Study set 15 for RN NCLEX (Kaplan)

The nurse assesses the newly-admitted client. Which data indicate the client is at risk for having a latex allergy? (Select all that apply.) 1. The client has an allergy to avocado. 2. The client received blood transfusions. 3. The client has a history of chronic bronchitis. 4. The client has undergone multiple surgeries. 5. The client is employed as a health care worker.

1) CORRECT - People with a food allergy to avocado are at increased risk for latex allergy. 2) INCORRECT - A history of blood transfusions may increase a client's risk for allergic transfusion reaction secondary to antibody formation. However, prior blood transfusions do not increase the risk for latex allergy. 3) INCORRECT - A history of asthma, not chronic bronchitis, increases a client's risk for latex allergy. 4) CORRECT - A client with a history of multiple surgical procedures is at increased risk for latex allergy. 5) CORRECT - Health care workers are at increased risk for latex allergy secondary to increased exposure to latex. *Think Like A Nurse: Clinical Decision Making* Most institutions are replacing latex products with nonlatex products whenever possible. The nurse is aware though true latex allergies resulting in anaphylaxis are not common and life-threatening. Every potential latex allergy is taken very seriously. Repeated exposure to latex is one risk factor. People with multiple existing allergies are at increased risk too, due to a hypervigilant immune response. The nurse is alert that allergies to apples, bananas, carrots, celery, kiwi, melons, papaya, and tomato are risk factors. The nurse needs to remember latex is found in gloves, syringes, vial stoppers, stethoscopes, IV tubing, catheters, tape, and other medical supplies and equipment. *Content Refresher* Latex allergy is a sensitivity reaction to certain proteins found in natural rubber latex. Triggers include exposure to latex through the skin, through inhalation, and through the blood. About 5% to 10% of health care workers have some form of latex allergy. Other people who are more at risk include those who have a defect in their bone marrow cells or a deformed bladder or urinary tract, and those who have had more than one surgery or a urinary catheter with a rubber tip. Additional factors include allergies; asthma; eczema; food allergies to bananas, avocados, kiwis, or chestnuts; rubber industry workers; and people who use condoms.

The nurse teaches an adolescent male client how to perform a testicular self-exam. Which client statement indicates to the nurse that the teaching was successful? 1. "I will perform the exam when I get out of the shower." 2. "I will remember to examine myself every 3 months." 3. "I will examine each testicle by gently rolling it between my middle and index fingers. 4. "I will remember the pea size lump on the side of my testicles is the epididymis."

1) CORRECT - The client should examine testicles monthly immediately after a bath or a shower, when scrotal skin is relaxed. 2) INCORRECT - The client should examine the testicles monthly. 3) INCORRECT - The client should examine each testicle by gently rolling it between thumb and fingers. 4) INCORRECT - The client should look and feel for any lumps, smooth, rounded masses, or any change in the size, shape, or consistency of the testes. Any lump or swelling should be reported to the health care provider as soon as possible. *Think Like A Nurse: Clinical Decision Making* Self-assessment screenings are encouraged to check for signs and symptoms of testicular cancer in men, breast cancer in men and women, and skin cancer in men and women. Self-assessment screenings should be performed on a regular schedule. For self-assessment to be effective, clients must be familiar with their own anatomy and body. This familiarity is what allows the client to note new or suspicious findings that lead to early diagnosis, treatment, and survival. New findings should be brought to the health care provider's attention for monitoring, testing, or further steps. *Content Refresher* Testicular cancer is the most common type of cancer in males between ages 15 and 44. Risk factors include an undescended testis, orchitis, human immunodeficiency virus (HIV) infection, maternal exposure to exogenous estrogen, testicular cancer in the contralateral testis, and family history of testicular cancer. The client with testicular cancer may notice a painless lump in the scrotum or scrotal swelling, or report a dull ache or a feeling of heaviness in the lower abdomen, perianal area, or scrotum. The scrotal mass is usually nontender and firm. Diagnostic studies include an ultrasound of the testicle and blood specimens for laboratory testing. A CT scan of the abdomen and pelvis and chest x-ray are performed to detect metastasis.

The nurse prepares to insert an indwelling urinary catheter into a male client. Which actions will the nurse implement? (Select all that apply.) 1. Select an 18 French size catheter. 2. Retract and maintain retraction of foreskin. 3. Hold penis perpendicular to body. 4. Use sterile technique on insertion. 5. Insert catheter 2 to 3 inches into urethra.

1) CORRECT - The general size of an indwelling catheter for men is between 16 and 18 French. 2) INCORRECT - The foreskin should be replaced to prevent paraphimosis. 3) CORRECT - Holding the penis perpendicular to the body straightens the urethra for easier insertion. 4) CORRECT - Sterile technique should be used to prevent an infection. 5) INCORRECT - The catheter should be inserted 6 to 7 inches in the male client to reach the bladder. *Think Like a Nurse: Clinical Decision-Making* Insertion of an indwelling urinary catheter is a sterile procedure. The size of the catheter for a male client should be between 16 to 18 French. The penis should be held in a position that is perpendicular to the abdomen. This is done to straighten the urethra for catheter insertion. The foreskin should be replaced after retraction to prevent the development of paraphimosis. The catheter should be inserted 6 to 7 inches to reach the bladder. Inserting the catheter 2 to 3 inches is appropriate for a female client. *Content Refresher* Urinary catheterization, a routine medical procedure, facilitates direct drainage of the urinary bladder. It may be used for diagnostic purposes or therapeutically. Explain the procedure, benefits, risks, complications, and alternatives to the client. Position the client supine with the knees flexed and uncover the genitalia. Be sure to follow aseptic technique to avoid healthcare-associated infection (HAI).

The nurse provides care for a client who is scheduled to receive spinal anesthesia. It is most important for the nurse to take which action when providing care to this client? 1. Ensure that the client is adequately hydrated before the procedure. 2. Assess for allergies to iodine. 3. Ensure that the client does not eat for 12 hours before the procedure. 4. Determine the specific gravity of the client's urine.

1) CORRECT - This addresses the circulatory concern of hypotension. Spinal anesthesia is associated with hypotension. Adequate fluid hydration is key to prevent hypotension and hypotension-related injury. 2) INCORRECT - Iodine preparations are not used in spinal anesthesia. 3) INCORRECT - This is theoretically not necessary for spinal anesthesia, as the client will not be unconscious and the gag reflex will not be inhibited. However, situations can arise that require general anesthesia or sedation. Therefore, clients may be NPO prior to spinal anesthesia, but this is not the most important nursing action specifically related to the anesthesia. 4) INCORRECT - This assessment is not necessary for spinal anesthesia. *Think Like a Nurse: Clinical Decision-Making* The nurse needs to be aware of the expected effects and adverse effects of all medications prescribed for a client, including anesthesia. Because the client is prescribed to receive spinal anesthesia, adequate hydration is necessary to prevent the development of hypotension. The reason for the action is because anesthetic agents in the spinal canal irritate nerve roots, many of which help control blood pressure. Preventative measures should be taken before the anesthesia is provided. *Content Refresher* Regional anesthesia blocks transmission of nerve impulses in a specific area. Spinal anesthesia is a type of regional anesthesia. When a client is receiving spinal anesthesia, the nurse needs to monitor vital signs, being especially alert to possible hypotension and respiratory paralysis.

The nurse provides care for a client diagnosed with moderate flail chest. Which interventions will the nurse anticipate including on the care plan? (Select all that apply.) 1. Monitor client 's vital signs. 2. Maintain closed-chest drainage system. 3. Administer pain medication. 4. Maintain mechanical ventilation. 5. Monitor arterial blood gases (ABGs).

1) CORRECT - Vital signs need to be assessed frequently to determine if the client is experiencing shock. The nurse needs to anticipate including this intervention on the care plan. 2) INCORRECT - A closed-chest drainage system is typically not used with the diagnosis of flail chest. The nurse should not anticipate this intervention being included on the client 's care plan. 3) CORRECT - Flail chest is caused by blunt chest trauma and is extremely painful. The nurse needs to anticipate that administering pain medications will be included on the client 's care plan. 4) CORRECT - Mechanical ventilation helps to maintain adequate gas exchange. The nurse needs to anticipate including this intervention on the care plan. 5) CORRECT - Monitoring ABGs is essential for it assesses for hypoxemia and hypercapnia. The nurse needs to anticipate that this intervention will be included on the care plan. *Think Like a Nurse: Clinical Decision-Making* Nursing care for the client diagnosed with flail chest is complex. Aggressive pain management is essential to decrease the discomfort associated with chest movement and allow for effective ventilation. An inability to effectively cough due to pain causes impaired airway clearance, which leads to retention of pulmonary secretions and atelectasis. Oropharyngeal suctioning may be needed and deep breathing is essential. Hypoventilation causes retention of carbon dioxide which, in turn, leads to respiratory acidosis. Endotracheal intubation and mechanical ventilation may be necessary. Metabolic acidosis also may develop due to inadequate tissue perfusion. Prioritize airway, breathing, and circulation. Monitor the client 's oxygenation status, including physical assessment findings, pulse oximetry readings, and arterial blood gas measurements. Careful monitoring of urine output and electrolyte balance is also required. *Content Refresher* Flail chest results from fracture of multiple adjacent ribs, thus causing the chest wall to become unstable. Paradoxical movement occurs during breathing (i.e. the affected side goes in with inspiration and out during expiration) and ventilations become inadequate. Administer supplemental oxygen. Administer prescribed analgesia to help promote adequate respiration. Endotracheal intubation and mechanical ventilation may be necessary. With time, the lung parenchyma and fractured ribs heal, but surgery may be necessary to repair traumatic injuries.

The nurse provides care to a client who is prescribed diphenhydramine. Which client conditions cause the nurse to question the prescription? (Select all that apply.) 1. Closed-angle glaucoma. 2. Diarrhea. 3. Urinary retention. 4. Peptic ulcer. 5. Nausea. 6. Small bowel obstruction.

1) CORRECT — Diphenhydramine is an antihistamine with anti-cholinergic effects. It is contraindicated in closed-angle glaucoma, as the anti-cholinergic effects will increase intra-ocular pressure. 2) INCORRECT— There is no contraindication to administering diphenhydramine for a client with diarrhea. The anti-cholinergic effects may reduce the diarrhea. 3) CORRECT — Diphenhydramine should not be used in clients with urinary retention, as the anti-cholinergic effects will worsen the retention. 4) CORRECT — Diphenhydramine should be avoided in clients with peptic ulcer disease as it increases the risk for bleeding. 5) INCORRECT— There is no contraindication to diphenhydramine use in clients with nausea. 6) CORRECT — Diphenhydramine should be avoided in clients with a small bowel obstruction, as the anti-cholinergic effects may contribute to the obstruction. *Think Like a Nurse: Clinical Decision-Making* The nurse must distinguish among a medication's therapeutic effects, side effects, and adverse effects. The nurse determines the medication's therapeutic effects based on the indications for administering the medication. Some drugs have unintended, beneficial side effects. However, adverse effects are always undesirable and may be life-threatening. Diphenhydramine blocks (antagonizes) histamine-1 receptors, which makes this medication useful for treating clients who are experiencing an allergic reaction. Diphenhydramine's anticholinergic action causes a side effect of drowsiness, which may be beneficial to clients who experience insomnia. The anticholinergic effects also may help with treatment of clients who experience diarrhea. Conversely, diphenhydramine may exacerbate constipation. The combination of antihistamine and anticholinergic effects may help reduce motion sickness for certain clients. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Perform appropriate client assessments and check for contraindications, including allergies, prior to administering medications. Verify the Rights of Medication Administration, which minimally include right client, right medication, right time, right dose, right route, right site, and right documentation. Educate the client about the medication, including indications for the medication's use. Diphenhydramine is a first-generation histamine receptor antagonist that is primarily used for treatment of clients who experience an allergic reaction. Contraindications include concurrent use of monoamine oxidase inhibitor (MAOI) medications and acute asthmatic attack. The expected outcome is that the client will demonstrate therapeutic effects of the medication without experiencing adverse effects.

The nurse provides care to a school-age client who is diagnosed with sickle cell anemia. Which statement by the client's parent indicates a need for further teaching? 1. "When my daughter says her legs hurt, I apply cold compresses to the areas where she's hurting." 2. "I try to keep my daughter away from people with infections." 3. "My daughter needs pain medicine around the clock when she hurts a lot." 4. "I encourage my daughter to drink a lot of water."

1) CORRECT — For the client who is diagnosed with sickle cell anemia, abnormally-shaped red blood cells become trapped in blood vessels and organs. Cold temperatures, including application of cold compresses or ice packs, will cause vasoconstriction and may further limit blood flow. 2) INCORRECT — Infection may trigger sickle cell crisis. Preventing exposure to individuals who have infections reduces the risk of infection transmission. 3) INCORRECT — To effectively control pain, analgesic medication should be administered at regular intervals as prescribed. Omitting medication doses or waiting until the pain becomes severe before taking analgesic medication is not advised. 4) INCORRECT — Triggers for sickle cell crisis include dehydration. Adequate hydration is essential to preventing sickle cell crisis. *Think Like A Nurse: Clinical Decision Making* Health promotion for the school-age client who is diagnosed with sickle cell anemia includes proper hand hygiene; vaccination against influenza, pneumonia, and meningitis; avoiding certain pets such as turtles, snakes, and lizards; not eating raw or unpasteurized milk or other dairy products; and antibiotic prophylaxis as ordered. Infection increases the oxygen demand of the body, which may trigger a sickle cell crisis. *Content Refresher* Sickle cell disease is a severe form of anemia in which a mutated form of hemoglobin distorts the red blood cells into a crescent shape at low oxygen levels. The nurse needs to educate the parents about promoting optimal oxygenation while providing adequate rest periods, hydration, nutrition, and pain management. In addition, routine immunizations are essential along with preventing life-threatening infections.

A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which findings cause the nurse to question the prescription of these medications? (Select all that apply.) 1. Client is attempting to become pregnant. 2. Client has a history of essential hypertension. 3. Client has a history of nonalcoholic fatty liver disease. 4. Client has chronic kidney disease. 5. Client gained 10 pounds over the past 3 months.

1) CORRECT — Pioglitazone is contraindicated in pregnancy and metformin must be used with caution. These medications should be questioned before providing to the client. 2) INCORRECT— Essential hypertension is not a contraindication for pioglitazone or metformin. 3) CORRECT — A history of liver disease contraindicates the use of pioglitazone and metformin. 4) CORRECT — A history of kidney disease or renal malfunction contraindicates the use of metformin. 5) INCORRECT— Recent weight gain is not a contraindication for pioglitazone or metformin. *Think Like a Nurse: Clinical Decision-Making* To prevent drug-to-drug interactions, medication reconciliation should be performed during admission and transfer and in response to any change in the client's condition. The nurse is also responsible for assessing prescribed medications during each shift and determining if there are any noted contraindications. When contraindications or drug-to-drug interactions are noted, the nurse questions the prescription. Noted contraindications for pioglitazone include symptomatic heart disease or a diagnosis of class III and IV heart failure. For clients who are pregnant or lactating, metformin should be used with caution. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Assess the client's medication history, including herbs, vitamins, and supplements. Perform appropriate client assessments and check for contraindications, including allergies, prior to administering medications. Provide client education regarding the medication. Verify the Rights of Medication Administration, which minimally include right client, right medication, right time, right dose, right route, right site, and right documentation. The medications pioglitazone and metformin are used to treat clients diagnosed with type 2 diabetes. Document the medication administration according to institutional policy. The expected outcome is that the client will demonstrate therapeutic effects of the medication without experiencing adverse effects.

A client returns for a follow-up appointment after treatment for renal calculi. Which instruction is most beneficial for the nurse to teach the client to prevent a recurrence of the health problem? 1. "Drink at least 3000 mL of fluid a day." 2. "Reduce the amount of dairy products and eggs in your diet." 3. "Increase the amount of whole grains and vegetables that you eat." 4. "Avoid foods that contain tyramine, such as wine and cheese."

