Review1

A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.

- "Dress the child in a shirt and knee socks under the straps." - "Lightly massage the skin under the straps daily." - "Place the diaper under the straps." =Regularly assess skin; skirt and knee socks; avoid lotions and powders; lightly massage the skin; 1 diaper at a time; apply diapers underneath the straps

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has reinforced discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective?

- "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." =Tablets are heat and light sensitive; take up to 3 pills in a 15-minute period; avoid fatal drug interactions; headache may occur

The nurse is reinforcing teaching for a client who developed pulmonary embolism after a scheduled surgical procedure and has a new prescription for warfarin. The client has no previous history of pulmonary embolism. Which of the following statements by the client would require follow-up? Select all that apply.

- "I will place small rugs on my wood floors to cushion a fall." - "I will take a baby aspirin if I experience mild chest pain." = Clients are taught interventions to prevent injury. Avoid aspirin, NSAIDs, and alcohol when taking warfarin

The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?

- "I will use the sliding scale to determine my NPH dose 4 times a day." =NPH is an intermediate-acting insulin with a duration of 12-18 hours and typically prescribed twice a day

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?

- "I've had the stomach flu for the past couple of days." =Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy

A client with a brain tumor is admitted or surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response?

- "It prevents seizure development." =Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors.

The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?

- "Night fears are common at this age. Look under the bed with your child." =Preschool children (age 3-5) are magical thinkers. It is appropriate for parents to acknowledge the child's fears.

The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement?

- "There is a red rash on my abdomen." =Sulfamethoxazole/trimethoprim (Bactrim, sulfa) is a common cause of drug allergy that manifests as fever, rash, and itching. Treating potential rash are the priority over management of expected symptoms for a known diagnosis

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?

- 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk =Iron supplements (eg, oral iron drops, iron-fortified formula) is usually needed by preterm infants at an earlier age (2-3 months)

The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply

- Anticipate ear pain and give acetaminophen as needed - Educate parents to expect the child to develop bad breath postoperatively - Notify the health care provider about frequent, increased swallowing =Postoperative tonsillectomy interventions include close observation for signs of bleeding (eg, frequent swallowing) as well as avoidance of routine oral suctioning and the use of straws. Expected findings include white, fluid-filled exudate in the throat with halitosis, low-grade fever, and referred ear pain.

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.

- Client with iron deficiency anemia takes iron supplements with milk - Client taking metronidazole mentions going to a wine-tasting party tonight - Client with closed-angle glaucoma takes over-the-counter diphenhydramine (Benadryl) for a clod =Clients taking metronidazole (Flagyl) should avoid alcohol. Those with glaucoma or urinary retention should avoid anticholinergic drugs. Oral iron is better absorbed on an empty stomach and with vitamin C. Phenazopyridine (Pyridium) will turn urine an orange-red color.

The practical nurse is assisting the registered nurse during a physical assessment of a 10-year-old client. Which actions do the practical nurse anticipate during the assessment? Select all that apply.

- Conduct a head-to-toe assessment in the same sequence as an adult assessment - Explain the purpose of the examination equipment and any procedures to the client - Offer the client a gown and allow the client to keep the underwear on during the examination - Use correct anatomical terminology while teaching the client about self-care =When performing a physical examination of a school-aged child, the nurse should conduct a head-to-toe assessment in the same sequence as an adult assessment, explain the purpose of the examination equipment and any procedures, use correct anatomical terminology, and promote privacy.

The nurse is reviewing recommended dietary modifications with a client with celiac disease. Which of the following menu selections by the client would indicate a correct understanding of the teaching? Select all that apply.

- Corn tortilla tacos with ground beef and cheese - Grilled chicken, backed potato, and strawberry yogurt - Rice noodles with chicken and broccoli =Celiac disease is an autoimmune disorder in which a client cannot tolerate gluten, a protein found in barley, rye, and wheat. Meats, fruits, vegetables, certain grains (eg, rice), and dairy products that contain no additives are gluten free and allowed in the diet.

The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification?

- Cyclobenzaprine for muscle spasms in a client with hepatitis =Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the body, which leads to toxicity and serious adverse effects.

The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?

- Discuss the procedure with the client using simple diagrams with correct anatomical terminology =During preprocedural education, the nurse should use developmentally appropriate methods of teaching. Using simple diagrams with correct anatomical terminology appropriately meets the psychosocial (ie, sense of industry) and cognitive needs (ie, concrete thinking) of school-aged children.

A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m3 (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine?

- Family's readiness for change =Before initiating a treatment program that requires a client and family to make major lifestyle and behavior changes, the nurse needs to assess readiness for change. Motivation and a desire for change are the keys to successful weight loss.

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply. EXHIBIT Viral signs Temperature 98.4 F BP 124/78 HR 46/min Resp 22/min

- Heparin subq injection - Lisinopril PO =Meds that decrese HR should be withheld in clients with bradycardia. Beta blockers such as metoprolol and timolol (including eye drops) and some CCB (eg, diltiazem, verapamil) shouldn't be given

The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects?

- Loss of appetite and restlessness =Anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential

The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate?

- Measure and document the size and location of the markings =The affected areas are usually bluish gray and may be misidentified as bruising in future health care assessments. Proper documentation is essential to avoid misinterpretation of findings

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? EXHIBIT Aspirin: 81 mg PO, daily Clopidogrel: 75 mg PO, daily Metoprolol XL: 50 mg PO, daily Furosemide: 40 mg PO, twice daily Fish oil: 4 g PO, daily

- Muscle cramps in the legs =Nurses caring for clients receiving potassium-wasting diuretics (eg, furosemide) should monitor for and report signs of hypokalemia (eg, muscle cramps), as unmanaged hypokalemia may result in lethal complications. Bruising, a side effect of antiplatelet medications, and fatigue, a side effect of beta blockers, should be monitored, but are not lethal.

The nurse is caring for a 3-year-old client with Kawasaki disease who is receiving IV immunoglobulin (IVIG) therapy. The nurse understands that IVIG therapy is prescribed to

- Prevent cardiac complications =Kawasaki disease (KD) is an acute systemic vasculitis that can lead to dangerous coronary artery aneurysms. Intravenous immunoglobulin in combination with aspirin is the recommended first-line treatment for KD, with the goal of preventing cardiovascular complications.

The nurse is planning diversional activities for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which activity would be appropriate for the nurse to suggest for the client?

- Reading an age-appropriate book