Study set 7 for RN NCLEX (Kaplan)

The nurse supervises care of clients at the local eye care center. The nurse determines that care of a client immediately after intracapsular cataract extraction is appropriate if the unlicensed assistive personnel (UAP) performs which action first? 1. Raises the head of the client 's bed 35 degrees. 2. Places an emesis basin at the client 's bedside. 3. Tapes the eye shield securely with paper tape. 4. Measures the client 's intake and output.

1) CORRECT- Raising the head of bed 35 degrees prevents an increase in intraocular pressure, which is a major complication following this procedure. This action by the UAP demonstrates appropriate care. 2) INCORRECT- Vomiting increases intraocular pressure and should be reported to the nurse and the health care provider immediately. Giving the client an emesis basin is not the appropriate first action. 3) INCORRECT- Securing the eye shield with paper tape is not within the scope of practice of the UAP. This is not an appropriate action by the UAP. 4) INCORRECT- The priority is placing the client in a semi-Fowler position to prevent increased intraocular pressure. Measuring the client 's intake and output is not the appropriate first action. *Think Like A Nurse: Clinical Decision Making* Currently, intracapsular cataract extraction (the entire lens is removed with the capsule intact) is rarely performed. More commonly, extracapsular extraction is done, in which the anterior capsule is opened and the lens nucleus and cortex are removed, leaving the capsule bag intact. The nurse should be familiar with appropriate task delegation to the UAP. Keeping the client 's head of bed at 35 degrees will reduce intraocular pressure. The nurse also may have to teach the client to avoid bending, stooping, coughing, or lifting during the immediate post-operative period. *Content Refresher* Although complications from cataract surgery are unusual, the following complications can occur: infection, detached retina, increased intraocular pressure, bleeding, and lens displacement. Recovery from cataract surgery typically takes 4 to 8 weeks. It is suggested that clients wait 8 weeks before obtaining new corrective glasses.

The nurse provides care for a client diagnosed with a cerebrovascular accident (CVA). Which action by the nurse is most important when creating a teaching plan? 1. Ask the client to discuss perception of health status. 2. Identify the client 's strengths and weaknesses. 3. Encourage the client to discuss concerns with a client who has rehabilitated after a CVA. 4. Offer the client an anticipated schedule and written plan of therapy.

1) CORRECT— For teaching to be successful, the nurse should assess client 's perception about the health problem first. 2) INCORRECT - Although appropriate, it is more important to determine a client 's perceptions of health first. 3) INCORRECT - Assess before implementing interventions. Meeting with other clients is part of rehabilitation and a possible support group intervention. 4) INCORRECT - Assess a client before implementing a plan of care. *Think Like A Nurse: Clinical Decision Making* The client recovering from a cerebrovascular accident (CVA) has many teaching needs. However, before planning teaching for this client, the nurse needs to assess the client's perception of the health problem, which may differ from the nurse's perception. This information is used as a guide to direct learning needs and strategies to achieve client goals. The client is likely to be more compliant with the plan of care if the client agrees with the problem and interventions. This client's teaching will need to be in small increments and address basic physiologic and safety needs first. *Content Refresher* When providing client teaching about stroke, the nurse should determine the learner 's knowledge level and previous experiences. Assess the client's perception of their health status. Create a positive learning environment. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Emphasize the information in a context relevant to the learner. Allow for the client to 'teach back' to nurse with sufficient amount of time, type, and variability for learners to become proficient. Provide feedback, allowing time for reflection. Encourage feedback regarding the instructional methods.

Several hours after an oxytocin infusion is started, a client 's contractions are sustained over 2 minutes. Which nursing action is most important for the nurse to take? 1. Discontinue the IV oxytocin. 2. Administer oxygen. 3. Reposition the client. 4. Decrease the IV oxytocin rate.

1) CORRECT— Sustained contractions can lead to a ruptured uterus or fetal distress. The IV oxytocin is stopped immediately. 2) INCORRECT - The administration of oxygen is important if fetal distress is apparent. This is not the most important action. 3) INCORRECT - This is important if fetal distress is apparent. 4) INCORRECT - This action is not appropriate for this situation. A client would continue to receive oxytocin, and it must be discontinued. *Think Like A Nurse: Clinical Decision Making* The nurse closely monitors any client in labor who is receiving IV oxytocin for adverse reactions to therapy. Uterine hyperstimulation, one such adverse reaction, occurs when one contraction lasts 2 minutes or longer or when five or more contractions occur within 10 minutes. This occurrence may cause fetal distress or uterine rupture. The nurse should consider the cardiovascular compensation that must take place when decelerations occur with a contraction, as well as the maternal heart rate necessary to maintain adequate uteroplacental blood flow and oxygenation. Therefore, the priority action in this situation is to stop the infusion. *Content Refresher* Oxytocin, a naturally occurring pituitary hormone, causes uterine contractions. Synthetic oxytocin is used to stimulate uterine contractions for labor induction. It works by increasing calcium ion concentration inside the muscle cells that control uterine contraction. An increase in calcium increases uterine contraction. Assess the client 's heart rate and blood pressure every 15 minutes to maintain safe induction. Monitor uterine contractions and fetal heart rate. Contractions should occur no more frequently than every 2 minutes and last no longer than 70 seconds. Stop the IV infusion if the contractions become more frequent or last longer than the safe limits, or upon signs of fetal distress.

The charge nurse precepts a newly-hired nurse. Which action by the new nurse would requires an intervention by the charge nurse? 1. The nurse tests the plantar reflex with a pointed object and notes flexion of all toes. 2. The nurse assesses a client's muscle strength by asking the client to push the foot against the nurse's hand. 3. The nurse assesses a client's grip strength by asking the client to squeeze the nurse's first two fingers of both hands. 4. The nurse obtains a Glasgow Coma Scale (GCS) score by asking the client to count backwards from 100 by 3s.

1) INCORRECT - Babinski's sign is dorsiflexion of the great toe and fanning of the other toes, which is an abnormal reflex in response to testing the plantar reflex with a pointed (but not sharp) object. This indicates the presence of central nervous system disease. The normal response is plantar flexion of all toes. 2) INCORRECT - Muscle strength can be assessed by asking to move against resistance, such as asking the client to push the foot against the nurse's hand. 3) INCORRECT - Having the client grip the first two fingers on each hand assesses muscle strength. The response should be bilaterally equal. The grip should be tight and with full flexion. 4) CORRECT - Glasgow Coma Scale is an objective and widely accepted tool for neurologic assessment and documentation of level of consciousness. It establishes baseline data for eye opening, motor response, and verbal response. The client is assessed and assigned a numerical score for each of these areas. A score of 15 represents normal neurologic functioning, and a score of 3 represents a deep coma state. *Think Like A Nurse: Clinical Decision Making* One of the functions of the professional nurse is to correctly complete a physical assessment. The nurse is aware that different techniques and tools can be used when assessing the body systems; however, the techniques and tools must be used correctly and for the specified purpose. The neurologic system is complicated to assess and includes cognition, cranial nerves, sensory and motor function, and reflexes. One common standardized assessment tool that can be used to assess a client's level of consciousness is the Glasgow Coma Scale. This scale assigns a numeric value to the response provided for verbal ability, motor activity, and eye opening. This scale does not ask the client to perform a complicated math calculation. *Content Refresher* The Glasgow Coma Scale (GCS) is a standardized assessment tool that uses scaled scores to assess level of consciousness. The components of level of consciousness that are assessed using the GCS are: verbal response, motor response, and eye opening. Scores are rated in each category for the client's best response. The higher score indicates a higher level of neurological functioning with a range of 3 to 15. To assess a client's verbal response, the nurse would engage the client in conversation and ask questions of orientation. Motor response is assessed at the highest level when the client is asked to perform a simple motor skill and does so correctly. Eye opening is assessed by spontaneously opening eyes when someone approaches. Changes from the client's baseline should immediately be reported to the health care provider.

The nurse screens clients at a health fair. The nurse recommends priority follow-up with a health care provider for which client? 1. The client with an apical pulse of 54 beats/min who is a marathon runner. 2. The client with a family history of coronary artery disease who drinks one to two glasses of red wine nightly. 3. The client with a body weight that is 20% more than recommended who has a glycated hemoglobin (HbA1C) level of 5.8%. 4. The client with a blood pressure of 162/96 mm Hg who stopped smoking 2 weeks ago.

1) INCORRECT - Long-term exercise conditions the heart, resulting in a lower rate at rest and quicker return to resting level after exercise. This client does not need to be seen by a health care provider. 2) INCORRECT - A family history of coronary artery disease (CAD) and drinking one to two glasses of red wine nightly do not indicate that the client needs to be seen by a health care provider. There is no documented association of wine with CAD. 3) INCORRECT - A hemoglobin A1C (Hb A1C) level of 4% to 6 % is normal. The test indicates the amount of glucose linked to hemoglobin. This client does not need to be seen by a health care provider. 4) CORRECT - The client is demonstrating stage 2 hypertension. The relationship between hypertension and cardiovascular events is direct and independent of other risk factors. The higher the client's blood pressure is, the greater the chance for coronary, cerebral, renal, and peripheral vascular disease. This client needs to be evaluated. *Think Like A Nurse: Clinical Decision Making* The nurse needs to analyze each client's presenting symptoms and the impact these symptoms have on the client's immediate health. Since there are variations to "normal," the nurse should focus on those symptoms that are abnormal. The marathon runner would have a naturally occurring lower heart rate because of cardiovascular conditioning. For some clients, red wine is recommended to prevent the development of cardiovascular disease. A hemoglobin A1c level that is within the normal range is not a concern. The client who has an elevated blood pressure despite removing a risk factor is of the greatest concern and should receive follow-up evaluation and treatment. *Content Refresher* An abnormal blood pressure or hypertension is a pressure higher than 120/80 mm Hg. Age, heart defects, diabetes mellitus, atherosclerosis, obesity, consumption of caffeine, and use of tobacco products are risk factors for hypertension. With hypertension, there may be no symptoms or the client may report headache, dizziness, blurred vision, and fatigue. If the client's blood pressure is abnormal, treatment may consist of nutrition modification (lowering sodium intake), exercise, cognitive behavioral therapy, and anti-hypertensive medications. Complications associated with hypertension include aneurysms, chronic kidney disease, cognitive changes, eye damage, heart attack, heart failure, peripheral artery disease, stroke, hypertensive crisis, and sudden death.

Which skin manifestation in a newborn most concerns the nurse? 1. Irregularly shaped pink patches on the nape of the neck. 2. Diffuse bluish-purple areas on the buttocks. 3. A solitary, flat, black plaque on the lower abdomen. 4. Red, raised, rough-surfaced, clearly delineated nodules.

1) INCORRECT - Telangiectatic nevi or "stork bites" may be pink or red and are often on the nape of the neck and/or on the eyelids, between the eyebrows, on the nose, or the upper lip. These fade as the client gets older. 2) INCORRECT - Mongolian spots may be bluish-black or gray-blue or purple, and may be mistaken as bruises initially. They usually appear in the sacral and/or gluteal area, back, or shoulders. They are common in newborns of African, Asian, Native American, or Hispanic descent, and gradually fade during the first or second year of life. 3) CORRECT - A congenital melanocytic nevi requires follow up due to the potential for malignancy. 4) INCORRECT - Strawberry hemangiomas are benign cutaneous capillary tumors that gradually disappear, usually in the first year of life. *Think Like A Nurse: Clinical Decision Making* The newborn with congenital melanocytic nevi requires further evaluation because as the child reaches adolescence, the incidence of melanoma increases substantially, with a rate of 13.2 cases per million children aged 15 to 19 years. A referral for dermatologic consult is warranted when a congenital melanocytic nevi is noted. *Content Refresher* Care of the newborn begins with assessments immediately after birth. Assess the newborn's respiratory effort, skin color, activity level, heart rate and rhythm, grimace, sucking effort, muscle tone, stimulation, overall responsiveness, length, weight, head and chest circumference, presence of lanugo and vernix, skin discoloration, and fontanelles. Administer prophylactic eye treatments and vitamin K. Obtain client's blood for newborn screening tests. Perform hearing screening. Use bulb syringe to clear secretions. Complete bath after temperature has stabilized. Assess the parents' interactions with the newborn.

The nurse in the pediatric clinic performs a physical assessment on an adolescent male client. Which finding by the nurse requires an immediate intervention? 1. The client reports his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes. 2. The nurse notes that the client has unilateral breast enlargement. 3. The client's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass. 4. The client's scrotum appears enlarged and red. The nurse palpates a thickened and swollen spermatic cord.

1) INCORRECT - These findings represent a varicocele, which is a scrotal mass due to enlarged veins of the spermatic cord. The client may require a scrotal support if uncomfortable. Varicoceles are a major cause of male infertility, but this is not an emergency situation. 2) INCORRECT - This finding represents gynecomastia. Transient gynecomastia occurs in approximately half of adolescent boys and may be either unilateral or bilateral. It usually lasts about 1 year before resolution. 3) INCORRECT - These findings represent an inguinal hernia, which is the protrusion of a loop of bowel into the scrotum. While the nurse should refer the client to a health care provider for further evaluation, this is not an emergency situation. 4) CORRECT - These findings represent torsion of the spermatic cord. This is very painful and is an emergency situation, which requires immediate surgical repair. Testicular torsion is the most common cause of testicular loss in young males due to hypoxic injury to the testicle. *Think Like a Nurse: Clinical Decision-Making* The nurse needs to mentally ask, "What should normally be expected when inspecting the genitals of an adolescent male?" The nurse is also aware that a thickened and swollen spermatic cord is not normal and could indicate testicular torsion, which is a surgical emergency. The client needs immediate intervention to prevent the loss of a testicle. The nurse needs to be aware that testicular torsion is most common among younger male clients. This population needs to be taught that any pain in the genitals should be reported immediately to a parent or health care provider. *Content Refresher* Adolescence is the period of time in which individuals become physically (puberty) and psychologically mature as they move from childhood to adulthood. Educate the adolescent about expected growth and development (physical and sexual). If high-risk behaviors are detected (tobacco, alcohol, and drug use, and sexual practice), intervene appropriately. Obtain a room to promote privacy when interviewing, examining, and educating the adolescent.

The nurse reviews the medical records of clients in the outpatient clinic. Which client has the greatest risk of developing type 2 diabetes mellitus (DM)? 1. A 26-year-old African American who follows a weight reduction diet and exercises three times per week. 2. A 36-year-old Caucasian who gave birth an 8-lb (3.6 kg) neonate, and whose mother-in-law has type 1 DM. 3. A 46-year-old Asian American who has a history of hypertension and whose blood cholesterol is normal. 4. A 56-year-old Native American who is 5'8" tall, weighs 200 lb (90.7 kg), and has two siblings diagnosed with type 2 DM.

1) INCORRECT - This client has one risk factor related to race. Weight reduction and exercise helps to prevent type 2 DM. 2) INCORRECT - This client has no risk factors. Newborns weighing more than 9 lb (4 kg) and family history (parents or siblings) are risk factors. 3) INCORRECT - This client has three risk factors of age greater than 45, Asian American ethnicity, and a history of hypertension. 4) CORRECT - This client has four risk factors and is of the highest risk. The risk factors are an age greater than 45, being Native American, obesity, and a family history of DM. Instruct the client to reduce calories, maintain a low-fat diet, and to exercise regularly. *Think Like a Nurse: Clinical Decision-Making* When the nurse makes a comparison between clients for the possibility of a specific disease process, the nurse needs to review the expected manifestations of the disease. The nurse then needs to determine the client at highest risk by mentally asking, "Which assessment data for each client is an indicator for disease development?" The nurse needs to remember there are both modifiable and non-modifiable risk factors for the development of DM. Non-modifiable risk factors include race/ethnicity, gender, age, and family history. Modifiable risk factors include weight, diet, and activity level. *Content Refresher* Type 2 diabetes mellitus (DM) is characterized by insulin resistance or insufficient insulin production. In type 2 DM, the pancreas continues to make some insulin. However, the amount is insufficient to meet the body's metabolic needs. Risk factors include heredity, obesity (especially intra-abdominal obesity), race/ethnicity, hypertension, elevated triglycerides, elevated cholesterol, and low levels of high-density lipoprotein (HDL). The classic symptoms of DM include polyuria, polydipsia, polyphagia, and elevated blood glucose levels. The hyperglycemia in type 2 DM is less severe than in type 1 DM, so only polyuria and polydipsia are usually seen. Other signs/symptoms may include obesity, fatigue, history of repeated infections, and visual disturbances. Treatment of type 2 DM may include weight loss, dietary management, exercise, and the use of anti-diabetic agents.

The nurse on the medical unit reviews laboratory results on four clients. Which result causes the nurse to notify the health care provider? 1. Theophylline level 15 mcg/mL (82.25 µmol/L ) for a client diagnosed with emphysema. 2. Digoxin level 2.5 ng/mL (3.2 nmol/L) for a client diagnosed with heart failure. 3. International normalized ratio (INR) 2.5 for a client who takes warfarin. 4. Lithium level of 1.2 mEq/L (1.2 mmol/L) for a client diagnosed with bipolar disorder.