1) CORRECT — Prevention of renal calculi includes ingesting between 3000-4000 mL of fluid per day. 2) INCORRECT— Reducing the intake of dairy products and eggs is helpful if the composition of the stones is known. This information is not provided. 3) INCORRECT— Dietary changes are helpful if the composition of the stones is known. This information is not provided. 4) INCORRECT— Foods containing tyramine should be avoided if taking a monoamine oxidase inhibitor medication, such as isocarboxazid, to treat depression. *Think Like A Nurse: Clinical Decision Making* Action to prevent the development of renal calculi includes ingesting large volumes of fluid each day. The fluid continually flushes the kidneys, preventing the build-up of toxins and byproducts of metabolism, which contribute to the development of stones. Dietary changes are applicable only if the composition of the renal calculi is known. *Content Refresher* In the kidney, urine normally contains substances that prevent the development of crystals. However, situations such as infections, concentrations of insoluble salts, and urinary stasis may cause stones to form. The nurse will suggest dietary modifications to prevent the development of stones. Increasing fluid intake to 3000 to 4000 mL per day will help to decrease the concentration of the insoluble salts responsible for the formation of renal stones, as well as preventing renal infections. Medications can be prescribed to reduce the formation of renal stones; appropriate teaching is important.

The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). Which clinical manifestation does the nurse anticipate when completing a physical assessment? 1. Red rash. 2. Xerostomia. 3. Erythema migrans. 4. Dysphagia.

1) CORRECT — The nurse can anticipate seeing a red rash, especially on the face, for this is a clinical manifestation associated with systemic lupus erythematosus. 2) INCORRECT — Ulcers in the mouth is a clinical manifestation of systemic lupus erythematosus, not xerostomia or dry mouth. 3) INCORRECT — Erythema migrans is a flat red lesion associated with lyme disease, not systemic lupus erythematosus. 4) INCORRECT — Dysphagia is a clinical manifestation associated with scleroderma, not systemic lupus erythematosus. *Think Like A Nurse: Clinical Decision Making* The nurse understands the client with systemic lupus erythematosus (SLE) experiences many physical and lifestyle changes. The nurse understands the importance of scheduling client care activities to minimize fatigue; encouraging exercise, as tolerated; assisting the client to maintain an optimal weight; teaching the client to recognize signs and symptoms of infection; and recognizing signs and symptoms of depression. The nurse should assist the client in identifying family and community support services, as needed. *Content Refresher* Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease that affects the skin, joints, mucous membranes, heart, lungs, kidneys, nervous system, and all the blood cell lines. The cause of SLE is unknown, but abnormal immune function results in the formation of antibodies directed against various components of the human body. Common symptoms include painful joints, fevers, rashes caused by sun exposure, hair loss, loss of circulation in toes or fingers, swelling in the legs, ulcers inside the mouth, swollen glands, and extreme tiredness.

The nurse provides care for a client who has undergone the repair of a gynecologic fistula. Which interventions will the nurse include in the client's immediate post-operative nursing care? (Select all that apply.) 1. Maintain urinary catheter. 2. Warm sitz baths. 3. Perineal hygiene. 4. Bladder training. 5. Increase oral fluids.

1) CORRECT — The urinary catheter usually stays in place for 7 to 10 days to avoid stress on the repaired areas and to prevent infection. 2) CORRECT — Sitz baths should be taken three to four times each day to promote healing. 3) CORRECT — Perineal hygiene is of great importance to reduce the risk of infection. 4) INCORRECT - Bladder training is not done until several days after surgery, after the urinary catheter is removed. 5) CORRECT — Increasing oral fluids helps increase urine output to keep the urinary catheter irrigated. *Think Like a Nurse: Clinical Decision-Making* Fistulas of the gynecologic organs are a potential complication of gynecologic malignancy. They may occur as a consequence of advanced-stage disease or surgical or radiation therapy. For example, in vesicovaginal fistula, the abnormal communication between the urinary bladder and the vagina results in the continuous involuntary discharge of urine into the vagina. The nurse anticipates the need to assist the client with perineal hygiene, pain management, and body image disturbance. Depending on the extent of the fistula, surgery might be required. The nurse reinforces routine pre-operative and post-operative teaching. *Content Refresher* Fistulas may develop between the client's vagina and bladder, urethra, ureter, or rectum. Most urinary tract fistulas are caused by gynecologic procedures. Childbirth and disease processes, such as cancer, may also cause fistulas. While small fistulas may heal on their own, others may require surgical repair. In addition to the post-operative care listed above, the client's first stool after bowel surgery may be delayed to prevent wound contamination and subsequent infection. If the client's indwelling urinary catheter requires irrigation because of clots, strict asepsis during irrigation is vital to prevent infection.

The nurse teaches a client how to obtain accurate blood pressure (BP) measurements at home. Which factors will the nurse include as causing a false high BP reading? (Select all that apply.) 1. Using a cuff that is too short. 2. Repeating assessments too quickly. 3. Positioning the brachial artery below the heart. 4. Using a cuff that is too wide. 5. Deflating the cuff too quickly.

1) CORRECT- A cuff that is too short may cause a false high reading. 2) CORRECT- Repeating assessments too quickly may cause a false high systolic reading. 3) CORRECT- If the arm is positioned below heart level, it may cause false high reading. 4) INCORRECT- A cuff that is too wide may cause a false low reading. 5) CORRECT- Deflating the cuff too quickly may cause a false high diastolic reading, as the last sound may be missed. *Think Like A Nurse: Clinical Decision Making* The nurse should ensure that the client has an appropriately sized blood pressure (BP) cuff. A cuff that is too short may cause a falsely elevated measurement. The client should place the arm at the level of the heart. If the arm is below the level of the heart, the reading will be falsely elevated. The client should release the pressure in the cuff slowly, as releasing it too fast may cause a falsely elevated diastolic measurement since the last sound may be missed. *Content Refresher* To obtain a blood pressure (BP), the client must gather a stethoscope and BP cuff with a mercury or aneroid sphygmomanometer or automated oscillometric BP device. The client needs to be in an upright position. Avoid obtaining a BP in the same arm in which there is an arteriovenous fistula, where lymphedema exists, or after lymph node dissection for treatment of breast cancer. The client needs to avoid consumption of caffeinated products, smoking, or exercise for at least 30 minutes prior to obtaining the BP measurement.

The nurse provides care to an older adult client with metastatic colon cancer. Which difference in pain tolerance because of the client's age will the nurse expect to assess? 1. Decreased. 2. Unchanged. 3. Increased. 4. No effect.

1) CORRECT- Aging lowers pain tolerance because of diminished adaptive capacity. 2) INCORRECT - Aging is proven to adversely affect pain tolerance. 3) INCORRECT - Pain tolerance is affected adversely by aging. 4) INCORRECT - Pain tolerance is affected by aging. *Think Like A Nurse: Clinical Decision Making* Before assessing this client's pain level, the nurse should mentally review the client's developmental and expected age-related changes. As the body ages, certain areas and receptors become altered. These changes will cause assessment findings to be different from those seen in a younger client. When assessing an older client for pain, the level of pain may be ranked higher or lower than what might be expected or seen in someone of a lesser age. The nurse needs to remember that pain assessment on an older adult client is subject to age-related body changes. The nurse should consider non-verbal communication and evaluation of vital signs when performing a pain assessment on an older adult client. *Content Refresher* Pain is an unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. Pain has a physiological component. Reactions to pain are considered "psychosocial" and Maslow states that physiological needs must be met first. Pain is a lower priority than the physiological requirements: oxygen, fluid, nutrition, temperature, elimination, shelter, rest, and sex. Pain has a biologically important protective function within the body's defense system, producing a reflexive retraction from the painful stimulus, tendencies to protect the affected body part while it heals, and avoidance of the harmful situation in the future. Acute pain can last a moment to about 6 months and chronic pain is an episode that lasts for 6 months or longer.

The nurse provides care for a client who is scheduled for a dipyridamole thallium-201 scan. Which food item does the nurse ensure that the client has avoided prior to the scan? 1. Caffeine. 2. Milk. 3. Fatty foods. 4. Sugar.

1) CORRECT- Caffeine intake up to 24 hours before the scan can interfere with the medication used in the stress test and the heart effects being measured. 2) INCORRECT - There is no need to avoid milk, as it does not affect the heart. 3) INCORRECT - There is no need to avoid fatty foods, as they do not immediately affect perfusion of the heart. 4) INCORRECT - There is no need to avoid sugar, as it does not immediately affect perfusion of the heart. *Think Like A Nurse: Clinical Decision Making* One role of the nurse is to ensure that a client is thoroughly prepared for a prescribed diagnostic test. At times, the client will need to have nothing by mouth after midnight, withhold prescribed medications, or avoid a specific food or substance. In this case, the client needs to avoid ingesting caffeine for 24 hours before the scheduled test. A dipyridamole thallium-201 scan uses dipyridamole to cause cardiac effects normally seen when the heart is stressed by exercise. Caffeine adversely affects dipyridamole and should be avoided to ensure the test results are accurate and valid. *Content Refresher* Intravenous dipyridamole, adenosine, or dobutamine are drugs that may be given to a client who is unable to perform physical exercise. These drugs mimic the effect of exercise on the heart, and an echocardiogram is performed to detect wall motion abnormalities. Prior to the procedure, explain the procedure to the client and obtain IV access. Monitor the client's vital signs before, during, and after the procedure. During the procedure, assess the client for chest pain, shortness of breath, dizziness, and nausea.

The nurse provides care to a client diagnosed with hydronephrosis secondary to renal calculi. After surgical removal of the calculi, post-obstructive diuresis occurs. Initial client assessment and monitoring include which nursing action? 1. Monitor daily serum electrolytes. 2. Assess urine output each shift. 3. Measure vital signs every hour. 4. Obtain weekly weight measurements.

1) CORRECT- Diuresis may cause electrolyte imbalances. Serum electrolytes must be monitored daily, as electrolyte imbalances may lead to serious complications, including cardiovascular events. 2) INCORRECT - To allow for effective assessment and monitoring of renal function, urine output should initially be assessed every hour, not each shift. 3) INCORRECT - For the first 4 hours following the procedure, vital signs should measured every 30 minutes. Vital signs should then be measured every 2 hours. 4) INCORRECT - Effective assessment and monitoring of the client's fluid volume status requires daily assessment of the client's weight. *Think Like A Nurse: Clinical Decision Making* Relief of urinary tract obstruction, which may occur after the removal of a renal calculi, can lead to a post-obstructive diuresis. Diuresis is increased or excessive production of urine. It may cause fluid and electrolyte imbalances. The nurse should closely monitor this client's urine output and assess for symptoms of electrolyte imbalance. Any data indicating an electrolyte imbalance should be reported to the health care provider for further evaluation and treatment. *Content Refresher* When caring for a client who is postoperative for surgical removal of renal calculi, the nurse should assess pain level and determine need for analgesia. Assess electrolytes and renal diagnostic studies. Assess amount of urinary output, color, and any urinary symptoms, such as burning, frequency, or urgency. Administer IV fluids and medications per provider prescriptions. Review post-procedure instructions including fluids, pain management, straining urine, and mobility. Emphasize need for follow-up. Reinforce about diet modifications needed after stone analysis is finished.

A client recovering from surgery is alert and stable but requests pain medication. Vital signs are BP 98/62 mm Hg and pulse 120 beat/min. Which response is the best for the nurse to make to the nursing assistive personnel (NAP) who questions giving pain medication because of a low blood pressure? 1. "The rapid heartbeat related to pain causes hypotension. " 2. "You don 't need to worry about that. " 3. "I think there is another client light on. " 4. "Did you check on the client in the next bed?"

1) CORRECT— Explaining how the rapid heart rate affects the blood pressure addresses the NAP 's question. Pain medication may cause the heart rate to slow and conversely increase the client 's blood pressure. 2) INCORRECT - Saying that the client 's blood pressure is not something that the NAP should worry about limits communication and does not support a caring environment for the client. 3) INCORRECT - Identifying another client light does not answer the NAP 's question. The nurse should explain the reason for the client 's low blood pressure in relation to the rapid heart rate and the impact pain medication will have on both. 4) INCORRECT - Evasiveness does not promote trust. The nurse should answer the NAP 's question. *Think Like A Nurse: Clinical Decision Making* Before responding to nursing assistive personnel (NAP), the nurse should recall that pain can adversely affect physiological processes. A person in pain can have rapid respirations. Unrelieved pain can cause the heart rate to increase. The increase in heart rate causes the blood pressure to decrease as an accommodation to the rapid heart rate. When pain medication is provided, the client's respirations will slow, the heart rate will decrease, and the blood pressure will rebound to near normal. It is important to explain this process to NAP so that future reports of pain will not be questioned and decisions will not be made solely on assessment of vital signs. *Content Refresher* Pain is an unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. Acute pain can last a moment to about 6 months, and chronic pain is an episode that lasts for 6 months or longer. Clinical manifestations associated with pain include increased blood pressure, increased heart rate, rapid respirations, increased perspiration, increased muscle tension, increased neuromuscular activity, nausea, vomiting, apprehension, anxiety, and irritability. The goal when managing pain is to identify and treat the underlying medical condition while the client verbalizes a decrease in pain while utilizing pharmacological and/or non-pharmacological interventions.

A client diagnosed with multiple myeloma experiences persistent lower back pain. In which position will the nurse place this client? 1. In bed with the head elevated 45 degrees and hips and knees moderately flexed. 2. In bed with the head elevated 60 degrees and arms resting on the overbed table. 3. In bed with the head of the bed elevated 15 degrees and legs extended. 4. In a straight-backed chair with feet resting on the floor.

1) CORRECT— Flexing the knees relieves pressure on the sciatic nerve and disk. 2) INCORRECT - Sitting in bed with the arms on the overbed table describes the orthopnea position. This position would put pressure on the lumbosacral region. 3) INCORRECT - Lying in bed with the head of the bed elevated 15 degrees and legs extended places tension on the lumbar spine. The knees should be flexed for comfort. 4) INCORRECT - Sitting in a straight-back chair would be uncomfortable. The knees should be higher than the hips for comfort. This client should be encouraged to make frequent position changes to include lying, sitting, and walking. *Think Like A Nurse: Clinical Decision Making* To maximize comfort and reduce pain, the client with low back pain is encouraged to sleep on the side with a pillow between the knees. The client can also sleep on the back with a pillow under the knees and a small pillow under the small of the back. The client is advised not to sleep on the stomach. During waking hours, the client is advised to sit as little as possible, and only for short periods (10 to 15 minutes). *Content Refresher* Multiple myeloma is a form of cancerof the bone marrow related to lymphoma and leukemia. It is characterized by swellings, malformations, and fractures of various bones and accompanied by pain, anemia, and weight loss. Though it usually cannot be cured, treatments usually slow its progression. Clients may exhibit swelling and malformation around affected bones, anemia, fractures, weight loss, pain, anorexia, difficulty urinating, and fatigue. Assess for signs of infection and implement measures to reduce infection. Encourage hydration, provide adequate nutrition, monitor weight, and institute strict intake and output measurement. Monitor for fractures and administer prescribed medications for nausea and pain.

A female adolescent client learns about having had intercourse 3 weeks ago with a person who has syphilis. Which manifestation does the nurse expect to see if the client has contracted syphilis? 1. A papule-like lesion in the vaginal area. 2. An abnormal Pap smear. 3. A non-reactive blood serology test. 4. A cluster of painful blisters on the genital area.

1) CORRECT— In primary syphilis a chancre develops within 2 to 6 weeks. It appears at the point of entry and starts as small papule that develops into a painless ulcer. 2) INCORRECT - A Pap smear is a screening test for cancer of the cervix. 3) INCORRECT - A Venereal Disease Research Laboratory (VDRL) test is a blood test to detect syphilis, and becomes reactive 2 to 6 weeks after the primary infection. Syphilis is treated with antibiotics. 4) INCORRECT - Genital herpes is identified by the appearance of clusters of painful blisters. The infected client may have difficulty voiding and there may be a recurrence during times of stress, infection, or menses. *Think Like A Nurse: Clinical Decision Making* The nurse understands it is not unusual for an adolescent to engage in sexual experimentation; however, there is a risk of contracting a sexually transmitted infection (STI). Since the client learned of exposure to such an illness, the nurse needs to consider the characteristic signs of the infection. For syphilis, the nurse should assess the genital region for the presence of a chancre sore. The signs for other STIs will depend upon the infecting organism. It is important for the nurse to interact with the client therapeutically and to present a non-judgmental attitude with the client. The scenario presents an excellent opportunity for the nurse to provide education. *Content Refresher* Syphilis is a bacterial infection that is transmitted through sexual contact. If left untreated, it progresses through three stages (primary, secondary, and tertiary syphilis). There is also a latent stage when no signs or symptoms of the infection are present. Symptoms of primary syphilis include one or more chancres at the infection site, whereas secondary syphilis is manifested by a skin rash, mucocutaneous lesions, and lymphadenopathy. Individuals with tertiary syphilis exhibit cardiac symptoms, gummatous lesions, tabes dorsalis, and general paresis. Intravenous penicillin is used to treat individuals during all phases of the disease. All sexual partners should also be treated. Ongoing follow up for testing and counseling to prevent pregnancy and STIs improves outcomes.

