Total Qbank

The nurse prepares to obtain vital signs on a client. The client's previous blood pressure reading was 138/76 mm Hg and the client's pulse rate was 68 beats/minute. How long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?

30 to 45 seconds. To ensure that the diastolic has been determined, the cuff shouldbe released slowly until the mid-60s mmHg for someone with the client'sprevious reading. Since the cuff should be deflated at a rate of 2 to 3 mm persecond, a range of 90 mmHg will require 30 to 45 seconds.

The nurse receives an informal mid-shift report from the nursing assistive personnel (NAP) assisting with client care. Which report does the nurse respond to first?

A client after a Billroth II procedure (gastrojejunostomy) wanted to lie down right after eating even after I told the client to sit up for at least half an hour to let the food digest. The client action requires immediate intervention. After a gastrojejunostomy, dumping syndrome can occur, and lying down after eating is recommended in order to delay the gastric emptying process. Eating lying down or semirecumbent is another measure that can be taken. The desire to lie down may be one of the early manifestations of dumping syndrome, which also includes vasomotor disturbances of syncope. The client needs evaluation and clarification of proper procedure, and the NAP needs to be taught that this client situation is the exception to the rule of not lying down after eating. Think Like A Nurse: Clinical Decision Making The client recovering from gastric surgery is at risk for developing dumping syndrome, which occurs when ingested carbohydrates move too rapidly into the small intestines. Reclining after eating is recommended to delay the gastric emptying process. This client has a physical need

Four clients are admitted at the same time to the medical unit. Which client will the nurse assign to a private room?

A client diagnosed with scabies. Scabies is a contagious skin disease caused by mites. It is transmitted by close contact, either directly person-to-person or via contaminated personal items such as clothing or bedding. It requires a private room and contact precautions.

The nurse provides care to several clients in an outpatient clinic. For which client does the nurse conduct a hearing assessment?

A client who is receiving cisplatin. Cisplatin, which is an antineoplastic medication, is ototoxic. For the client who is prescribed cisplatin, hearing acuity should be assessed. Cimetidine, which is an H 2 histamine-receptor antagonist, is not known to cause ototoxicity. Cisplatin, an antineoplastic medication, may cause ototoxicity. Think Like a Nurse: Clinical Decision-Making Many medications can result in ototoxicity by damaging sensory cells in the middle ear. This results in ear damage, hearing loss, tinnitus, or balance issues. Aminoglycoside antibiotics, platinum chemotherapy agents, aspirin, non-steroidal anti-inflammatories (NSAIDs), quinine, and loop diuretics are known to cause this effect. When these drugs are administered in combination, the risk of developing ear damage increases. In some instances, ear damage is temporary; in many cases, it is permanent.

The nurse observes a nursing assistive personnel (NAP) provide care for clients. Which observation by the nurse requires an intervention?

A client with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress. This action is to be avoided by having the upper leg mildly flexed and resting on a pillow from groin to feet. A potential trouble area of the side-lying position is hip joints that are internally rotated, adducted, and unsupported. Think Like A Nurse: Clinical Decision Making The nurse should identify client postures that could damage joint and motor function. When placing a client in the side-lying position, the upper leg should be flexed with the hip supported. A small pillow under the knees when in the high-Fowler position prevents sliding towards the foot of the bed. A small pillow under the head when in the side-lying position prevents neck flexion. A pillow under the legs when in the prone position keeps pressure off of the toes.

The nurse provides care for a client who requires neurological checks every 2 hours. The nurse identifies which components as part of the Glasgow Coma Scale (GCS)? (Select all that apply.)

Best verbal response — confused. Eye-opening response — none. Best verbal response — incomprehensible sounds. Best motor response — localizes pain. Think Like A Nurse: Clinical Decision Making The Glasgow Coma Scale (GCS) is used to assess verbal and motor response, and eye opening. The score for each category is based upon the action assessed. For incomprehensible sounds, the verbal score would be a 2. For confusion the verbal score would be a 4. For a motor response to localized pain, the score would be a 5. Since the client does not open the eyes, the score for eye opening would be a 1.

Broiled pork chop, cream of potato soup, and pudding

Clients who sustain a full-thickness burn demonstrate an increased metabolism, as well as a need for increased protein. Significant protein is found in a broiled pork chop, cream of potato soup, and pudding. In addition, creamed soup and pudding provide additional calories.

peritoneal dialysis

Determine if the client is menstruating Because of the hypertonicity of the dialysate, blood from the uterus can be pulled through the fallopian tubes into the effluent. This is common in premenopausal female clients during menstruation. No intervention is required.

seizure diagnostic test

Electroencephalogram

An older adult client diagnosed with emphysema becomes restless and confused. The nurse takes which action first?

Encourage the client to perform pursed-lip breathing The client is experiencing symptoms of hypoxia. Pursed-lip breathing prevents collapse of the alveoli between breaths and assists with the exhalation of carbon dioxide Think Like a Nurse: Clinical Decision-Making The nurse who works with clients diagnosed with chronic lung disease needs to be aware of the manifestations of the disease. The nurse must assess clients who are diagnosed with chronic lung disease for indications of elevated levels of carbon dioxide in the blood. This often causes the client to be restlessness and confused. When this occurs, the nurse encourages the client to perform pursed-lip breathing. This technique keeps the alveoli inflated while allowing excess carbon dioxide to be exhaled.

The nurse completes a screening questionnaire with a client scheduled for a magnetic resonance imaging (MRI) exam. Which assessment finding most concerns the nurse?