1) INCORRECT— The therapeutic range for theophylline is 10 to 20 mcg/mL (56 to 111 µmol/L). Toxicity occurs with levels over 20 mcg/mL (111 µmol/L). Theophylline is a xanthine-derivative bronchodilator. 2) CORRECT — The normal therapeutic level of digoxin in the blood is between 0.5 and 2 ng/mL (0.6 to 2.6 nmol/L). The client with a digoxin level of 2.5 ng/mL (3.2 nmol/L) has digoxin toxicity, and this should be reported to the health care provider. Digoxin is a cardiac glycoside and a positive inotrope. 3) INCORRECT— The therapeutic range for the INR for a client prescribed warfarin varies by diagnosis, but it is generally 2 to 3. The optimal dose of warfarin prolongs the prothrombin time, which reduces the risk for clotting. 4) INCORRECT— The therapeutic range for lithium dosage is 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). Lithium is a medication used to treat bipolar disorder, particularly acute mania. *Think Like a Nurse: Clinical Decision-Making* Certain medications require periodic blood tests to evaluate the blood level of the medication, the medication's effects, or both. Medications for which blood level monitoring is indicated include theophylline, digoxin, and lithium. For clients who are prescribed warfarin, monitoring of prothrombin time (PT) and international normalized ratio (INR) is indicated. The client who experiences digoxin toxicity is at high risk for cardiac dysrhythmias. Implement continuous ECG monitoring and immediately notify the health care provider of the client's elevated serum digoxin level. Potential causes of digoxin toxicity include excessive consumption of digoxin, hypokalemia, and renal dysfunction. Further assessment is needed to determine the underlying cause of the client's increased digoxin level and the plan of treatment. *Content Refresher* Digoxin decreases heart rate and increases the force of heart contractions. Typically, digoxin is prescribed to clients diagnosed with heart failure or atrial fibrillation. Clinical manifestations of digoxin toxicity include abdominal pain, weakness, anorexia, nausea and vomiting, cardiac dysrhythmias, and visual changes, including blurred vision, halos around objects, and diplopia. Treatment for digoxin toxicity includes administering digoxin immune Fab.

The nurse assesses a client who had a thyroidectomy eight hours ago. The nurse notes that the client has a weak voice and hoarseness. Which is the best action from the nurse? 1. Tell the client this is likely due to edema. 2. Administer intravenous calcium gluconate. 3. Notify the health care provider immediately. 4. Monitor the client for esophageal bleeding.

1) CORRECT - Initial hoarseness after a thryoidectomy often occurs as a result of edema or use of an endotracheal tube during surgery and will subside. Persistent hoarseness may be indicative of a laryngeal nerve injury. 2) INCORRECT - Calcium gluconate is not indicated related to the signs observed. 3) INCORRECT - While it is appropriate for the nurse to document the client's hoarseness and notify the provider upon clinical rounds, immediate notification is not warranted. Persistent hoarseness could indicate laryngeal nerve injury and would require follow-up. 4) INCORRECT - This is unnecessary because the findings are unrelated to bleeding. *Think Like a Nurse: Clinical Decision-Making* The nurse is aware the client having a thyroidectomy will have an incision across the front of the throat in order to have the gland removed. The position of the body during the surgery and the use of a breathing tube can cause the throat to be irritated. The nurse needs to reassure the client recovering from a thyroidectomy that throat soreness is expected and a temporary manifestation. The nurse understands the importance of closely monitoring the client for actual complications, which include bleeding, thyroid storm, and hypocalcemia. During surgery, the parathyroid glands can accidentally be damaged (resulting in hypocalcemia), and after surgery, a thyroid storm can occur if remnants of thyroid tissue are left behind. *Content Refresher* Thyroidectomy is surgical removal of the thyroid gland and may be either a total removal or partial removal of the gland. It may be done for Grave disease, which is a frequent cause of hyperthyroidism, and for suspicious nodules. Complications following a thyroidectomy include bleeding or edema that obstructs the airway, electrolyte imbalance, and thyroid storm. Following removal of the thyroid gland, monitor dressings for bleeding. Assess vital signs and monitor for changes. Monitor for edema or swelling around laryngeal area and notify the health care provider, if indicated. Frequently evaluate fluid and electrolytes levels and administer supplemental doses as needed. Assess for Chvostek and Trousseau signs, which indicate hypocalcemia is present. Monitor calcium, phosphorus, and thyroid hormone levels (TSH, T3, T4) following surgery.

A client prescribed to receive a dose of nifedipine has a pulse rate of 50 beats per minute. Which action is the most appropriate for the nurse to take? 1. Withhold the medication. 2. Check urinary output. 3. Administer the medication. 4. Increase potassium intake.

1) CORRECT - Nifedipine is calcium-channel blocker used as an antihypertensive. Bradycardia is an untoward effect of this medication. The nurse should withhold the medication and notify the health care provider of the client's pulse rate. 2) INCORRECT - Checking urine output is appropriate if the medication is a diuretic. However, this is not a priority at this time. 3) INCORRECT - The medication could cause the heart rate to be even slower and would be dangerous. 4) INCORRECT - Adjusting potassium intake will not cause the client's heart rate to be within a normal range. *Think Like A Nurse: Clinical Decision Making* As a calcium channel blocker, nifedipine can slow down heart rate. However, the medication also has been shown to cause reflex tachycardia due to rapid lowering of blood pressure. The nurse should closely monitor the client's vital signs as well as assess for angina. Taking nifedipine with grapefruit juice has been shown to result in doubling in nifedipine AUC (area under the plasma drug concentration-time curve) with no change in half-life. The increased plasma concentrations most likely result from inhibition of first-pass metabolism. The client should be reminded to avoid ingestion of grapefruit and grapefruit juice while taking nifedipine to minimize drug toxicity. *Content Refresher* Medicationadministration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Nifedipine is a calcium channel blocker medication. Assess the client's medication history, which includes the medications, herbs (ginkgo may increase effects of nifedipine and ginseng may cause nifedipine toxicity), or vitamins that the client takes. Assess for any medication contraindications, precautions, and adverse effects. Document administered medications according to institutional policy and assess for expected outcomes for the administered medications.

The client taking sitagliptin asks the nurse for breakfast suggestions from the hospital menu. Which foods will the nurse recommend? (Select all that apply.) 1. Scrambled egg with salsa, whole wheat toast, and fruit jelly. 2. One biscuit with sausage gravy, fried egg, and coffee. 3. Whole grain cereal with sliced banana and 1% milk. 4. Pancakes with low-calorie syrup and apple juice. 5. Poached egg, cinnamon roll, and two strips of bacon. 6. Yogurt with blueberries and almonds, and hot tea with lemon.

1) CORRECT - Sitagliptin is prescribed for clients with type 2 diabetes mellitus, and these clients should be instructed to limit trans fats and increase whole grains, fruits, and vegetables. This meal contains protein, vegetables (salsa), and whole grains, while limiting fats. 2) INCORRECT - Clients with type 2 diabetes mellitus should be instructed to limit trans fats and increase whole grains, fruits, and vegetables. This meal is high in fat and contains no fruits or vegetables. 3) CORRECT - Clients with type 2 diabetes mellitus should be instructed to limit trans fats and increase whole grains, fruits, and vegetables. This meal contains whole grains and fruits, with minimal fat. 4) INCORRECT - Clients with type 2 diabetes mellitus should be instructed to limit trans fats and increase whole grains, fruits, and vegetables. This meal contains mostly carbohydrates, with minimal protein. While apple juice contains fruit, it is also high in sugar. 5) INCORRECT - Clients with type 2 diabetes mellitus should be instructed to limit trans fats and increase whole grains, fruits, and vegetables. Although the poached egg is a good protein source, the cinnamon roll and bacon are high in calories and fat. 6) CORRECT - Clients with type 2 diabetes mellitus should be instructed to limit trans fats and increase whole grains, fruits, and vegetables. Yogurt and almonds are good protein sources, and blueberries and lemon provide vitamins with few calories. *Think Like A Nurse: Clinical Decision Making* Dietary management is an essential skill for the client with type 2 diabetes. Clients may perceive a diagnosis of type 2 diabetes as signaling "the end of eating anything that tastes good," and will struggle to replace old dietary habits with new ones. Because diabetes is a primary risk factor for heart disease, client education emphasizes selecting low-carbohydrate meal options and adding taste without increasing fat content. Assisting the client with choosing meals that are within recommended dietary parameters is an opportunity for the nurse to both teach the client and allow for evaluation of the client's learning. *Content Refresher* Type 2 diabetes mellitus (DM) is characterized by insulin resistance or insufficient insulin production. Clients with type 2 DM typically have a slow onset of symptoms. Assess for symptoms of DM, including polyuria and polydipsia. Polyphagia is usually absent in type 2 DM. Assess for history of infections or impaired wound healing. Assess for changes in visual acuity. Clients with type 2 DM typically do not develop ketosis because they produce sufficient insulin to prevent the breakdown of fats. Treatment of type 2 DM may include weight loss, dietary management, exercise, and prescription of anti-diabetic agents.

The nurse in the outpatient clinic receives a phone call from an adolescent who states, "There is no reason to live. I am going to shoot myself." Which response by the nurse is best? 1. "Do you have access to a gun?" 2. "Why do you want to shoot yourself?" 3. "Think about how this will affect your family." 4. "Share with me what happened to you today."

1) CORRECT - The nurse should first ensure the client's safety by determining if the client has a plan and the means to carry out the plan. 2) INCORRECT - The nurse should avoid "why" questions as they can be interpreted as judgmental. The "why" is not relevant at this time. It is more important to determine if the client has the means to carry out the suicide. 3) INCORRECT - This places the focus on the family as opposed to the client. The priority is the client's safety. 4) INCORRECT - The nurse should offer the client the security that the nurse is concerned about the client's safety. This may be a relevant assessment, but first the nurse must ensure the client's safety. *Think Like a Nurse: Clinical Decision-Making* Because the adolescent client specifically said "shoot myself," the nurse needs to immediately assess if the client has access to a firearm. This is one instance when it is appropriate and necessary to ask the client a direct "yes/no" question since it is paramount to determine the lethality of the client's statement. Ongoing assessment, communication, and interventions will depend upon the client's response. *Content Refresher* Suicide is defined as intentionally killing oneself. A suicide risk assessment tool may be administered to determine the client's risk for self injury. The nurse needs to speak openly and directly about suicide, with an empathic and authentic approach. Explore alternatives and focus on ambivalent thoughts/feelings related to suicidal ideation and suicide planning.

The nurse assigns the LPN/LVN to perform a moist-to-dry dressing change on the client's 2-inch incision. Which behavior, if performed by the LPN/LVN, requires an intervention by the nurse? 1. The old dressing is saturated with sterile saline before it is removed. 2. Dry dressings are placed over the saline-moistened gauze in the incision. 3. Wound debris and necrotic tissue are removed with the old dressing. 4. The gauze is moistened with sterile saline before it is packed into the incision.

1) CORRECT - The old dressing should be removed dry so that wound debris and necrotic tissue are removed with the old dressing. The primary purpose of this dressing is to promote debridement. 2) INCORRECT - This is a correct action. This is done to protect clothing and bedding. 3) INCORRECT - This describes the primary purpose of moist-to-dry dressing. 4) INCORRECT - This is an appropriate procedure. For a moist-to-dry dressing, the wound should be packed with moist dressings that will then dry prior to removal. *Think Like A Nurse: Clinical Decision Making* Wound debridement prepares the wound bed for healing by removing debris and necrotic tissue. A moist-to-dry dressing may be used for wound debridement. This method involves placing a saline-moistened dressing on the wound surface and then removing it when it dries. Removal of the dry dressing facilitates removal of the debris and necrotic tissue from the wound. When assigning a task such as wound care to an LPN/LVN, the nurse should provide supervision (as needed), evaluate the performed task, and provide feedback. In this case, the nurse should provide feedback that reinforces the proper method for performing moist-to-dry dressing changes. *Content Refresher* When caring for the client with a wound dressing, the nurse should adjust wound care and dressings depending on the amount and type of exudate and condition of the wound. Consult a wound nurse, if needed. Don gloves to remove old dressings. Perform wound irrigation, cultures, or cleansing as indicated by health care provider prescriptions. Apply new dressings using sterile or clean technique. Document the wound appearance including size, location, amount of exudate, condition of skin surrounding the wound, and client tolerance of dressing change procedure. Educate the client about the procedure as it is being performed.

The nurse teaches a client diagnosed with type 1 diabetes mellitus (DM) about measures to prevent long-term complications. Which instruction does the nurse include? 1. "Wear slippers around the house." 2. "Wear socks made of synthetic fibers." 3. "Avoid wearing insulated boots in cold weather." 4. "Wear knee-high nylons instead of pantyhose."

1) CORRECT — The nurse will instruct the client to avoid walking barefoot. Compromise of skin integrity to the feet, such as a laceration or puncture, may result in wounds that go unnoticed due to peripheral neuropathy associated with DM. In addition, these wounds are likely to be slow to heal as a result of associated peripheral vascular disease. 2) INCORRECT— The nurse will encourage the client to wear socks made with natural fibers, such as wool or cotton, which are more breathable than synthetic fibers, such as polyester. Natural fibers allow perspiration to dry, which assists in preventing compromised skin integrity. Clients with DM will be at higher risk for fungal infections of the feet. 3) INCORRECT— The nurse will instruct the client to wear warm and insulated boots in cold weather. This decreases the risk of injury from the cold. Clients with DM are likely to experience peripheral arterial or peripheral vascular disease, which leaves them more vulnerable to the impact of cold temperatures. 4) INCORRECT— The nurse will instruct the client to avoid wearing nylons or pantyhose altogether because they may exacerbate circulatory problems. The client should avoid wearing constricting clothes to avoid compromising peripheral blood flow. *Think Like A Nurse: Clinical Decision Making* A client with diabetes mellitus is at risk for developing peripheral neuropathy, which causes changes in sensation of the lower extremities. These changes can result in complications related directly to an injury, or from the inability to recognize the severity of an injury due to impaired sensation. The client should be instructed to never walk barefoot, even in the house. *Content Refresher* When providing teaching about diabetes mellitus, the nurse should address foot care. The nurse should instruct the client to inspect the feet daily and assess pedal pulses. Avoid using over the counter chemicals such as hydrogen peroxide on the feet. Avoid placing heating pads or ice packs on the feet. Do not apply lotion between toes. Question client about use of proper foot wear. Educate the client on proper foot care.

The nurse works on a new care area, created through the merging of two separate areas. The staff from the original care areas differ on client care approaches, which creates conflict between the two groups despite having meetings together to try to improve collaboration. Which suggestion is the most appropriate for the nurse to make to the charge nurse to reduce the amount of conflict between the two groups of staff? 1. Assign staff members to clients from both care areas. 2. Hold an in-service about the benefits of merging the two units. 3. Institute disciplinary action for staff members who talk negatively. 4. Require all staff to listen to hand-off communication on all of the clients.

1) CORRECT- Assigning staff to clients from both care areas encourages the staff to work together and experience the different types of clients to expect on the newly created care area. 2) INCORRECT - Because previous meetings have not affected change in staff behavior, more meetings are unlikely to change staff members' feelings. 3) INCORRECT - Negative talk will impact client care. Assigning staff to care for clients from both units allows the staff to better understand the needs of all the clients. 4) INCORRECT - Expecting all staff to listen to all hand-off communication is not an effective use of time. Although this might expose the staff to different client care needs, it would not be appropriate unless the staff is assigned to care for the client. *Think Like A Nurse: Clinical Decision Making* The merging of the two staffs has created a conflict. One way to overcome the conflict is to have the staff members share or participate in the care of both types of clients. This approach gives the staff the opportunity to share and learn about the different types of clients. *Content Refresher* Conflict resolution is managing the opposition, friction, disagreement, or discord that arises between individuals or within a group. This occurs when the beliefs or actions of one or more individuals are either resisted by or deemed unacceptable to one or more other individuals. Resolve the conflict through tactics that achieve better working relationships and get more of what each person wants. Resolve the conflict in ways to gain respect, improve self-esteem, and build courage.

The nurse provides care for an older adult client diagnosed with bilateral cataracts. The client repeatedly asks the nurse "Why did this happen to me? " Which statement by the nurse is the best response? 1. "The lenses of the eyes gradually lose moisture and increase in density as you age. " 2. "The pressure within the eye increases, causing a reduced ability to focus. " 3. "The lenses in your eyes become hardened and inflexible. " 4. "The retina becomes detached from the inner part of the eye. "

1) CORRECT- Cataracts are partial or total opacity of the normally transparent crystalline lens. This occurs because the lens becomes less hydrated and more dense. This statement is a correct response to the client. 2) INCORRECT- An increased pressure within the eye occurs with glaucoma, not cataracts. This is not a correct statement. 3) INCORRECT- The flexibility is not related to transparency of the lens. This is not a correct statement. 4) INCORRECT- Cataracts is not a detached retina. This is not a correct statement. *Think Like A Nurse: Clinical Decision Making* Providing factual information is key in client education. In similar encounters, the nurse may assess the client's baseline knowledge and use this as the basis for teaching. For optimal comprehension and compliance, education material should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. It is best to use the teach-back method to verify the clients understanding of what was taught. *Content Refresher* Risk factors for cataracts include genetics, environment (excessive exposure to sunlight), and lifestyle choices (cigarette smoking and drinking excessive amounts of alcohol). Other risk factors include eye trauma or injury, previous eye surgery, high blood pressure, obesity, diabetes mellitus, and prolonged use of certain medications. The greatest risk factor for cataractsis increasing age.