The nurse provides care for a client reporting anorexia, belching, heartburn, and a sour taste in the mouth. The health care provider (HCP) prescribes a number of tests. Which test does the nurse recognize as being time sensitive when scheduling? 1. Upper gastrointestinal (GI) flouroscopy. 2. Colonoscopy. 3. Ultrasound of the abdominal region. 4. Electrocardiogram (EKG)

1) CORRECT— The barium radiography that is used in an upper gastrointestinal flouroscopy can interfere with other tests; therefore, this test is the most time sensitive of the tests presented. It may interfere with x-rays, ultrasound, proctoscopy, colonoscopy, and any other test using iodine. Therefore, the upper GI flouroscopy is scheduled after any of these tests. 2) INCORRECT - A colonoscopy should be performed before the upper GI endoscopy to ensure that the colon is thoroughly cleansed. 3) INCORRECT - The barium used in the upper GI endoscopy interferes with the transmission of sound waves and should be scheduled after the abdominal ultrasound. 4) INCORRECT - An EKG is not affected by other tests. *Think Like a Nurse: Clinical Decision-Making* When scheduling diagnostic tests, the nurse should be aware of any planning or preparation needed so that the results are valid. The nurse needs to apply knowledge of the individual tests in order to schedule the sequence correctly. The goal is to arrange the tests so that one does not interfere with the remaining testing. When analyzing the list of diagnostic tests in this scenario, the one with the largest implication for planning is the upper gastrointestinal series. This test uses barium as a contrast medium, which interferes with direct visualization of intestinal structures and mutes sound waves. Because of this, the abdominal ultrasound and colonoscopy should be scheduled and completed before the upper gastrointestinal series. *Content Refresher* Several conditions are diagnosed with an upper GI series including diverticula, ulcers, esophageal varices, hiatal hernia, polyps, and tumors of the esophagus, stomach, and duodenum. The nurse should prepare the client for the procedure, providing client/family with information about what to expect. Inform client to abstain from food, fluids, gum, or tobacco products for 8 to 12 hours before the test. Provide client/family with teaching about need to increase fluids and fiber-rich foods to facilitate passage of barium after the test. Other diagnostic tests can be scheduled prior to the upper GI series.

The home health nurse visits a home occupied by two parents, their preschool-age child, and an older adult grandparent who has been living with them for 2 months. The nurse visits to assess the grandparent after treatment for a fall and broken arm. Which statement by the child most concerns the nurse? 1. "My grandparent 's cat got a cut on his stomach and will not come out of the corner. Can you fix it? " 2. "Sometimes when I drink milk, I throw up. " 3. "We never go anywhere anymore since my grandparent moved in with us. " 4. "I want to be a doctor when I grow up and take care of hurt children and animals all over the world. "

1) CORRECT— The cat 's injuries and behaviors may indicate pet abuse, which can be a sign of other abuse going on in the home. This home has three categories of people at risk for abuse: child, spouse, and older adult. The grandparent was treated for injuries that might have been related to abuse. The nurse should further assess the situation for indicators of abuse. 2) INCORRECT— This may indicate a lactose allergy and requires further investigation; however, this does not pose a risk of immediate physical harm. This is not the priority concern. 3) INCORRECT— This may indicate sadness or anger on the part of the child and requires further investigation; however, this does not pose a risk of immediate physical harm. This is not the priority concern. 4) INCORRECT— This is not a concern. *Think Like A Nurse: Clinical Decision Making* Older adults are vulnerable and may be at risk for abuse. The nurse should be aware of various forms of abuse, including financial, physical, emotional, and sexual. For clients who are suspected of being abuse victims, a detailed medical evaluation is necessary as signs and symptoms of medical and psychiatric conditions may mimic manifestations of abuse. Signs of abuse may include specific patterns of injury. Interviewing clients and caregivers separately is helpful. Evaluation for possible abuse should include assessment of cognitive function. *Content Refresher* Most elder abuse is inflicted by caregivers and family members. Symptoms of elder abuse include lacerations, bruises, fractures, burns, pressure injuries, pain, insomnia, decreased nutrition and hydration, exacerbation of pre-existing health conditions, anxiety, fear, depression, and social isolation. Evaluate reports of injury as described by both the older adult client and the caregiver. Tactfully ask if the older adult client feels threatened. Assess the elder client 's height and weight, and compare the actual body mass index (BMI) to the norm. Ask about financial status and management of finances. All suspected elder abuse should be reported to Adult Protective Services for assessment, treatment, and referral.

An adult male client is referred to the occupational nurse. The client tells the nurse of feeling tired all of the time and having headaches unrelieved by 2 tablets of acetaminophen. Which action is most important for the nurse to take? 1. Obtain the client's blood pressure. 2. Schedule an appointment with the nephrologist. 3. Ask when the client last saw a health care provider. 4. Refer the client to a local health care provider.

1) CORRECT— The client's age, gender, and clinical manifestations are reflective of hypertension. Fatigue may indicate early development of kidney disease. The most important nursing action is to take the blood pressure and then refer the client to the health care provider. 2) INCORRECT - Before that referral to a specialist more data is required. 3) INCORRECT - While this is an important question for the interview, the priority nursing action is to complete the assessment. 4) INCORRECT - The nurse completes the assessment before implementing a referral to the health care provider. *Think Like A Nurse: Clinical Decision Making* The nurse considers the client's symptoms and identifies them as potential indicators of hypertension. The nurse needs to recognize that the client first needs to be assessed for possible causes or contributing factors to the client's symptoms. In a non-emergent situation, the assessment of vital signs is appropriate. The nurse should measure the client's blood pressure to determine if the client is hypertensive, which could be the cause of the headaches, and then plan care according to the finding. *Content Refresher* Hypertension refers to a persistent increase in systemic arterial blood pressure. Criteria for Stage 1 hypertension includes systolic blood pressure (SBP) of 140 to 159 mm Hg and/or diastolic blood pressure (DBP) of 90 to 99 mm Hg. Stage 2 hypertension criteria include SBP of 160 mm Hg or greater and/or DBP of 100 mm Hg or greater. Prehypertension is characterized by SBP of 120 to 139 mm Hg and/or DBP of 80 to 89 mm Hg. Initially, increased blood pressure may be the only overt sign of hypertension. With severe hypertension, secondary symptoms occur in response to increased cardiac workload, damage to blood vessels, or injury to specific organs. Such secondary symptoms may include dyspnea, dizziness, fatigue, and angina.

The public health nurse visits an Asian American client who receives directly-observed therapy for tuberculosis. Which nursing actions demonstrate cultural competence when providing care to this client? (Select all that apply.) 1. Understanding the differences between the client 's and the nurse 's cultures. 2. Ensuring that the client understands why tuberculosis treatment requires Western medicine. 3. Understanding that different cultures hold different beliefs about health and disease. 4. Accepting the stereotypes based on the client 's culture. 5. Respecting the client 's values and beliefs.

1) CORRECT—A culturally competent nurse understands the differences between the nurse 's own culture and the culture of the client. 2) CORRECT—The nurse who demonstrates cultural competence is able to recognize that the client may have different views about Western medicine and may not understand the importance of drug therapy in treating tuberculosis or may want to utilize therapies used in their own culture. 3) CORRECT—A culturally competent nurse understands that different cultures hold different beliefs about health and disease, including the cause of disease. 4) INCORRECT - The nurse who displays cultural competency does not stereotype a client based on their culture. 5) CORRECT—A culturally competent nurse should respect the individual client 's culture and beliefs. *Think Like a Nurse: Clinical Decision-Making* Cultural competence includes recognizing that individuals and groups differ in terms of their beliefs, perceptions, and values. Moreover, cultural competence includes understanding that within a specific cultural group, not all members necessarily think alike. Presuming an Asian American client does not understand the relevance of Western medicine in the treatment of tuberculosis may constitute stereotyping. Rather than making assumptions based on ethnicity, the nurse 's role is to tactfully explore the client 's beliefs and preferences. The nurse then advocates for incorporating the client 's preferences into the plan of care whenever it is possible to safely do so. If the nurse seeks first to understand, then to teach and care, clients are often happy to explain their perspective. *Content Refresher* Complete a cultural assessment. This includes an ethnohistory (cultural orientation and background), family structure, education, communication patterns (e.g., eye contact), nutritional practices, and spiritual and religious beliefs. Be open to various cultural traditions, values, and beliefs when providing care. Establish a trusting, respectful nurse-client relationship. Use interpreters as needed to promote effective communication. Observe verbal and nonverbal communication. Use culturally sensitive language. Incorporate cultural practices when providing care. With the client 's permission, include family members and loved ones in decision making and caregiving tasks if congruent with cultural values and beliefs.

The intensive care unit (ICU) nurse receives a phone call stating a client diagnosed with a head trauma must be admitted. There are no empty beds. Which client is most stable and eligible for a transfer to the step-down neurological unit? 1. A client with increased intracranial pressure (ICP) and a Glasgow Coma Scale of 8. 2. A client diagnosed with a cervical spinal injury 3 days ago with halo traction. 3. A client diagnosed with a cerebrovascular accident (CVA) and subdural hematoma 1 day ago. 4. A client with increased intracranial pressure (ICP) and a tracheostomy.

1) INCORRECT - A client with an increased ICP and a Glasgow Coma Scale of 8 or less (indicates coma) are indications for ICP monitoring. This client should not be transferred. 2) CORRECT - The halo traction provides immobilization and allows early ambulation. This client can be safely transferred. 3) INCORRECT - A second stroke may occur up to 72 hours after the first one. A hematoma adds a complication that needs to be resolved before transferring this client. 4) INCORRECT - This client requires close monitoring and cannot be transferred. *Think Like a Nurse: Clinical Decision-Making* When an intensive care unit reaches maximum capacity and a critically ill client requires admission to the unit, the nurse must think, "Which client on the unit is most clinically stable and can be safely transferred to a lesser level of care?" A client with increased intracranial pressure (ICP) requires continuous advanced monitoring. This specialized monitoring is not available in a lesser level of care. Additionally, the client with a stroke and subdural hematoma requires close monitoring for signs of neurologic deterioration associated with increased ICP. Halo traction stabilizes the cervical spine, protecting the spinal cord from injury. After the halo traction device is applied, if the client's condition remains stable, the client can ambulate and perform activities of daily living in a lesser level of care until ready for discharge. *Content Refresher* A closed head injury, usually caused by trauma, can lead to increased intracranial pressure. As swelling increases, cerebral blood flow is reduced and ischemia occurs. The body attempts to compensate by raising the blood pressure. However, as the condition progresses, the body loses its ability to autoregulate and the edematous mass causes increased pressure. Intracranial pressure can also be raised by an elevation in carbon dioxide levels, as well as a decrease in venous outflow. Use the Glasgow Coma Scale to assess level of consciousness. The client may have bradycardia, hypertension with a widened pulse pressure, and irregular breathing (known as the Cushing triad). The client may also have an unequal pupil response, weakness, slow or slurred speech, and seizures.

The nurse provides care for an infant. Which assessment finding indicates to the nurse that the infant is in pain? 1. Short attention span. 2. Increased oxygen saturation. 3. Hypotension. 4. Stiff posture.

1) INCORRECT - A short attention span is an assessment finding seen in older children and adolescents who are in pain, but not in infants. 2) INCORRECT - If an infant is in pain, the nurse would see a decrease, not an increase, in oxygen saturation. 3) INCORRECT - If an infant is in pain, the infant would experience hypertension, not hypotension. 4) CORRECT — Because infants cannot talk, the nurse needs to be aware of nonverbal signs of pain. A stiff posture is an assessment finding associated with infants who are in pain. *Think Like A Nurse: Clinical Decision Making* Assessment is an important function in nursing and is the first step in formulating a plan addressing the client's needs. The nurse who works with clients who do not possess the ability to verbalize needs, must be aware of other methods of client communication. An infant is unable to articulate the presence or location of pain. Because of this, the nurse needs to assess the infant's nonverbal behavior. In this particular scenario, a stiff posture is the infant's attempt to guard an area of discomfort and indicates the presence of pain. *Content Refresher* Pain is an unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. Pain has a physiological component while reactions to pain are considered psychosocial. The client in pain may exhibit increased blood pressure, rapid, irregular respirations, increased perspiration, increased muscle tension, increased neuromuscular activity, nausea, vomiting, and irritability. Indicators of pain will vary with the age of the client, and with the ability of the client to verbally communicate. Understanding about the non-verbal indicators of pain is important for the nurse to possess.

The nurse performs teaching for a client being discharged on dexamethasone 0.75 mg PO daily. Which statement by a client helps the nurse to determine teaching is successful? 1. "I will take my medication when I first get up in the morning. " 2. "I will take my medication with breakfast. " 3. "I will take my medication 3 hours after eating. " 4. "I will take my medication before I eat lunch."

1) INCORRECT - A steroid medication is to be taken with food at breakfast to prevent gastrointestinal upset. 2) CORRECT— Oral steroids have ulcerogenic properties and need to be administered with meals. If prescribed daily, they should be administered in the morning with breakfast. 3) INCORRECT - Steroid administration is best done with breakfast, unless ordered otherwise. 4) INCORRECT - Steroid administration is usually prescribed once a day and taken with breakfast. *Think Like A Nurse: Clinical Decision Making* To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. Dexamethasone has a wide variety of uses, such as controlling autoimmune reactions, reducing cerebral edema, reducing inflammation, and shortening exacerbations of such conditions as asthma and arthritis. Even with low-dose, temporary therapy, teaching is important to ensure that the client understands how to safely take the medication. Dexamethasone may cause gastric irritation, hyperactivity or euphoria, mood swings, and hyperglycemia. The client should be aware of these possible adverse effects and measures to take to prevent them. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Inform the client about the medication, the reason for its administration, and how and when effectiveness will be determined. The client should also be taught about possible adverse effects of dexamethasone, which may include (but are not limited to) gastrointestinal upset and peptic ulceration, sodium retention, edema, heart failure, hypertension, hypokalemia, hypocalcemia, hyperglycemia, and pancreatitis.

The nurse provides instruction to a client diagnosed with myasthenia gravis about the condition. Which statement by the client indicates to the nurse the need for further teaching? 1. "I cannot drink alcoholic beverages." 2. "I should not go places that are crowded." 3. "I should try to stay calm." 4. "I can use my hot tub daily."

1) INCORRECT - Alcoholic beverages should be avoided, as they can interfere with medications given as treatment for the condition. 2) INCORRECT - Since the client is being treated with steroids, it is necessary to avoid situations that can cause an infection. The client's immune system is compromised. 3) INCORRECT - Emotional extremes can exacerbate the condition. 4) CORRECT - The client should avoid heat (such as sauna, hot tubs, sunbathing) or extremes in cold, as they will exacerbate the symptoms of the condition. *Think Like A Nurse: Clinical Decision Making* Aspiration and ineffective breathing are the nurse's primary concerns for the client diagnosed with myasthenia gravis. The nurse must provide this client with education regarding disease management prior to discharge. Information should be presented in layman's terms so that it is easily understood by the client. During the teaching session, the nurse includes information on activities or circumstances that aggravate the impaired nerve to muscle communication, including heat, respiratory illness, too little sleep, emotional stress, and some medications. Heat includes heat from the sun, hot bath water, fever, and hot drinks. Heat causes muscles to be more active, thereby increasing acetylcholine demand when the body is already deficient. Once all the information is presented to the client, the nurse evaluates client understanding. *Content Refresher* Myasthenia gravis is an autoimmune disorder characterized by a deficiency of acetylcholine. This disease process causes ptosis, diplopia, speaking alterations, chewing fatigue, swallowing difficulty, and general musculoskeletal weakness. Monitor the client for respiratory complications. Place the client in semi-Fowler position. Advise the client to wear an eye patch if double vision occurs. Consult physical and occupational therapy to maximize functioning. Consult with a dietitian regarding nutritional needs. Maintain a well-balanced diet and determine if a gastrostomy tube is needed. Consult with speech therapy to maintain speaking skills and evaluate swallowing issues. Treatment for myasthenia gravis includes medications, such as anticholinesterases, glucocorticoids, and immunosuppressants.