Has an aneurysm clip. An aneurysm clip is a contraindication for the exam. The clip could heat up, become dislodged, and possibly result in hemorrhage and/or death. The health care provider should be notified. A hearing aid can be removed. This is not a contraindication for the exam. Think Like A Nurse: Clinical Decision Making The nurse needs to be familiar with the process and contraindications related to the diagnostic test that is prescribed for a client. A magnetic resonance imaging (MRI) test uses a magnet as the method of capturing images of internal structures. Because a magnet is used, the client should not be wearing anything that is metal or have any metallic object implanted in the body. In this scenario, the nurse should recognize the risk for injury due to the presence of a metal aneurysm clip.

adrenal insufficiency.

Irritability, weight loss, nausea, vomiting, and postural hypotension

herbal licorice

Licorice can increase potassium loss and may cause digoxin toxicity and arrhythmias.

iron-deficiency anemia causes

May occur with removal of duodenum. Associated with chronic blood loss. Most common type of anemia.

hypocalcemia

Numbness and tingling of the toes and fingers and painful muscle spasms

The nurse administers an incorrect dose of medication to the client. Which actions are appropriate for the nurse take in this situation? (Select all that apply.)

Record the dose of medication administered Perform an assessment of the client. Contact the health care provider. Document any adverse reaction the client experienced.

latex allergy.

Runny nose. Angioedema. Bronchospasm. Shock.

The reason combination of TB meds

The combination of medication prevents the development of resistant organisms.

Parkinson disease

Tremors. Bradykinesia. Slurred speech. Propulsive gait.

transdermal patch

change every 7 days

polycystic kidney disease

low Na+ diet

The nurse counsels an older client about peripheral vascular disease. Which client statement indicates that further teaching is needed?

"I should use warm packs if my hands and feet get cold. " Decreased sensitivity may result in burns. The client should be instructed to use gloves and socks to warm the hands and feet. Warm moist packs hold heat longer than warm packs and increase the risk for injury. Exercise increases collateral circulation. The client should walk until pain begins, rest, and then walk a little farther. Think Like A Nurse: Clinical Decision Making In clients with peripheral vascular disease (PVD) , an important nursing outcome is prevention of injury to the affected leg. The client should be informed that due to reduced circulation and sensation, the leg is at a higher risk for injury. The nurse should use the teach-back method to verify the client's knowledge related to foot care. The client is taught to inspect feet and legs daily, wear clean cotton or wool socks and well-fitting shoes, avoid sitting with legs crossed, and avoid prolonged standing.

The nurse provides education to a client who is newly diagnosed with systemic lupus erythematosus (SLE). Which client statement indicates to the nurse a need for further instruction? (Select all that apply.)

"I will wear SPF 15 sunscreen when I am outside." The rash on my face will go away in time." "I may need to take a medication that will boost my immune system. Individuals with SLE should wear sunscreen with a minimum SPF of 30 when exposed to direct sunlight. Think Like A Nurse: Clinical Decision Making Systemic lupus erythematosus is an autoimmune disorder that affects all organs and body systems. The client should be instructed to use a sunscreen with a minimum of SPF 30 and wear clothing and a hat to further reduce exposure to direct sunlight. The butterfly rash, which is a hallmark symptom of the disorder, does not fade.

Haemophilus influenzae type B (Hib) vaccine

"It prevents Hib disease, which can cause meningitis, brain damage, and deafness."

The nurse prepares to perform a breast examination on a 20-year-old female client. Which question is most important for the nurse to ask before beginning the examination?

"When was your last menstrual period? Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breasts are at a low level. Think Like A Nurse: Clinical Decision Making A breast examination is considered a part of the physical assessment. However, before beginning this portion of the examination the nurse should mentally ask, "What is the most common event that can impact this examination?" Using knowledge of anatomy and physiology, the nurse should recognize the importance of determining when the client last had a menstrual cycle. If the breasts are assessed immediately before or during menses, the client may exhibit swelling and tenderness and experience unnecessary discomfort during the examination.

The nurse provides care for clients in the dermatology clinic. The nurse understands that which client is the best candidate for ultraviolet (UV) light therapy

A client diagnosed with ulcerative colitis and psoriasis. This client is the best candidate for UV light therapy, which can be used to treat psoriasis. Ulcerative colitis is not a contraindication to UV light therapy. Think Like a Nurse: Clinical Decision-Making The nurse considers both the skin condition and other diagnoses to identify contraindications for ultraviolet (UV) light therapy. The use of UV light therapy is an approach to treat psoriasis. This therapy is not contraindicated in the treatment of a client with ulcerative colitis since the light will not adversely affect that health problem. The nurse must think in terms of safety, as UV light therapy could harm the client or the fetus if conditions such as pregnancy, cataracts, or skin cancer are present.

The nurse provides care for clients in the emergency department. Which client does the nurse assess first?

A client reporting a bee sting, causing diffuse redness. A sting should cause a local reaction. What is described is the start of a systemic reaction, which may lead to anaphylaxis and airway loss if not treated promptly. This client requires evaluation for the cause of the bleeding, such as bladder cancer, but is likely not losing enough blood in the urine to experience cardiac output decrease and is not the priority. Think Like a Nurse: Clinical Decision-Making Bee stings can potentially cause a life-threatening anaphylactic reaction. The nurse should examine this client first and assess the client for airway patency and adequate oxygenation. The nurse should also anticipate providing epinephrine and diphenhydramine as needed and supplemental oxygen. Local care for the stung area includes cleaning with soap and water, applying ice to ease pain and swelling, and applying creams, such as hydrocortisone. The client's vital signs should be monitored closely.