The nurse provides care for a client who has a pulmonary injury. Which clinical manifestation indicates to the nurse that the client is experiencing a tension pneumothorax? 1. Tracheal deviation. 2. Hypertension. 3. Flattened neck veins. 4. Bradycardia.

1) CORRECT- Tracheal deviation toward the unaffected (i.e. uninjured) side is a late sign of tension pneumothorax. Breath sounds may be diminished or absent over the affected lung. Shifting of the heart and great vessels will cause decreased cardiac output and hypotension. Additional manifestations of tension pneumothorax include tachycardia and distended neck veins. Tension pneumothorax is a life-threatening medical emergency that requires immediate treatment. Interventions may include needle decompression to release air trapped in the pleural space and chest tube insertion. 2) INCORRECT - Manifestations of tension pneumothorax include hypotension, not hypertension. 3) INCORRECT - Distended neck veins, not flattened neck veins, are a sign of tension pneumothorax. 4) INCORRECT - Tension pneumothorax causes tachycardia, not bradycardia. *Think Like A Nurse: Clinical Decision Making* The nurse needs to recall the pathophysiology of a tension pneumothorax and mentally ask, "What is occurring in the thorax when this problem develops?" The nurse recognizes that a pneumothorax develops when the pressure inside of the lung is the same as the pressure outside of the lung. The lung collapses and can no longer support body tissue oxygenation. In a tension pneumothorax, the structures within the thorax are shifted towards the inflated lung, or away from the collapsed lung. This is because free air in the thoracic cavity increases the pressure in the thorax and moves the organs away from the collapsed lung. One structure that shifts is the trachea. *Content Refresher* Negative pressure in the lungs allows for expansion. The lung needs to maintain negative pressure for ventilation and the exchange of oxygen and carbon dioxide. In a pneumothorax , pressure in the lung is no longer negative due to the accumulation of air in the pleural space. Risk factors include chronic obstructive pulmonary disease (COPD), smoking, insertion of a central intravenous line, and trauma such as a stabbing or gunshot wound. The signs and symptoms of a pneumothorax include tachycardia, tachypnea, and decreased breath sounds. Treatment of a pneumothorax may include administration of oxygen, thoracentesis, and/or the insertion of a chest tube. Complications include a tension pneumothorax, infection at the site of chest tube insertion, and respiratory distress.

The nurse obtains a health history from the parent of a client with acute glomerulonephritis. Which question is most important for the nurse to ask? 1. "Has the client had any recent skin infections? " 2. "Is there a family history of glomerulonephritis? " 3. "Was the client a low-birth weight infant? " 4. "Has the client ever had a bladder infection? "

1) CORRECT— Acute glomerulonephritis is a complex immune system disease that occurs about 10 days after a skin or throat infection. Symptoms include fever, chills, hematuria, dyspnea, weight gain, edema, hypertension, headache, decreased level of consciousness, confusion, and abdominal or flank pain. 2) INCORRECT— Acute glomerulonephritis is not hereditary. It occurs secondary to other infections or systemic diseases such as systemic lupus erythematosus, cirrhosis, sickle-cell disease, or infective endocarditis. 3) INCORRECT— The client's birth weight is not related to acute glomerulonephritis. 4) INCORRECT— Bladder infections are usually caused by E. coli. Glomerulonephritis is caused by Streptococcus. Treatments include medications such as antibiotics, corticosteroids, antihypertensives, and immunosuppressive agents. Nonpharmacologic interventions include restricting sodium intake, restricting water if oliguric, daily weights, monitoring intake and output, bed rest, and a high-calorie, low protein diet. *Think Like A Nurse: Clinical Decision Making* Acute glomerulonephritis is caused by the beta hemolytic streptococcus bacterium. This bacterium is implicated in throat and skin infections. Therefore, the client needs to be assessed for any recent skin infections that may have caused the kidney infection. Acute glomerulonephritis is not a genetic disorder, related to weight at birth, or associated with urinary tract or bladder infections. *Content Refresher* Streptococcal infection is the most common cause of acute glomerulonephritis. Other risk factors for acute disease include bacterial endocarditis and viral infections such as human immunodeficiency virus (HIV), hepatitis B, and hepatitis C. Risk for chronic disease increases as a result of autoimmune disorders such as lupus, diabetes, vasculitis, Goodpasture's syndrome, primary glomerular diseases such as IgA nephropathy, and chronic hypertension. Additional risks are being older, male, and African-American.

The professional development educator teaches novice nurses about the causes of systemic inflammatory response syndrome (SIRS). Which types of injury will the nurse include in the teaching? (Select all that apply.) 1. Burn injuries. 2. Crush injuries. 3. Major surgeries. 4. Bowel ischemia. 5. Viral infection.

1) CORRECT— Burn injuries cause mechanical tissue trauma, a trigger for SIRS. 2) CORRECT— Crush injuries cause mechanical tissue trauma, a trigger for SIRS. 3) CORRECT— Major surgeries can cause mechanical tissue trauma, a trigger for SIRS. 4) CORRECT— Bowel ischemia causes mechanical tissue trauma, a trigger for SIRS. 5) INCORRECT - This infection causes microbial invasion, not mechanical trauma. *Think Like A Nurse: Clinical Decision Making* The nurse is aware other potential causes of systemic inflammatory response syndrome (SIRS) include intra-abdominal abscess, pancreatitis, bacteremia, sepsis, shock states, post-cardiac resuscitation, and massive myocardial infarction. The nurse is expected to closely monitor the client's hemodynamic status, including viral signs, urine output, and central venous pressure. One of the goals of treatment in SIRS is to keep the mean arterial blood pressure higher than 65 mm Hg for septic clients. Comprehensive assessment will require closely monitoring the client's neurological status, urine output, and tissue oxygenation. Sources of infection should be actively treated with appropriate antibiotics, after cultures are drawn. *Content Refresher* Systemic inflammatory response syndrome (SIRS) may result from a variety of life-threatening conditions, including sepsis, shock states, and myocardial infarction. With SIRS, the inflammatory response is activated, resulting in the release of inflammatory mediators, direct damage to the endothelium, hypermetabolism, increased vascular permeability, and activation of the coagulation cascade. Compromised organ function results from hypotension, decreased perfusion, microemboli, and redistribution or shunting of blood flow. SIRS can potentially lead to multiple organ dysfunction syndrome (MODS), which is the failure of two or more organ systems in an acutely ill client.

The nurse provides care for a client diagnosed with a closed head injury. The client begins to vomit. Which additional finding, if occurring with the noted emesis, does the nurse report to the health care provider (HCP)? 1. Increased lethargy. 2. Heart rate of 80 beats/min. 3. Sodium of 145 mEq/L (145 mmol/L). 4. Facial symmetry.

1) CORRECT— Changes in a client's level of consciousness, such as increasing drowsiness or difficulty arousing, are initial signs of increased intracranial pressure. Report these changes to the HCP immediately. 2) INCORRECT - The heart rate is within normal limits with no reason to report it to the HCP. 3) INCORRECT - This is a normal sodium level and does not necessitate reporting to the HCP. The normal range is serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). 4) INCORRECT - Facial symmetry is a normal finding and does not need to be reported to the HCP. *Think Like A Nurse: Clinical Decision Making* The nurse will use knowledge or anatomy and physiology when caring for a client with a head injury. In a closed head injury, the brain has experienced an injury that can cause bleeding or edema within the cerebral tissue. Because the cranium is within a closed vault, the swelling and bleeding displace the cerebral contents, causing symptoms of increased intracranial pressure. The nurse will frequently assess for common symptoms of increasing intracranial pressure, which includes nausea and changes in level of consciousness. This finding should be immediately reported to the health care provider. *Content Refresher* Increased intracranial pressure occurs when there is an abnormal accumulation of cerebrospinal fluid in the brain causing cerebral edema. This cerebral edema may be caused by lesions, head/brain injury, cerebral infections, vascular insult, or encephalopathies. Report changes in level of consciousness, abnormal posturing, seizures, and vomiting. Brain injury or insult will most likely be present. Monitor for altered respiratory patterns and rise in systolic blood pressure. Assess using the Glasgow Coma Scale..

The nurse provides care for a client who is involuntarily admitted to the psychiatric unit for assaultive behavior toward others. The client asks to leave the facility today. Which statement is an accurate response by the nurse? 1. "You may not want to be here, but you have been legally ordered to remain here due to your behavior to others." 2. "You agreed to treatment here and you should follow through with your commitment." 3. "You signed admission paperwork agreeing to a 3-day treatment program." 4. "You demanded to be treated here. Help me understand why you want to leave."

1) CORRECT— Involuntary commitment is made without the client's consent because the person is a danger to self or others, is in need of psychiatric treatment, or is unable to meet basic needs. Involuntary commitment is ordered by a judge. Clients cannot leave while under involuntary commitment. 2) INCORRECT— This describes a voluntary admission. A client who is voluntarily admitted may sign out of the facility at any time, unless the client's status is changed to involuntary commitment (after a mental status examination). 3) INCORRECT— This is not a correct response for an involuntary commitment. 4) INCORRECT— This is not a correct response for an involuntary commitment. *Think Like a Nurse: Clinical Decision-Making* Failure to establish a therapeutic relationship could result in stress, poor communication, and an inability to achieve positive client outcomes. When communicating with a client who is involuntary admitted, the nurse must provide accurate information. Generally, involuntary admission occurs by way of one of three processes. The first process, which is medical certification, requires client examination by two physicians and certification of the need for involuntary care and treatment in a psychiatric facility. The second process involves certification by a director of community services, or by an examining physician designated by the director of community services, in which the examiner states the individual is diagnosed with a mental illness that is likely to result in serious harm to self or others and for which immediate inpatient care and treatment is appropriate. The third process is an emergency admission based on the claim that the person has a mental illness that is likely to result in serious harm to self or others and for which immediate observation, care, and treatment in a psychiatric center is warranted. *Content Refresher* A consistent approach is essential when providing care to a client who is aggressive, including the use of teamwork and collaboration. If aggression is escalating, seek help from others. Appropriate interventions include: Setting limits and reducing stimuli as needed. Administering prescribed medications. Being empathetic when listening and responding. Being respectful, genuine, concrete, specific, honest, and factual. Clarifying misconceptions.

The nurse instructs a client and spouse on how to suction the client 's laryngectomy tube. Which observation indicates to the nurse that teaching is effective? 1. The client takes several deep breaths before the suction catheter is inserted. 2. The spouse selects a tonsil tip catheter to suction the laryngectomy tube. 3. The spouse applies suction while introducing the sterile catheter into the stoma. 4. The spouse suctions the mouth and then the laryngectomy tube.

1) CORRECT— Taking deep breaths hyper-oxygenates the client 's lungs and prevents anoxia during suctioning. 2) INCORRECT - A tonsil tip catheter is used for oral suctioning of mouth. 3) INCORRECT - Suction is applied only as the catheter is withdrawn, not during its insertion. 4) INCORRECT - First, the laryngectomy tube is suctioned and then mouth, in order to prevent introducing bacteria from the mouth into the lungs. *Think Like A Nurse: Clinical Decision Making* Hyperoxygenation is an essential activity prior to suctioning as it prevents hypoxia and other hypoxia-related complications, such as dysrhythmia and agitation. In the conscious and cooperative client, this can be achieved by having the client take deep breaths. For clients attached to a ventilator, hyperoxygenation can be done automatically using a hyperoxygenation function. Since suctioning can be hazardous and causes discomfort, it is not recommended in the absence of apparent need. The nurse should assess the breath sounds before and after suctioning. *Content Refresher* A laryngectomy is the surgical removal of the larynx (partial or total). Post-operatively, management of the tracheostomy is required (i.e., suction, humidification, and regular tracheostomy care). Other interventions include elevating the head of bed and promoting lung expansion (e.g., with an incentive spirometry). Administer pain medications as prescribed to maintain adequate pain management. Monitor the client for hemorrhage and skin breakdown following surgery. Maintain fluid and nutritional intake through enteral or parenteral feedings. Since the larynx is affected, speech therapy is often needed.

A client diagnosed with terminal cancer asks the nurse's opinion about complementary therapy. The nurse notices that the client has stopped taking fluorouracil. Which response by the nurse is appropriate? 1. "Tell me more about the complementary therapy that interests you." 2. "The only thing that is going to help you is the chemotherapy." 3. "How did you hear about the complementary therapy?" 4. "Is the chemotherapy causing side effects?"

1) CORRECT— The client has the right to choose the treatment modality for the cancer. The nurse should obtain more information about what the client is taking and ensure that the client understands the benefits and drawbacks of utilizing complementary therapy. 2) INCORRECT - This response is judgmental and ends the conversation. The nurse should assess the client's understanding of complementary therapy and provide factual information on the therapy, including the benefits and drawbacks of both traditional and complementary approaches. 3) INCORRECT - This is not a relevant assessment. 4) INCORRECT - This closed-ended (yes/no) question does not address the client's question. While the nurse should assess for side effects, it is more important to respond directly to what the client is saying. Think Like A Nurse: Clinical Decision Making The nurse needs to be aware that additional assessment is needed in order to respond appropriately to the client's question. So, prior to responding to the client's question, the nurse should first assess the client's knowledge about the proposed complementary therapy. This approach provides the nurse with information about the client's opinion and helps formulate the best way to respond to the client's question. Therapeutically, the nurse needs additional information so the nurse can address any learning needs the client may have about the complementary therapy. The goal is to keep communication open. *Content Refresher* The nurse needs to use therapeutic communication when caring for this client. Therapeutic communication includes the following communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad open statements, 6) asking about thoughts and feelings, 7) restating and reframing, 8) reflecting, 9) presenting reality, 10) sharing observations, and 11) clarifying meaning. The nurse needs to avoid non-therapeutic communication techniques such as reassuring, rejecting, approving or disapproving, agreeing or disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse observes a client have a tonic clonic seizure lasting about 90 seconds, followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to have another seizure. Which action is most important for the nurse to take? 1. Administer diazepam as prescribed. 2. Monitor serum glucose levels closely. 3. Assess the client's blood pressure and pulse. 4. Remove excessive clothing.

1) CORRECT— The client is experiencing repeated seizures. The nurse immediately administers diazepam to stop the seizures. 2) INCORRECT - While this may be needed, there is no indication that the client is experiencing hypoglycemia. The nurse first takes action that will keep the client safe. 3) INCORRECT - There is no indication that the client is experiencing abnormal vital signs. The client is currently experiencing a seizure. The nurse first takes action that will keep the client safe. 4) INCORRECT - The nurse should loosen restrictive clothing to protect client from injury, but there is no indication that the client is hyperthermic. The nurse first administers diazepam to stop the seizures. *Think Like A Nurse: Clinical Decision Making* It is important for the nurse to recognize when a client with an identified disorder is becoming unstable. It is not commonly expected for a client diagnosed with seizures to have back to back episodes. The client is demonstrating the beginning signs of status epilepticus or sustained seizure activity. This means that the frequency of the seizures is increasing and the recovery time between the seizures is short. The best intervention at this time is to administer the medication diazepam which stops seizure activity. *Content Refresher* Nursing interventions when caring for a client with epilepsy include: Monitor and document seizure activity and client's level of consciousness before during and after a seizure. Have oxygen and suction equipment at the bedside. Turn the client onto the side and protect from injury during the seizure. Administer oxygen using a face mask during the seizure. Note the duration of the seizure. Following the seizure, ask the client if an aura was present. Assist with diagnostic testing. Maintain seizure precautions. Educate the client/family about medication(s) used to prevent seizures. Ask about barriers to adherence to treatment. Provide information about drug toxicity and address concerns about pregnancy if anti-convulsants are prescribed. Frequent blood levels need to be evaluated.

The nurse provides care to a toddler with epiglottitis. Which observation indicates to the nurse that the client is experiencing an early complication of hypoxemia? 1. Heart rate of 148 beats per minute. 2. Bluish discoloration of the skin. 3. Bluish discoloration around the mouth. 4. Difficulty swallowing.

1) CORRECT— The heart rate correlates with hypoxemia and is an early finding, along with restlessness. 2) INCORRECT— Cyanosis is a late sign of hypoxemia. 3) INCORRECT— Circumoral cyanosis is a late sign of hypoxemia. 4) INCORRECT— Difficulty swallowing is a sign of epiglottitis. *Think Like A Nurse: Clinical Decision Making* Children have a higher metabolic rate than adults. Their resting respiratory rates are faster and their demand for oxygen is higher. Adult oxygen consumption is 3 to 4 liters/minute, while infants consume 6 to 8 liters/minute. In any situation of respiratory distress, infants and children will develop hypoxemia more rapidly than adults. Tachycardia is seen as a compensatory response to the event of hypoxemia. The nurse should keep in mind "ABC" (airway, breathing, circulation) in all assessment and interventions. *Content Refresher* When ventilatory effort is diminished (due to pain or weakness), adequate oxygen is not taken into the lungs and limits the amount that is available for gas exchange at the alveolar level. If the size of the airway is reduced (due to constriction or presence of mucous), an inadequate amount of oxygen is taken in and available for alveolar gas exchange. These factors create the condition for hypoxemia and resulting hypoxia. If an infectious source is identified, an anti-microbial is required.

