PrepU

Which nursing action would be most beneficial to a client and her spouse who state they wish to go through labor without the use of analgesics or anesthetic agents?

Act as an advocate for the couple and verbalize their wishes to nurses and physicians. Nurses are ethically responsible for giving childbearing families the autonomy to make informed choices about the care they receive. This also fosters a collaborative relationship with the family. Nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct. A client should never be left alone in labor. Providing information about or encouraging the use of drugs may leave the client and family feeling as though the nurse is not supportive of the couple's choices by encouraging actions that are contradictory to the family's birth plan.

The nurse is providing an education program to a group of adolescents on the importance of testicular self-examinations. One of the participants asks the nurse, "when is the best time to do the examination?" What is the best response by the nurse?

when you are in the shower or immediately after Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures. The nurse should inform the group that the best time to perform a testicular self-examination is in the shower or immediately afterward because the scrotum is relaxed. When the male first rises in the morning, in the evening, or prior to urinating, the scrotum is not in the optimal condition for the examination.

A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?

6 months Pediatricians recommend that infants be given either breast milk or formula until at least 6 months of age because of the neonate's difficulty digesting solid foods. Giving solid foods too early can lead to food allergies. Because chewing movements do not begin until 7 to 9 months of age, foods requiring chewing should be delayed until this time.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether the client wants the family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach in confidentiality, while providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first?

the client with unilateral leg swelling who reports anxiety and shortness of breath The client who reports anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.

When examining a client who has abdominal pain, a nurse should assess

the symptomatic quadrant last. The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

The nurse is caring for a primigravid client at about 9 weeks' gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she makes which statement?

"Nausea and vomiting can be decreased if I eat a few crackers before arising." Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.Nipples should not be cleansed with soap.Cotton, not nylon, underwear should be worn if there is a vaginal discharge. The client should contact her health care provider for evaluation of the discharge.Leg cramps should be treated with heat, not ice. Adequate hydration and moderate physical activity, such as walking, can help decrease the incidence of leg cramps.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next?

Check the computerized care plan to determine what test was scheduled. Glulisine is a rapid-acting insulin with an action onset of 15 minutes. The client could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not necessary to call the client's HCP; the nurse should determine what test was scheduled and then locate the client and provide either breakfast or 4 oz (120 mL) of fruit juice. To bring the client back to the room would be wasting valuable time needed to prevent or correct hypoglycemia.

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?

Keep feedings small, but frequent. Because children with heart defects fatigue so quickly, frequent small meals are suggested to ensure that the child receives adequate nutrition. Rough play would be considered too physically demanding on the child. Most children do not need oxygen at home.

A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation?

Notify the local Child Protective Services. If a nurse suspects abuse of any nature, it must be reported to the appropriate authorities, such as Child Protective Services. The other options are incorrect because they do not demonstrate the required action of the nurse in this situation.

A nurse is caring for an infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent?

Obtain consent from the foster parents. Foster parents have the right to consent to medical care of minors in their care. The parents of a minor in foster care don't have authority to make decisions regarding the child's care. The nurse should call Child Protective Services only if she has concerns about a foster parent's authenticity. The nurse needn't notify the director of nursing unless complications occur.

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses. Visual acuity is usually measured with a Snellen chart. A client with 20/40 vision is able to read the same sized letters from 20 feet away as a person with "normal" vision would be able to read at 40 feet away. The client with 20/40 vision would be referred to a healthcare provider for the possible need for corrective lenses, as 20/20 vision is considered normal. The client would need to be evaluated by a healthcare provider prior to suggesting the purchase of corrective lenses for reading. In most jurisdictions, 20/40 vision qualifies for an unrestricted driver's license, so corrective lenses may not be required. However, the client must first see the healthcare provider before that can be determined.

The nurse is auscultating S1 and S2 in a client. Identify the area where the nurse should hear S1 the loudest.

S1 is loudest at the mitral area which is the 5th intercostal space, midclavicular line.

A client presents to the nurses' station with symptoms of a panic attack, including shortness of breath, dizziness, trembling, and nausea. Which is the nurse's first intervention?