The nurse counsels a mother breastfeeding her 4-week-old infant about birth control. Which client statement indicates that further teaching is necessary?

"I think that oral contraceptives will be the best for me." Oral contraceptives suppress the production of breast milk and are not the best contraceptive option for this client. Think Like A Nurse: Clinical Decision Making Postpartum clients often request information about birth control and before providing the information the nurse should review specific information about the client. The nurse should mentally ask, "Since this mother is breastfeeding, what birth control methods should be avoided and why?" Oral contraceptives should not be provided as an option for breastfeeding clients, because the hormone within the medication adversely effects breast milk production.

intravenous pyelogram allergy

"My face flushes when I eat shrimp. Facial flushing when eating shrimp can indicate a sensitivity to iodine. The contrast medium used for an intravenous pyelogram contains iodine. If used, the client may develop anaphylaxis. The nurse should assess for an allergy to shellfish, iodine, chocolate, eggs, and milk.

The nurse supervises an unlicensed assistive personnel (UAP). Which tasks does the nurse delegate to the UAP? (Select all that apply.)

Apply an abdominal binder Assist a client with use of a urinal Application of an elastic bandage cannot be delegated to the UAP. It is the nurse's responsibility to assess circulation immediately after application. Think Like A Nurse: Clinical Decision Making Before delegating tasks to an unlicensed assistive personnel (UAP), the nurse should recall the scope of practice for this member of the health care team. The UAP should be assigned standard, unchanging procedures for stable clients. Assessment of a client's health condition, medication administration, and sterile irrigations are not included in the UAP's scope of practice. Tasks that are appropriate for the nurse to delegate to the UAP include the application of an abdominal binder, along with assisting a client with elimination and hygiene needs

A client is in a hip spica cast after a fall and dislocation of the right hip. The LPN/LVN reports to the nurse that the client is feeling bloated, is reporting abdominal pain and nausea, and has vomited for the past 2 hours. After assessing the client, which action will the nurse take next?

Call the health care provider and report the symptoms. These symptoms indicate cast syndrome, also known as superior mesenteric artery syndrome. This is an unusual, but serious and urgent complication most often seen in clients in a hip spica or body cast. The cast pressure itself and/or accumulated intestinal gases cause the duodenum to be compressed between the aorta and the superior mesenteric artery, resulting in distention, abdominal pain, nausea, and vomiting. The nurse may need to cut a window into the abdominal area of the cast to relieve pressure. Alternative options include bivalving the cast or inserting a nasogastric tube to decompress the intestine.

The nurse administers meperidine 25 mg IV to a client in labor. Which fetal heart rate (FHR) pattern does the nurse anticipate as a result of administering this medication?

Decreased variability. Opioid medications, such as meperidine, cause decreased variability by depressing the fetal central nervous system (CNS), which causes FHR to decrease. Think Like A Nurse: Clinical Decision Making Any medication administered during labor has the potential to affect the fetus. Opioids depress the fetal central nervous system and, therefore, alter control of fetal heart rate. This effect is transient and minimal, but requires close monitoring for prolonged effect or fetal bradycardia. If non-reassuring variable decelerations are noted, the nurse repositions the client, administers a fluid bolus, supplies oxygen by facemask, and assesses the mother and fetus for other causes.

The nurse provides care for an infant who is six months of age. Which action does the nurse implement when conducting a neonatal reflex assessment?

Eliciting the Babinski reflex. he Babinski reflex is present in the infant who is 6 months of age. It disappears at 12 months of age. Think Like A Nurse: Clinical Decision Making The nurse is aware that every body system and organ does not function at an optimal level upon birth. The neurologic system is still developing, which may cause challenges during an assessment. Because of this, the nurse can rely on the assessment of infant or primitive reflexes to determine normal neurologic functioning. These reflexes slowly disappear as the infant develops. The one reflex that is the last to disappear is the Babinski reflex. This reflex remains intact until approximately 12 months of age. Other primitive reflexes disappear by 5 months of age.

prevent neural tube defects

Folic acid (vitamin B9)

The nurse in a community clinic evaluates a client diagnosed with type 1 diabetes mellitus. Which observation indicates to the nurse that the client is not rotating insulin injection sites?

Glucose levels rise temporarily Failure to rotate sites results in poor absorption of the insulin, which increases the blood glucose level. A wheal at an injection site indicates an allergic reaction to the insulin. Think Like A Nurse: Clinical Decision Making Clients diagnosed with diabetes mellitus are often required to perform self-injection of prescribed insulin. The nurse teaches the client to use sites on the front of the body. The abdomen absorbs insulin the fastest, followed by the arms, thighs, and buttocks. The client is reminded to keep a record of which injection sites are used and to rotate appropriately so that absorption is not negatively affected. For optimal comprehension and compliance, education material used by the nurse 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 client understands what was taught.

Heart rhythm

Heart rhythm is more appropriately used to identify an undesirable effect of the dopamine.

The nurse provides care to a client receiving radioactive iodine I-130 to treat hyperthyroidism. Which symptoms will the nurse monitor for in this client based on the current treatment?

Lethargy, sensitivity to cold, dry skin, weight gain, depression Think Like a Nurse: Clinical Decision-Making When being treated for hyperthyroidism, there is a risk that thyroid function might be excessively slowed or altered. If that occurs, the client will demonstrate signs of hypothyroidism, which includes lethargy, sensitivity to cold, dry skin, weight gain, and depression. The other lists of symptoms described health problems that are not related to the function or treatment of a thyroid disorder.

infectious mononucleosis.