The client has signs of pressure injury on the residual limb after removal of the artificial leg. Which nursing concern is appropriate for the nurse to place in the plan of care? 1. Altered body image due to loss of a body part. 2. Chronic leg pain due to phantom limb sensation. 3. Challenged physical mobility due to the leg amputation. 4. Skin breakdown due to an improperly fitting prosthesis

1) INCORRECT - Altered body image is primarily related to the amputation, not to the pressure injury due to an improperly fitting prosthesis, which is an immediate problem. 2) INCORRECT - There is no evidence of pain or phantom limb sensation. 3) INCORRECT - There is no evidence of immobility at this time. 4) CORRECT - The pressure injury is most likely due to an improperly fitting prosthesis. This is an immediate problem for this client. *Think Like a Nurse: Clinical Decision-Making* Upon finding a pressure injury, the nurse should assess the client thoroughly for characteristics of the injury and possible contributing factors. In the scenario, the nurse should assess particularly for proper fitting of the artificial leg prosthesis. The client is reminded that the prosthesis should be removed before going to bed. The client or the nurse should examine the prostheses for loose parts or damage, which can cause injury. The nurse should reinforce teaching to the client about examination of the residual limb for blisters or other signs of irritation. Regular inspection of the residual limb to look for injuries or wounds using a mirror is recommended. *Content Refresher* Pressure injuries are caused by ischemia to the skin and underlying tissues. Assess pressure injury risk using the Braden Scale or other skin assessment tool on admission. All skin areas, especially those over bony prominences (e.g. heels, elbows, sacrum), should be inspected when repositioning the client. Observe and palpate all areas of skin discoloration, assessing for blanching. Do not massage red or discolored areas. If a skin area is identified as a pressure injury, stage, measure and photograph the wound. Teach the client and family about changing positions, using offloading devices, and monitoring for pressure injuries. Collaborate with the wound care specialist.

The nurse learns that an older adult client refused a prescribed sleeping medication and was awake most of the night. Which actions will the nurse take? (Select all that apply.) 1. Ask why the medication was refused. 2. Ask if pain or discomfort interrupts sleep. 3. Offer a visit by the hospital chaplain. 4. Obtain information about sleep habits when at home. 5. Instruct nursing staff to administer pain medication at bedtime to promote sleep. 6. Instruct nursing staff to minimize unnecessary noise and talking in the hallway.

1) INCORRECT - Asking why the medication was refused is confrontational. The nurse should assess if the client regularly takes sleeping pills at home and if the client had concerns about taking the prescribed medication. 2) CORRECT - Assessing pain level is a part of every assessment, and pain may impact a hospitalized client's sleep. 3) INCORRECT - There is no evidence the client is experiencing a spiritual need. 4) CORRECT - Information about the client's sleeping habits at home will determine if nighttime wakefulness is normal for this client. 5) INCORRECT - The nurse should not administer pain medication without assessing for pain. 6) CORRECT - Environmental factors, such as alarms and staff conversations, often interrupt sleep in hospitalized clients. *Think Like A Nurse: Clinical Decision Making* The nurse should assess the client for reasons for not taking the prescribed sleeping medication. It is important to consider that some sedatives are deemed potentially inappropriate for use by older adult clients due to risk for delirium, falls, and poor renal clearance. Assessment and treatment for the client who experiences sleep pattern disruption requires an interdisciplinary approach. The nurse can implement simple but effective interventions, such as keeping the room door closed to eliminate noise and light, maintaining a cool room temperature as desired by the client, and avoiding performing non-essential tasks (such as bed baths) at 0400. *Content Refresher* Assessment, which comprises careful observation and data collection regarding a client's health status, is the first step of the nursing process. Physical assessment techniques include inspection, palpation, percussion, and auscultation. The nurse needs to establish rapport and interview the client to collect relevant data. Use of open-ended questions is preferred. Educate the client about the therapeutic effects of the prescribed sleep medication and allow time for discussion and questions. Encourage the client to resume normal bedtime rituals while hospitalized. Explore other reasons the client may not be sleeping, such as anxiety related to the medical diagnosis or scheduled tests.

The nurse provides care to a client diagnosed with iron-deficiency anemia. Which findings does the nurse anticipate as characteristic of this disorder? (Select all that apply.) 1. Autoimmune-related disease. 2. May occur with removal of duodenum. 3. Associated with chronic blood loss. 4. Most common type of anemia. 5. Lack of intrinsic factor.

1) INCORRECT - Autoimmune-related diseases occur with a cobalamin deficiency. 2) CORRECT — Removal of the duodenum results in the malabsorption of iron. 3) CORRECT — Chronic blood loss causes a loss of iron. 4) CORRECT — More cases of iron-deficiency anemia occur than other types of anemia. 5) INCORRECT - Lack of intrinsic factor occurs with a cobalamin deficiency. *Think Like a Nurse: Clinical Decision-Making* There are many types of anemia. However, underlying causes of anemia typically fall into three main categories: acute blood loss, decreased red blood cell (RBC) production, and increased RBC destruction. Iron is needed to make hemoglobin, which is the component of the RBC that carries oxygen. The duodenum is the main site of iron absorption. If the client has undergone surgical removal of the duodenum (duodenectomy), iron supplementation will likely be needed. Because oral iron supplements are not well absorbed by the gastrointestinal tract, intravenous iron infusions may be prescribed. *Content Refresher* Iron is necessary to support normal red blood cells and helps produce hemoglobin. Hemoglobin carries oxygen to the body 's tissues. Causes of iron deficiency anemia include inadequate dietary iron intake, impaired iron absorption, and slow, chronic bleeding (e.g., from a gastric ulcer or colon cancer). Additional risk factors for iron deficiency anemia include low birth weight infants, premature infants, frequent donation of blood, vegetarians, and women with heavy menstrual periods. Signs and symptoms of iron deficiency anemia include weakness, extreme fatigue, pale skin, poor appetite, cold hands and feet, brittle nails, chest pain, tachycardia, shortness of breath, inflammation of the tongue, headache, dizziness, lightheadedness, and cravings for non-nutritive substances, such as ice.

The nurse provides care for a client who has received preoperative medications. The client insists on getting up and going to the bathroom. Which response by the nurse is most appropriate? 1. "You should have gone to the bathroom before receiving the medications." 2. "You can walk to the bathroom if you are not feeling groggy." 3. "I would suggest that you use the bedpan right now." 4. "I will see if your health care provider can prescribe an indwelling urinary catheter."

1) INCORRECT - Because pre-operative medications may interfere with balance, the nurse should have asked the client to void before receiving the medication. This response is not appropriate and non-therapeutic. 2) INCORRECT - Preoperative medications may interfere with balance and create a safety concern. The client should not get up at this time. 3) CORRECT— Preoperative medications may interfere with balance and create a safety concern. The client should remain in bed and be encouraged to use the bedpan. 4) INCORRECT - Seeking a prescription for an indwelling urinary catheter places the client at an increased risk for an infection. The client needs to be encouraged to use the bedpan. *Think Like A Nurse: Clinical Decision Making* The nurse should mentally ask, "How can the client's needs be met without causing a risk to safety?" Since preoperative medications often include a sedative or an agent that has sedative adverse effects, the client should not be permitted to ambulate after administration of this medication. Offering the client a bedpan ensures the client's safety. Making this decision is an example of the nurse using clinical judgement to come to the conclusion that meets both client and safety needs. *Content Refresher* During a surgical procedure, an anesthesia care provider delivers anesthesia, medications that produce local, regional or general effects, such as sedation, loss of reflexes, freedom from pain, loss of sensation, and relaxation. The nurse should prepare the client for the procedure and ensure the client's privacy. Preoperative care includes teaching the client about anesthesia, administering medications that typically sedate the client, and implementing interventions to ensure the client's safety.

The home health nurse is conducting a home safety assessment in the home of an older adult client who lives alone. Which observation made by the nurse requires follow up and teaching? (Select all that apply.) 1. The cleaning supplies are left unlocked under the kitchen sink. 2. The testing supplies for diabetes management are left on the kitchen counter. 3. The client purchases non-childproof caps that are easy to open for medications. 4. The bottom drawer on the client's nightstand is broken and will not stay closed. 5. The client has a weekly laundry service that delivers clean laundry inside the front door.

1) INCORRECT - Cleaning supplies left unlocked under the kitchen sink is not a safety threat for an older adult client who lives alone. 2) INCORRECT- Leaving testing supplies for diabetes management on the kitchen counter is not a safety threat for an older adult client who lives alone. 3)INCORRECT- Using non-childproof caps for medications is not a safety threat for an older adult client who lives alone. 4) CORRECT - The client may trip over the nightstand drawer when getting out of bed, which creates a risk for falls. This observation would require follow up and teaching by the nurse. 5) CORRECT - The client may trip over laundry baskets or bags, which creates a risk for falls. This observation would require follow up and teaching by the nurse. *Think Like a Nurse: Clinical Decision-Making* A priority when planning care, including teaching needs, is client safety. An older adult client, who lives alone in the home, is at risk for falling. The nurse must carefully assess the environment, and plan care, to decrease this client's risk. A drawer that will not stay closed along with laundry bags in a walkway both increase this client's risk for falling. The nurse must address these issues as they impact the client's safety. The other situations do not represent a safety risk for the older adult client who lives alone in the home. *Content Refresher* Safety is the ability to perform tasks without fear of accidents or trauma and security in one's environment. The older adult client is vulnerable to injury related to sensory and cognitive changes, mobility limitations, blood pressure fluctuations, and medication effects. The nurse needs to assess the client's environment for potential safety risks and help with environmental adaptations to keep the client safe. The nurse should specifically assess for any environmental hazards that pose a risk for tripping or falling, including unsecured electrical cords, uneven floors or steps, objects lying on the floor such as throw rugs or books, and poor lighting.

A client is being discharged after a liver transplant with cyclosporine oral solution as one of the prescribed medications. Which statement made by the client indicates further teaching is necessary? 1. "I will report cold symptoms to my health care provider." 2. "I will store the cyclosporine solution at room temperature." 3. "I will take the cyclosporine with meals exactly as prescribed." 4. "I will mix the cyclosporine in a glass of grapefruit juice."

1) INCORRECT - Cold symptoms such as fever, sore throat, and fatigue can be symptoms of an infection in an immunosuppressed client, and should be reported immediately. This statement indicates understanding of the information presented. 2) INCORRECT - The solution should be stored at room temperature in a tightly closed container and protected from light. This statement indicates understanding of the information presented. 3) INCORRECT - Taking the medication with meals prevents nausea, vomiting, and GI irritation. Take exactly as prescribed. This statement indicates understanding of the information presented. 4) CORRECT - Grapefruit juice and cyclosporine should not be taken together because the juice causes the bioavailability of cyclosporine to increase by 20 to 200%. It is even advised by some that no drinking of grapefruit juice should occur when a patient is on this drug. The medication is always mixed in glass, not plastic, and with a room temperature liquid, such as orange or apple juice. *Think Like A Nurse: Clinical Decision Making* To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client's understanding. When the client states that the medication will be mixed with grapefruit juice, the nurse knows that additional education is required regarding which juices are acceptable for mixing with this medication, such as orange juice, and possibly teaching about why grapefruit juice is avoided with cyclosporine to help the client remember this important fact. *Content Refresher* For teaching and learning, ensure a comfortable environment with adequate lighting. Prepare for the teaching activity. Question learners regarding their expectations. Determine the learner's knowledge level and previous experiences. Allow time for discussion and questions. Stop for a break when the learner indicates that one is needed. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Determine which factors help or hinder the learning process. Evaluate the effectiveness of the teaching/learning session.

The client receives supplemental feeding via an NG tube. Upon entering the room, the nurse notes the client has a weak, nonproductive cough and dusky lips. Which actions are appropriate for the nurse to take based on the current data? (Select all that apply.) 1. Continue the infusion as prescribed. 2. Assess posterior lung sounds only. 3. Discontinue the tube feeding. 4. Contact the health care provider. 5. Suction the client 's airway.

1) INCORRECT - Continuation of the feeding is not appropriate as the client possibly aspirated. 2) INCORRECT - The nurse assesses lateral, posterior, and anterior lung fields. 3) CORRECT— The tube feeding should be stopped as assessment data indicate possible aspiration. 4) CORRECT— The health care provider should be notified as assessment data indicate possible aspiration. 5) CORRECT— The nurse suctions the client 's airway to clear any possible obstruction. *Think Like a Nurse: Clinical Decision-Making* For the client who receives supplemental feeding via an NG tube, signs and symptoms of hypoxia should prompt the nurse to discontinue the tube feeding. If aspiration has occurred, the NG tube may be malpositioned. Verification of proper positioning of the distal end of the NG tube is warranted. Regardless of the underlying cause of the client 's hypoxia, emergency airway interventions may be needed. Ensure client 's airway patency and adequacy of breathing. Promptly notify the health care provider of the client 's status. *Content Refresher* Enteral nutrition increases the client 's risk for aspiration. Verify that a chest X-ray was performed to rule out placement of the distal end of the NG tube in the client 's lung. Verify NG tube placement by aspirating contents and determining pH; pH consistent with acidic stomach contents is ≤4. Elevate the head of bed at 30 to 45 degrees during feeding administration and for 30 to 60 minutes after conclusion of a scheduled feeding. Observe and document the client 's tolerance of the tube feeding, the amount and pH of gastric aspirate, and the appearance of stools (tube feedings may cause diarrhea).

The nurse asks the unlicensed assistive personnel (UAP) to perform soapsuds enemas for a client scheduled for a diagnostic test. Which action does the nurse expect from the UAP? 1. The UAP describes the returns from the enema. 2. The UAP observes the returns from the enemas in the bedside commode. 3. The UAP asks the client to describe the returns from the enema. 4. The UAP palpates the client's abdomen, noting firmness and tenderness.

1) INCORRECT - Describing returns from the enema is outside the scope of practice for the UAP. The nurse should monitor performance and results according to established goals. 2) CORRECT— Performing an enema is a standard, unchanging procedure that can be delegated to the UAP with the responsibility and authority for performing the task. It is the nurse's responsibility to describe clear outcomes. Observing returns is a part of the task delegated and should be performed by the UAP. 3) INCORRECT - The UAP is responsible for observing the returns from the enema to determine effectiveness. 4) INCORRECT - Abdominal assessment is performed by the nurse if the client reports tenderness or the UAP identifies a problem with the procedure. *Think Like a Nurse: Clinical Decision-Making* Before delegating a skill, the nurse needs to consider the scope of practice of the care provider. Unlicensed assistive personnel (UAP) are permitted to provide soapsuds enemas if competency on the skill is validated and the client is stable. When delegating the task, the nurse should clearly explain the expectations. For the soapsuds enemas, UAP should observe the returns and report these findings to the nurse. Remember that assessment is beyond the scope of practice for UAP. *Content Refresher* An enema is the administration of solution into the rectum or sigmoid colon. The purpose is to relieve constipation and promote defecation. To administer an enema, assist client to left side-lying position and gather supplies (waterproof pad, enema, gloves and lubricant) and bedpan if needed. If an enema bag is used, fill bag to ordered amount of warm tap water and release clamp to fill tubing. Lubricate the tip of tube and gently insert into the rectum approximately 3 to 4 inches for an adult or 2 to 3 inches for a child. Never force the tubing. Once in position, unclamp tubing and instill the fluid. Instruct the client to hold the fluid as long as possible. Assist the client to the bathroom or position on a bedpan. Observe and document results.

The nurse provides care to a client receiving furosemide. Which is the most important assessment for the nurse to make? 1. Potassium level for hyperkalemia. 2. Orthostatic blood pressure measurement. 3. Bowel movements for diarrhea. 4. Eyes for visual disturbances.