Stay with the client, and offer support. Staying with the client and offering support will provide a sense of security. Never leave a client alone during a panic attack. Teaching relaxation techniques and helping the client identify triggers are not appropriate during an acute panic attack, but they are important interventions when the client is calmer and able to receive information. Administering anxiety medication isn't the best initial action, because they don't take effect immediately.

The nurse creates a program to decrease the primary cause of disability and death in children. What is the most important action to include in the plan?

Teach health and safety practices to children and their parents. The primary cause of disability and death in children is injury from accidents. Teaching safety measures to children and their parents is the best way to decrease injury and accidents. Add a Note

The caregiver of a 2-month-old client calls stating that the client is "fussy and has a runny nose." The caregiver states that the client has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the caregiver?

Use a bulb syringe to suction out the nasal passages. Children under 2 years of age should not take over-the-counter cough-and cold-medications. The symptoms that the caregiver is describing are for the common cold and antibiotics are not needed. Aspirin is contraindicated in children for the treatment of a fever due to the risk of Reye's syndrome. A bulb syringe to suction out the nasal passages of the client is an appropriate intervention.

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. To assure client safety, the nurse first writes the results on the chart, then reads them back to the caller and waits for the caller to confirm that the nurse has understood the results. The nurse may receive results by telephone; and although electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nurses station.

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet?

canned tomato juice Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The nurse should teach the client to read labels carefully. Apples and whole wheat breads are not high in sodium. Hamburger would have less sodium than canned foods or tomato juice.

A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess

chest movements. The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say the word "ninety-nine" the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation.

A nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity

results from exposure of an antigen through immunization or disease contact. Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it is temporary. Passive immunity may be transferred by mother to neonate.

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship?

communication barriers between the mother and staff The communication barrier is the most significant and would require immediate attention. Strategies need to be implemented that include taking the time to share information via the written word with all new members of the healthcare team and the mother. Fear, loss of control, and lack of knowledge about the illness of the child may contribute to the overall stress of the situation.

A nurse-manager appropriately behaves as an autocrat in which situation?

directing staff activities if a client experiences a cardiac arrest In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

The nurse is providing cost-effective, evidence-based care health education to a client. Which choices are examples of cost-effective, evidence-based care? Select all that apply.

education on healthy dietary choices education on beginning an exercise regime Cost-effective, evidence-based care includes education on healthy lifestyle choices. Education on extended health insurance plans and medical expenses can be provided but is not considered cost-effective care. Education on healthcare legislation is not the priority.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client?

lactose enzyme deficiency Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population and suicide is a common health problem for the Native American and white middle-class populations.

The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate?

risk for injury related to altered mobility Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, risk for injury is the most appropriate nursing diagnosis. Activity intolerance related to sedentary lifestyle assumes that the client with osteoarthritis is limited in physical activity. Self-care deficit related to immobility assumes that the client with osteoarthritis is unable to complete self-care activities. Imbalanced nutrition: Less than body requirements is incorrect because osteoarthritis does not affect nutrition.

The nurse should refer the parents of an 8-month-old child to a health care provider (HCP) if the child is unable to demonstrate which gross motor ability?

sit without support for long periods of time According to the Denver Developmental Screening Examination, a child of 8 months should sit without support for long periods of time. An 8-month-old child does not have the ability to stand without hanging onto a stationary object for support. His muscles are not developed enough to support all his weight without assistance. His balance has not developed to the point that he can stand and stoop over to reach an object.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?

Collaborate with the physician to make a referral to social services. Collaborating with the physician to make a referral to social services helps the client by creating a plan and providing support. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the police, and follow up with a written report. Although confrontation can be used therapeutically, this action will most likely provoke anger in the suspected abuser. Questioning the client in front of her partner does not allow her the privacy required to address this issue and may place her in greater danger. If the woman is not in imminent danger, there is no need to call hospital security.

A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that the client's children work and no one has time to assist the client with self-care activities. The nurse should

Contact the nursing supervisor. A nurse has a legal responsibility to report suspected abuse or neglect of an elderly client or a child. The nurse must follow the chain of command and facility policies for reporting such suspicions. Notifying the family isn't the nurse's primary concern or responsibility. The police will be notified after the nurse has fulfilled the facility's policies.