The nurse provides care for the client diagnosed with hemophilia. The nurse intervenes if the client makes which statement? (Select all that apply.) 1. "I drink two beers every day after work." 2. "I receive intramuscular pain injections weekly." 3. "I play golf on the weekends with my cousin." 4. "I take meloxicam daily for arthritis pain." 5. "I always wear my medical alert bracelet."

1) CORRECT— The nurse should intervene because alcohol interferes with platelet aggregation, which increases the risk for bleeding for a client diagnosed with hemophilia. 2) CORRECT— The nurse should intervene because intramuscular injections place the client diagnosed with hemophilia at risk for bleeding at injection sites. 3) INCORRECT— Golfing is an appropriate leisure activity. The client diagnosed with hemophilia should avoid contact sports (e.g., football, hockey) that can increase the risk for injury. 4) CORRECT— The nurse should intervene because meloxicam interferes with platelet aggregation, which increases the risk for bleeding for a client diagnosed with hemophilia. 5) INCORRECT— Wearing an alert bracelet is an appropriate action. In addition, the client should have a written emergency plan that includes what to do in specific situations as well as names and phone numbers of emergency contacts. *Think Like a Nurse: Clinical Decision-Making* An essential first step is to assess the client's teaching and learning needs, including literacy issues. The client should be encouraged to ask questions. Key prevention messages from the National Hemophilia Foundation 's National Prevention Program Tips for Healthy Living include: (1) Get an annual comprehensive checkup at a hemophilia treatment center, (2) Get vaccinated against hepatitis A and B, (3) Treat bleeds early and adequately, (4) Exercise and maintain a healthy weight to protect your joints, and (5) Get tested regularly for blood-borne infections. *Content Refresher* Hemophilia is a medical condition in which the ability of the blood to clot is severely reduced, causing the client to bleed severely from even a slight injury. A client diagnosed with hemophilia should avoid injections and rectal medications while avoiding aspirin products and non-steroidal anti-inflammatory products (NSAIDs). The nurse needs to assist the client in identifying sports and recreation activities in which the client can safely participate. Overall, the client must maintain a safe environment to reduce the risk of bleeding.

The nurse admits an older adult client who reports fever and chills to the medical unit. Which assessment finding most concerns the nurse? 1. The client's HR 120 beats/min and BP is 90/60 mm Hg. 2. The client's RR is 18 breaths/min and BP is 110/70 mm Hg. 3. The client's white blood cell count is 16000/µL (16.00×109/L). 4. The client's platelet count is 325 ×10 3/µL (325×109/L).

1) CORRECT— These symptoms indicate that the client is experiencing septic shock, a life-threatening condition. Immediate intervention is necessary. 2) INCORRECT - The client's RR and BP are within normal limits. 3) INCORRECT - The client's white blood cell count is elevated, but this is expected with a suspected infection. 4) INCORRECT - The client's platelet count is within defined limits (150-350). *Think Like A Nurse: Clinical Decision Making* It is important for the nurse to assess and evaluate findings for a client who is in distress. The nurse evaluates each assessment finding to determine whether the client is unstable. While multiple assessment findings for this client are consistent with infection, a rapid heart rate and low blood pressure indicates the development of septic shock. This condition can be life-threatening, and the client needs immediate cardiovascular support and treatment to combat the infection. *Content Refresher* Shock is defined as inadequate tissue and organ perfusion as a result of inadequate blood volume or inability to circulate blood. Types of shock include hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic. Irreversible organ damage can occur if shock is not diagnosed quickly. A client experiencing shock will exhibit hypotension, pale, cool skin, hypoxia, and tachycardia. Shock leads to inadequate tissue perfusion and oxygenation. Hypotension reflects inadequate tissue perfusion and needs to be treated aggressively and promptly to prevent complications and organ failure.

The nurse provides care for a client diagnosed with chronic venous insufficiency. Which findings does the nurse note as being consistent with this diagnosis? (Select all that apply.) 1. Thick, dark skin on bilateral lower extremities. 2. Varicose veins in the right leg. 3. Pain in the lower extremities while sitting. 4. A tender, red area on one lower extremity. 5. Crater-like lesions on the lower extremities.

1) CORRECT— Thick, dark skin on the lower extremities is consistent with the diagnosis of chronic venous insufficiency. Chronic edema causes changes in consistency and color of the skin. 2) CORRECT— Varicose veins are consistent with the diagnosis of chronic venous insufficiency. 3) CORRECT— Pain in the lower extremities while sitting is consistent with the diagnosis of chronic venous insufficiency. Venous insufficiency may cause pain in dependent positions. 4) INCORRECT— A tender area describes phlebitis, not venous insufficiency. This finding is inconsistent with the diagnosis of chronic venous insufficiency. 5) CORRECT — This finding is consistent with the diagnosis of chronic venous insufficiency. Crater-like lesions on the lower legs describes venous stasis ulcers. *Think Like a Nurse: Clinical Decision-Making* Chronic venous insufficiency (CVI) is a common cause of leg pain and swelling, and is commonly associated with varicose veins. The nurse should perform a thorough neurovascular assessment of both lower extremities, focusing on pain, pallor, pulse, and paresthesia. An ankle-brachial index (ABI) is a non-invasive diagnostic tool used to differentiate arterial from venous insufficiency. Right after the assessment is an excellent opportunity to teach the client about foot care and how to prevent injury. *Content Refresher* Chronic venous insufficiency develops over a period of time due to poor venous return, which results in blood pooling in extremities. Clinical manifestations associated with venous insufficiency include pain during walking or activity, edema, non-healing wounds, and skin color changes. The nurse should educate the client about reducing risk for development and progression of the disease. Assess non-healing wounds for infection and perform wound care as prescribed.

The nurse performs skin checks for cancer at a local community center. Which observation most concerns the nurse? 1. A lesion with an irregular surface and variegated colors. 2. A flat, red lesion that is nonpalpable. 3. A circumscribed lesion filled with fluid. 4. A lesion that is shiny and translucent.

1) CORRECT— This describes a lesion that is characteristic of malignant melanoma. 2) INCORRECT - This describes a macule, but is not as concerning for skin cancer. 3) INCORRECT - This is not concerning for skin cancer. This may represent a blister. 4) INCORRECT - This is not as concerning for skin cancer. This represents some atrophy of the skin, which may occur with age or overuse of topical steroids. *Think Like A Nurse: Clinical Decision Making* Before making a decision, the nurse should recall the characteristics of the different types of lesions and ask the question, "Which lesion is the most irregular and could indicate a pathological condition?" A skin lesion that is a different color, texture, and size could indicate skin cancer. The characteristics of malignant melanoma include an irregular surface and have various colors. This is the lesion that should cause the most concern. The other characteristics describe lesions that may occur from minor skin trauma or age-related changes. *Content Refresher* The nurse should assess the skin for expected changes of aging, such as seborrheic keratosis, cherry angiomas, age spots, and skin tags. The nurse should also assess moles for irregular borders, asymmetry, or changes in color or size, which could indicate possible skin cancer. If suspicious lesions are noted, the nurse should refer the client to the health care provider. Clients should be taught about the causes of skin cancer and be encouraged to wear sunscreen and/or protective clothing.

A client, crying hysterically, calls the nurse at the prenatal clinic. The client reports that she is a few days late for her period, has a positive home pregnancy test, and just noticed a scant amount of blood on the tissue when she voided. The client is afraid that she is having a miscarriage. Which initial response by the nurse is most appropriate? 1. "You seem really upset. Take some slow deep breaths." 2. "A small amount of bleeding is nothing to worry about." 3. "Bleeding from implantation is expected at this time." 4. "Come to the clinic immediately. The health care provider will see you."

1) CORRECT— This response reflects the client's feelings. In addition, it gives the client the opportunity to verbalize concerns and thoughts. This is an appropriate therapeutic response for the nurse to make. 2) INCORRECT— This response dismisses the client's feelings and is not therapeutic. 3) INCORRECT— The nurse should talk in terms that the client understands. Based on the client's emotional state, this is not the most appropriate response by the nurse. 4) INCORRECT— Spotting is not abnormal during pregnancy and is not necessarily an emergency. Therefore, the client does not need to be seen immediately by the health care provider. This is not the most appropriate response by the nurse. *Think Like A Nurse: Clinical Decision Making* The nurse's statement "You seem really upset. Take some slow deep breaths" validates the client's concerns and offers practical action to cope with the situation at hand. The nurse may ask relevant questions about the client's symptoms and provide explanations. The nurse cannot rule out miscarriage at this point, but this is not an emergency situation. Active listening and being in the moment are an excellent guide when providing therapeutic communication. *Content Refresher* The nurse needs to use therapeutic communication when talking to this client. Therapeutic communication includes the following communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad open statements, 6) asking about thoughts/feelings, 7) restating and reframing, 8) reflecting, 9) presenting reality, 10) sharing observations, and 11) clarifying meaning. The nurse needs to avoid non-therapeutic communication techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse palpates a pregnant client's uterus. The nurse notes that the fetal position is left sacrum anterior (LSA). Which location does the nurse place the Doppler to hear the point of maximum intensity of the fetal heart tone? 1. Mother's left side near the level of mother's umbilicus. 2. Mother's right side below the mother's umbilicus. 3. Mother's left side below the mother's umbilicus. 4. Mother's right side near the level of mother's umbilicus.

1) CORRECT—This is correct positioning of the Doppler to hear point of maximum intensity of fetal heart tone at LSA. 2) INCORRECT - This placement is used for either right occiput anterior or right occiput posterior fetal positions. 3) INCORRECT - This placement is used for either left occiput anterior or left occiput posterior positions. 4) INCORRECT - This placement is used for the right sacrum anterior position. *Think Like A Nurse: Clinical Decision Making* Before assessing the fetal heart tone, the nurse should attempt to determine the fetal position. In this scenario, the fetal position is a sacrum presentation, which is seen in a fetus who is considered breech. The position means that the head is not pointing down into the client's pelvic region however the sacrum is. Because of the direction of the fetus, the heart is higher up in the client's uterus. The location to assess for a fetal rate rate would be closer to the client's umbilicus. *Content Refresher* Fetal position refers to the relationship of the fetal presenting part with the mother's pelvis. Position is represented by a three-letter abbreviation. The first letter of the abbreviation represents the fetal position in relation to the mother's right or left side; the second letter, the presenting part (occiput, mentum, or sacrum); and the third letter, anterior or posterior positioning. The nurse should use Leopold maneuvers to determine fetal presentation and position, and then subsequently identify the point of maximal intensity (PMI) for auscultating the fetal heart rate (FHR). The PMI of fetal heart tones varies according to the fetal position. The PMI for a fetus in left sacrum anterior (LSA) is on the left side level with the umbilicus.

The home health nurse visits a client with a history of type 1 diabetes mellitus. The client has recently experienced permanent loss of vision and is having difficulty adjusting. Which action by the nurse is most appropriate? 1. Ask the health care provider for a psychiatric referral. 2. Recommend that the client join a support group. 3. Warn the client that failure to adapt can increase risk for injury. 4. Reassure client that a change in visual abilities does not change personal identity.

1) INCORRECT - A loss of sight can be a devastating experience. Having difficulty adjusting does not necessarily indicate that the client has psychiatric problems. This action by the nurse would not be most appropriate at this time. 2) CORRECT— Clients often respond more positively to peers with the same health alterations than to health care providers. The most appropriate action at this time is to recommend that the client join a support group. 3) INCORRECT - This response appears to be a threat and this often does not effect change. This action is not appropriate because a threat by the nurse is disrespectful and unethical. 4) INCORRECT - This action provides false reassurance to the client and does not address the issue. This is not an appropriate action by the nurse. *Think Like A Nurse: Clinical Decision Making* The client has recently lost a major sensory organ and is having difficulty adjusting to the loss. The best recommendation would be for the client to attend a support group with others who are experiencing a similar situation. A psychiatric referral would be premature since the client is not demonstrating any signs of a mood or other mental health disorder. The client should not be threatened. While the vision loss may not affect personal identity, the nurse's reassurance does not improve the client's ability to cope with the loss. *Content Refresher* One role of the nurse is to provide information about health care resources. The nurse should identify specific resources (supplies and/or support groups) needed to promote health and prevent additional illness/complications. Determine resources that are available in the community and accessible to clients. Identify financial resources. Recognize resources that are limited and needed to promote health (financial).

The nurse assesses a 2-hour old newborn. The nurse notes the newborn's hands and feet are bluish in color. To which reason does the nurse attribute this finding? 1. A lack of adjustment to environmental temperature. 2. Poor perfusion of blood to the periphery of the body. 3. A lowered oxygen tension. 4. A low hemoglobin level.

1) INCORRECT - Acrocyanosis is not related to the environmental temperature. 2) CORRECT - Acrocyanosis is a bluish color of hands and feet of the newborn. This is an expected finding and is caused by sluggish peripheral circulation. 3) INCORRECT - Newborns have an elevated oxygen tension level. 4) INCORRECT - Newborns have an elevated hemoglobin level level. *Think Like A Nurse: Clinical Decision Making* After delivery the nurse needs to focus on two clients: the mother and the newborn. Assessment of the newborn is focused on how well the baby is adjusting to extrauterine life. This assessment is completed through the use of the Apgar scoring system. One criteria is the color of the infant's body and extremities. Ideally, the body and extremities should be pink, which indicates adequate perfusion. If the extremities are blue-tinged, perfusion of the newborn is not at the maximum level and the newborn needs more time to adjust to being outside of the uterus. *Content Refresher* Acrocyanosis, the bluish discoloration of the hands and feet, is a normal infant finding that may be present for up to 24 hours after birth. However, central cyanosis (bluish lips and mucous membranes) is an abnormal finding that indicates a late sign of hypoxemia and can result from inadequate oxygen delivery to the alveoli; poor perfusion of the lungs, inhibiting gas exchange; or cardiac dysfunction. Acrocyanosis should not be confused with Mongolian spots, which are bluish black areas of pigmentation in newborns whose ethnic origins are Latin America, Asia, Africa, or the Mediterranean area. Mongolian spots most commonly occur on the back and buttocks, but can occur over any part of the infant's body.

The nurse in the outpatient clinic receives a phone call from a young adult client who says a friend has overdosed. In caring for the overdosed client, which action does the nurse take first? 1. Instruct the friend to call emergency medical services. 2. Instruct the friend to call the Poison Control Center. 3. Find out what the client ingested and in what amount. 4. Determine if the client is responsive and alert.

1) INCORRECT - After assessing airway, breathing, and circulation, the nurse instructs the friend to notify emergency medical services (EMS). While waiting for EMS, the nurse can guide the friend and the client further, if needed. 2) INCORRECT - The nurse should complete an assessment before implementing. The client may not benefit from the services of the Poison Control Center. If the client is not breathing well, this action wastes precious time. 3) INCORRECT - Determining what the client overdosed on is important information, but the priority is determining the client's current condition. 4) CORRECT— Ask the friend if the overdosed client is conscious, if there are breathing difficulties, and what the respiratory rate is. Guide the friend through this assessment. *Think Like A Nurse: Clinical Decision Making* A drug overdose incident is an emergency. The nurse can first instruct the caller to verify if the client is responsive, and then to tell the caller to call 911 immediately. As a general guide in handling drug overdose, the nurse should assess and activate; check for unresponsiveness and call for nearby help; have someone to call 911 and get automated external defibrillator (AED) and naloxone. Observe client for breathing, versus not breathing or only gasping. If client is unresponsive with no breathing or only gasping, begin cardiopulmonary resuscitation (CPR). *Content Refresher* Overdose is defined as the overuse of a drug that can result in toxic effects to the brain, including respiratory depression, coma, and death. Monitor vital signs and level of consciousness. Administer oxygen, if indicated. Anticipate immediate administration of naloxone, a narcotic antagonist, if an opioid overdose is suspected. If administered, monitor effectiveness of naloxone and assess for signs and symptoms of opioid withdrawal (e.g., shivering, abdominal cramping, muscle and bone pain, vomiting, and diarrhea). Provide supportive comfort care and unconditional positive regard for the client.

