, problems with memory or thinking, sleep problems, loss of coordination; later symptoms range from agitation and disorientation to unconsciousness and coma.

A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client?

INSTITUTE SEIZURE PRECAUTIONS If AGN is untreated, renal failure, seizures and heart failure may result. Clients with AGN should restrict salt intake during the acute phase to control edema and volume-related hypertension. A protein-restricted diet may also be indicated. Underlying infections would be treated with antibiotics. Nursing care would include frequent monitoring of blood pressure, daily weights, intake and output, and seizure precautions.

The nurse is caring for a client who had a total hip arthroplasty 24 hours ago. The nurse should position the client in a manner that will prevent the affected leg from which position?

INTERNAL ROTATION AND ADDUCTION Internal rotation and adduction of the operative can cause the newly placed hip prosthesis to become dislocated. A wedge pillow is often used to ensure the proper leg position in the early postoperative period. All alternate positions are not indicated in care after total hip arthroplasty.

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse?

MINIMAL DRAINAGE INTO THE URINARY BAG The LPN should report minimal drainage in the urinary collection bag because this puts the client at risk for bladder rupture. The flow rate of the continuous irrigation would need to be slowed until the health care provider is notified. If an order to irrigate the system is written, sterile technique would be used. The other options are all expected findings after this procedure

A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?

MONITOR THE INFANTS URINE OUTPUT Toxicity from aminoglycoside results in increased serum creatinine levels. Decreased urine output is one of the first findings of nephrotoxicity and renal failure. You will note that two of the options focus on "output." Remember that a priority intervention typically begins with data gathering; the word "monitor" is a "data collecting" word.

A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)?

PARESTHESIA AND MUSLCE CRAMPING Because the parathyroid gland may be damaged in this surgery, secondary acute hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Mild dysphagia and hoarseness is an expected postoperative finding and may last for six to eight weeks after surgery.

The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis?

PEAK AIR FLOW VOLUME The peak air flow volume decreases about 24 hours before clinical findings occur for acute asthma attacks. A peak flow meter is a small, hand-held device used to manage asthma by monitoring air flow through the bronchi and thus the degree of restriction in the airways. The peak flow meter measures the client's maximum ability to expel air from the lungs, or peak expiratory flow rate (PEFR or PEF). Peak flow readings are higher when clients have normal airways and lower when the airways are constricted. Most have colors to help explain the results: green = good or 80 to 100% of normal air flow; yellow = therapy (inhaler) needed 50 to 80% of normal air flow; and red = rapid response needed/medical alert or less than 50% of normal air flow.

A toddler is brought to the clinic. The grandmother states that the child has been "scratching his bottom" and "has been irritable and restless." Based on this information, what health issue should the nurse anticipate?

PINWORM Pinworm is a common parasitic infection in children. Findings of pinworm infection include intense perianal itching. The itching is usually worse at night, which is why the child will also exhibit poor sleep patterns, general irritability, restlessness, bedwetting, distractibility and a short attention span. The eggs will stick to a piece of clear cellophane tape placed against the rectum and the eggs can be seen under a microscope. The nurse can also take some samples from under the child's fingernails to look for eggs. Recall that "P in worms" are found where the "pooh" comes out - the anal/rectal area. Scabies is an itchy skin condition caused by a tiny mite that burrows under the skin, causing small, itchy bumps or blisters; the most commonly affected areas of the body are the hands and feet. Ringworm is a fungal infection with characteristic round, itchy rashes on the skin.

A newborn who has hyperbilirubinemia is undergoing phototherapy with a fiberoptic blanket. Which intervention is indicated during this therapy?

PROVIDE MORE FREQUENT FEEDINGS There is no reason to withhold feedings for phototherapy and, in fact, this would be counterproductive. Frequent feedings of breast milk or formula are given to help with bowel motility, which, in turn, should increase the excretion of bilirubin. Protecting the eyes of the neonates is a priority when under the ultraviolet lights to prevent damage but because a fiberoptic blanket is used, eye protection is unnecessary. The neonate's skin is exposed to the light and the temperature is monitored continuously so a heater is not often necessary.

A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse?

PROVIDE PRIVACY WITH ENCOURAGEMENT TO WORK THROUGH FEELINGS A 12 year-old child needs the opportunity to express emotions privately. The incorrect responses may provide distraction and are not client-focused to deal with the observed behavior of crying.

A client is admitted to the mental health inpatient unit with a diagnosis of MAJOR DEPRESSION after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics?

PSYCHOMOTOR RETARDATION/ AGITATION Somatic or physiologic findings of depression include fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido. Notice the data given in the stem relates to feelings and the question is asking: what findings other than feelings might be observed? Because two of the options deal with feelings or emotions, these can be eliminated. Compare the remaining options and determine which behavior is most likely to occur with a diagnosis of depression - attention to grooming and hygiene or psychomotor retardation and agitation.

A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization?

TYMPANIC TEMP OF 104F 40 DEGREES C Body temperature greater than 104 F (40 C) should be immediately reported to the health care provider. Another adverse reaction to report is inconsolable crying (sustained crying for more than three hours).