The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time?

oxytocin An epidural can slow contractions, so many clients will need to have oxytocin to maintain contraction strength. Magnesium sulfate and terbutaline are tocolytic medications to decrease contractions, and methergine is used for postpartum hemorrhage.

The nurse is teaching a pregnant client about injury prevention. Which instruction should the nurse include?

"Change your shoes from high heels to flats." Balance changes during pregnancy. Wearing high heels places the woman off balance and can lead to falls. They can also lead to leg fatigue and increased swelling. Low heel or flat-heeled shoes are more appropriate for correct balance. When traveling in a car, the shoulder belt should cross between the breasts and over the upper abdomen, above the uterus. The lap belt should cross over the pelvis below the uterus. The steering wheel should be positioned as best as possible away from the uterus. Going to the gym every day is good exercise for the pregnant client, but the purpose is not for balance. Exercise promotes a sense of well-being, improves circulation, helps reduce constipation, and promotes muscle strength, tone, and endurance. For the working pregnant client, it is recommended to take two 10-15 rest periods in an 8-hour workday.

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?

"Gradually eliminate one feeding at a time." The client should wean the infant gradually, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the mother desires; she does not have to breastfeed for 4 months. Most infants (and mothers) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy.

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?

7 days after fertilization Implantation occurs at the end of the first week after fertilization, when the blastocyst attaches to the endometrium. During the second week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the third week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the fourth week (28 days after implantation), cellular differentiation and organization occur.

A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. What should the nurse try first?

Allow a parent to assist. Parents can be asked to assist when their child becomes uncooperative during a procedure. Most commonly, the child's difficulty in cooperating is caused by fear. In most situations, the child will feel more secure with a parent present. Other methods, such as asking another nurse to assist or waiting until the child calms down, may be necessary, but obtaining a parent's assistance is the recommended first action. Restraints should be used only as a last resort, after all other attempts have been made to encourage cooperation.

A community health nurse is caring for a Vietnamese client with a diabetic foot ulcer. The client's children, spouse, and best friend are the only people available that speak English. What should the nurse do to provide optimal client care? Select all that apply.

Request that a health related interpreter to come to the home. Utilize a trained telephone interpreter while providing care. When speaking with a client that does not speak the dominant language, the nurse should use a trained interpreter. If an on-site interpreter is unavailable, the nurse should other methods including bilingual staff, webcam, or telephonic interpreting. Family and friends should be avoided as interpreters as they may be protective of the client or not agree with the treatments offered and therefore not the most reliable translators.

A client and her partner, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as:

the inability to conceive after 1 year of unprotected attempts. The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse. The inability to sustain a pregnancy doesn't factor into the definition of infertility. A low sperm count and decreased motility may contribute to infertility, but they don't determine infertility.

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate?

"I will ask the surgeon to come speak to you about the procedure." It is the surgeon's responsibility to explain the procedure to the client and to answer questions so the client can provide an informed consent. The nurse can reinforce the information after the consent is obtained and clarify the information, but the surgeon must explain the procedure initially.

A 15-year-old primipara who gave birth to a term neonate vaginally tells the nurse, "My mother started feeding me rice cereal when I was only 2 weeks old." What would be the most appropriate response to the client?

"Wait until the infant is at least 4 months of age before using cereal." Breast milk or formula should provide adequate nourishment for a neonate until 4 to 6 months of age.Cereal, regardless of the amount, given before the age of 4 months is not easily digested by the neonate and may lead to food allergies and possibly aspiration.Cereal should not be given in a bottle. Doing so could lead to obesity or aspiration.The infant's iron stores need to be fortified with formula with iron or cereal with iron at 4 to 6 months of age.

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse?

"I will find you a computer that is not being used so you can enter the order into the computerized order entry system." The nurse cannot give the furosemide right away because the prescription needs to be put in the computerized order entry system first. This is not an emergency. The correct response is to have the health care provider put the prescription in the computerized order entry system because it is not an emergency. Verbal orders are for emergencies only. The charge nurse does not need to know about the prescription. The charge nurse does not need to put the order in the computerized order entry system. The nurse assigned to the client is responsible for the client's care. The nurse can call the pharmacy right away to have the furosemide sent, but the prescription needs to be entered first. The pharmacy will not send the medication, because it is not an emergency, without an order first. The nurse should not put the prescription in the computerized order entry system. The health care provider needs to put the prescription in the computerized order entry system. Verbal orders are for emergencies only.