Mononucleosis is an infectious disease caused by the Epstein-Barr virus. Besides extreme fatigue, other indications include malaise, fever, headache, epistaxis, and severe sore throat.

hyperemesis gravidarum

Parenteral hydration is the best way to rehydrate the client. The client will initially be NPO to rest the gastrointestinal tract.

compartment syndrome

Parethesia is a characteristic

cognitive impairment

Poor judgment. Memory deficits. Following a stroke, the client can show very little emotion or a flat affect. The client may also have personality changes or mood swings. These symptoms indicate behavioral changes. Think Like A Nurse: Clinical Decision Making In addition to physical impairments, a stroke, or cerebrovascular accident (CVA), may also cause cognitive changes. For example, following a stroke, the client's problem-solving skills, short-term memory, and ability to learn new information may be impaired. The nurse helps the client learn to cope with these challenges. Speech-to-text note-taking applications can be helpful for short-term memory challenges, such as making a grocery list. Clients are encouraged to rest between cognitive tasks to enhance recall and understanding. For the client, adaptation requires patience from self and others. Members of the interdisciplinary team, including the occupational therapist, play critical roles in the client's rehabilitation.

The nurse receives report about four pregnant clients in active labor. Which client does the nurse assess first?

The multipara client with cervical dilation of 8 cm with the presenting fetal part at +2 station. he transition phase of labor and delivery is quick for many multipara women. Think Like A Nurse: Clinical Decision Making The transition phase of labor (part of the first stage of labor) is marked from 7 cm dilatation until the cervix is fully dilated to 10 cm. Since the transition phase can be relatively short for multiparous clients, the nurse should assess this individual first. Typically, the transition phase of labor lasts anywhere from 30 minutes to 2 hours. The client will experience contractions that are longer, stronger, and more intense and can overlap. The nurse encourages the client to relax between contractions.

pneumococcal and influenza vaccine

administered at the same time but different sites

Heat under a cast

is a sign of pressure. The nurse should first perform a neurovascular assessment to evaluate circulation.

trifluoperazine

no breast feeding with this med

The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client?

"Amoxicillin is an antibiotic that will help you get well." For the school-age client, discussion of facts is appropriate. School-age clients can process information about their treatments and benefit from participating in their plan of care. Although the school-age child appreciates being informed about the plan of care, the information is incorrect. Amoxicillin may be administered without regard to food or beverages. The client may drink a beverage immediately before or after taking amoxicillin. Amoxicillin suspension also may be mixed with ginger ale, fruit juice, water, milk, or (as appropriate) formula. Think Like A Nurse: Clinical Decision Making School-age clients are given facts about their care. Telling things that are false, tricking, and trying to make the client fearful of other medication options is not professional, and will cause the child to become argumentative or distrustful. The nurse is honest and describes the client's care in age-appropriate words, empowering the child to help manage his or her own well-being.

The nurse teaches staff members about developmental considerations related to bowel elimination. Which statements are appropriate for the nurse to include in the teaching? (Select all that apply.)

"An infant's stool will vary depending on how the infant is fed." "Bowel control is usually achieved before bladder control "Constipation in the older adult can be related to decreased gastrointestinal motility." "Fecal impaction may be associated with oozing of liquid feces." The formula-fed infant excretes pale yellow to light brown stools. They are firmer in consistency than those of the breastfed infant. The stools of infants fed with breastmilk are seedy, and the color and consistency of mustard with a sweet-sour smell. 2) CORRECT - Bowel control is usually achieved before bladder control. 3) INCORRECT - Voluntary control of anal and urethral sphincters begins at about 18 to 24 months 4) CORRECT - Older adults may experience slowed peristalsis related to the loss of muscle elasticity, reduced intestinal mucous secretion, or a low-fiber diet. 5) CORRECT - The cardinal sign of impaction is continuous oozing of liquid stool, with no normal stool. Oozing occurs as the liquid portion of feces higher in the intestines seeps around the mass. Think Like A Nurse: Clinical Decision Making Comprehensive bowel assessment requires an understanding of normal gastrointestinal (GI) functions in various developmental stages. During the interview of clients with diarrhea or constipation, the nurse should inquire about its onset, duration, and character, as well as associated symptoms and alleviating factors. The nurse can inquire about the client's usual bowel patterns, routines followed to promote bowel elimination, diet and fluid intake history, medication use, and medical-surgical conditions affecting the GI function.

The nurse in the outpatient clinic prepares a client for a pap smear. The client's only significant history is hypertension, for which the client takes an anti-hypertensive medication daily. It is most important for the nurse to follow-up on which client statement?

"Black cohosh helps my hot flashes." Herbal remedies, such as black cohosh, used in management of menopausal symptoms may cause hypotension when used in combination with antihypertensive drugs. The use of this herbal product can affect blood pressure and circulation; therefore, this is the priority statement for the nurse to further assess. Think Like A Nurse: Clinical Decision Making The nurse must differentiate between a medication 's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports ingesting supplements and drugs that may interact, such as black cohosh and anti-hypertensive medications. The nurse assesses the client 's needs and educates the client regarding possible hypotension.

The nurse assesses a 10-year-old client during a well-child visit. Which statements will the nurse expect the client to make? (Select all that apply.)