1) INCORRECT - Hypokalemia, not hyperkalemia, is the most commonly encountered electrolyte imbalance seen with loop diuretics and may be very dangerous. 2) CORRECT - Monitoring of therapy for the client receiving furosemide includes frequent assessment of blood pressure and pulse rate, including orthostatic blood pressures and pulse rates (supine and standing), hydration status, and capillary refill, as well as daily measurement of weight. 3) INCORRECT - Constipation, not diarrhea, is a side effect of furosemide. 4) INCORRECT - Visual disturbances are not side effects of furosemide. *Think Like A Nurse: Clinical Decision Making* When preparing to assess a client, the nurse needs to keep in mind the type and expected effects of any medication the client may be taking. In this scenario, the nurse should recall the mechanism of action of furosemide and the purpose it is prescribed. Since this medication removes excess fluid from the body and does not spare potassium, the assessment should focus on parameters that measure body fluid balance. This would include heart rate and blood pressure. Body weight should be routinely measured in this client as the most accurate measurement of body fluid status. The nurse will also monitor the client's lab results and monitor for hypokalemia. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Perform appropriate client assessments and check for contraindications, including allergies, prior to administering medications. Verify the rights of medication administration, which minimally include the right client, right medication, right time, right dose, right route, right site, and right documentation. Educate the client about the medication. Common side effects of furosemide include dizziness, weakness, headache, itching, and abdominal cramping. Potential adverse effects of furosemide include hypotension, hypokalemia, hypothyriodism, pancreatitis, and liver failure. Document the medication administration and evaluate outcomes of the administered medication.

The nurse provides care to a client who practices Orthodox Judaism. When collaboratively planning the client's meals, which food selection does the nurse offer the client? 1. Meat lasagna. 2. Broiled shrimp. 3. Smoked salmon. 4. Pork chops.

1) INCORRECT - Individuals who practice Orthodox Judaism do not combine milk products with meat. As such, meat lasagna would not be an appropriate food selection for the client. 2) INCORRECT - Orthodox Judaism forbids consuming shellfish. Because shrimp are a type of shellfish, any preparation of shrimp would not be an appropriate food selection for the client. 3) CORRECT— Salmon is acceptable for consumption by individuals who practice Orthodox Judaism. Dietary products that are forbidden by Orthodox Judaism include pork products, shellfish (such as shrimp), and foods that combine dairy products and meat (such as lasagna). 4) INCORRECT - Because Orthodox Judaism forbids the consumption of pork, all pork products must be excluded from the client's diet. *Think Like A Nurse: Clinical Decision Making* Health-related dietary restrictions must be observed and dietary needs considered while helping the client to find food choices that meet their preferences and personal needs. Hospital food can present a challenge when clients make meal choices based on cultural or religious beliefs. Often, if possible, the nurse encourages family to bring in home-cooked food. Requests can be made of the dietary department, such as ensuring food is kosher. *Content Refresher* The nurse is responsible for education of clients about proper nutrition and ensuring clients receive therapeutic diets, consistent with their nutritional needs. The nurse should determine the client's food intake, food preferences, recent weight changes, health history, and medications, as well as activity level. Assess client/family attitudes, beliefs, and values about food including cultural values and beliefs.

An older adult client diagnosed with diabetes mellitus is at risk for amputation. Which outcome does the nurse establish for this client? 1. Maintain a normal cholesterol blood level. 2. Wear a protective helmet when riding a bike. 3. Maintain optimal blood glucose control. 4. Use e-cigarettes instead of regular cigarettes.

1) INCORRECT - Normal cholesterol levels help to prevent coronary heart disease in clients of all ages. 2) INCORRECT - The helmet will protect against head injury but not trauma to the extremities. 3) CORRECT - Peripheral vascular disease (PVD) secondary to diabetes mellitus among older adults is the most common cause of amputation. Maintaining glycemic control is essential in preventing amputation. 4) INCORRECT - There is no evidence suggesting that use of e-cigarettes instead of regular cigarettes prevents PVD in clients with diabetes mellitus. *Think Like A Nurse: Clinical Decision Making* Glycemic control is essential for the entire body. Blood glucose levels affect cognition, cardiovascular health, nerve function, kidney function, retinal health, immune system function, and wound healing. This client is facing an amputation due to a long history of poor glycemic control, which resulted in severe peripheral vascular disease (PVD), decreased blood supply to the lower extremities, and death of tissue in the leg. Wounds do not heal in the presence of uncontrolled blood glucose levels, so the nurse's goal for this client is glycemic control before and after the surgical amputation. *Content Refresher* Most amputations are performed due to peripheral vascular disease (PVD), especially in older adult clients with diabetes mellitus (DM). Consequences of DM include peripheral neuropathy, which may progress to skin ulcers and gangrene. Signs of PVD include pale or discolored skin, weak or absent pulses, reduced body hair, poor wound healing, and thick, opaque nails. Preoperative testing is done to determine the circulation present at different levels of the extremity. This is accomplished through transcutaneous partial pressure oxygen readings, Doppler flowmetry, segmental blood pressure measurement, and angiography.

A newly hired nurse is being screened for vaccination history by employee health. The newly hired nurse reports to the employee health nurse that hepatitis B immunity was established with a previous employer. Which response by the employee health nurse is most appropriate? 1. "You must repeat the hepatitis immunity screen." 2. "Would you like to verify your immunity to hepatitis B with a blood test?" 3. "Do you have a copy of the results of your hepatitis screening?" 4. "Did you receive the hepatitis vaccine in the deltoid?"

1) INCORRECT - Once hepatitis immunity has been established, there is no need to reconfirm it. 2) INCORRECT - There is no reason to reconfirm the immunity if it has already been established. 3) CORRECT— This enables the employee health nurse to confirm immunity. 4) INCORRECT - The dorsal gluteal site is avoided for hepatitis B immunization injections because it is associated with low antibody formation rates. However, it is more important to ask the newly hired nurse for a copy of the record. This will confirm immunity. *Think Like A Nurse: Clinical Decision Making* The nurse should think, "How can I confirm the nurse's immunity to hepatitis B?" Repeating the hepatitis immunity screening through blood testing is not needed. Additionally, it wastes resources, incurs unnecessary expense, and causes added discomfort for the nurse. Documentation of immunity from the prior employer provides sufficient confirmation of the nurse's immunity. The injection site where the nurse received the hepatitis B vaccine does not help confirm immunity. *Content Refresher* A diagnostic workup to assess immunity for a variety of infections includes a complete blood count and differential, immunoglobulin levels in the blood, specific antibody production, oxidative burst, Nitroblue Tetrazolium test, dihydrorhodamine 123 test, total hemolytic complement assay, chemistry panel, toxoplasma IgG, viral hepatitis screen, syphilis serology, and a purified protein derivative tuberculosis (TB) skin test. The hepatitis B vaccine is produced utilizing yeast cells and recombinant technology. The vaccine is recommended to be administered in three doses for immunization against hepatitis B. Immunization with the hepatitis B vaccine stimulates the immune system to develop antibodies against hepatitis B, thereby protecting the client against the virus.

The nurse provides care for a toddler diagnosed with pneumonia caused by Haemophilus influenzae type b. Which transmission-based precautions will the nurse implement? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

1) INCORRECT - Standard precautions are used when caring for all clients, regardless of diagnosis or possible infection. 2) INCORRECT - A toddler diagnosed with pneumonia caused by Haemophilus influenzae type b must be placed in droplet precautions, not airborne precautions. 3) CORRECT— Droplet precautions are indicated when clients are diagnosed with pneumonia caused by Haemophilus influenzae type b. Droplet precautions are implemented when the illness can be transmitted by droplets larger than 5 microns. 4) INCORRECT - Pneumonia caused by Haemophilus influenzae type b is transmitted via droplets. This client needs to be placed in droplet precautions, not contact precautions. *Think Like A Nurse: Clinical Decision Making* Droplet precautions should be implemented for clients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a client is in a health care facility. Staff should don a facemask when entering the room of a client with suspected or confirmed influenza. Remove the mask when leaving the room, dispose of it in a waste container, and perform hand hygiene. The nurse is expected to receive the annual influenza vaccination as part of an influenza infection prevention strategy. *Content Refresher* Transmission-based precautions are infection control practices used in health care and applied when clients are known or suspected to be infected or colonized with infectious agents. Transmission-based precautions are used in addition to standard precautions. The three types of transmission-based precautions are contact, droplet, and airborne. Droplet precautions require the wearing of a mask upon entry into a client's room. Droplet precautions protect the nurse from infections that can be spread through close respiratory or mucous membrane contact.

As part of a health center educational program on tuberculosis (TB), skin tests are offered as a screening measure. Which statement by a participant to the nurse requires further exploration by the nurse? 1. "My grandfather had tuberculosis and died from it." 2. "When I have these skin tests, nothing ever shows up." 3. "I had a shot for tuberculosis 5 years ago." 4. "I won't take medicine even if they do find something."

1) INCORRECT - TB is not hereditary, although close associates of the infected person, such as family, may be particularly at risk for exposure and contracting of the disease. 2) INCORRECT - Skin testing results indicate that the client has not had past infection with TB. 3) CORRECT - This statement is indicative of possible contraindication for skin testing. The nurse explores meaning of the word "shot" and what was actually done. This may have been the bacillus Calmette-Guerin (BCG) vaccine used to promote active immunity to TB, and false-positive reactions to tuberculosis skin testing can occur in individuals who received this vaccine. 4) INCORRECT - This indicates a potential future noncompliance problem and further exploration may be useful, but there is nothing to clarify currently. *Think Like A Nurse: Clinical Decision Making* The statement "I had a shot for tuberculosis 5 years ago" requires clarification because bacille Calmette-Guerin (BCG) is not generally recommended for immunization in the United States because of the low risk of infection with Mycobacterium tuberculosis. The nurse should be familiarized with required immunization for adults and children. BCG vaccination may cause a false-positive reaction to tuberculin skin test (TST), which may complicate decisions about prescribing treatment. The presence or size of a TST reaction in persons who have been vaccinated with BCG does not predict whether BCG will provide any protection against tuberculosis (TB) disease. *Content Refresher* Mycobacterium tuberculosis (TB) is an airborne gram-positive bacteria. Infection occurs primarily in the lungs but can be transported via the lymph system to other organs. Interferon-gamma release assays (IGRAs) may be used to screen for TB. IGRAs are the preferred screening procedure for those who have been vaccinated against TB. When screening tests are positive, sputum samples are obtained and cultured. Positive cultures are definitive for a diagnosis of TB.

The nurse observes a nursing assistive personnel (NAP) preparing to lift an object. Which principle of body mechanics does the nurse recommend to the NAP? 1. "Bend at the waist when you lift objects. " 2. "Carry objects close to your body or above your head. " 3. "Bend your knees when you lift objects. " 4. "Lean forward when you lift objects. "

1) INCORRECT - The NAP should bend at the knees to increase body balance and lower center of gravity. 2) INCORRECT - An object should be carried close to body 's center of gravity to help balance, but should not be carried above the head. 3) CORRECT— By bending the knees, the person maintains a better body balance when lifting. It protects the muscles of the back and moves the center of gravity closer to the object. 4) INCORRECT - Leaning forward would put unnecessary stress on the back. Bend the knees when lifting. *Think Like A Nurse: Clinical Decision Making* The nurse knows that the implementation of proper body mechanics decreases the risk of injury for both staff and clients. The principles of proper body mechanics are the safe use of the body and should be learned and practiced at all times. Principles include maintaining a wide base of support, using large muscle groups, and keeping objects near the center of gravity. The nurse needs to remind all staff members about the use of proper body mechanics as a means of protecting personnel and personal health. The greatest cause of personnel injury is from not using proper body mechanics. Staff injuries and absences can have a negative impact on client care. *Content Refresher* Proper body mechanics is the use of body positioning and assistance from others or a device(s) while ambulating, lifting, transferring, or other activities to reduce the risk of musculoskeletal strain or injury. The nurse must provide information to client, family, and/or colleagues about proper body mechanics. To ensure proper body mechanics when moving a client, ensure that the bed is in low position, place non-slip footwear on client, use a wide base of support, work close to the body, and avoid twisting the body. Failure to use proper body mechanics could result in injury to both the client and the nurse.

A nurse with postpartum care experience is reassigned to a medical-surgical care area. Which client will the charge nurse assign to the postpartum care nurse? 1. Client with facial trauma after a motor vehicle crash. 2. Client with heat stroke. 3. Client having a systemic reaction to latex. 4. Client with progressive systemic sclerosis who is experiencing Raynaud phenomenon.

1) INCORRECT - The client with facial trauma after a motor vehicle crash requires close monitoring to assess for a patent airway, eye functioning, and neurological changes. This is not a stable client and should not be assigned to a nurse with postpartum care experience. 2) INCORRECT - The client with heat stroke may be experiencing dehydration and hyperthermia. The client should be placed in an air-conditioned room, lying flat with the legs elevated, and receiving oxygen. This is not a stable client and should not be assigned to a nurse with postpartum care experience. 3) INCORRECT - The client having a systemic reaction to latex may be experiencing an anaphylactic reaction. This is not a stable client and should not be assigned to a nurse with postpartum care experience. 4) CORRECT— Progressive systemic sclerosis is a chronic connective tissue disease that causes inflammation, fibrosis, and sclerosis of the skin and vital organs. This is a stable client who can be assigned the nurse with postpartum care experience. *Think Like A Nurse: Clinical Decision Making* At times, nurses in a care facility may be reassigned to meet a staffing need for another care area. In this scenario, a nurse with women's health experience is assigned to care for clients with which the nurse may have limited experience. The charge nurse should take this into consideration and asks, "Which client is the most stable and will fit with the nurse's skill level?" Of the clients available, the one with the most predictable outcome is the client experiencing manifestations of Raynaud disease. The nurse will be able to assess this client's vital signs and skin change manifestations that occur with the disorder. The reassigned nurse may not have the experience to thoroughly assess the effect of traumatic injuries, provide treatment for an acute problem, or quickly recognize a life-threatening situation. *Content Refresher* Unit to unit assignment is the process of reassigning nurses from their regular unit assignments to short-staffed areas. An assignment to the reassigned nurse should be made based on stable client situations with predictable outcomes. Assign a resource nurse to the reassigned nurse and provide assistance and/or supervision with unfamiliar tasks. The assigning nurse should evaluate which client's care falls under the general nursing skills that would be expected from nurses in all areas of client care. The nurse being assigned also has the responsibility to share with the assigning nurse any uncertainties about client care.

The nurse assists the anesthesia health care provider with the insertion of a central venous catheter. During the insertion, the nurse notes that the tip of the device brushes the underside of the sterile field. Which action is correct? 1. Wipe the tip with alcohol before connecting to the system. 2. Notify the primary health care provider of the occurrence. 3. Back-flush the catheter for several seconds before connecting. 4. Obtain a new device and prepare for a second attempt.

1) INCORRECT - The equipment is contaminated. Obtain new equipment. 2) INCORRECT - If the nurse acts correctly, there will be no reason to notify the client's primary health care provider. 3) INCORRECT - The equipment is contaminated and should be disposed of. 4) CORRECT - When equipment becomes contaminated during a sterile procedure, obtain new equipment. *Think Like A Nurse: Clinical Decision Making* Insertion of a central venous catheter is a sterile procedure. The catheter is contaminated if it comes into contact with anything other than the sterile field. The catheter needs to be replaced. *Content Refresher* Aseptic technique refers to the process of providing care while keeping an area, object, or person free from disease-causing microorganisms. If equipment is accidentally contaminated, begin the procedure again, using new equipment. Ensure any contaminated items are properly disposed of.

The nurse notes that a client, experiencing dull pain in the anterior and posterior neck, has full neck range of motion and no throat redness or enlargement of the head or neck lymph nodes. Which assessment will the nurse complete next? 1. Examination of the ears. 2. Palpation of the liver. 3. Auscultation of heart sounds. 4. Auscultation of bowel sounds.

1) INCORRECT - There is no direct correlation between the ears and the pain reported. 2) CORRECT - The right neck and the flank are common areas of referred pain from liver damage, so the liver should be examined when dull pain in the anterior and posterior neck occurs. 3) INCORRECT - The heart does not correlate with the reported area of pain. 4) INCORRECT - The gastrointestinal tract does not correlate with the reported area of pain. *Think Like a Nurse: Clinical Decision-Making* The nurse needs to understand the assessment principles that are needed when assessing pain. Most frequently, pain is located in the specific area related to an acute injury or a chronic illness. However, the nurse should understand that sometimes the reason for the pain is not as obvious. In this scenario, the nurse assesses for all of the obvious reasons first. If the data are inconclusive, then the nurse should mentally ask, "What area of the body would cause the client to experience referred pain at this site?" The right side of the neck and flank area are sites for referred pain from the liver. So after assessing the neck region and finding no evidence for injury, the nurse should assess the liver. *Content Refresher* The client with liver disease may experience weight loss, weakness, anorexia, edema, elevated blood pressure, presence of ascites, splenomegaly, abnormal bleeding, jaundice, pruritus, clay-colored stools, elevated ammonia levels, confusion, and altered fluid and electrolyte levels. Liver disease often results in right upper quadrant pain, but the client may experience referred pain, felt in the right flank, shoulder, or neck. The client is at risk for altered metabolism and bleeding due to impaired liver function.