When assessing a client admitted to rule out a myocardial infarction, the nurse determines a history of alcoholism. Which question is a priority for the nurse to ask the client? 1. "What over-the-counter medications do you take? " 2. "How much alcohol do you consume each day? " 3. "When did you have your last drink? " 4. "Have you ever had symptoms of withdrawal? "

1) INCORRECT - Although asking about current medications is important, it is more important to determine when the client last had a drink. 2) INCORRECT - The amount of alcohol a client consumes will impact the severity of the withdrawal symptoms. However, it is more important for the nurse to anticipate when withdrawal might occur. 3) CORRECT— The symptoms of withdrawal occur from 48 to 72 hours after the last drink. This information helps the health care team determine needed medications and ensure client safety. 4) INCORRECT - Asking about previous withdrawal episodes is appropriate, but the priority is determining when withdrawal might occur. *Think Like A Nurse: Clinical Decision Making* The nurse must first determine if the client is drinking alcohol by asking when the client took a drink last. The client will respond that it has been a prolonged period of time, or just recently. The nurse knows that the client with alcoholism is likely to experience withdrawal in the hospital setting due to the absence of alcohol intake. Withdrawal places significant stress on the body and could result in client harm. Assessing for the time of the last drink gives the nurse an idea as to if or when to expect the client to demonstrate symptoms of withdrawal. This allows the nurse to plan for interventions to ensure client safety. *Content Refresher* When caring for a client who may be experiencing alcohol withdrawal , the nurse should: Assess when the client had last consumed an alcoholic drink. Assess how long the client has been drinking and how much alcohol they consume daily. Determine how the alcohol consumption has impacted the client 's life. Assess blood alcohol levels. Assess serum electrolytes, complete blood count, and coagulation studies. Assess for pain. Assess level of consciousness and orientation.

The nurse performs a physical assessment on a client diagnosed with bulimia nervosa. Which finding warrants an immediate referral to the health care provider? 1. Bilateral parotid gland enlargement. 2. A hoarse voice that is barely audible. 3. Grey to black eroded teeth with foul odor. 4. Multiple papulopustular skin eruptions.

1) INCORRECT - Bilateral parotid gland enlargement is a hallmark sign of chronic vomiting as the glands become clogged with foreign matter. This is not a priority. 2) CORRECT - The client with a hoarse voice is at high risk for tracheoesophageal fistula from esophageal tear secondary to forceful vomiting. Laryngitis is a danger sign. 3) INCORRECT - Eroded teeth is a sign of chronic vomiting as gastric acid erodes teeth. The client needs an eventual dental referral. 4) INCORRECT - Skin eruptions indicate acne vulgaris related to binge eating and poor personal care. *Think Like A Nurse: Clinical Decision Making* Bulimia nervosa is a type of feeding disorder that starts in adolescence and presents a variety of symptoms from recurrent vomiting that begins in the oral cavity and may reach down to the larynx, causing laryngeal and voice disorder alterations. Nurses should consider bulimia as one of the causes of clinical pictures similar to gastroesophageal reflux disease (GERD). Although not all voice changes in clients with bulimia nervosa are life-threatening, the nurse should refer the client for further evaluation for tracheoesophageal fistula. *Content Refresher* Bulimia nervosa is an eating disorder characterized by consuming large amounts of food in a short time (binging) and engaging in repeated behaviors to lose weight, including purging, excessive exercise, or fasting. Inpatient management may be required to treat medical problems such as fluid and electrolyte imbalances, anemia, and gastrointestinal problems. Evaluate diet and percentage eaten. Monitor client after eating for evidence of purging. Provide emotional support and allow client to verbalize feelings about food consumption. Educate about medications (antidepressants may be prescribed). If client is suicidal, intervene to promote safety.

The new graduate nurse on the neurology unit reviews care for a client with increased intracranial pressure (ICP) secondary to a supratentorial head injury. Which statement by the new graduate nurse requires correction by the preceptor? 1. "I will give the client a cool sponge bath if a fever occurs." 2. "I will do as many procedures close together as I can." 3. "I will hyperventilate the client before and after suctioning." 4. "I will keep the head of the bed elevated to 30 degrees."

1) INCORRECT - Fever may be due to damage to the hypothalamus, and a neurological fever will respond better to external cooling measures (hypothermia blanket or cool sponge bath) than antipyretics. 2) CORRECT - Nursing care is spaced out to minimize elevation of the ICP. Clients are sensitive to sudden and/or noxious stimuli, such as touching, jarring, loud noises, and bright lights, all of which can further increase ICP. 3) INCORRECT - Manual hyperventilation prior to and after suctioning is indicated. Aggressive hyperventilation is avoided because it may cause cerebral vasoconstriction and decrease cerebral perfusion. 4) INCORRECT - Client should be supine, with head and spine aligned or midline and with head of the bed (HOB) elevated 30 degrees, unless contraindicated. *Think Like a Nurse: Clinical Decision-Making* Normally, clustering nursing care is a great plan for the nurse and the client. However, the nurse should always take individual client considerations into account when planning care. The client with increased intracranial pressure requires a balance of rest periods and nursing or medical interventions. Brain injuries are often associated with confusion and disorientation. Overstimulation may necessitate the administration of sedative medications, which can mask further mental alterations and delay the client's progress. *Content Refresher* Increased intracranial pressure (ICP) refers to an increase in cerebrospinal fluid pressure or an increase in the pressure within the brain itself. Causes of increased ICP include lesions, head or brain injury, cerebral infections, vascular insult, or encephalopathies. Prescribed medications may include IV diuretics to decrease cerebral edema, corticosteroids, and anti-emetics. Maintain neutral, midline positioning of the client's head and neck. Ensure airway patency and continuously assess for changes in level of consciousness. Initiate seizure precautions if necessary. Monitor ICP (normal is 5 to 15 mm Hg) and notify the health care provider of any changes. Teach the client to avoid activities that increase ICP, such as bearing down during a bowel movement.

A client seeks medical attention after experiencing an eye injury while working at a welding plant. Which question is the most important for the nurse to ask to begin providing this client with care? 1. "Can you tell me exactly what happened?" 2. "Weren't you wearing the Occupational and Health Safety Act (OSHA) required eye protection?" 3. "Did the plant have safety guidelines in place?" 4. "Do you know what type of material entered your eye?"

1) INCORRECT - Finding out what caused the injury is not necessary to determine the client's immediate needs. 2) INCORRECT - Asking about wearing eye protection will not help the client with the required care needs. Discussing safety can occur at a later time. 3) INCORRECT - Asking about plant safety guidelines does not help the client's current injury needs. This question is not relevant to the client's current condition. 4) CORRECT - Since the client works in a welding plant, it is essential to know what material might have caused the injury. Some materials, such as copper, iron, and steel, can result in an intense inflammatory reaction. Knowing the material that entered the eye assists the nurse to determine the extent of the injury. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that care of the client with eye trauma can be complicated and careful assessment is necessary before implementing any action. The immediate reaction might be to flush the eye with copious amounts of fluid to remove foreign particles. However, before initiating any intervention the nurse needs to first assess the client in order to prevent additional harm or injury. Since the injury occurred when the client was at work, the nurse needs to ask what type of materials could have caused the injury. Once that is known or speculated, the nurse can proceed with emergency treatment, which might include immediate transport to an emergency department for diagnostic testing and surgical care. *Content Refresher* Assessment is the careful observation and evaluation of a client's health status. It is the first step of the nursing process. A holistic assessment is necessary to obtain data that enable the nurse to make an accurate nursing diagnosis, identify and implement appropriate interventions, and assess their effectiveness. The goal is that the nurse will obtain data through assessment that will accurately and appropriately contribute to the holistic treatment of the client. Assessment of the cause of injury is designed to gather information about chemical exposure to avoid doing further harm to the eye.

The nurse provides care for a client diagnosed with a malignant brain tumor located in the left frontal lobe. Which sign or symptom does the nurse expect the client to exhibit? 1. Unilateral hearing loss. 2. Personality changes. 3. Visual impairments. 4. Bowel and bladder incontinence.

1) INCORRECT - Hearing is controlled by the temporal lobe. 2) CORRECT— The frontal lobe controls voluntary activity, executive function, personality, concentration, motivation, ability to plan, and problem solving. 3) INCORRECT - Vision is controlled by the occipital lobe. 4) INCORRECT - The bowel and bladder are innervated through the spinal column. *Think Like A Nurse: Clinical Decision Making* The nurse needs to use knowledge regarding the anatomy and physiology of the brain, and consider the specific functions of the frontal lobe. One function of the frontal lobes, in general, is to control behavior and personality. However, since the client's pathology is specifically located in the left frontal lobe, the nurse will most likely assess a change in the client's personality. *Content Refresher* The client with a brain tumor is at risk for increased intracranial pressure. Utilize the Glasgow Coma Scale to assess level of consciousness. Notify the health care provider (HCP) immediately if there is a change in level of consciousness. Implement neurological checks and monitor vital signs. The nurse can anticipate changes in the client's functioning dependent upon the area of the brain affected by the tumor. For clients with a frontal lobe tumor, the nurse can expect to see a deterioration or significant change in motivation, planning, sustained mental effort, problem solving, and personality.

The nurse teaches a breastfeeding class for expectant and new mothers. Which antibody does the nurse explain is passed through breastmilk to the infant? 1. IgE. 2. IgD. 3. IgG. 4. IgM.

1) INCORRECT - IgE is produced by the child's body in response to the exposure to an antigen. It is not passed through breastmilk. 2) INCORRECT - IgD is produced by the child's body in response to the exposure to an antigen. It is not passed through breastmilk. 3) CORRECT - IgG is passed to the child from the mother during breastfeeding. 4) INCORRECT - IgM is produced by the child's body in response to the exposure to an antigen. It is not passed through breastmilk. *Think Like A Nurse: Clinical Decision Making* The nurse is aware that one decision that a new mother makes is the method by which to provide nutrition to the newborn. The nurse knows there are pros and cons for both bottle feeding and breastfeeding, and should support the clients decision. One major advantage of breastfeeding is providing immune support to the newborn. One immunoglobulin, IgG is passed from the mother to the newborn through breast milk. The newborn's immature immune system is "boosted" by receiving IgG via breastmilk; therefore, helping to prevent the development of infections or disease. *Content Refresher* Immunoglobulin G (IgG) is the only immunoglobulin transported across the placenta and is responsible for passive immunity. The IgG antibodies are transferred from the mother to the fetus starting as early as 14 weeks' gestation. At term, the infant's cord blood levels of IgG are higher than those in the maternal blood. Because of the transfer of IgG, the infant is usually provided with sufficient passive immunity during the first 3 months of life.

The nurse leads a group therapy session. The nurse notes that a client, who has never spoken in group, is listening intently and maintains eye contact with others while they share their feelings. Which response by the nurse is most appropriate? 1. "You used to look sad. Now you have a positive view to share." 2. "Why do you refuse to share your feelings with the group?" 3. "Express yourself verbally so the group will understand you." 4. "It appears that you have some feelings about what is being said."

1) INCORRECT - It is unclear whether the client has a positive view or not. This statement does not encourage the client to verbalize their feelings. 2) INCORRECT - This is a nontherapeutic response. The nurse should avoid "why" questions, as these are confrontational and appear to express judgment. 3) INCORRECT - This is a command. The client will be less likely to share feelings. 4) CORRECT — This is an open-ended statement that conveys to the client that the nurse is following the client's feelings and is interested in what the client has to say. *Think Like A Nurse: Clinical Decision Making* The nurse who is leading a group therapy session should mentally ask, "How can I encourage the clients to share their thoughts and feelings?" The nurse needs to recognize the client's interest may indicate thoughts that could be beneficial for the client and to the groups in general if shared. Asking the client an open-ended statement gives the client an opportunity to respond or explain the interest that is being shown in a nonverbal way. *Content Refresher* Therapeutic communication skills include: 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. The nurse avoids non-therapeutic techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

An ice storm paralyzes a community during the night. The two nurses on a 24-bed medical/surgical unit learn that it will be 12-15 hours before they can expect the next shift to arrive. Which action do the nurses take first? 1. Each nurse takes a shower while the other nurse cares for all of the clients. 2. Instruct the nursing assistive personnel (NAP) to begin morning care at 0400. 3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12-15 hours. 4. Plan to administer all of the clients' as needed pain medication before they ask for it.

1) INCORRECT - Leaving the unit is unsafe for the clients. A shower is not essential at this time. 2) INCORRECT - While the NAP may need to start a little early to ensure that all clients receive morning care, this is not essential. The priority is to ensure that clients receive the most important treatments and medications. 3) CORRECT— The priority is to determine treatments and medications that are vital to the well-being of the clients. 4) INCORRECT - The nurse should not make as needed medications routine. These medications are not essential. *Think Like A Nurse: Clinical Decision Making* After an ice storm paralyzes a community, two night shift nurses working on a 24-bed medical/surgical unit must continue caring for clients on the unit because the day shift nurses cannot access the hospital. To combat the staffing dilemma, the nurses should think, "What essential care must we give to protect the clients from harm?" The nurses should determine which essential medications and treatment interventions, with consideration of the ABCs (airway, breathing, circulation), that they must provide to ensure the clients' well-being. Nonessential interventions should be eliminated. *Content Refresher* The nurse, when acting as case manager, must use various sources of information such as interdisciplinary observations and discipline specific plans of care and documentation to identify client and family needs. These issues and concerns address the immediate needs based on the current health status of the client and anticipated needs based on the client's anticipated optimal level of function. Case management is critical during disaster planning.

The nurse plans care for a client with Grave disease. The nurse intervenes when the client drinks which fluid? 1. Whole milk. 2. Beef broth. 3. Orange juice. 4. Iced tea.

1) INCORRECT - Milk is not limited for Grave disease. 2) INCORRECT - Beef broth is not limited for Grave disease. 3) INCORRECT - Orange juice is not limited for Grave disease. 4) CORRECT — Tea is a caffeinated beverage, a stimulant that would increase metabolic rate. The client with Grave disease is in danger due to an already high metabolic rate. *Think Like A Nurse: Clinical Decision Making* The overproduction of thyroid hormone can lead to hypermetabolic signs such as fever, tachycardia, and palpitations. All emotional stress should be managed, both acute and chronic. Stress can raise cortisol and adrenaline levels, further increasing the signs of this hypermetabolic state. Caffeine and nicotine must be avoided, including caffeine found in "healthy" options like green tea. Caffeine is found in chocolate, decaffeinated and caffeinated coffee and tea, and soda. Anything that increases this metabolic rate further can cause a dangerous crisis for the client. *Content Refresher* Grave disease, an autoimmune disease of unknown etiology, results in diffuse thyroid enlargement and the excess secretion of thyroid hormones (T3, T4, or both) leading to hyperthyroidism. Signs and symptoms include, but are not limited to, exophthalmos; weight loss; tremors; palpitations; hypertension; diarrhea; warm, smooth, moist skin; and fine, silky hair. Treatment for Grave disease includes antithyroid drugs (e.g., propylthiouracil or methimazole), large doses of oral iodine (not an effective, long-term solution because of a reduction in the therapeutic effect), radioactive iodine therapy, β-adrenergic blockers (e.g., atenolol), and thyroidectomy.

The nurse prepares a teaching plan for a client with open-angle glaucoma. Which information will the nurse emphasize with the client? 1. Limit eye movements. 2. Wear protective eyewear in sunlight. 3. Instill mydriatic eye drops every 4 hours. 4. Schedule periodic tonometer readings.

1) INCORRECT - Moderate use of the eyes is permitted in the client with open-angle glaucoma. Glaucoma is an abnormal increase in intraocular pressure, leading to visual disability and blindness caused by an obstruction of the outflow of aqueous humor. 2) INCORRECT - Protective eyewear in sunlight should be worn by all people and not just by those with glaucoma. 3) INCORRECT - Mydriatics dilate the pupil and are contraindicated in the client with glaucoma. 4) CORRECT— The client with open-angle glaucoma should have tonometer or eye pressure measurements one or two times a year. Normal intraocular pressure is 10 to 21 mm Hg. Symptoms of glaucoma include cloudy, blurry vision or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; and pain, headache, nausea, and vomiting. *Think Like A Nurse: Clinical Decision Making* The client may not be aware of a worsening eye condition, as the sensory nervous system has the ability to compensate for gradual changes in peripheral vision. However, without proper treatment, glaucoma can result in loss of vision. The client with glaucoma should be instructed to have regular eye exams with tonometry to measure intraocular pressure. Tonometry can be performed via direct pressure from a probe, touching a probe to the eye to gain an electronic reading, or puffing air toward the eye to flatten the cornea. Tonometry assists the health care provider with evaluating the effectiveness of glaucoma medications. Desired outcomes of medications used for treatment of the client with glaucoma include maintaining low intraocular pressure and preventing disease progression. *Content Refresher* Glaucoma is the name for a group of eye diseases that damage the optic nerve and cause increased pressure within the eye, resulting in gradual loss of sight. The primary risk factor for glaucoma is being over the age of 60. Glaucoma may develop following an eye injury or after eye surgery. Some medicines (e.g., corticosteroids) that are used to treat other diseases may also cause glaucoma. Assist in maintaining client's quality of life through the use of visual aids, such as large-print items and special video systems. Ensure client safety. Identify adaptations in the home to promote the client's autonomy and independence.

The nurse provides care for a client diagnosed with ventricular tachycardia and angina. Which medication does the nurse administer first? 1. Nitroglycerin. 2. Morphine sulfate. 3. Amiodarone. 4. Metoprolol.