"I am allergic to strawberries. Whenever I eat one my lips get real big." "I have a kitten. I love having an animal." "A child in my class has hurt feelings when teased by others." According to Piaget's concrete operational stage, children should be able to take on the perspective of others. Think Like a Nurse: Clinical Decision-Making Based on Piaget's stages of cognitive development, concrete operational development occurs among school-age children (7 to 11 years of age). When providing care to the school-age client during a well-child visit, the nurse expects certain behaviors based on the stage of cognitive development. During the concrete operational stage, the child learns by manipulating concrete objects, lacks the ability to think abstractly, learns that certain characteristics of objects remain constant, understands the concept of time, starts collecting items, understands relationship among objects, and can reverse thought processes.

A health care provider (HCP) notifies the charge nurse of an inpatient unit that the city mayor is being admitted. The HCP states that one of the nurses on the unit is "disheveled and unkempt" and asks that the nurse be reassigned during the mayor's hospitalization. Which response does the charge nurse provide to the HCP in this situation?

"I am unable to comply with your request." Client care assignments are made based on the knowledge and abilities of staff members. The charge nurse is in the best position to assess the needs of the clients and make the appropriate assignments. This is an inappropriate request by the HCP. Think Like A Nurse: Clinical Decision Making The request to reassign a nurse based upon physical appearance is unacceptable. The charge nurse must explain the decision-making process that is used when making client care assignments with the health care provider, reiterating that the nurse will not be reassigned. Nursing assignments are based on the scope of practice of each member of the health care team, the acuity of the clients, and the number of staff needed to safely care for the clients.

The nurse performs diet teaching for a client diagnosed with heart failure. Which statement by the client indicates to the nurse that further teaching is needed?

"I eat salami sandwiches for lunch each day." Processed meats such as cold cuts, sausage, and bacon are high in added sodium and should be avoided by a client with heart failure. The nurse should provide further teaching and encourage the client to choose lower-sodium meat options, including baked chicken breast or baked fish. While the client with heart failure should avoid excessive fluid intake, drinking 4 ounces of fluid at each meal will only contribute a total of 360 mL of fluid daily. Think Like A Nurse: Clinical Decision Making The client with heart failure should be instructed to reduce sodium intake in order to avoid fluid overload. Processed meats are high in sodium and should be avoided. Fresh fruit and vegetables are recommended to manage blood pressure in the client with heart failure. Whole wheat items are high in fiber and low in sodium. Even though some clients with heart failure may be prescribed a fluid restriction, 4 oz of liquid with every meal would not be contraindicated.

The nurse teaches a client diagnosed with chronic gout about the prescribed allopurinol. Which client statements indicate that teaching has been effective? (Select all that apply.)

"I need to switch to decaffeinated coffee." I can use ibuprofen for discomfort." It is safe to crush allopurinol as the medication is not extended release. Non-steroidal anti-inflammatory medications are safe to take during an acute attack of gout. Think Like A Nurse: Clinical Decision Making During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. The nurse ensures the client understands allopurinol use and health management related to gout. Uncontrolled gout can lead to permanent damage from hard crystal formation in the joints. To promote adequate hydration, the client should drink at least 2 liters of fluid per day; ideally, water. Educate the client about the importance of maintaining a healthy weight and reducing or eliminating alcohol. Therapeutic effectiveness for this client means a reduction in gout attacks.

The nurse provides discharge teaching to a client recovering from an appendectomy. Which client statement indicates that teaching is effective?

"I shall eat a diet high in protein, high in calories, and high in vitamin C. " Supplemental vitamin C, iron, and multivitamins aid in wound healing and formation of red blood cells hink Like A Nurse: Clinical Decision Making Protein, vitamin C, and sufficient calories are required for adequate wound healing. A diet low in protein and calories does not support wound healing. Fat and carbohydrates do not promote wound healing, however, they are required for a balanced diet.

The nurse provides teaching for a client diagnosed with herpes zoster. Which client statements indicate to the nurse a correct understanding of the information presented? (Select all that apply.)

"I should expect only one side of my face to hurt." This pain may linger for months." "I will try not to scratch the lesions." Herpes zoster follows dermatomes on one-half of the body. Herpes zoster may lead to post-herpetic neuralgia, a nerve pain that persists for days to months after the infection is cleared. 5) CORRECT — Lesions are known to cause itching as well as pain. The client is advised not to scratch primarily to avoid secondary bacterial infection. Think Like a Nurse: Clinical Decision-Making Treatment for a client diagnosed with shingles may span from weeks to months. Prescribed pharmacologic agents typically include antivirals and medications for treatment of neuropathic pain. Education includes teaching the client about managing pain and preventing complications, such as secondary infection. Shingles cannot be transmitted to others. However, individuals who have never had chickenpox or who have not received the varicella zoster vaccine could develop chickenpox as a result from coming in contact with an individual who is experiencing shingles. The nurse reinforces the need to maintain excellent hand hygiene to prevent disease transmission and to protect open lesions from becoming infected.

The nurse instructs a client who is newly diagnosed with type 1 diabetes mellitus (DM) about proper foot care. Which client statement indicates to the nurse that additional teaching is needed?

"I should inspect my feet once a week." The client should inspect feet daily for blisters, sores, ingrown nails, and cuts. This statement indicates that additional teaching is needed. The client should cut toenails straight across, for this prevents ingrown nails. This statement indicates understanding of the teaching. Think Like A Nurse: Clinical Decision Making When caring for a client with type 1 diabetes mellitus (DM), the nurse needs to apply knowledge about factors that can negatively impact the client's health and wellbeing. Because of the risk for foot wounds caused by changes in peripheral nerve sensation, the client with diabetes mellitus should be instructed to examine the feet every day. This can be accomplished by having the client hold a mirror up to the bottom of the foot to conduct a complete inspection.