A client is participating in a cardiac research study in which the client's physician is directly involved. Which statement indicates a need for additional teaching about the client's rights as a research study participant?

"I'll have to find a new physician if I don't complete this study." The client stating a requirement to find a new physician if the client does not participate in the study indicates a need for additional teaching. Whether the client participates in this study should not influence the relationship with the physician. The client has the right to withdraw from a study at any time without penalty. All information provided by the client is kept confidential and used only by members of the study team for scientific purposes. The client must be informed of all risks associated with study participation.

The mother of a 10-year-old girl with diabetes asks the nurse's advice about whether or not her child, who has always been compliant with treatment, should be allowed to go trick-or-treating on Halloween with several friends. The nurse should tell the mother:

"Yes, she needs to be with friends and do the things other children do." The nurse should advise the mother to allow the child to go trick-or-treating. Children need to be treated like their peers. Sheltering them from all temptation does not allow them the opportunity to develop coping strategies for dealing with the restraints made necessary by their disease. Eating sweets can result in hyperglycemia. Although not desired, hyperglycemia is not life threatening in this context. Trust between the parent and child is essential in managing this disease. Telling the mother that she must go with her child and watch her would not promote trust. It would not be advisable to give extra insulin because this action could result in severe hypoglycemia, especially if this usually compliant child remains faithful to the treatment regimen.

A 10-month-old looks for objects that have been removed from his view. How does the nurse explain the finding to the parents?

The child understands objects are there even though the child cannot see them. Understanding object permanence means that the child is aware of the existence of objects that are covered or displaced. Neuromuscular development, curiosity, and the ability to transfer objects are not associated with the principle of object permanence. Although, at 10 months, neuromuscular development is sufficient to grasp objects and a child's curiosity has increased, neither are related to the thought process involved in object permanence.

A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She does not have transportation. How can the nurse help this client be compliant with her care?

Ask the clinic case manager to speak with the client. The nurse should ask the case manager to speak with the client because the case manager is familiar with community resources that can assist with transportation. Resources and additional support will greatly increase the client's compliance. The nurse can't set up cab service if the client doesn't have the funds to pay for transportation. The client may be noncompliant if she has no assistance or if she has to rely on a friend to help.

A nurse prepares to care for a client who has just been admitted to the health care facility. Which activity will the nurse perform first?

Collect data. The nurse will first collect relevant data from various sources. Based on the data collected, the nurse will formulate a plan of care including nursing diagnoses, interventions, and appropriate client outcomes.

The nurse is caring for a recently circumcised newborn. Based on the progress note, what would be the most appropriate nursing intervention? 2/10 0800 Progress Note Tab Three-day-old male, two days post-circumcision by Mogen clamp. Small amount of yellow-white exudate noted around glans. No bleeding or swelling noted. Axillary temp 36.4° C (97.5° F). Nursing eagerly, latching on well. Voided x4 post-circ.

Provide routine care to the circumcised area. The yellow-white exudate is part of the granulation process and is a normal finding for a healing penis following circumcision. Routine vital signs and normal layering would be recommended for this neonate as this temperature is normal in a newborn. It is not necessary to increase monitoring or covering of the neonate. Pacifiers do soothe pain in the neonate; however, there is no indication in this progress note that the neonate is in pain.

A client had a cast applied to the left femur to stabilize a fracture. To promote early rehabilitation, what should the nurse do?

Teach the client how to do isometric exercise of the quadriceps. The nurse should teach the client how to do isometric exercise, contraction of the quadriceps muscle without movement of joint, to maintain muscle strength. Physical therapy may assist the client later, and will then teach the client how to do active exercises and crutch walking if prescribed. The client will be able to move the unaffected limb; the family will not need to assist. If the client will be using crutches, building upper extremity strength will be helpful, but the immediate need is to maintain and develop strength in the quadriceps.