1) INCORRECT - Nitroglycerin is a potent coronary vasodilator. Nitroglycerin will treat the angina, but will not terminate the ventricular tachycardia, which is causing the angina. The nurse first administers the medication that will stop the cause of the ventricular tachycardia before treating the angina. 2) INCORRECT - Morphine sulfate decreases pain and is given for chest pain caused by MI to reduce preload and afterload pressure. The client with ventricular tachycardia and angina is unstable. The nurse will first administer medication to correct the ventricular tachycardia. Administration of morphine sulfate will require a neurological assessment, which will be necessary once the client is stable. 3) CORRECT - The nurse administers a drug that will terminate the rhythm causing the angina first. Ventricular tachycardia indicates severe myocardial irritability and causes chest pain, dizziness, and fainting. Amiodarone is the drug of choice for hemodynamically unstable ventricular tachycardia. This medication inhibits adrenergic stimulation and prolongs repolarization, allowing for a normal rhythm to occur. 4) INCORRECT - Metoprolol is a beta-blocker that will decrease the automaticity of heart contractions. This may be a maintenance medication or an adjuvant to the anti-arrhythmic medication. *Think Like a Nurse: Clinical Decision-Making* The action of the nurse after noticing that a client is in ventricular tachycardia (VT) is to activate the advance cardiac life support protocol such as performing an ABC check for 10 seconds. Ventricular tachycardia without a pulse is treated like ventricular fibrillation and requires immediate defibrillation. Depending on the client's co-morbid conditions, epinephrine 1 mg every 3 to 5 minutes may be also given in a full-blown cardiac arrest. The nurse should keep in mind that amiodarone poses a high risk for phlebitis when given IV and should monitor the IV site frequently. *Content Refresher* The nurse should treat dysrhythmias with prescribed medications, cardioversion, or defibrillation as needed, and then provide a medication to treat the angina.

The community health nurse provides care to an older adult client who recently developed decreased hearing acuity. The client's family is concerned because the client insists on taking evening walks alone. Which recommendation by the nurse is most appropriate? 1. "It's best for you to walk in the morning." 2. "Consider visiting an audiologist." 3. "You'll need to find a walking partner." 4. "Carry a cell phone with you at all times."

1) INCORRECT - Potential risks related to decreased hearing acuity, including not hearing approaching vehicles or people, would be concerning regardless of the time the client walked. Ideally, to emphasize preserving the client's autonomy and independence, the focus should center on optimizing health and wellness. An audiologist may prescribe hearing aids, which may resolve the issue. 2) CORRECT— Primary concerns for the older adult client include optimizing health and wellness to preserve autonomy and independence. Visiting an audiologist is the most appropriate recommendation, as the audiologist may prescribe hearing aids, which would enhance the client's autonomy and independence. 3) INCORRECT - Finding a walking partner may help decrease the potential risks related to decreased hearing acuity, including not hearing approaching vehicles or people. However, the focus should center on optimizing the client's health and wellness to preserve the client's autonomy and independence. Visiting an audiologist is the most appropriate recommendation, as the audiologist may prescribe hearing aids. 4) INCORRECT - Carrying a cell phone may enable to the client to call for help. However, potential risks related to decreased hearing acuity, including not hearing approaching vehicles or people, would still remain. To optimize the client's health and wellness, nursing recommendations should center on preserving the client's autonomy and independence. The most appropriate recommendation involves visiting an audiologist, as hearing aids may be prescribed. *Think Like A Nurse: Clinical Decision Making* The community health nurse should think, "What could I recommend that would help address the client's hearing loss and the family's concerns regarding the client's safety?" An audiologist can help assess the client's hearing loss and recommend possible solutions. Insisting that the client walk with a partner diminishes the client's independence. A client with hearing loss may not hear approaching people or vehicles, increasing the risk for client harm. This risk remains present regardless of the time of day. Carrying a cellphone enables the client to call for help should a problem arise, but it does not protect the client from harm. *Content Refresher* Ask client, family, or caregivers about their perception of client's hearing loss, when it started, and its severity. Assess client's ability to hear varied speech tones and determine if hearing loss is unilateral or bilateral. Review health history and determine occupational exposures to loud noise, use of ototoxic medications, and chronic illnesses that contribute to hearing loss. Refer to audiologist for pure-tone air conduction hearing test, if indicated. Teach client and family about presbycusis-related hearing loss and treatment options such as training in lip reading, hearing aids, cochlear implants, and assistive listening devices. Refer to community support services, if indicated.

The nurse provides care for a client diagnosed with substance abuse. The nurse recognizes the client is using projection as a defense mechanism when the client makes which statement? 1. "There is genetic predisposition in my family to alcoholism." 2. "My spouse takes handfuls of medications, and I don't do that." 3. "I have one or two glasses of wine at dinner with my spouse." 4. "Many psychologists do not believe addiction is a disease."

1) INCORRECT - Rationalization is the justification of an unreasonable act or idea to make it appear reasonable. Rationalizations are usually plausible, but not the reasons for the behavior. 2) CORRECT— Attributing one's feelings, impulses, thoughts, or wishes to another person is projection. Pointing out that someone else was driving faster and is more deserving of a speeding ticket is another example. 3) INCORRECT - Denial is failure to acknowledge an intolerable thought, feeling, experience, or reality. Claiming to be a social drinker is an example of denial. 4) INCORRECT - Intellectualization is the excessive use of reasoning or logic to prevent a person from feeling. Explaining how the client might not really have an addiction is an example of intellectualization. *Think Like A Nurse: Clinical Decision Making* The use of ego defense mechanisms can be both adaptive and maladaptive. They may be used to manage anxiety. The nurse may conduct a comprehensive anxiety assessment. The nurse may acknowledge anxious behavior and assist the client in reflecting and clarifying. Acknowledge the defense mechanism but provide reality orientation. *Content Refresher* Coping mechanisms are behaviors, thoughts, or feelings that enhance control or bring psychological comfort to a person experiencing stress. There are positive coping mechanisms (e.g., exercise, listening to music, talking to a close friend, or doing a creative activity) and negative coping mechanisms (e.g., smoking, eating or drinking too much, abusing drugs, or self-criticizing). Assess the client's previous methods of coping with stress. Assess the client's support system. Identify triggers that cause stress. Provide effective communication, emotional support, and a list of community resources that may be able to help decrease stress.

The nurse provides cares for a client reporting pain at the intravenous (IV) access site. Upon assessment, the nurse notes tenderness and redness at the site and redness proximally along the vein. It is most important for the nurse to take which action? 1. Slow the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Remove the IV and apply a pressure dressing. 4. Remove the IV and apply warm soaks.

1) INCORRECT - The client is experiencing phlebitis. Continuing the infusion, even at a slow rate, will worsen the phlebitis. 2) INCORRECT - The IV catheter should be removed and warm soaks applied. The nurse will notify health care provider if the signs and symptoms are severe, if they persist, or as indicated by the facility's policy. Otherwise, the nurse will treat the client with warm compresses, document the action appropriately, and monitor the site. 3) INCORRECT - The nurse will remove the IV, but will not apply a pressure dressing. The client is experiencing inflammation of the vein. A warm soak is required. 4) CORRECT - The IV catheter will be removed to prevent further damage to the vein. Warm soaks decrease inflammation, swelling, and discomfort and should be applied. *Think Like A Nurse: Clinical Decision Making* Pain and redness at an intravenous site and along the vein indicate phlebitis. The catheter needs to be immediately removed and warm soaks are applied to reduce swelling and pain. The infusion should not be continued since this can worsen the condition. *Content Refresher* Administration of intravenous fluids is a routine procedure used to treat dehydration and fluid or blood loss. The nurse should assess the IV access site for signs of infiltration, phlebitis, infection, hematoma, and venous obstruction. The client should be assessed for signs of fluid overload and air embolism. Heat therapy dilates the blood vessels, stimulates blood circulation, reduces muscle spasms, and alters the sensation of pain. Ensure that heat therapy is applied to the skin for no longer than 20 minutes at a time. Avoid heat therapy for skin that is cut or injured. Apply heat therapy devices such as a heating pad, a heat pack, a hand towel soaked in hot water, a warm water soak, or a hot water bottle.

The new graduate nurse is asked by the preceptor why the time spent with the client was longer than expected. The new graduate replies, "I taught the client how to use the incentive spirometer. The client did not understand that you have to inhale and hold your breath." The preceptor responds, "It's not inhale with an incentive spirometer, it's exhale." Which action does the new graduate nurse take? 1. Return to the client and explain that they should hold their breath on exhalation, not inhalation. 2. Suggest that the preceptor join the new graduate in reviewing the manufacturer's guidelines for use of the machine. 3. Explain that it was stressed in class that inhalation, not exhalation, was appropriate for the incentive spirometer. 4. Tell the preceptor that this erroneous information is shocking and the matter needs go to the manager.

1) INCORRECT - The new graduate was correct and should not confuse the client with additional instructions. 2) CORRECT - Reference to supporting legitimate and respected documents defuses emotional nature of the situation and enables resolution. Incentive spirometry requires inhalation or holding of the breath 3 to 5 seconds. This is beneficial because deep inhalations expand alveoli and prevent atelectasis. 3) INCORRECT - This places the preceptor on the defensive by implying the preceptor is not up-to-date. 4) INCORRECT - This action will antagonize the preceptor and set up a powerfully conflictive situation. Reserve proceeding up the chain of command for resolution if the nurse is unwilling to use policy, directions, or evidence to correct the practice. *Think Like A Nurse: Clinical Decision Making* The situation described requires delicacy and careful consideration when a new graduate nurse needs to correct a preceptor. One possible action is to create a mutual purpose. In this case, it is to learn the correct method of using the spirometer by reviewing the manufacturer's guidelines. The new graduate nurse can say, "I don't want you to think I don't appreciate your guidance. I do want to make sure I am teaching the client correctly. Can we review together the manufacturer's instructions?" *Content Refresher* Conflict resolution is managing the opposition, friction, disagreement, or discord that arises between individuals or within a group. Assess which conflict resolution strategy works best in a specific situation. Instances of conflict are minimized by using appropriate resolution strategies. Resolve the conflict in ways to gain respect, improve self-esteem, and build courage. Use effective communication skills. As conflict arises, it is addressed in productive ways to achieve positive results for the client, the nursing unit, and the health care organization.

The nurse finds a school-age client having a tonic-clonic seizure. Which action will the nurse take first? 1. Call for help. 2. Place a padded tongue blade between the teeth. 3. Place a pillow under the head. 4. Straddle the legs and hold the arms.

1) INCORRECT - The nurse must protect the client. Calling for help is important but is not the first action. Depending upon where the client is located, the nurse might need to raise the bed side rails or ease the client to the floor. 2) INCORRECT - Nothing should be inserted into the mouth of a client experiencing a seizure. 3) CORRECT— The client needs to be protected from injury. Depending upon where the client is located, placing a pillow under the head would be essential. The nurse may also need to raise the bed side rails, pad the side rails, loosen clothing, or clear space around the client if the client is on the floor. 4) INCORRECT - Straddling the legs and holding the arms is an attempt to restrain the client's movements. This could cause a fracture or dislocation. The nurse should protect both the client and self from flailing arms and legs while protecting the client from injury. *Think Like A Nurse: Clinical Decision Making* The first action to take for a client having a tonic-clonic seizure is to protect the client from injury. In this case, placing a pillow under the head would be appropriate. Calling for help can be done after the client's safety is ensured. Nothing should be placed in the mouth of a client who is having a seizure. The client's extremities should not be restrained during a seizure. This can cause harm to both the client and nurse. *Content Refresher* When providing care for a client with a seizure, the nurse should prevent injury by maintaining seizure precautions and plan education about disease and medications to treat disease. During an observed seizure, the nurse should monitor and document seizure activity and client 's level of consciousness before, during, and after the seizure. Have oxygen and suction equipment at the bedside. Turn client on side and protect from injury during the seizure. Administer oxygen using face mask during seizure. Note duration of seizure. Following seizure, ask client if aura was present.

The nurse provides care for a school-age child newly diagnosed with asthma. The nurse teaches the child's parent about the child's return to school. Which instruction does the nurse include in the teaching? 1. Provide the child's teacher with the inhaler and instructions on its use. 2. Have the child use the inhaler before going to school to prevent an attack. 3. Tell the child to carry the inhaler and spacer in a pocket at all times. 4. Provide the school nurse with an inhaler, spacer, prescription, and directions for use.

1) INCORRECT - The nurse should advise the parent to provide the school nurse (not the child's teacher) with an inhaler, spacer, prescription, and directions for use should the child have an acute asthmatic episode at school. 2) INCORRECT - The nurse should instruct the parent about using the inhaler when an acute asthmatic episode occurs, not routinely before school. 3) INCORRECT - The child should not carry medication around in school. Instead, the parent should provide the school nurse with an inhaler, spacer, prescription, and directions for use should the child have an acute asthmatic episode at school. 4) CORRECT— The nurse should advise the parent to provide the school nurse with an inhaler, spacer, prescription, and directions for use should the child have an acute asthmatic episode at school. *Think Like A Nurse: Clinical Decision Making* The nurse recognizes that a child with asthma has special learning and care needs. One of these needs is to ensure for the client's health and welfare when away from the home. This means that the client's health problem should be supported when at school. The school nurse is the person to whom information about the client's health problem and method of treatment should be addressed. The nurse should prepare a plan that identifies the client's symptoms of distress and action to take, including medications and method of delivery. The nurse should offer to review this information with the school nurse so that the client and parents are secure in the school nurse's ability to handle any emergency situation. *Content Refresher* Teach the client and family about asthma, including identification of triggering experiences and how to reduce exposures. Teach the client and family about symptom monitoring and appropriate interventions based on the level of symptom presentation. Provide information about the prescribed medications, including the differences in use and adverse effects. In collaboration with provider and client/family, an asthma action plan will be developed. This asthma plan should include information about triggers, prescription, inhaler type(s), and use of spacer. Risk factors include exposure to cigarette smoke, air pollutants, occupational chemicals, food additives, mold, pollen, dust, animal dander, and viral or bacterial infections. Additional risk factors include food and drug allergies, nose and sinus problems, and genetic predisposition.Status asthmaticus is a life threatening complication of asthma, which may have a rapid, acute onset. Continued compromised respiratory function may lead to chronic debilitation and limitations.

During shift hand-off report, a client's ventilator alarm is activated. Which action does the nurse take first? 1. Notify the respiratory therapist. 2. Inspect the ventilator tubing. 3. Deactivate the alarm. 4. Auscultate breath sounds.

1) INCORRECT - The nurse should first assess the client, even if the ventilator is the problem, because the client's respiratory functioning must be supported. 2) INCORRECT - Assess the client first and then the equipment. 3) INCORRECT - Silencing the alarm does not deactivate it or determine why the alarm sounded. Failure to address the cause can result in client harm. 4) CORRECT— The nurse must support the client while identifying and correcting the ventilator problem. The nurse observes rate and quality of respirations and assesses for hypoxia. *Think Like A Nurse: Clinical Decision Making* Troubling shooting for ventilator alarms should take into consideration the safety of the client. Typically, the computer screen on the ventilator will display the type of alarm triggered (e.g. low or high volume alarm). The nurse should perform a focused respiratory assessment, including monitoring the oxygen saturation and vital signs. If the alarm persists after trouble shooting, the client should be disconnected from the ventilator and manually ventilated using a bag-valve device (e.g. ambu) while the scenario is escalated to the next level (e.g. calling for a replacement ventilator). The client should be offered reassurance and all procedure must be explained. *Content Refresher* When caring for a client at risk for hypoxia, the nurse should assess baseline vital signs, including pulse oximetry and skin color, temperature, and degree of hydration of skin. Assess cardiac output. Assess rate, depth, and quality of respirations.

A client who is breastfeeding reports a dry cough, fever, headache, and muscle aches. Which instruction is the best for the nurse to provide to this client? 1. Suggest discontinuing breastfeeding during the illness. 2. Encourage increased fluid intake. 3. Instruct the client to wear a surgical mask. 4. Remind the client to uncover the breasts before washing hands.

1) INCORRECT - There is no reason for the client to discontinue breastfeeding. 2) INCORRECT - Although increasing fluids is appropriate, this is not the best teaching to provide to the client. 3) CORRECT— The client needs to prevent the spread of infection to the infant. This is best accomplished by wearing a mask and continuing to do so until the feeding is completed. 4) INCORRECT - Uncovering the breasts will not help prevent the spread of infection to the infant. *Think Like A Nurse: Clinical Decision Making* During any "ordinary" illness such as a cold, sore throat, flu, or mastitis, the client should continue to breastfeed. Wearing a surgical mask will prevent transmission of respiratory infectious agents to the newborn. The client, along with all caregivers, should be reminded to practice proper hand hygiene at all times. The client should be reminded to inform the health care provider of the breastfeeding so that if a prescription is required, the health care provider can choose lactation-compatible medications. *Content Refresher* Contraindications associated with breastfeeding include clients who are HIV positive or have varicella, active tuberculosis that is untreated, or active herpes to the breast. In addition, clients who take certain medications (e.g., chemotherapy or radioactive isotopes), use illicit drugs, or smoke should avoid breastfeeding. Finally, an infant diagnosed with galactosemia should not be breastfed.