The home health nurse visits a client who has urinary incontinence following a prostatectomy. The client reports that he is changing incontinence pads every 2 hours. Which action by the nurse is appropriate? 1. Encourage the client to drink 1000 mL per day. 2. Instruct the client to use artificial sweetener. 3. Instruct the client to do pelvic muscle strengthening exercises. 4. Administer terazosin 1 mg orally per day.

1) INCORRECT - There is no need to restrict fluids, and doing so will cause additional issues for the client. 2) INCORRECT - Artificial sweetener will irritate the bladder and may increase incontinence. 3) CORRECT - Performing pelvic muscle strengthening exercises several times a day is an appropriate action for incontinence. The exercises will improve bladder control. 4) INCORRECT - Terazosin is an alpha 1-adrenergic blocker that is used for treatment of benign prostatic hyperplasia (BPH). The client has had a prostatectomy. Therefore, this is not an appropriate treatment. *Think Like A Nurse: Clinical Decision Making* Due to the location of the prostate gland in relation to the structures of the male urinary tract, urinary incontinence is a common adverse effect after the prostate gland is removed. One action to help reduce the incidence of urinary incontinence after a prostatectomy is to perform pelvic strengthening exercises. These exercises help tone the bladder, which prevents accidental release of urine. The exercises need to be performed consistently and may take a few weeks before improvement in continence occurs. The nurse will use the principles of teaching and learning to provide information and evaluate client understanding. *Content Refresher* Micturition is a voluntary act, but both neurogenic and non-neurogenic causes may disrupt this function. The bladder has sensory fibers to help with cognitive recognition of the need to void; bladder detrusor muscles and sphincters allow control over urine elimination. In addition, the parasympathetic nervous system helps to transmit the signal for voiding from the bladder to the brain. Causes of incontinence include weakness of pelvic floor muscles, increased abdominal pressure, infections, over-distention of the bladder, sphincter weakness, and cognitive impairments. Age-related changes in bladder size and sensory impairments can also cause urinary incontinence. Clients with incontinence may require bladder training and scheduled toileting.

The nurse provides care for a client after a thoracentesis. The nurse observes the client for which symptoms related to this procedure? 1. Severe headache, diaphoresis, nasal congestion, and anxiety. 2. Shortness of breath, faintness, chest pain, and bloody sputum. 3. Abdominal pain, rigidity and distention, nausea, and vomiting. 4. Muscle spasms, and tingling sensations in fingertips and mouth.

1) INCORRECT - These symptoms are related to autonomic hyperreflexia/ autonomic dysreflexia, which is a complication of a spinal cord injury. 2) CORRECT - Pulmonary edema, hypoxia, hemothorax, pneumothorax, subcutaneous emphysema, and spleen and liver puncture are all potential complications of a thoracentesis. Any of these are reported immediately to the health care provider. 3) INCORRECT - These symptoms indicate peritonitis, which is a complication of a paracentesis. 4) INCORRECT - These symptoms are related to tetany (hypocalcemia). *Think Like A Nurse: Clinical Decision Making* Thoracentesis involves insertion of a needle into the pleural space, which is located between the lungs and the chest wall. Symptoms of post-procedure complications are often associated with the creation of a track between the pleural space and the outside of the body. Pneumothorax may occur as air enters through the surgical opening. Bleeding is a risk after any procedure, but this client may develop a hemothorax, which impairs lung expansion and causes respiratory difficulty. If a large amount of fluid (>1L) is removed from the pleural space, re-expansion of the lung may lead to pulmonary edema, possibly due to sudden shifts in intrapleural pressure. *Content Refresher* A thoracentesis is a procedure in which a large bore needle is inserted through the chest wall and into the pleural cavity so that pleural fluid can be removed for therapeutic or diagnostic purposes. Ensure the client has provided informed consent. Provide pre-procedure cough suppressant, if indicated. Assist with positioning during the procedure. Monitor vital signs intra-procedure and post-procedure and notify the health care provider of any sign of complications. Assist with collection of specimen and preparation for transport to laboratory for analysis. Apply dressing over puncture site and position client on unaffected side. Obtain a chest X-ray to ensure an absence of pneumothorax.

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one-to-one observation of the client? 1. "This is not the first time I felt this way." 2. "I will not sign a no-suicide contract." 3. "This is my fifth hospitalization for depression." 4. "My mother attempted suicide at age 40."

1) INCORRECT - These thoughts often recur and it is not an indication for one-to-one supervision. The nurse assists with problem-solving and decision-making to give client a sense of control other than through suicide. 2) CORRECT - Place the client on one-to-one observation and stay with client to help control self-destructive impulses. The client is never out of sight of a supervisory health care staff member. One-to-one observation is required for clients currently verbalizing a clear intent to harm self, unwilling to sign a no-suicide contract, with poor impulse control, and who have already attempted suicide in the past by a lethal method (hanging, gun). 3) INCORRECT - Repeated hospitalizations for depression does not indicate that the client is self-destructive. Depression is a response to a real or imagined loss with symptoms such as low self-esteem, self-deprecation, and feeling helpless or hopeless. 4) INCORRECT - Predisposing factors include males over age 50, age range of 15 to 19 years, poor social attachments, and previous suicide attempts. *Think Like A Nurse: Clinical Decision Making* Refusing to sign a no-suicide contract is a red-flag to the nurse. The client is at risk for suicide and should be constantly observed. The client may be at risk for suicide because of a family history of the behavior. *Content Refresher* Suicide is defined as intentionally killing oneself. The nurse needs to speak openly and directly when caring for a client experiencing suicidal thoughts. The nurse needs to ask the client about suicidal ideation (frequency of suicidal thoughts, intensity, and duration over time), suicide plan (method, lethality of method, time and place, whether or not they have prepared for suicide), any suicidal behaviors (rehearsals, prior attempts, aborted attempts, and non-suicidal self-injuries), and the client's intent to follow through with the plan.

The nurse performs an assessment on a family in a mental health clinic. Which behaviors does the nurse identify as associated with a dysfunctional family process related to impaired communication? 1. Acknowledgment of personal needs and role responsibilities. 2. Congruence between verbal and nonverbal messages. 3. Appropriate response to other family members ' needs. 4. Inability to meet the emotional needs of other family members.

1) INCORRECT - This assessment indicates a functional family unit. One of the functions of the family unit is to assist the members to meet their physiological, emotional, and safety needs. 2) INCORRECT - Congruence between verbal and nonverbal messages would be observed in a functional family unit. 3) INCORRECT - Appropriate responses to others' needs indicate a functional family unit. 4) CORRECT— A functional family unit helps the family members meet their physical, psychosocial, and safety needs. The inability to meet these basic needs is associated with a dysfunctional family. *Think Like A Nurse: Clinical Decision Making* When performing a mental health assessment on a family, the nurse needs to mentally review the principles of therapeutic communication and recognize behaviors that interfere with the process. The nurse reviews each behavioral finding and evaluates for dysfunction. The inability of the family members to meet the emotional needs of each other indicates dysfunction. The nurse will attempt to positively influence how the family members communicate by teaching and demonstrating therapeutic communication principles. *Content Refresher* When caring for a family unit in which there is poor communication, the nurse can model therapeutic communication skills such as: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad openings, 6) providing leads and encouragement, 7) timing events, 8) focusing, 9) asking about thoughts/feelings, 10) encouraging comparisons, 11) restating and reframing, 12) reflecting, 13) presenting reality, 14) sharing observations, 15) clarifying meaning, 16) expressing doubt, 17) interpreting feelings, and 18) formulating a plan for care.

A nurse manager notes a significant increase in inpatient client falls causing injury. To help resolve this problem, which action by the nurse manager is most appropriate? 1. Schedule a mandatory staff inservice about client safety and assessing fall risk. 2. Inform staff that evaluations and raises will reflect the unit's "zero falls" goal. 3. Convey to the staff the manager's confidence in their abilities to provide safe care. 4. Form a group to design and implement a plan to prevent further incidents.

1) INCORRECT - This intervention presumes that lack of knowledge is the cause, and that education is the solution. 2) INCORRECT - Coercive techniques usually have temporary outcomes and reduce morale. 3) INCORRECT - Building self-esteem for employees does not problem solve. 4) CORRECT - Involvement of staff is likely to have a more permanent effect. Nurses have firsthand knowledge of why the problems are occurring. *Think Like A Nurse: Clinical Decision Making* Since the staff is responsible for ensuring client safety, the best approach is to have staff members create a plan to prevent further falls. The staff most likely have the knowledge to assess fall risk and plan appropriate interventions. *Content Refresher* Risk management entails analyzing, classifying, and prioritizing risks to ensure client safety. Develop a plan to avoid risks. Gather and evaluate data, and modify the risk reduction plan as necessary.

The home care nurse visits a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse instructs the client's caregiver about how to prevent infection. Which is the most important instruction the nurse will give to the caregiver? 1. "Cover your nose and mouth when you sneeze or cough." 2. "Get rid of all pets in the home." 3. "Wash your hands frequently." 4. "Wash the client's dishes separately."

1) INCORRECT - This is an appropriate action because the client is susceptible to illness. However, the priority is to ensure that the caregiver is performing hand hygiene, as this is the largest source of contamination. 2) INCORRECT - This is not necessary. The client should not touch litter boxes, feces, bird droppings, or water in the fish tank. The nurse should encourage the client to wash hands with soap and water after handling the family pet. 3) CORRECT - Hand hygiene is the single best way to kill germs. The caregiver should wash hands after going to the bathroom and before and after fixing food. The caregiver should also wash hands before and after caring for the client. 4) INCORRECT - This is not necessary. All dishes may be washed together. *Think Like A Nurse: Clinical Decision Making* The nurse knows that the first line of defense against the transmission of infection is good hand hygiene. This is the most important information to provide to the client's caregiver to prevent the spread of infection. If needed, teach the caregiver how to properly wash his or her hands (wet hands, apply soap, lather for at least 20 seconds, rinse thoroughly, and dry). *Content Refresher* Acquired immunodeficiency syndrome (AIDS) is a bloodborne sexually transmitted disease caused by a retrovirus, human immunodeficiency virus (HIV). Once the virus enters the body, it attaches to the CD4 receptor on T lymphocytes and uses the lymphocytes as hosts to replicate. With successive copying of the virus, the T lymphocytes die and immunosuppression results. Once the CD4 count drops below 200 cells/mm 3, the client is diagnosed with AIDS and is susceptible to further complications from immunosuppression, such as infection. Promoting handwashing to prevent the transfer of an infection to the client is the priority.

The nurse overhears the unlicensed assistive personnel (UAP) discussing a client's medical condition and test results with other clients. Which response by the nurse is appropriate? (Select all that apply.) 1. "Don't worry others yet. The tests will be repeated tomorrow." 2. "Stop discussing the client's condition." 3. "I think the client will improve with this new medication." 4. "Read the medical record silently, please." 5. "Only those with a 'need to know' should be informed of the client's test results."

1) INCORRECT - This response does not stop the UAP's violation of client privacy and confidentiality. 2) CORRECT - This response immediately stops the violation of client privacy. Medical information is used only for the purpose of diagnosis and treatment. Other clients are not involved in a client's treatment plan. 3) INCORRECT - This response does not stop the violation of client privacy. The nurse should not further promote the violation of the client's rights. 4) INCORRECT - This response is not appropriate as medical information is confidential and used only for purpose of diagnosis and treatment. 5) CORRECT - This response provides an explanation to the UAP as to why the action is wrong. It also provides further instruction of maintaining a client's privacy. *Think Like a Nurse: Clinical Decision-Making* The privacy and confidentiality of protected health information (PHI) is federally mandated by the Health Insurance Portability and Accountability Act (HIPAA). All members of the health care team are required to protect client privacy and confidentiality. Given that the UAP works under the nurse's supervision, if a breach of privacy and confidentiality is observed, the nurse intervenes to correct the breach and reinforce understanding of the requirement to protected health information data. Additional action may be indicated based on the organization's disciplinary guidelines. As a rule, staff members should have access only to confidential or sensitive information that is necessary to perform their jobs. This means staff should not review electronic files or paper records of clients for whom they are not assigned to provide care. *Content Refresher* Confidentiality refers to protecting and safeguarding a client's personal, identifiable health information and data. In 2003, the federal statute known as the Health Insurance Portability and Accountability Act (HIPAA) mandated the protection of client data. Unless officially authorized to do so by the client, health care workers do not discuss or share the client's personal information, including health care data, with family, friends, coworkers, other members of the health care team, insurance providers, or financial aid organizations. The nurse should hold self and colleagues accountable when it comes to respecting client confidentiality and privacy.

The nurse provides care for a client who is on therapeutic hypothermia and is being considered for rewarming. Which outcome is the most appropriate to establish? 1. Turn and reposition the client every 2 hours. 2. Rewarm at a rate of 0.45°F. (0.5°C) per hour. 3. Restore the body temperature to 98.6°F. (37°C) in 2 hours. 4. Assess the sedation level every hour.

1) INCORRECT - Turning and repositioning are not appropriate goals during rewarming. 2) CORRECT- Gradual rewarming is important, keeping the rate of increase at 0.45°F. (0.5°C) per hour. This will safely rewarm the client without untoward effects. 3) INCORRECT -Rapid rewarming can lead to electrolyte abnormalities, cerebral edema, and seizures. It defeats the benefits of therapeutic hypothermia. 4) INCORRECT -Sedation level assessment is essential. However, it is not the primary goal during rewarming. *Think Like A Nurse: Clinical Decision Making* The nurse is aware there are a variety of reasons for therapeutic hypothermia to be prescribed; however, the most common reason is to reduce body functions and metabolism following successful cardiopulmonary resuscitation (CPR). Once the client is stabilized (usually after 24 hours), rewarming is implemented. This is a delicate situation and one that requires close monitoring and assessment. The body is slowly in order to maintain stability of body tissues and organs. The speed of rewarming is typically just under one-half of a degree Fahrenheit of temperature per hour. Depending upon the starting temperature, rewarming can be a prolonged process. *Content Refresher* Therapeutic hypothermia, also known as targeted temperature management, is often used when a client remains unconscious after cardiopulmonary resuscitation (CPR).The client's body temperature should be maintained between 32ºC and 36ºC for a period of at least 24 hours. Gradual rewarming is implemented by increasing the client's temperature by 5ºC/hour over a period of approximately 8 hours. Monitor the client for hypotension and avoid hyperthermia during the rewarming period.

The nurse provides care to a client with candidiasis. Which finding will the nurse expect when assessing the client's oral cavity? 1. Blisters. 2. White patches. 3. Numerous small pinpoint lesions. 4. Purple patches.

1) INCORRECT - Viruses and some medications can cause oral blisters. 2) CORRECT- White patches appear on tongue, palate, and buccal mucosa in oral candidiasis. 3) INCORRECT - Canker sores, viruses, and allergic reactions can cause small pinpoint lesions. 4) INCORRECT - Purple patches are associated with acquired immune deficiency syndrome (AIDS). *Think Like A Nurse: Clinical Decision Making* Prior to providing care to this client, the nurse should mentally review the pathophysiological process of the infection. In this scenario, the client is diagnosed with an infection caused by a yeast microorganism. The nurse will assess and make note of the manifestations related to the microorganism, along with other identifying features. The expected appearance of candidiasis infection is the appearance of white patches on the client's oral mucous membranes. Other more general manifestations would include redness and possible swelling. *Content Refresher* Mouth care is the process one takes to maintain healthy teeth, gums, and tongue. Abnormal changes in the mouth could be dryness, cracked tongue, missing teeth, teeth in bad repair, ill-fitting dentures, and the presence of lesions, foul odors, or discolorations. Risk factors for abnormal changes include poor oral hygiene, poor fluid intake, and certain medications such as an inhaled corticosteroid. When assessing a client's mouth, the nurse should inspect the lips, tongue, teeth or presence of dentures, gums, and oral mucous membranes. Note any foul odors, swelling, pallor, lesions, or drainage. The nurse needs to encourage the client to seek medical attention if lesions are present. Treatments will vary based on the cause.