The nurse provides education about influenza treatment and prevention at a local health fair. Which statements from participants demonstrate correct understanding of oseltamivir? (Select all that apply.)

"I will begin taking the medication as soon as I experience flu symptoms." If the medication upsets my stomach, I can take it with food." CORRECT - To lessen the severity of influenza symptoms, influenza sufferers should take oseltamivir as soon as symptoms appear. 2) INCORRECT - Capsules may be opened and mixed with flavoring if needed. 3) CORRECT - Oseltamivir may cause stomach upset, and taking it with food should decrease this side effect. 4) INCORRECT - Children as young as 1 year of age may take oseltamivir. 5) INCORRECT - Annual influenza immunizations are still recommended as the virus changes from year to year. Prevention is preferable to treatment, which only decreases the duration, and sometimes the intensity, of the infection. 6) INCORRECT - There is no contraindication for taking oseltamivir in persons allergic to eggs.

The nurse instructs a client who is prescribed clozapine. Which client statement indicates to the nurse that the teaching session was successful?

"I will contact the doctor for a sore throat or fever." Clozapine is a medication that has the potential to suppress bone marrow and cause agranulocytosis. This potentially fatal side effect occurs in 1 to 2% of clients. Think Like A Nurse: Clinical Decision Making Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. Clozapine is an atypical antipsychotic agent. It is not likely to cause extrapyramidal syndrome (EPS). Serious side effects include seizure and agranulocytosis.

The nurse prepares a client diagnosed with cervical cancer for the insertion of an internal radiation implant. Which client statement requires immediate follow-up by the nurse?

"I will get up only when I have to urinate, and then I will go right back to bed." This is the priority concern. The client will be on strict bed rest, supine with the head of the bed elevated no more than 20 degrees. Movement is restricted and an indwelling catheter is inserted into the bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts. Severe radiation burns can result from a distended bladder or from the client attempting to go to the bathroom and void. This is of concern, but another client response is of greater concern to the nurse. Prior to the client receiving the implant, an enema is given in order to empty the rectum to facilitate placing the implant through the vagina and into uterus. Bowel movements during the implantation period (1 to 3 days) are avoided in order to prevent the implant from dislodging. Think Like A Nurse: Clinical Decision Making The client is having radium implants in the vagina to treat cervical cancer. Because the implant can dislodge, the client will be prescribed bed rest and have an indwelling urinary catheter inserted. The client is discouraged from having routine bowel movements during treatment since the implant can be dislodged.

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one-to-one observation of the client?

"I will not sign a no-suicide contract." Place the client on one-to-one observation and stay with client to help control self-destructive impulses. The client is never out of sight of a supervisory health care staff member. One-to-one observation is required for clients currently verbalizing a clear intent to harm self, unwilling to sign a no-suicide contract, with poor impulse control, and who have already attempted suicide in the past by a lethal method (hanging, gun). Think Like A Nurse: Clinical Decision Making Refusing to sign a no-suicide contract is a red-flag to the nurse. The client is at risk for suicide and should be constantly observed. The client may be at risk for suicide because of a family history of the behavior.

The clinic nurse instructs a client about an ambulatory electrocardiogram (ECG). Which client statements indicate to the nurse a need for additional education? (Select all that apply.)

"I will wrap the device with plastic wrap before taking a shower." "I will contact the health care provider if I experience lightheadedness." "I will decrease my fiber during the monitoring." CORRECT - The monitor cannot get wet so the client needs to avoid taking a bath or shower during monitoring. The nurse needs to provide additional education based on this statement. 4) CORRECT - If the client experiences dizziness, the client needs to document it in the event log along with pushing the event-marker button on the monitor. The client does not need to call the health care provider. This statement indicates that additional education is needed. 5) CORRECT - There is no reason to change diet while being monitored. This statement indicates that additional education is needed. Ambulatory ECG continuously records cardiac activity and the client needs to avoid electrical equipment while being monitored. Therefore, the client should not use an electric razor or hairdryer while the monitor is in place. This is a correct statement by the client. Think Like a Nurse: Clinical Decision-Making Often called a Holter monitor, an ambulatory ECG is a portable device that is used to record a client's heart rhythm for 1 or 2 days. Just like a typical heart monitor, it has leads that attach externally on the torso. The client records symptoms by pushing a button on the device. This device is excellent for capturing episodic dysrhythmias or cardiac conduction abnormalities that only occur under certain circumstances. The client needs explicit instructions about using the device in order for it to be effective and worthwhile.

The nurse provides care for the client receiving radiation therapy for breast cancer. Which client statements indicate to the nurse that further intervention is needed due to the effects of radiation? (Select all that apply.)

"I'm having trouble swallowing these days." "I need to work from home most days." I seem to have a rash under my arm." Difficulty swallowing indicates pain and/or swelling and requires further intervention. Radiation therapy causes inflammation of nearby epithelial cells, and this can result in further consequences such as malnutrition. 2) CORRECT - This statement may indicate fatigue, a common side effect of radiation therapy. If the fatigue is severe enough to interfere with daily activities, further assessment and possible intervention is warranted. Redness or desquamation can occur from radiation and can be severe if not managed properly. At a minimum, the nurse must assess that the client is not using deodorant or applying commercial lotions to the area. Think Like a Nurse: Clinical Decision-Making Effects of radiation therapy vary according the type and length of treatment. The nurse should teach the client and family about the treatment regimen, supportive care options (e.g., anti-emetics), and what to expect during the course of treatment. The client should be taught which signs and symptoms to report to the provider indicating potential complications (e.g., fever and increasing fatigue). Teaching should be customized to meet the client's needs.