The nurse provides care to a client who is vomiting brown material that has a fecal odor. Which condition does the nurse suspect is causing this type of vomitus? 1. Gastric outlet obstruction. 2. Obstruction below the pylorus. 3. Intestinal obstruction. 4. Excessive hydrochloric acid in the gastric area.

1) INCORRECT - There would be undigested food in the vomitus if gastric outlet obstruction was the problem. 2) INCORRECT - The vomitus would be bile-stained green if there was an obstruction below the pylorus. 3) CORRECT— A bowel obstruction is indicated with vomitus that is brown with a fecal odor as described. 4) INCORRECT - The vomitus would be burning and bitter-tasting if excessive hydrochloric was the issue. *Think Like A Nurse: Clinical Decision Making* Before deciding the reason why a client would be having emesis that resembles fecal material, the nurse should apply knowledge about the anatomy and physiology of the gastrointestinal system. If the problem is with the stomach, the client would have undigested food or the emesis would burn due to the presence of gastric acid. If the problem is around the pyloric valve, the emesis would be green in color, reflective of bile released into the digestions process at this point. However, since the emesis resembles fecal material, the nurse recognizes the problem is lower in the digestive tract. The client most likely is experiencing an obstruction somewhere within the bowel, which is preventing the fecal material from advancing and being excreted as a bowel movement. *Content Refresher* When caring for a client with a possible intestinal obstruction, the nurse should complete a health history to identify risk factors for intestinal obstruction. Assess for signs and symptoms of small or large intestinal obstruction. Assess abdominal size and shape, bowel sounds, and presence of tenderness or masses on palpation. Ask about flatus, last bowel movement, nausea, vomiting, and pain. Monitor vital signs and intake and output for signs of hypovolemia. Maintain NPO status until peristalsis returns and insert and maintain suction through gastrointestinal tube, as prescribed. Provide intravenous fluids. Frequently assess peripheral pulses, skin color, temperature, urinary output, and capillary refill for signs of hypovolemic shock. Promptly report signs/symptoms of deteriorating condition.

The nurse provides care for clients on the medical-surgical unit. The nurse notes that a client is anxious and in respiratory distress. In which position does the nurse place the client? 1. Flat on back with thighs flexed and legs abducted. 2. Lying with the head of the bed elevated 15 ° to 45°. 3. Lying on the left side with legs bent. 4. Lying with the head of the bed elevated 60 ° to 90°.

1) INCORRECT - This describes the lithotomy position, which increases vaginal opening for examination. 2) INCORRECT - This describes the semi-Fowler position, which does not sufficiently elevate the head of the bed to promote optimal lung expansion. 3) INCORRECT - This describes the Sim position, which decreases abdominal tension and allows drainage of oral secretions. 4) CORRECT - The high-Fowler position allows optimal pulmonary expansion. It also decreases venous return, which assists in lowering the ventricular output and pulmonary congestion. *Think Like A Nurse: Clinical Decision Making* A simple maneuver to assist a client improve lung expansion in the event of respiratory distress is to sit the client up. The nurse should simultaneously obtain a full set of vital signs, perform a focused respiratory assessment, and apply supplemental oxygen as needed. Depending on the individual scenario, the nurse may activate the rapid response team (RRT). The nurse should not leave the client alone. *Content Refresher* The nurse should place the client in high-Fowler position to improve ventilation and assess the client's respiratory rate and pulse oximetry for comparisons.

A young adult is informed of the diagnosis of breast cancer by the health care provider. Which statement by the nurse is best? 1. "Do you have any questions about your diagnosis?" 2. "Tell me how you are feeling about what you have been told." 3. "I am sure you want to be alone for a few minutes." 4. "I will contact your minister."

1) INCORRECT - This is a closed-ended (yes/no) question and is not the most therapeutic. 2) CORRECT— This is an open-ended statement that allows the client to respond emotionally to the diagnosis. 3) INCORRECT - This is not therapeutic. The nurse should stay with the client. 4) INCORRECT - The nurse should first support the client. Later, the nurse can assess if the client would like a spiritual advisor to be contacted. *Think Like A Nurse: Clinical Decision Making* Communication with a client who is receiving a diagnosis of cancer must be therapeutic. The nurse needs to explore the client's feelings in order to offer support and answer any questions the client may have. The most effective method for the nurse to use is to ask an open-ended statement to facilitate discussion. The most appropriate and therapeutic statement to make is to ask the client to share personal feelings regarding the diagnosis. *Content Refresher* The nurse needs to use therapeutic communication when caring for this client. Therapeutic communication includes the following communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad open statements, 6) asking about thoughts/feelings, 7) restating and reframing, 8) reflecting, 9) presenting reality, 10) sharing observations, and 11) clarifying meaning. The nurse needs to avoid non-therapeutic communication techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

The nurse attaches an external electronic fetal monitor to the abdomen of a pregnant client in labor. Which action does the nurse take next? 1. Determine the frequency of contractions. 2. Identify the types of accelerations. 3. Determine the intensity of contractions. 4. Assess the baseline fetal heart rate.

1) INCORRECT - This is an important data point to assess, but is not the first priority. 2) INCORRECT - This is an important data point to assess, but it is not the first priority. 3) INCORRECT - This assessment is most accurately measured by an internal fetal monitor. 4) CORRECT - The baseline fetal cardiac rate is the most important initial assessment so that abnormal variations of the baseline rate can be identified, if they occur. *Think Like A Nurse: Clinical Decision Making* When caring for a client in labor, the nurse needs to remember that there are two clients who require care. The mother's needs should be addressed; however, the viability and impact of labor on the fetus needs to be monitored closely. One way to ensure that labor is not causing stress to the fetus is through electronic fetal monitoring. The device monitors the fetal heart rate, which can be assessed for changes related to the length and strength of contractions. The first action for the nurse to take is to acquire a tracing of the fetal heart rate, which is used as a baseline reference for all future tracings. *Content Refresher* When caring for a client in labor, assess the client for signs of active labor. Check the cervix for dilation and effacement and determine fetal station. Apply an external fetal monitor and then assess the baseline fetal heart rate and note the pattern of contractions. Monitor the mother's uterine contractions for frequency and duration and assess the fetal response. Note fetal heart characteristics and any patterns of accelerations and declarations.

The nurse witnesses a neighbor fall from the roof of a house. The nurse goes to the victim and determines the need to open the airway. Which procedure does the nurse use to open the airway in this victim? 1. Flexed position. 2. Jaw thrust. 3. Head-tilt, chin-lift. 4. Modified head-tilt, chin-lift.

1) INCORRECT - This is an inappropriate position for opening the airway and could cause further injury to the client's cervical spine. 2) CORRECT - If a cervical spine injury is suspected, this is the maneuver used to open the airway to prevent further injury. 3) INCORRECT - This produces hyperextension of the neck and could cause complications if a cervical spine injury is present. 4) INCORRECT - This position can still produce hyperextension of the cervical spine, which could cause complications if there is a cervical spine injury. *Think Like a Nurse: Clinical Decision-Making* If basic life support (BLS) providers suspect a cervical spine injury in a client, they should open the airway using a jaw thrust without head extension. Because maintaining a patent airway and providing adequate ventilation are priorities in cardiopulmonary resuscitation (CPR), the 2015 guidelines from the American Heart Association (AHA) suggest using the head tilt, chin lift maneuver if the jaw thrust does not adequately open the airway. If the nurse is the only rescuer on the scene, the nurse should initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C) to reduce delay to first compression. The single rescuer should begin CPR with 30 chest compressions followed by two breaths. *Content Refresher* CPR is the use of chest compressions and ventilation for clients in cardiac arrest. A jaw thrust is used for known or suspected cervical spine injuries because they are associated with respiratory complications and quadriplegia. Once the airway is open, check for normal breathing, taking no more than 10 seconds. If the client is not breathing, pinch the nostrils shut for mouth-to-mouth breathing. Tightly seal your lips around the client 's mouth and give two rescue breaths. Observe for a rise in the client 's chest.

The nurse discovers an older adult client on the floor of the waiting room in the outpatient clinic. The client is unconscious and not breathing, but has a pulse. Which action does the nurse implement next? 1. Lift the back of the client's neck and check the airway. 2. Move the lower jaw backward and push the tongue to the side. 3. Turn the client's head to one side and shake the client firmly. 4. Tilt the client's head back and lift the chin.

1) INCORRECT - This is not the best way to position the client to open the airway. 2) INCORRECT - This will not open the airway. 3) INCORRECT - The client is unresponsive and not breathing. The priority is to open the airway and begin rescue breaths. 4) CORRECT - This opens the airway. The nurse should place a hand on the client's forehead, applying backward pressure. The nurse should place the fingers of the other hand under the client's chin and lift forward. *Think Like a Nurse: Clinical Decision-Making* The nurse understands that the first step of cardiopulmonary resuscitation (CPR) is to determine client responsiveness by tapping or shaking the client's shoulder and asking, "Are you okay?" If the client does not respond, the nurse knows to check for breathing while simultaneously performing a carotid pulse check for at least 5 seconds, but for no more than 10 seconds. For the pulseless client, the nurse understands the importance of high-quality CPR and early defibrillation if the client's cardiac rhythm is ventricular fibrillation or pulseless ventricular tachycardia. *Content Refresher* When performing cardiopulmonary resuscitation (CPR) on a client who has a pulse, but is not breathing, the nurse needs to open the client's airway using the head-tilt, chin-lift maneuver and deliver one rescue breath every 5 to 6 seconds. The nurse should recheck the client's pulse every 2 minutes. If the client's pulse is no longer palpable, the nurse should deliver a compression-ventilation ratio of 30 compressions to two breaths. If a nurse finds a client unresponsive and the client is not breathing and does not have a palpable pulse, CPR is initiated using the compressions-airway-breathing (CAB) approach.

The nurse is delivering external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which action is most important for the nurse to take? 1. Maintain a position close to the client 's side with the nurse 's knees apart. 2. Maintain vertical pressure on the client 's chest through the heel of the nurse 's hand. 3. Recheck the nurse 's hand position after every 10 chest compressions. 4. Check for a return of the client 's pulse after every eight breaths by the nurse.

1) INCORRECT - This is not the most important action. The nurse needs to be in a position to apply pressure to client 's chest in a correct manner. 2) CORRECT— It is most important that the elbows should be locked, arms straight, shoulders directly over the hands when delivering chest compressions. Incorrect pressure can cause damage or fail to produce adequate circulation. 3) INCORRECT - The heel of the hand should be on the lower half of the sternum. The nurse should not routinely recheck hand position, as this takes away from delivering compressions at the rate needed. 4) INCORRECT - The client 's pulse should be rechecked after every minute, not every eight breaths. *Think Like A Nurse: Clinical Decision Making* A client who is unresponsive, not breathing, and has no heart beat requires immediate cardiopulmonary resuscitation (CPR). Nurses and other health care providers will be prepared to provide CPR. When providing chest compressions, proper technique is required to prevent injury to the ribs, lungs, and xiphoid process and to ensure effectiveness of the compression. The nurse should place the heel of one hand over the lower third of the client's sternum, place the other hand directly on top of the other hand, straighten the arms, and compress the chest. Any deviation from this technique alters the effectiveness of resuscitation efforts. *Content Refresher* To perform chest compressions during cardiopulmonary resuscitation (CPR), the client needs to be placed on a firm surface. The nurse must kneel next to the client's neck and shoulders, and place the heel of one hand over the center of the client's chest between the nipples, while placing the other hand on top of the first hand. Keeping elbows straight, the nurse needs to position shoulders directly above the hands. Using upper body weight, the nurse should push straight down to compress the chest at the appropriate depth and rate, based on the age and size of the client.

The nurse makes rounds on clients on the medical-surgical unit. It is important for the nurse to intervene for which observation? 1. A client 10 hours post-tonsillectomy sits in a bedside recliner watching television. 2. A client admitted 4 hours ago with a closed head injury lies flat in bed with legs elevated. 3. A client 3 days post-below knee amputation (BKA) lies prone in bed. 4. A client admitted yesterday with COPD sits with the head of the bed elevated 45 degrees.

1) INCORRECT - This is proper positioning for this client. The nurse assesses for postoperative bleeding after attending to priority clients. 2) CORRECT - Clients with closed head injuries are prone to increased intracranial pressure. A modified Trendelenburg is dangerous for the client. Elevate head of bed 30 to 45 degrees to promote venous drainage. 3) INCORRECT - At 72 hours post-BKA the nurse would start to be concerned with development of contractures, and a prone position will stretch the hip flexors and quadriceps muscle to prevent contractures. 4) INCORRECT - Although the client with COPD is usually most comfortable in a 60- to 90-degree position, a 45-degree position is acceptable (the patient is not flat). *Think Like A Nurse: Clinical Decision Making* Proper client positioning in consideration of illnesses or procedures is an essential and frequent nursing function. For the client with the potential for increased intracranial pressure, reducing pressure from venous return and arterial blood pressure is partially accomplished by positioning the client with the head and upper body raised into the semi-Fowler position, which promotes blood drainage. Standard Fowler may be considered, but high-Fowler position is avoided unless autonomic dysreflexia is suspected. *Content Refresher* Increased intracranial pressure (ICP) refers to an increase cerebrospinal fluid pressure or an increase in the pressure within the brain itself. Causes of increased ICP include lesions, head or brain injury, cerebral infections, vascular insult, or encephalopathies. Prescribed medications may include IV diuretics to decrease cerebral edema, corticosteroids, and anti-emetics. Maintain neutral, midline positioning of the client's head and neck. Ensure airway patency and continuously monitor for changes in level of consciousness. Initiate seizure precautions if necessary. Monitor ICP (normal is 5 to 15 mm Hg) and notify the health care provider of any changes. Teach the client to avoid activities that increase ICP, such as bearing down during a bowel movement.

A client visits the clinic 1 week after being assaulted. The client is taking alprazolam 0.25 mg PO every 6 hours for anxiety. Which client statement indicates to the nurse a correct understanding of this medication? 1. "I can take this whenever I feel upset. " 2. "I should only take this with water. " 3. "I guess I need to stop drinking wine. " 4. "This medication will help me forget. "

1) INCORRECT - This statement indicates a need for further medication teaching because it is only prescribed every 6 hours. Taking it more often will result in overdose. 2) INCORRECT - This statement indicates a need for further medication teaching. Other fluids do not alter absorption. 3) CORRECT— Benzodiazepines should not be taken while regularly using alcoholic beverages. 4) INCORRECT - This statement indicates a need for further medication teaching as alprazolam does not cause amnesia of past or recent events. *Think Like A Nurse: Clinical Decision Making* One nursing responsibility is to evaluate client understanding regarding the plan of care or specific information taught in regards to treatments, including medication prescriptions. Clients who are prescribed benzodiazepines, such as alprazolam, must be provided information to ensure safety. Alcohol should not be used during treatment with benzodiazepines to reduce the risk of sedation. The client is advised not to drive a car or operate potentially dangerous machinery. It is essential to inform the client not to stop taking alprazolam abruptly or decrease the dose without consulting the health care provider, since withdrawal symptoms can occur. Benzodiazepines, including alprazolam, produce additive CNS depressant effects when co-administered with other psychotropic medications, anticonvulsants, antihistaminics, and other drugs that themselves produce CNS depression. *Content Refresher* Alprazolam is a benzodiazepine used to treat anxiety and panic disorders. Assess risk for drug dependence and suicide. Ask about pregnancy status because alprazolam is not recommended during pregnancy. With older adult clients, monitor for risk of falls and complete drug reconciliation to reduce risk of polypharmacy. Advise client to avoid alcohol, other central nervous system depressants, smoking (which may decrease drug 's effectiveness), and grapefruit juice (which may increase drug level) while taking the medication. Teach about relaxation, deep breathing, yoga, meditation, and other ways to reduce anxiety.

The nurse provides care to a client receiving topiramate. For which client statement will the nurse intervene? 1. "I drink at least 10 glasses of water each day. " 2. "I change positions slowly. " 3. "I should contact my health care provider if I have blurred vision. " 4. "I use oral contraceptives. "

1) INCORRECT - Topiramate is an anticonvulsant. The client should drink 2000 to 3000 mL of fluid daily to prevent kidney stones. 2) INCORRECT - Topiramate may cause orthostatic hypotension. Changing positions slowly is an appropriate action. 3) INCORRECT - Topiramate should be discontinued if ocular symptoms occur. If left untreated, ocular changes may lead to blindness. 4) CORRECT - Non-hormonal contraceptives should be used when taking topiramate. *Think Like a Nurse: Clinical Decision-Making* Topiramate, an enzyme-inducing anti-epileptic medication, can affect pharmacokinetics of oral contraceptives, leading to contraceptive failure. Generally, the efficacy of combined oral contraceptives is diminished in clients taking enzyme-inducing anti-epileptic drugs, such as, phenytoin, phenobarbital, and carbamazepine. The client and partner should be informed about using other methods of birth control, such as a condom, when taking these medications. *Content Refresher* Plan client education regarding medication administration, including the importance of taking the drug as prescribed. Inform the client about the medication, the reason for its administration, and how and when effectiveness will be determined. Teach the client not to drive or operate heavy machinery until the central nervous system effects of topiramate are known. Assess for expected outcomes and adverse effects, such as suicidal thoughts, depression, or leukopenia Document the medication administration according to institutional policy.