The nurse provides care for clients diagnosed with dementia in a long-term care facility. A client's family member is trying to explain a financial issue to the client and expresses frustration to the nurse about the client's lack of insight into the problem. Which is the best response by the nurse? 1. "People with dementia are more confused at night. You should try to have this conversation in the morning." 2. "People with dementia take longer processing ideas. You need to explain more slowly and use pictures." 3. "Why are you talking to the client about the issue? Let me get the social worker to help you." 4. "That sounds frustrating. Poor judgment and memory deficits are part of the disease process."

1) INCORRECT - While many clients with dementia experience sundowning, there is no indication that the conversation is happening at night or that the client is experiencing sundowning. Clients with dementia have difficulty with insight and memory. 2) INCORRECT - Longer processing times are common in older adult clients. But clients with dementia have difficulty with insight and memory, making it difficult for them to follow a conversation or engage in problem-solving. 3) INCORRECT - The nurse should avoid the use of "why" as this is non-therapeutic. A social worker may be helpful, but the nurse should first empathize and assess the situation further. 4) CORRECT— In this response, the nurse first provides empathy and then provides objective information on the disease process. *Think Like A Nurse: Clinical Decision Making* Validation is a technique that the nurse can use to recognize and acknowledge the client's and family's thoughts, feelings, and needs. Hearing "That sounds frustrating. Poor judgment and memory deficits are part of the disease process," the family member will know that he or she is being heard and taken seriously when the nurse addresses the issue. The nurse should explore with the client's family member the ability to cope and offer practical advice to address frustrations. *Content Refresher* The objective of therapeutic communication is to establish a trusting, effective, client-centered, and goal-directed professional relationship with the client and the client's family members. Stating to the family member, "That sounds frustrating. Poor judgment and memory deficits are part of the disease process," is therapeutic, encourages the expression of thoughts and feelings, and presents reality regarding the client's disease process. The nurse should avoid non-therapeutic techniques, such as reassuring, rejecting, approving or disapproving, agreeing or disagreeing, giving advice, belittling, stereotyping, probing, and using denial.

The client reports, "I can't get warm. I'm cold all the time" to the nurse. The client's spouse reports recent behavior changes and forgetfulness. The client is unsure when daily medications were taken last. The nurse notes the client has periorbital edema and a flat affect. Vital signs reveal T 95.6°F (35.3°C); BP 100/60 mm Hg; pulse 58 beats/min; respirations 26 breaths/min. Laboratory data reveal serum pH 7.25; PaCO2 50 mm Hg; HCO3 23 mEq/L; serum T4 is 4.2 mcg/dL; serum TSH 6.3 mcg/dL. Which action does the nurse take when providing client care? (Select all that apply.) 1. Reorient client every 15 minutes. 2. Administer oral levothyroxine sodium. 3. Administer intravenous (IV) hydrocortisone. 4. Obtain a stat 12-lead electrocardiogram (ECG). 5. Place client on continuous cardiopulmonary monitoring.

1) INCORRECT — The client is conscious and alert, so reorienting doesn't apply at this time. 2) CORRECT— The client has advanced hypothyroidism. The initial and least invasive treatment to prevent myxedema coma is oral T4 replacement therapy. 3) INCORRECT — IV hydrocortisone is administered when a client is unconscious or unable to swallow. This client is conscious. 4) INCORRECT — A stat 12-lead ECG is obtained immediately after acute cardiac changes or symptoms of acute coronary syndrome are identified (e.g., ST elevation, reports of chest pain), and then typically after pharmacologic treatment is initiated. 5) CORRECT— The client is at risk for acute cardiopulmonary changes. The continuous monitoring captures acute changes in cardiac rhythm and oxygenation (O2 sat). Blood pressure can be monitored in time intervals, usually every 5 to 15 minutes, and provides real-time data for emergent response. *Think Like a Nurse: Clinical Decision-Making* The client is experiencing hypothyroidism and needs interventions to support metabolic functioning. Thyroid replacement medication should be immediately provided. Continuous cardiac monitoring should be implemented due to the risk of cardiovascular effects. *Content Refresher* The client is experiencing myxedema resulting from hypothyroidism. If hypothyroidism remains untreated, myxedema coma may occur. The nurse should monitor vital signs, weigh the client, encourage increase in fluid intake and provide foods high in fiber to prevent constipation, promote periods of rest, implement measures to keep the client warm, implement interventions to maintain skin integrity, and address any early signs of skin breakdown. Levothyroxine (thyroxine, T4) is the drug of choice to treat hypothyroidism. A thyroid replacement medication must be taken for life.

The nurse provides care for a client diagnosed with migraine headaches. Which statement indicates to the nurse that the client understands migraine triggers? (Select all that apply.) 1. "I should take propranolol after the migraine begins." 2. "I should track the number of hours I sleep each day." 3. "Avoiding red wine, even at parties, is essential to prevention." 4. "I need a new favorite snack now that I can't eat cheddar cheese." 5. "Topiramate is taken before situations that cause migraines." 6. "Zolmitriptan will prevent migraines if I take a dose weekly."

1) INCORRECT — The client is incorrect because this medication is not taken on as needed basis. Propranolol is a beta-blocker medication that is often prescribed to prevent migraines. This prophylactic medication is titrated up to an optimal dose over a period of weeks. 2) CORRECT— Sleep deprivation is a migraine trigger. The client uses a journal to record food, sleep, and other common triggers or patterns. 3) CORRECT — Sulfites are used as preservatives in red wine and can cause migraines. In addition, alcohol increases blood flow to the brain and can cause dehydration, both known triggers. 4) CORRECT— Aged cheese contains tyramine, a migraine trigger. 5) INCORRECT — Topiramate is an antiseizure medication that is often prescribed to treat migraines. It is not taken on an as needed basis. The dose is titrated up to an optimal dose over about four weeks. 6) INCORRECT — Zolmitriptan is a triptan medication that is often prescribed to treat migraines. It is taken only when the client experiences a headache or an aura (flashing lights, dark spots). It is not used to prevent migraines. *Think Like a Nurse: Clinical Decision-Making* Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. Migraine triggers varies among clients. The nurse should explore with the client about specific triggers such as menstruation cycle, salty food, monosodium glutamate (MSG), alcohol, and weather changes. *Content Refresher* The priority treatment goals for migraines are pain relief and preventing reoccurrence. Medications such as triptans, which inhibit serotonin reuptake, cause vasoconstriction, reduce inflammation, and may reduce pain transmission. Ergotamine preparations may also be prescribed to reduce the pain. Medications to prevent the onset of migraines include anti-seizure medications, beta blockers, calcium channel blockers, and anti-depressants (SSRIs and SNRIs). Clients should also be assisted with identifying triggering factors (i.e. foods such as fermented/pickled foods, caffeine, monosodium glutamate, aspartame, red wine, and aged cheeses), as well as assisted with lifestyle changes to eliminate these factors.

The nurse receives a phone call from a person who states, "The client in room 203 is my family member. Can you give me a status update?" Which response by the nurse is appropriate? 1. "The client is requiring intravenous pain medications." 2. "The client is scheduled for a colonoscopy in the morning." 3. "The client is receiving aggressive antibiotic therapy." 4. "I am unable to give you any information at this time."

1) INCORRECT — This statement violates the client's protected health information (PHI). 2) INCORRECT — This statement violates the client's PHI. 3) INCORRECT — This statement violates the client's PHI. 4) CORRECT— The nurse should always exercise caution about the release of information on the phone because it is difficult to accurately identify the caller. *Think Like A Nurse: Clinical Decision Making* All health care providers and client care personnel should be acutely aware that client information is kept confidential. Failure to do so is seen as a violation of the Health Insurance Portability and Accountability Act (HIPAA) regulation. The nurse performs many roles, one of which is to ensure the privacy and confidentiality of the clients. When faced with a situation in which client confidentiality may be compromised, the best action for the nurse to take is to refuse to share information. At no time should the nurse provide information to someone who has not been identified by the client as a person who can receive such information. *Content Refresher* Confidentiality is the right of an individual to have personal, identifiable medical information kept private. Confidentiality is how nurses treat private information once it has been disclosed to them. Never assume the right to look at any type of client health information unless it is needed to do the job. Unless otherwise instructed to do so by the client, nurses should not discuss or share information regarding client care or diagnosis with family, friends, co-workers, other nurses, insurance providers, or financial aid organizations.

The nurse reviews nutrition with a client who plans to breastfeed for the next 6 months. Which client statement indicates to the nurse that teaching was successful? 1. "I will mix baby cereal in a formula bottle when I am ready to give my baby cereal." 2. "My breast milk should be discarded if left in the freezer for 3 months." 3. "I should introduce fortified cereal at 2 months of age." 4. "My breast milk contains iron that is more easily absorbed than iron-fortified formula."

1) INCORRECT- Cereal should not be mixed into the formula bottle when feeding the healthy newborn. It should be fed by spoon. 2) INCORRECT- Breast milk can be stored in a freezer for 6 months. 3) INCORRECT- Solid foods should be introduced at age 6 months and fed by spoon to the newborn. 4) CORRECT - While the amount of iron in breast milk is less than that in iron fortified formula, it is more easily absorbed by the infant. Neonates born at term have enough iron stores from the mother to last for the first 4 months of life. *Think Like a Nurse: Clinical Decision-Making* The new mother has a variety of teaching needs. One of the major learning deficits is that of providing nutrition to the newborn. When preparing teaching for the mother, the nurse should consider, "What information does a breastfeeding mother need regarding nutrition for the newborn?" One nutrient that is present in breast milk is iron. Because the baby is breastfeeding, the mother's iron stores will support the baby for the first few months. This is information that the nurse should emphasize with the mother. *Content Refresher* When providing care for a pregnant or postpartum client, ask about the mother's plan for feeding the newborn. Assess the mother's understanding that breast milk is the best form of nourishment for newborns and infants, particularly in the first six months of life. Assist mothers in learning to breastfeed their babies and in recognizing the signs that indicate adequate nutrition. Educate mothers about the number of wet and soiled diapers the baby should have each day. Breastfed infants benefit from the introduction of iron-fortified cereal, fed with a spoon, between 4 to 6 months of age. Babies who were born early (before 37 weeks) or at a low birth weight (less than 5 pounds, 8 ounces, or 2.6 kg) need special nutrition to meet their growth and development needs.

The nurse provides care for clients in the pediatric clinic. The nurse performs an assessment of a toddler-age client. The nurse recognizes appropriate cognitive development when the client exhibits which behavior? 1. Removes wet diaper and discards it. 2. Cries when parent leaves sight. 3. Builds block castle with playmate. 4. Draws a picture of a dinosaur.

1) CORRECT— According to Erikson's stages of psychosocial development, from 12 months to 3 years the toddler learns self-control and how to directly influence the environment. Failure to develop autonomy results in defiance and negativism, shame and doubt. Toddlers who remove their own diaper, try toilet training, attempt to dress themselves, or say no when offered food are exercising autonomy. 2) INCORRECT - From birth to 18 months, the infant learns to trust self and others through the interaction with a predictable and dependable caretaker. Demonstrations of separation anxiety are common at this age while learning that parents will return. If the infant does not learn to trust, the person will demonstrate insecurity in interpersonal relationships and all unfamiliar experiences throughout life. 3) INCORRECT - Preschoolers begin to evaluate their own behavior and learn limits on their influence in the environment. Taking initiative in activities, social interaction, and demonstrating ambition in completing activities is the correct task for this age group. The negative outcome is the person becomes fearful, pessimistic, and lacks self-confidence. 4) INCORRECT - The school-age child develops a sense of self-confidence and uses creative energies to influence the environment. Failure to develop industry results in feelings of inadequacy, mediocrity, and self-doubt. *Think Like A Nurse: Clinical Decision Making* Young toddlers engage in tertiary circular reactions and progress to mental combinations. Rather than just repeating a behavior, the toddler is able to experiment with a behavior to see what happens. By 2 years of age, toddlers are capable of using symbols to allow for imitation. With increasing cognitive abilities, toddlers may now engage in delayed imitation. For example, they may imitate a household task that they have observed a few days ago. *Content Refresher* When assessing a toddler's psychosocial development, assess family dynamics, environmental opportunities for the child to demonstrate independence, child's behaviors during play, presence of separation and stranger anxiety, child's temperament, and child's readiness for toilet training. Provide opportunities for socialization, emotional support, and positive reinforcement for good behavior; distract the child from participating in unsafe or unwanted behaviors; keep routines simple and consistent; set reasonable limits; give simple rationales; provide two selections when providing child with a choice; and follow through on discipline.

The nurse provides care for a client in an outpatient clinic who reports vaginal itching. Which recommendation to the client by the nurse is appropriate? 1. "Supplement your diet with yogurt and dairy products. " 2. "Douche with an over-the-counter preparation. " 3. "Wash the area with soap and water several times a day. " 4. "Wear underwear that is lined with a cotton crotch. "

1) INCORRECT - These foods contain bacilli that naturally exist in gastrointestinal tract, but they have no effect on vaginal pH. 2) INCORRECT - Douching may alleviate discomfort of vaginal discharge but would disrupt normal pH of the vagina. Douching is not recommended. 3) INCORRECT - This frequency of washing would cause dryness and increase itching in the vaginal area. 4) CORRECT - Cotton-lined underwear is more absorbent and allows for better circulation of air to the body. Dampness aggravates itching. *Think Like a Nurse: Clinical Decision-Making* The client diagnosed with vaginitis is reminded to maintain proper hygiene. Vaginal sprays or heavily perfumed soaps are not recommended. Douching may cause irritation and, more importantly, could hide or spread an infection. It also removes the healthy bacteria around the vagina. Douching is never recommended. The client is informed to avoid clothes that hold in heat and moisture. Tight jeans, non-breathable gym shorts and leggings, nylon underwear, and pantyhose without a cotton panel can lead to yeast infections. The client should be screened for risk for sexually transmitted infection and be treated accordingly. *Content Refresher* Vaginal itching, discharge, burning, and painful urination are symptoms of vaginitis. Risk factors for vaginitis include hormonal changes; sexual activity; sexually transmitted infections; medications (e.g., antibiotics, steroids); uncontrolled diabetes mellitus; use of bubble bath, vaginal deodorants, and sprays; and frequent douching. Prepare the client for a pelvic exam. If infection has evolved into pelvic inflammatory disease (PID), treat it immediately to prevent damage to reproductive organs. If the client is pregnant, treat the infection with medications as prescribed to prevent preterm labor, miscarriage, or low birth weight.

The nurse provides care for clients on a cruise ship. The nurse interviews several clients who are experiencing severe vertigo unrelieved by dimenhydrinate. Which client does the nurse assign to see the health care provider first? 1. A client with a temperature of 100°F (38°C) who complains of hearing loss in the right ear. 2. A client who reports that objects seem to be moving around him. 3. A client who has a full feeling in the ear with a crackling and popping sound. 4. A client who reports ringing in the ears and occasional vertigo.

1) CORRECT— This client has symptoms that indicate infection. This is the priority client. 2) INCORRECT - This client is experiencing the symptoms of vertigo, which is uncomfortable for the client but not life-threatening. The client with an infection takes priority. 3) INCORRECT - This client is experiencing the symptoms of serous otitis media related to eustachian tube obstruction. This can occur due to flying or scuba-diving and does not require treatment. The client with an infection takes priority. 4) INCORRECT - This client is experiencing tinnitus, which is uncomfortable for the client but is not life-threatening. The client with an infection takes priority. *Think Like A Nurse: Clinical Decision Making* The client with the infection is the priority in the scenario described. Though not restricted solely to acute infections, the following are highly suggestive that infection may be present: abrupt onset of fever; high fever, greater than 102°F to 105°F (38.9°C to 40.6°C), without chills; respiratory symptoms; malaise, muscle and joint pains, photophobia, headache; nausea, vomiting, diarrhea; lymph node enlargement; and meningeal signs. The nurse should consider that an older adult with an infection will have atypical manifestations, such as delirium, falls, and incontinence. *Content Refresher* Otitis media is an inflammatory disease of the middle ear. Infection in the middle ear results from migration of bacteria and viruses up the eustachian tube to the middle ear. Risk factors for otitis media include respiratory infection, influenza, bottle-fed infants, Down syndrome, children who attend day care, those with cleft palates or poor immune systems, allergies, post-nasal drainage, sinus infections, cystic fibrosis, asthma, family history of ear infections, and male gender. Administer antibiotics and oral and topical analgesics, as prescribed. Position client with head elevated and instruct the client to lie on the unaffected ear. Assess hearing frequently. Tympanic membrane perforation is a complication of otitis media.