The nurse is teaching a class on birth control options to a group of clients. Which client statements indicate to the nurse that teaching was effective? (Select all that apply.)

"If I take an oral contraceptive, I may need to use additional measures to prevent pregnancy if I take the antibiotic rifampin. The copper in the ParaGard intrauterine device (IUD) decreases the likelihood that sperm and ovum will unite." "The sponge prevents sperm from entering the uterus and releases a spermicide." "The sponge prevents sperm from entering the uterus and releases a spermicide." The ParaGard IUD uses copper to prevent pregnancy. The copper ions are toxic to sperm and also induce a thickening of cervical mucus, making sperm motility more difficult. The ParaGard IUD uses copper to prevent pregnancy. The copper ions are toxic to sperm and also induce a thickening of cervical mucus, making sperm motility more difficult. Think Like A Nurse: Clinical Decision Making Before teaching, the nurse should first assess the client's baseline knowledge. The teach-back method is used to verify a client's understanding. The nurse may inform the client of medications that can decrease the effectiveness of combined hormone contraception. These include carbamazepine, phenytoin, amoxicillin, ampicillin, doxycycline, metronidazole, penicillin, tetracycline, and benzodiazepines. Medications that may increase the combined hormone contraception pill action include acetaminophen, ascorbic acid, and fluconazole. Birth control pills can increase clotting factors and decrease the effectiveness of anticoagulants. The client should be encouraged to ask questions.

The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the nurse, "How will I know if I am overdoing it? " Which response by the nurse is best?

"If you feel fatigued, you have done too much. Fatigue is a useful guide in gauging activity tolerance in clients with decreased cardiac output. Think Like a Nurse: Clinical Decision-Making One of the first symptoms that indicates activity intolerance is fatigue. Another is acute dyspnea or shortness of breath. Increased sputum production could mean the development of pulmonary edema and should be reported to the health care provider. The client should be encouraged to maintain as much independence as is physically possible. The nurse's advice to follow the health care provider's directions does not address the client's question.

The nurse provides care to a client newly diagnosed with schizophrenia who is prescribed chlorpromazine 25 mg PO tid. Which client statement indicates to the nurse a correct understanding of the medication administration instructions? (Select all that apply.

"It is important that I brush my teeth three times a day." "It may take 6 weeks for my medication to work." I need to have blood drawn regularly for a few months." "I should not be concerned if my urine turns pink." I need to have blood drawn regularly for a few months." Dry mouth is an adverse effect of chlorpromazine, so it is important to maintain good oral hygiene. 2) CORRECT - It can take at least 6 weeks before the client notices improvement in symptoms. There is a risk of leukopenia in the first three months, and this necessitates lab work. 6) CORRECT - Pink urine is an expected side effect of chlorpromazine. Think Like A Nurse: Clinical Decision Making Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. The nurse should keep in mind that chlorpromazine is also used to control nausea and vomiting and relieve prolonged hiccups.

A client who takes isophane insulin and regular insulin for type 1 diabetes mellitus is prescribed propranolol. Which information does the nurse instruct the client about this medication?

"Propranolol may mask symptoms of hypoglycemia, removing your body 's early warning system. " Propranolol is a beta-blocker that binds beta-adrenergic receptor sites. This prevents adrenaline from causing symptoms and glycogenolysis. Think Like A Nurse: Clinical Decision Making Propranolol hydrochloride is a synthetic non-selective beta-adrenergic receptor blocking agent. When beta-receptor sites are blocked by propranolol, the chronotropic, inotropic, and vasodilator responses to beta-adrenergic stimulation are decreased proportionately. This is why propranolol masks the tachycardia typically associated with hypoglycemia. The nurse should carefully assess the client 's neurological status when hypoglycemia is suspected and not solely depend on the autonomic manifestations of low blood glucose.

The nurse in the critical care unit reviews postoperative care for a client after a supratentorial craniotomy. Which instruction is important for the nurse to communicate to the unlicensed assistive personnel (UAP)?

"Put an ice pack on the client's eyes and a cool compress on the forehead." It is appropriate to delegate the application of heat or cold to a closed inflamed or painful area to the unlicensed assistive personnel (UAP). The client may have periorbital edema and burning after the surgery. Ice will cause vasoconstriction and decrease the edema. The cool compress is a comfort measure. Think Like a Nurse: Clinical Decision-Making When assigning tasks for delegation, the nurse must remember the scope of practice for each team member. The unlicensed assistive personnel (UAP) can be delegated routine client care tasks. For the client recovering from a craniotomy, the task that can be safely delegated to the UAP is the application of a cool compress to the head. The nurse should inform the UAP of, and to report, unusual/abnormal findings or changes with this client.

The nurse observes that two staff members have been in frequent conflict for the last several weeks. The nurse schedules a meeting with both staff members after observing them argue while putting a client back to bed. When meeting with the staff members, which statement by the nurse is most appropriate?