A nurse working on a critical care unit was informed by a client with multiple sclerosis that the client did not wish to be resuscitated in the event of cardiac arrest. The client is no longer able to express their wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may cause

ethical distress The nurse is involved in a situation that involves ethical distress. Ethical distress occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action. Paternalism is acting for clients without their consent to secure good or prevent harm. Deception and confidentiality can result in ethical problems for nurses when there is a conflict between the client's and nurse's values and interests. In this scenario, the nurse is aware of the client's wishes but the conflict lies with the family and thus the nurse will experience ethical distress.

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

identity According to Erikson's theory of personal development, the adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent is trying to develop a sense of identity, and peer groups take on more importance. The hospitalized adolescent is separated from the peer group and the adolescent's body image may be altered. This alteration in body image may interfere with the ongoing development of the adolescent's identity. Toddlers are in the developmental stage of autonomy versus shame and doubt. Preschool children are in the stage of initiative versus guilt. School-age children are in the stage of industry versus inferiority.

A client was admitted for treatment of the symptoms of bipolar disorder after failing to comply with community treatment and continuing to expose their sexual partners to a sexually transmitted form of hepatitis. The court appointed a guardian because this client was not able to understand the consequences of the decisions being made. Which terms describes the status of this client?

legally incompetent Legally incompetent describes the client who is not able to understand the consequences of decisions. A guardian is appointed for the client who is incompetent. Admitted with consent or voluntary describes a client who is voluntarily admitted and who has the right to demand and obtain release. Emergency involuntary admission is an involuntary admission for a specific time period to prevent dangerous behavior. The term competent describes the client who is able to understand the consequences of decisions.

The parent tells the nurse that an 8-year-old child is continually telling jokes and riddles to the point of driving the other family members crazy. The nurse should explain this behavior is a sign of which factor?

mastery of language ambiguities School-age children delight in riddles and jokes. Mastery of the ambiguities of language and of sentence structure allows the school-age child to manipulate words, and telling riddles and jokes is a way of practicing this skill. Children who suffer from inadequate attention from parents tend to demonstrate abnormal behavior. Peer influence is less important to school-age children, and while the child may learn the joke from a friend, he is telling the joke to master language. Watching television does not influence the extent of joke telling.

An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?

pulling up the client under the left shoulder when getting the client out of bed to a chair Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop.

A child age 4, begins to use curse words. Concerned about this behavior, the parents ask the nurse how to discourage it. Which advice should the nurse offer?

"Tell the child it isn't acceptable and they will be disciplined if it continues." The nurse should advise the parents to tell the child it isn't acceptable because by explaining their objections and expectations, the parents teach the child why the behavior is unacceptable and help the child understand that it must stop. Telling the parents to ignore the behavior, or telling the child the behavior makes the parent angry, wouldn't teach the child that the behavior is inappropriate. Advising the parents to tell the child that good little children don't use curse works would reinforce the impression that the child is "bad," diminishing the child's self-image while doing little to change the objectionable behavior.

A client returns to the postnatal ward with her 3-week-old infant. Which statement by the client would prompt the nurse to evaluate the infant for inadequate intake?

"The baby does not exhibit a steady weight gain." Newborns differ in their feeding needs and preferences. Most breastfed babies need to be fed every 2-3 hours, nursing for 10-20 minutes on each breast. Formula-fed babies usually feed every 3-4 hours, finishing a bottle in 30 minutes or less. Weight gain is the best measure of the infant receiving adequate nutrition. If the newborn seems satisfied, wets 6-10 diapers per day, produces several stools a day, sleeps well, and is gaining weight regularly, then the baby is receiving adequate fluid intake and nutrition. Newborns swallow air during feeding, which can cause fussiness and discomfort. They should be burped several times throughout the feeding. The amount of burping does not relate to weight gain.

While performing an assessment, a nurse observes a 6-month-old infant transferring an object from one hand to another and reaching for the nurse's stethoscope. The parent tells the nurse this is new behavior and asks if it is normal. The nurse educates the parent about growth and development parameters for a 6-month-old infant. What does she tell the parent?