The nurse provides care for a 3-month-old infant diagnosed with developmental dysplasia of the left hip. The health care provider prescribes a Pavlik harness. The nurse instructs the parent about how to care for the infant in the harness. Which statements by the parent indicate to the nurse that additional teaching is necessary? (Select all that apply.) 1. "I need to place a shirt under the chest straps. " 2. "I should check for reddened areas under the straps." 3. "I should place my baby 's diaper over the straps. " 4. "I will adjust the harness every couple of weeks . " 5. "I will avoid swaddling my baby's legs. " 6. "I will place knee socks on my baby. "

1) INCORRECT - Placing a shirt under the chest strap prevents skin irritation. This is an appropriate action when caring for an infant in a Pavlik harness. 2) INCORRECT - It is important to check the skin for reddened areas under the straps as this prevents skin breakdown. This is an appropriate action when caring for an infant in a Pavlik harness. 3) CORRECT— The diaper should be placed under the straps of the Pavlik harness. This statement by the parent would require additional teaching. 4) CORRECT— The straps of the Pavlik harness may require adjustment every 1 -2 weeks because of the infant 's growth. However, this should be done by a health care provider, not the parent. This statement would require additional teaching. 5) INCORRECT - The parent needs to avoid swaddling the infant's legs together. This is an appropriate action when caring for an infant in a Pavlik harness. 6) INCORRECT - Placing knee socks on the infant will prevent skin breakdown. This is an appropriate action when caring for an infant in a Pavlik harness. *Think Like a Nurse: Clinical Decision-Making* Before evaluating teaching provided, the nurse should recall the pathophysiological process of the health problem for which the treatment is prescribed. The Pavlik harness is used for a client with hip dysplasia or dislocation of the hip joint. Treatment with the harness is done to keep the joint from dislocating. The device is to be kept on the client continuously. The skin under the harness should be kept dry and free from excoriation. The device should not be adjusted by the parents; however, adjustments may be done by the health care provider during routine follow-up appointments. *Content Refresher* Dysplasia of the hip is a hip socket that does not fully cover the ball portion of the upper thighbone. As a result, the hip joint becomes partially or completely dislocated. Most clients with hip dysplasia are born with the condition. Infants may have one leg longer than the other and one hip may be less flexible than the other. The age of the client and the extent of the hip damage will determine which treatment is necessary. Infants are usually treated with a Pavlik harness, which is a soft brace that holds the ball portion of the joint firmly in its socket for several months to help the socket mold to the shape of the ball.

The home health nurse visits an older adult client with diabetes and osteoporosis. The client lives with an adult child in a two-story home. Which statement by the child most concerns the nurse? 1. "My parent loves taking a hot bath with scented bath oil." 2. "My parent is taking more interest in daily activities." 3. "I feel guilty leaving my parent alone, even for half an hour." 4. "I am not sure what we are going to do when winter comes."

1) CORRECT- The hot bath with oils presents a safety risk. Oils in the bath water can result in a slippery shower or bathtub surface. This is particularly concerning for the client with osteoporosis. Hot bath water can dry or damage the skin. The client with diabetes may have neuropathy, which can decrease the client's ability to perceive pain and recognize an injury. 2) INCORRECT- Increasing interest in activities and events is a positive occurrence and reflects an interest in life. If the client had a recent history of depression and was suddenly more energetic, this might suggest a risk for suicide. 3) INCORRECT- Expressing feelings of guilt may indicate that the adult child is overly focused on the caregiver role. This statement suggests the need to explore the caregiver's feelings and offer options, such as respite care. 4) INCORRECT- The nurse should further assess the child's concern about winter, but this is not of greatest concern. *Think Like A Nurse: Clinical Decision Making* This client has co-morbidities and multiple risk factors to consider. The client is older, will likely have altered gait stability, and lives in a home with stairs. Diabetes decreases sensation in the feet and increases risk of injury. Osteoporosis increases the risk of fractures. The client may experience vasodilation and hypotension after a hot bath and is creating slippery skin by using oil. The risk of injury is a more immediate threat compared to the other concerns and is a physiological need according to the Maslow hierarchy, making this the nurse 's priority. *Content Refresher* Osteoporosis is a condition in which bone density is lost. It is usually seen in older women. The loss of bone mass increases the risk of fractures. Determine if there has been a loss of height or a history of falls or fractures. Areas commonly fractured are the spine and the neck of the femur. Observe for kyphosis. Question the client about dietary intake and use of medications. Review vitamin D level. Instruct client about food sources of calcium, vitamin D, and protein. It is recommended that clients consume 1000 to 1500 mg of dietary calcium daily.

The nurse attends a conference on health promotion. Which statements by the nurse indicate a correct understanding of health promotion? (Select all that apply.) 1. "Having eyes tested for glaucoma is primary health prevention. " 2. "Participating in cardiac rehabilitation following a heart attack is secondary health prevention. " 3. "Having a Papanicolaou smear test is secondary health prevention. " 4. "Participating in a skin screening for cancer detection is primary health prevention. " 5. "Participating in physical therapy following a total knee replacement is tertiary health prevention. "

1) INCORRECT - Secondary prevention may be directed at individuals who are at risk for developing a disease. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having eyes tested for glaucoma is secondary health prevention. 2) INCORRECT - Participating in cardiac rehabilitation following a heart attack is tertiary health prevention 3) CORRECT - Secondary prevention may be directed at individuals who are at risk for developing a disease. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having a Papanicolaou smear test is secondary health prevention. 4) INCORRECT - Secondary prevention may be directed at individuals who are at risk for developing a disease. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Participating in a skin screening for cancer detection is secondary health prevention. 5) CORRECT - Tertiary prevention, also known as the treatment or rehabilitation stage of preventive care, is implemented when a condition or illness is permanent and irreversible. The aim of care is to reduce the number and impact of complications and disabilities resulting from a disease or medical condition. Participating in physical therapy following a total knee replacement is tertiary health prevention. *Think Like a Nurse: Clinical Decision-Making* Primary prevention activities promote health and protect against exposure to risk factors that lead to health problems (e.g., immunization). Secondary prevention focuses on activities to stop or slow the progression of disease (e.g., annual screening test). Tertiary prevention includes actions to prevent the progression of negative consequences of chronic conditions, reduce disability, and minimize suffering, as well as preventing complications and deterioration (e.g., cardiac rehabilitation). Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding. The nurse assesses a client 's risk and then screens the client for the condition. *Content Refresher* Primary prevention includes activities that promote health and prevent illness, such as nutritious diet, proper exercise, and immunizations. Secondary prevention includes identifying health issues at the earliest opportunity, along with preventing complications, such as biometric screening, physical examination, eye examinations, and mammograms. Tertiary prevention focuses on restoring individuals, families, or communities to their highest level of functioning, such as providing rehabilitation services. Assist clients in identifying specific health risks . Help clients set realistic health goals. Teach about illness prevention specific to the identified individual 's health risks. Provide support to promote behavior changes.

The nurse manager on the unit is fiscally responsible for meeting goals related to personnel and supply expenses. To meet budget expectations, it is important for the nurse manager to take which action? 1. Share budget expectations with the personnel on the unit. 2. Designate a staff nurse to assist with budget planning. 3. Post the budget on the bulletin board. 4. Ensure that provider needs are met.

1) CORRECT - Sharing the budget and monitoring activities with staff allows the staff to develop cost-conscious nursing practices. 2) INCORRECT - Staff nurses help meet budget expectations, but are not directly accountable for the budget process. 3) INCORRECT - It is not appropriate or useful to post the unit budget. 4) INCORRECT - When making budget decisions, make sure that client needs are being met. Client needs are the priority over provider needs. *Think Like A Nurse: Clinical Decision Making* Budgeting is a nurse manager's responsibility. However, adhering to the budget affects all staff. Explaining the budgetary constraints to the staff helps achieve adherence. Client needs are the priority. *Content Refresher* The professional behaviors expected of nurses are respect, responsibility, honesty, integrity, appearance, teamwork, belief in human dignity, client equality, and the desire to prevent and alleviate suffering.

The nurse observes a student nurse assess neonates in the nursery. Which student nurse action requires intervention by the nurse? 1. Documenting a negative red light reflex in a neonate who is two days old. 2. Testing the tonic neck reflex by lying the neonate supine and turning the head to one side. 3. Testing the rooting reflex by stroking the corner of the neonate's mouth. 4. Documenting a positive Babinski reflex in a neonate who is one day old.

1) CORRECT - A negative (absent) red light reflex indicates a severe neurological deficit, possibly caused by increased intracranial pressure. It must be evaluated immediately. 2) INCORRECT - This is an appropriate method of testing the tonic neck reflex. 3) INCORRECT - This is an appropriate method of testing the rooting reflex. 4) INCORRECT - This is appropriate documentation of a normal reflex. *Think Like a Nurse: Clinical Decision-Making* The nurse is aware that assessment techniques change according to the age of the client. When assessing a newborn, the nurse will use techniques that are appropriate for age and development of the client (special consideration is made for the client that is premature). The nurse needs to know what assessment findings are expected and which findings indicate an abnormality. A newborn should have red reflex when assessing the eyes. The absence of this reflex could indicate a severe neurological health problem that needs to be immediately reported to the health care provider for further evaluation and treatment. *Content Refresher* A red reflex examination is recommended for all neonates to screen for retinoblastoma. A lack of red reflex in the pupil is also known as "cat's eye." In addition, strabismus, is also sometimes present. Reddened eye(s), fixed pupil(s), and blindness are apparent as the condition worsens. The condition is diagnosed through indirect ophthalmoscopy under general anesthesia. Ultrasound, CT scan, and MRI are used to confirm and stage the tumor. Laser therapy combined with chemotherapy is most often used to treat the tumor(s) if diagnosed early. Hematopoietic stem cell transplantation, chemotherapy, and radiation are used when the condition is detected later in life.

The nurse provides medication teaching to a client who is prescribed valsartan. The client asks the nurse why the medication is required since lower leg swelling only occurs when standing too long. Which responses will the nurse make to this client? (Select all that apply.) 1. "It works by dilating blood vessels, which then reduces your blood pressure." 2. "This medication helps slow and strengthen your heartbeat, and that will give you more energy." 3. "Do you have a bathroom scale at home?" 4. "You may feel dizzy at first when taking this medication. Get up slowly to avoid falls." 5. "This medication is prescribed with a large dose at first, and then it is tapered off as the symptoms improve." 6. "If you are careful to elevate your legs for 30 minutes each hour, this medication will not be required."

1) CORRECT — Valsartan, an angiotensin II receptor blocker (ARB), causes dilation of blood vessels, decreases release of aldosterone, and increases renal excretion of sodium and water. 2) INCORRECT— Slowing and strengthening the heartbeat describes cardiac glycosides, not ARBs. 3) CORRECT — Measuring daily weight is important to determine changes in fluid volume in the client with heart failure. 4) CORRECT — Valsartan lowers blood pressure and can cause orthostatic hypotension. 5) INCORRECT— A low dose of this medication is initially prescribed and then increased or changed according to the status of the client's heart failure. 6) INCORRECT— Elevating the legs for half of each hour is unrealistic. Elevating the legs may be helpful but will not eliminate the need for pharmacologic treatment in heart failure. *Think Like a Nurse: Clinical Decision-Making* This client's question indicates a need for teaching related to both the client's health alteration and the desired effect of the prescribed medication. Valsartan, which is an angiotensin II receptor blocker (ARB), decreases blood pressure. Valsartan is prescribed for management of clients diagnosed with hypertension or heart failure. Research suggests valsartan improves survival among individuals diagnosed with heart failure. Peripheral edema may occur due to right-sided heart failure. Valsartan may increase excretion of sodium and water for some clients; however, valsartan is not specifically intended to decrease peripheral edema. The medication's therapeutic effects may not be perceptible to the client. *Content Refresher* For the client diagnosed with heart failure, assess vital signs, oxygen saturation, ECG, and urine output. Assess respiratory rate and effort, lung sounds, and use of accessory muscles for breathing. Assess for chest pain (angina), auscultate heart sounds, and monitor for cardiac dysrhythmias. Monitor the client's weight. Prescribed treatments for the client diagnosed with heart failure may include angiotensin receptor blocking drugs (ARBs), inotropic drugs, vasodilators, diuretics, angiotensin-converting enzyme (ACE) inhibitors, and aldosterone-blocking agents.

The nurse provides care for a client receiving prednisone. The nurse determines that teaching is effective when the client makes which statement? 1. "I should take the medication with a glass of orange juice. " 2. "I should take the medication with a full meal. " 3. "I should take the medication in between meals. " 4. "I should take the medication on an empty stomach. "

1) INCORRECT- Oral steroids cause GI upset, and a glass of orange juice may precipitate additional gastrointestinal irritation. 2) CORRECT- Oral corticosteroids cause gastric irritation and should be taken with meals. 3) INCORRECT- Prednisone is taken with a meal to reduce gastric irritation. 4) INCORRECT- Taking prednisone on an empty stomach may cause gastric ulcers and gastrointestinal bleeding. *Think Like A Nurse: Clinical Decision Making* Prednisone can cause gastric distress if taken on an empty stomach. To prevent this, the medication should be taken with a full meal. Orange juice can exacerbate gastric distress if taken with prednisone. Prednisone should be taken with meals and not between meals or on an empty stomach. *Content Refresher* When administering medication, the nurse should take the following steps. Plan to check for medication incompatibilities and interactions. Plan client education regarding medication administration. Verify the rights of medication administration, which minimally include right client, right medication, right time, right dose, right route, right site, and right documentation. Check allergies and identify the client following institutional policy. Inform the client about the medication, the reason for its administration, and how and when effectiveness will be determined. Assess for expected outcomes for the administered medication.

The nurse placed a client on therapeutic hypothermia 1 hour ago. Which action does the nurse take to determine whether the client is having an adverse reaction to therapeutic hypothermia? 1. Install a working suction setup. 2. Monitor the client for seizure activity. 3. Measure the Braden Scale score. 4. Assess bowel sounds every 2 hours.

1) INCORRECT— Installing a working suction setup is a part of the comprehensive management of the client. However, it does not address monitoring the client for an adverse reaction to therapeutic hypothermia. 2) CORRECT— The client is monitored for seizure activity, which is an adverse reaction to hypothermia. 3) INCORRECT— The Braden Scale is used to predict pressure injury risk. It is part of a routine assessment. It is not specific to clients receiving hypothermia. 4) INCORRECT— There is no reason to assess for bowel sounds every 2 hours while the client is on therapeutic hypothermia. *Think Like A Nurse: Clinical Decision Making* The nurse has a responsibility to understand the purpose, expectations, and unexpected responses to prescribed treatment. Therapeutic hypothermia is prescribed for serious conditions, such as after cardiac arrest. The nurse needs to be aware seizures are common in comatose clients receiving the prescribed therapy. The nurse might anticipate routine use of electroencephalogram (EEG) monitoring to assist in early detection of seizures in this client, providing an opportunity for intervention to potentially improve outcomes. The nurse should also remember that hypothermia, or a temperature less than 95.9°F (35.5°C), causes peripheral vasoconstriction, and a shift of the oxygen-hemoglobin dissociation curve to the left. A shift to the left indicates that less oxygen is released from hemoglobin to the tissues, causing tissue hypoxemia. *Content Refresher* Therapeutic hypothermia is induced after a client regains a return of spontaneous circulation (ROSC) after cardiac arrest. Therapeutic hypothermia is recommended for all clients who are comatose or who do not follow commands after ROSC. Therapeutic hypothermia reduces the cerebral metabolic rate for oxygen. Protocols vary among institutions, with the goal temperature ranging between 89.6°F to 96.8°F (32°C to 36°C). Closely monitor the client's cardiac rhythm, mean arterial pressure, potassium level, and glucose level. The client remains in the hypothermic state for 24 hours, and then passive rewarming occurs over a period of 8 to 12 hours.