The nurse provides care for a client diagnosed with Hantavirus pulmonary syndrome (HPS). Which action by the nurse is most appropriate? 1. Assess the client for signs/symptoms of seizures. 2. Assess the client for signs/symptoms of renal failure. 3. Assess the client for signs/symptoms of thrombocytopenia. 4. Assess the client for signs/symptoms of liver failure.

1) INCORRECT — Hantavirus pulmonary syndrome is spread by rodents. The symptoms include fever, aching, and nausea. Seizure activity is not expected. 2) INCORRECT — Hantavirus pulmonary syndrome may cause severe cardiopulmonary disease. The nurse should teach clients in rural areas to avoid rodent droppings. 3) CORRECT — Thrombocytopenia is caused by HPS. The nurse should observe for hematuria, hematemesis, bleeding gums, and melena. 4) INCORRECT — Hantavirus pulmonary syndrome impacts the lungs and cardiac systems. *Think Like A Nurse: Clinical Decision Making* The nurse caring for a client infected with Hantavirus pulmonary syndrome (HPS) knows that the this virus primarily attacks the circulatory and pulmonary systems. HPS can cause hemorrhagic fever, which causes the client to bleed from access sites and mucous membranes. This client should be thoroughly assessed for any signs of bleeding from the gums, intravenous insertion sites, and gastrointestinal and urinary tracts. If the client experiences hemorrhagic fever, the client may develop renal failure secondary to shock. However, the risk of bleeding poses a more acute risk of harm to the client. *Content Refresher* Hantavirus pulmonary syndrome (HPS) is a disorder caused by exposure to rodents who carry the virus and results in severe cardiopulmonary illness. Those at risk for developing this disorder include individuals who live in rural areas and are exposed to rodents and their droppings. Signs and symptoms include fever, aching muscles, nausea, and shortness of breath. Complications associated with HPS include thrombocytopenia, hemoconcentration, and cardiopulmonary compromise.

The nursing team consists of a nurse, a LPN/LVN, and two nursing assistive personnel (NAPs). Which client does the nurse assign to the LPN/LVN? 1. A client 2 days postoperative after abdominal hysterectomy asking to ambulate in the hall. 2. A client with a colostomy requiring assistance with an irrigation. 3. A client with a right-sided cerebrovascular accident (CVA) requiring assistance with bathing. 4. A client refusing medication for treatment of cancer of the colon.

1) INCORRECT — This can be assigned to an NAP. The nurse will give clear directions as to how far to ambulate the client and any untoward effects that should be reported to the nurse. 2) CORRECT — This is a stable client with an expected outcome who needs a task performed that is within the scope of practice of the LPN/LVN. 3) INCORRECT — This is a standard, unchanging procedure and may be assigned to the NAP. 4) INCORRECT — This client requires evaluation and teaching. The nurse will remain with this client. *Think Like A Nurse: Clinical Decision Making* The LPN/LVN should be assigned to a client who is stable, has a predictable outcome, and requires care within their scope of practice. The client requiring assistance with a colostomy irrigation is the most appropriate client to assign to the LPN/LVN. Clients requiring basic care, such as the client who needs to ambulate and the client who needs assistance with bathing, can be safely assigned to the nursing assistive personnel (NAP). The client refusing medication requires assessment and teaching, so this client should be cared for by the RN. *Content Refresher* Each state has a nurse practice act, which protects the public by legally defining and describing the scope of nursing practice. Nurse practice acts also regulate the functions of nurses through licensing requirements. When assigning client care, the nurse needs to review the scope of practice for ancillary staff, such as LPN/LVNs. Delegate tasks or make client assignments that are within their scope of practice.

The nurse provides care for a client diagnosed with laryngeal cancer who is scheduled for a laryngectomy. Which action does the nurse implement to assess the client's laryngeal nerve function? 1. Observe for excessive salivating. 2. Check the ability to swallow. 3. Assess the amount of neck edema. 4. Tap the neck and observe for facial twitching.

1) INCORRECT- This is seen with facial paralysis and Bell's palsy. 2) CORRECT- This effectively demonstrates the ability of the nerve to support the esophageal functions. 3) INCORRECT- This is not an accurate method of assessing for the nerve function. 4) INCORRECT- This is the test for hypocalcemia and tetany. *Think Like a Nurse: Clinical Decision-Making* The nurse applies knowledge of anatomy and physiology and evaluates laryngeal nerve function by assessing the client's ability to swallow. A laryngoscopy or bronchoscopy may be required for definite diagnosis. Concurrent injury to the laryngeal nerves may cause difficulty breathing. Laryngeal cancer can damage the laryngeal nerve. However, laryngeal nerve damage has also been seen in thyroidectomies, endotracheal intubation, and viral infection affecting the laryngeal nerves. *Content Refresher* Clinical manifestations of laryngeal cancer include a neck mass, shortness of breath, hoarseness, pain or difficulty swallowing, weight loss, and bad breath. Laryngectomy , surgical removal of the larynx (partial or total), is indicated for treatment of laryngeal cancer. Post-operatively, manage the client's tracheostomy (suction, humidification, tracheostomy care). Elevate the head of the client's bed to promote lung expansion. Administer IV fluids and enteral or parenteral feedings, as prescribed to meet the client's hydration and nutritional needs. Monitor the client for signs of hemorrhage. Prevent skin breakdown, especially around the tracheostomy site. Administer prescribed pain medications. Assist the client with communication (consult speech therapy).

A community experiences a prolonged heat wave. The emergency department has several clients admitted from a construction project. Which indications will alert the nurse to the diagnosis for heat stroke? 1. Elevated temperature, diaphoresis, nystagmus. 2. Hypotension, tachypnea, tachycardia. 3. Hemiplegia, diplopia, dysarthria. 4. Headache, hot dry skin, hypertension.

1) INCORRECT— Anhydrosis (absence of sweating or diaphoresis) is usually present in heat stroke, so skin will be hot and dry. An elevated temperature is the primary symptom of 105°F (40.6°C) or above. Nystagmus (involuntary eye movements) is not a symptom of heat stroke. 2) CORRECT — A client will have a temperature of 105°F (40.6°C) or above with skin that is hot and dry. A client's behavior may be bizarre, with confusion or delirium, or the client may be comatose. 3) INCORRECT— These symptoms are of a cerebrovascular accident (CVA) (stroke/brain attack), not of heat stroke. 4) INCORRECT— Hypotension is present in heat stroke due to the dehydration. A headache may be an initial symptom of hyperthermia. The skin is hot and dry in heat stroke. *Think Like A Nurse: Clinical Decision Making* Heat stroke occurs when the body is not able to dispel accumulated body heat from exposure to high temperatures or warm environments. Manifestations of heat stroke include a drop in blood pressure, rapid heart rate, and rapid respirations. *Content Refresher* Hyperthermia occurs when the heat-loss mechanisms are not able to keep up with the excessive heat production. The nurse should assess vital signs with temperature and trend the client's temperature to determine fever patterns. Assess the client's symptoms and obtain a health history. Palpate the skin while observing the client's behavior and appearance. Interventions include limiting physical activity, keeping clothing and linen dry, providing oral care, and encouraging adequate nutrition and fluid intake. Administer oxygen, if needed. Promote comfort (control room temperature and apply a cool cloth to the forehead).

The nurse visits a client diagnosed with herpes zoster. Which statement, if made by the client to the nurse, indicates the client understands the cause of the illness? 1. "I will avoid exposure to children with measles." 2. "I had chicken pox in grammar school." 3. "I must use a condom during intercourse." 4. "I should bathe more often than in the past."

1) INCORRECT— Herpes zoster is contagious to anyone who has not had chicken pox, not just to those with measles. 2) CORRECT—Herpes zoster (shingles) is a reactivation of latent varicella (chicken pox), which occurs more frequency in adults with a weakened immune system. Pain, tenderness, and pruritus over the affected region will occur. Herpes zoster is contagious to anyone who has not had chicken pox or who is immunosuppressed. 3) INCORRECT— Herpes zoster is not a sexually transmitted infection. 4) INCORRECT— Herpes zoster is not related to hygiene and does not require additional bathing. *Think Like A Nurse: Clinical Decision Making* In educating clients, the nurse verifies the client's knowledge and corrects misconceptions. Some people have a greater risk of getting shingles (localized herpes zoster). This includes people who have certain cancers, such as leukemia and lymphoma, and human immunodeficiency virus (HIV), and receive immunosuppressive drugs, such as steroids and drugs that are given after organ transplantation. *Content Refresher* Herpes zoster (shingles) occurs when the virus that causes chickenpox (varicella zoster) becomes active in the body. After the individual recovers from chickenpox, the virus becomes dormant in the nerve roots. It stays dormant in some people forever. In others, the virus becomes active when disease, stress, or aging weakens the immune system.

The nurse provides care for a client with a hemoglobin level of 6.8 g/dL (68 g/L). Which intervention does the nurse implement first when providing care for this client? 1. Draw a type and crossmatch for 2 units of packed red blood cells. 2. Place the client on 2 liters of oxygen per nasal cannula. 3. Insert a 19-gauge intravenous catheter. 4. Place the client on a cardiac monitor.

1) INCORRECT— This is an appropriate action, but there is another action that is a higher priority. The nurse will first attend to the client's immediate airway, breathing and circulatory needs (ABCs). The nurse will first apply oxygen, then place the client on a cardiac monitor, then start the intravenous catheter and finally draw the blood work. 2) CORRECT — This hemoglobin level is critically low, which indicates less circulating oxygen. It is important to be certain that the available hemoglobin is well-oxygenated. The nurse first will apply oxygen to the client to address the oxygenation needs. The normal hemoglobin for men is 13 to 18 g/dL (130 to 180 g/L), and for women it is 12 to 16 g/dL (120 to 160 g/L). 3) INCORRECT— This is an appropriate action, but there is another action that is a higher priority. The nurse will first attend to the client's ABCs. The nurse will first apply oxygen, then place the client on a cardiac monitor, then start the intravenous catheter and finally draw the blood work. 4) INCORRECT— This is an appropriate action, due to the risk of cardiac dysrhythmia secondary to tissue hypoxia. However, there is another action that is a higher priority. The nurse will first attend to the client's ABCs. The nurse will first apply oxygen, then place the client on a cardiac monitor, then start the intravenous catheter and finally draw the blood work. *Think Like A Nurse: Clinical Decision Making* Hemoglobin is the oxygen-carrying capacity of the blood. When the hemoglobin level is low, the amount of available oxygen to nourish the body organs and tissues is affected. The priority action is to provide supplemental oxygen to maximize tissue oxygenation. *Content Refresher* Anemia is diagnosed through a complete blood count. Further diagnostic testing may be done to determine cause of anemia. The nurse should monitor vital signs and assess for symptoms such as increasing weakness, fatigue, dizziness, chest pain, and palpitations. The following are indications for oxygen therapy: oxygen saturation below 95%, tachypnea, dyspnea, or signs of decreased perfusion such as hypotension, decreased pulse strength, pallor, cool skin, prolonged capillary refill, and decreased level of consciousness.

The clinic nurse assesses a client who presents with a documented history of a gastric ulcer. Current symptoms include nausea, vomiting, and diarrhea of 2 days' duration. Which client statement requires immediate intervention by the nurse? 1. "I take aspirin for headaches and arthritis pain, and antacids for this ulcer of mine." 2. "I have been drinking more fluids to keep from getting dehydrated, but I am urinating less than I thought I would." 3. "On my last visit to the health care provider, I was told I may be developing cataracts." 4. "I knew I was under a lot of stress at work, but I thought I was coping well."

1) INCORRECT— This is concerning, as aspirin can contribute to gastric ulcer development and worsening. The nurse should further assess the client and provide additional teaching. This is a potential problem, but there is another problem that is a higher priority. 2) CORRECT — It is particularly important to assess urine output because of the potential for fluid volume deficit and resultant shock. In the first stages of shock there is decreased urine output, even when there is normal fluid intake. It is especially important for the nurse to elicit information about fluid intake and output during the preceding 24 hours. This client has an ulcer, which might be bleeding and, in addition, the client is experiencing loss of fluid from vomiting and diarrhea. These could result in hypovolemic shock. This is an actual circulatory problem and is the highest priority. 3) INCORRECT— This is a chronic problem and is not a concern at this time. 4) INCORRECT— The client may need recommendations for stress management in the future, but this is not a physical concern and as such, is not the highest priority. *Think Like A Nurse: Clinical Decision Making* Urine output is a good indirect indicator of cardiac output, central perfusion status, and blood volume. This client could have reduced cardiac output from gastric hemorrhage or from excessive diarrhea and vomiting, coupled with poor oral intake. The nurse assesses how much the client has actually had to drink, frequency of urination, color of the most recently voided urine, and stool characteristics, including color and any clots. Additionally, the nurse will assess other indicators of cardiac output, such as blood pressure and pulse. *Content Refresher* Irreversible organ damage can occur if shock is not diagnosed quickly. Treatment of hypovolemic shock includes insertion of two large bore IV catheters for administration of isotonic fluids (0.9% normal saline or Ringer's lactate). Monitor urinary output as it reflects cardiac output. Monitor the client's kidney function and complete blood count. Monitor vital signs closely. Assess strength of peripheral pulses, color of skin, warmth, and other indicators of perfusion. Administer antiemetics and antidiarrheals as prescribed to control volume losses.

The school nurse is teaching high school students about safe practices when it comes to loud noises and hearing. A student reports, "My parents are always yelling at me about my loud music and that I will go deaf. I tell them that when I get old, if I need a hearing aid, I will just get one. I already wear glasses." What is the best response by the nurse? 1. "It sounds as though your parents really care about you." 2. "Let me explain about the two main kinds of hearing loss." 3. "It is not that simple. Hearing aids are quite different from glasses." 4. "You seem really upset about this issue with your parents."

1) INCORRECT— This may be true, but it does not respond to the adolescent's concern. This response by the nurse could seem patronizing or imply that the nurse is allying with the parents. 2) CORRECT — Adolescents can think abstractly and logically, and this response provides important information from an adult outside the family. Hearing loss includes conductive and sensorineural types. The sensorineural type of hearing loss can be caused by prolonged exposure to noise, such as loud music. This type is usually permanent and is not helped with medical or surgical treatment (such as hearing aid use). 3) INCORRECT— This is not the best response. Although correct (hearing aids are unlikely to be of much, if any, help in sensorineural hearing loss), it does not address the adolescent's misconception. 4) INCORRECT— This is not the best response. Although a reflective empathic statement, it misses the opportunity for direct health teaching about hearing. *Think Like A Nurse: Clinical Decision Making* The student's response about treatment for hearing loss indicates the need for teaching. The nurse should explain the types of hearing loss and which can be aided by a hearing device. Addressing the student's comment about eyeglasses does not focus on the most important issue, which is that the student does not understand the types of hearing loss, how they occur, and the methods available to treat them. *Content Refresher* The cumulative effects of repeated exposure to loud noise can cause sensorineural hearing loss. Noise-induced hearing loss is caused by long-term exposure to sounds that are either too loud or last too long. This kind of noise exposure can damage the sensory hair cells in the ear that allow one to hear. Once these hair cells are damaged, they do not grow back and the ability to hear is diminished.

The nurse provides care to the client who had a bowel resection 6 hours earlier. The client reports nausea. In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) 1. Administer PRN IV Odansetron 2. Auscultate for bowel sounds 3. Assess NG tube patency 4. Lightly Palpate abdomen 5. Reassess in 45 minutes for continued nausea

First, assess. The most likely cause of nausea in a post-operative client is a malfunctioning NG tube, so the nurse first determines if this is the problem and corrects it. Second, assess the second most likely cause. The nurse assesses for ileus by auscultating the abdomen. Third, the nurses lightly palpates the abdomen for tenderness or rigidity only after auscultation. Fourth, implementing pharmacologic treatment with an ordered PRN antiemetic is an appropriate nursing action. Fifth, after assessment and interventions are complete, reevaluate the client's nausea. Anti-emetic administration must be followed by evaluation of the effectiveness of the intervention. If the client continues to experience nausea, the nurse starts the nursing process again. *Think Like A Nurse: Clinical Decision Making* Nausea immediately after surgery may be related to anesthesia. For clients who had bowel surgery, this could be due to lack of peristalsis and inflammation of the bowels. The nurse should perform a focused abdominal assessment, including making sure that the nasogastric tube (NGT) is patent and in the right place. The nurse should monitor effectiveness of ondansetron and monitor the client for adverse effects such as QT interval prolongation. *Content Refresher* When performing an abdominal assessment, the nurse should begin with inspecting the abdomen for color, lesions, scars contour, and shape. Next, the nurse should auscultate the abdomen using the diaphragm of the stethoscope. During auscultation, the nurse assesses for quality, pitch, and presence of bowel sounds in each quadrant. Percussion and palpation follow to determine organ size, abdominal tenderness, and tone.