"This behavior is typical for a 6-month-old infant." The nurse should say this behavior is normally seen because an infant typically transfers objects from one hand to another and reaches for objects between ages 4 and 6 months, so the infant is demonstrating normal developmental behavior. This is a fine-motor adaptive skill, not a personal-social skill. A 2-month-old grasping a rattle is an example of a fine-motor adaptive skill.

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to family members. What is the most appropriate action for the nurse to take?

Encourage the client to speak with the family member about the diagnosis if the client has not already done so. Encouraging the client to talk with their spouse is the nurse's only option. According to the Privacy Acts, a client's diagnosis is confidential information that shouldn't be shared with anyone, including a spouse, without the client's permission. Telling a family member about the diagnosis is a violation of the client's confidentiality. The nurse isn't legally obligated to report the diagnosis to family members. It isn't appropriate for the nurse to provide information that would allow other agencies to contact the client's spouse.

After having multiple medication errors, the nurse admits to abusing narcotics to the nurse manager. What are the implications of narcotic abuse for the impaired nurse? Select all that apply.

The nursing license can be suspended. The State Board of Nursing will publish the nurse's license suspension in a newsletter. The nurse can have the nursing license suspended from the State Board of Nursing. The State Board of Nursing will publish the nurse's license suspension in a newsletter available for healthcare providers. The impaired nurse will be able obtain a future nursing license after treatment. The hospital cannot publish the nurse's license suspension in the hospital newsletter. The local newspaper will not be notified of the narcotic abuse unless a crime has been committed.

A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client's face. How will the nurse proceed?

Verify placement of the tube. The NG tube placement should be verified prior to re-taping the NG tube; the other options require verification of the NG tube placement first and the healthcare provider will need to know.

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. The nurse can refer to the client and care providers by name in the medical record because it is kept secure and contains numerous identifiers already. Practitioners being referred to in a note should be identified by name instead of by titles (e.g., physician or charge nurse). The nurse is accountable for the information recorded and therefore shouldn't leave any blank lines in which another healthcare worker could make additions.

The nurse is caring for a client who wishes to stop medical treatment. Which action by the nurse best demonstrates the role of the nurse as a client advocate?

Communicate the client's wishes to the healthcare provider. Nurses advocate on a client's behalf when a change needs to be made in the plan of care. Communicating the client's wishes to the healthcare provider is the best example of client advocacy. Nurses must act as advocates even when they disagree with the client's decisions, so the nurse would not encourage the client to continue with medical treatment. Asking the client what lead to the decision may influence the client's decision. Informing family members of the decision violates the client's right to privacy.

A charge nurse asks a group of staff nurses to cover part of the next shift because a nurse called off. A staff nurse states, "40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The charge nurse tells the unit's nurse manager, "You should adjust her schedule to make her wish she'd volunteered." How should the nurse manager respond?

Counsel the charge nurse about her comment. It would be discriminatory and punitive for the nurse manager to alter the staff nurse's schedule. The remark by the charge nurse is inappropriate and unprofessional, and the charge nurse should receive counseling. The nurse manager could choose to ignore the comment, but any leader who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the charge nurse to the nursing administration should be avoided. Institutional documentation should exist for such matters. It is inappropriate for the nurse manager to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

What should the nurse teach the client with neutropenia to avoid?

using suppositories or enemas The neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defense and a direct port of entry for infection. The client with neutropenia is encouraged to wear a HEPA filter mask and to use an incentive spirometer for pulmonary hygiene. The client needs to know the importance of completing meticulous total body hygiene daily, including perianal care after every bowel movement, to decrease the flora at normal body orifices. The client also needs to know the importance of performing oral care after every meal and every 4 hours while the client is awake to decrease the bacterial buildup in the oropharynx.

An agitated client demands to see the chart to read what has been written about the client. Which statement is the nurse's best response to the client?

"You have the right to see your chart. Please discuss your wish with your physician." The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. The client should discuss the request with the physician so the physician can determine if information might be detrimental to the client. The client doesn't need an attorney's intervention to view the chart or wait until after discharge to view it.

A 35-year-old female client is diagnosed with aplastic anemia. Which is the most important nursing measure to incorporate into the client's plan of care?

Alternate periods of activity with rest to decrease fatigue. Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions.Antibiotics will not be administered prophylactically. The client should be taught self-care activities to decrease the likelihood of developing an infection.Adequate fluid intake is important, but the client does not need to force fluids. Hemoconcentration is not a problem in aplastic anemia.The client should be taught good handwashing techniques and limit contact with individuals who have respiratory illnesses; however, the client does not have to avoid all social situations.

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly. Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight.

A client who is 6 months postpartum asks the nurse about an effective method of birth control. What is the nurse's most appropriate response?

"Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding." Condoms are classified as barrier contraception in that they create a physical barrier to prevent the transmission of sexually transmitted infections. Cervical caps are another form of barrier contraception that are safe for breastfeeding mothers; they provide 85-98% effectiveness rate against pregnancy. Breastfeeding reduces the risk for pregnancy but not as much as other methods of birth control. The "Minipill," a progestin-only oral contraceptive, can be used during lactation, but combined birth control pills that contain estrogen should not be taken, because they can interfere with production of breast milk. Spermicidal foam is only 71-82% effective against pregnancy, which is lower than the other forms mentioned.

A hospitalized client with end-stage heart failure does not want to be resuscitated. The health care provider (HCP) has written the do-not-resuscitate (DNR) prescription on the client's record. The client has a cardiac arrest, and the wife tells the nurse she wants the client to be resuscitated and asks the nurse to "do something." What should the nurse do?

Discuss the DNR prescription with the wife. The nurse must respect the wishes of the client who has indicated that he does not wish to be resuscitated and not to initiate CPR. Nurses who resuscitate clients who have directed otherwise may be considered to be battering the client. In this situation the HCP has written the DNR prescription, and it is not necessary for the nurse to page the HCP. The nurse can be most helpful by explaining the client's decision to the wife and helping her manage her understand her husband's wishes and manage her own grief.

A nurse is caring for a client with schizophrenia. Which outcome requires revising the client's care plan?

The client spends more time alone. The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time alone wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking through use of talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved through close observation, removal of any dangerous objects, and medication administration. Because the client with schizophrenia may have difficulty meeting self-care needs, fostering the ability to independently perform self-care is a desirable client outcome.

A client has been prescribed a brand-name medication for a newly diagnosed condition. The client tells the nurse, "I do not know what to do. I cannot afford that medication. I may just have to keep suffering with these symptoms." What should the nurse do to best assist this client?

Recommend the client ask the health care provider if the client can take the generic brand of the medication instead of the brand-name medication. Generic medications are cheaper than brand-name medications, and usually are equally effective. The nurse recommending that the client ask the provider if the client can take the generic brand of the medication instead of the brand-name medication would be a cost-effective way of assisting this client to afford the medication. Researching other medications to treat this condition and telling the client to ask the health care provider to prescribe a different brand-name medication is outside of the scope of the nurse's practice, as it is recommending a medication for a condition and should be avoided. Telling the client that the nurse understands choosing not to take a prescribed medication due to cost, and that the nurse would do the same thing, does not assist this client in obtaining cost-effective medication or promoting optimal health. Informing the client that the client's health should be the priority, and the client needs to take this medication as prescribed no matter what it costs would not assist this client. It is not helpful and could lead to the client compromising other basic necessities such as food to obtain this medication, when a cheaper generic-brand option could alleviate the client's problems.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply.

Use the hospital code for HIV when documenting care. Ask all family members, except the client's significant other, to wait outside when she's educating the client. Every facility uses a specific code to designate HIV-positive clients. To protect confidentiality, the nurse should speak about the diagnosis only with the client and any person the client designates. A nurse should never discuss a client with anyone who is not directly involved in that client's care. For instance, if the client does not give the nurse permission to speak with the client's mother, the nurse may not give the mother information about the client. Keeping a log of all HIV-positive clients violates client confidentiality.

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to have his child declared legally incompetent. Which response by the nurse is most therapeutic?

"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." The client is temporarily unable to make decisions about health care and safety. After receiving emergency care and treatment, the client will probably be able to safely manage daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting civil rights. A guardian doesn't assume financial responsibility.

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first?

Document findings on the woman's medical record, and continue to monitor labor progress. The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or oxygen, as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean birth.