"Summarize what you hear the other person saying. The other person will then validate the summary." Summarizing what was heard enhances communication. Each party is actively listening and hears the other person's perspective. Think Like A Nurse: Clinical Decision Making The nurse is asking the conflicting staff members to engage in active listening, which is a therapeutic communication technique. This is an effective conflict-resolution technique. Since the conflict is ongoing, something needs to be done to improve the situation between the staff members.

The nurse teaches the spouse of a client about changing the dressing on a central venous catheter (CVC). The spouse asks, "What is that round foam disc for?" Which response by the nurse is accurate?

"The disc has anti-microbial properties to help prevent infection." The disc is impregnated with an anti-microbial product intended to help prevent infections at the insertion site. Think Like a Nurse: Clinical Decision-Making The nurse is aware that a central venous catheter is inserted using a sterile procedure, and all care of this site is done using the same approach. Because the access site provides a direct line into the client's vascular system, extra effort should be taken to reduce the risk of an infection. In this scenario, the client's spouse is asking about part of the existing dressing. The nurse will explain that the central line wound care kit includes a gauze sponge impregnated with an anti-microbial substance to help prevent infection of the site and subsequent infection in the client's body. This sponge is placed over the site and changed according to the manufacturer's recommendations.

The parents sit at the bedside and discuss a bicycle accident involving their older son who was riding his bicycle and accidentally hit their school-age daughter, who experienced a concussion. Which statement made by a parent validates the nursing diagnosis of dysfunctional family process?

"This would not have happened if you had not stopped at the bar on the way home." Blaming a spouse for the accident combined with potential substance abuse indicates a dysfunctional family process. Substance abuse is a primary cause of dysfunctional family systems. Think Like A Nurse: Clinical Decision Making Evidence of a dysfunctional family includes blaming and using substances or alcohol to cope with stressful life situations. Planning to talk with a child about bicycle safety is evidence of a well-functioning family unit.

The nurse prepares an adult client for discharge following treatment for myocardial infarction (MI). The client asks the nurse when sexual activity can be resumed. Which response by the nurse is best?

"You can resume your usual sexual activity when you can walk one city block without having chest pain." Sexual activity can be safely resumed when the client can tolerate the physical activity of climbing two flights of stairs or walking one city block without dyspnea or chest pain. The client should maintain a supine position and should not have intercourse after a heavy meal. Think Like A Nurse: Clinical Decision Making The psychosocial needs of clients must be addressed after a myocardial infarction. Sexual activity and intimacy, both psychosocial needs, are important parts of one's life. The nurse must provide education to the client regarding when it is safe to resume sexual activity. The amount of physical activity expended during sexual intercourse is equivalent to walking one city block or climbing two flights of stairs without experiencing shortness of breath or chest pain. Once the client is able to perform one or both of these activities, sexual activity can resume. It is important that the information is presented in a matter of fact and easily understood manner.

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

"You seem really upset. Take some slow deep breaths." 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. 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.

The home health nurse is scheduled to see a Native American client for follow-up care regarding a new diagnosis of type 2 diabetes mellitus. Based on the client's cultural background, which action by the nurse is best?

.Being flexible with the time of arrival CORRECT- Many Native Americans are present-oriented and often do not live by the clock. Therefore, the nurse should allow for scheduling flexibility within practical limits. 2) INCORRECT - It is culturally insensitive to expect a client to exhibit nonadherent behavior based solely on ethnicity or culture. Think Like a Nurse: Clinical Decision-Making The nurse must provide culturally responsive care to all clients and their families. When providing care to a client from a different culture, the nurse must first identify personal assumptions, biases, attitudes, prejudices, and stereotypes. Once the nurse has completed this task, it is essential for the nurse to conduct a cultural assessment of the client as part of the overall assessment process. Be aware of rituals, customs, and practices of the different cultural groups served, being sure to recognize that generalizations may not hold true at the individual level. It is essential for the nurse to not make assumptions about cultural beliefs and practices.

The emergency department triage nurse has a limited number of open beds. Which client does the nurse place in an emergency bed? (Select all that apply.)

17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival. 63-year-old client who reports a severe, localized headache with no history of headaches. 77-year-old client who has had generalized weakness for the past day. This client requires activated charcoal and possible administration of acetylcysteine. Therefore, the nurse places this client in an emergency bed. This client requires a head CT to rule out hemorrhage. Therefore, the nurse places this client in an emergency bed. 4) CORRECT - This client requires assessment and diagnostic work-up to exclude myocardial infarction, electrolyte imbalance, and stroke. Therefore, the nurse places this client in an emergency bed. Think Like A Nurse: Clinical Decision Making Maslow's hierarchy of needs can be used to make decisions regarding the acuity of the clients. An attempted suicide places the client at high risk for self-harm and needs immediate intervention. A severe localized headache could represent a cerebral hemorrhage and needs immediate assessment. Generalized weakness could indicate a cardiac, neurologic, or electrolyte imbalance problem and requires immediate assessment.

The nurse evaluates a group of pediatric clients for risk of dental caries. The nurse identifies which client as having the highest risk for dental caries?

A 2-year-old who takes a bottle of milk to bed each night. Nursing caries (bottle-mouth caries) result from the teeth being consistently bathed in a carbohydrate-rich liquid. The child nurses the bottle while sleeping, when saliva and swallowing are reduced. This results in stasis of the milk (or other liquid). If a bottle is permitted in bed, it should contain only water. Think Like A Nurse: Clinical Decision Making Early childhood caries is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a preschool-age child between birth and 71 months of age. The American Dental Association recommends eliminating unrestricted and at-will intake of sugary liquids during the day or while the child is in bed, so infants should finish their bottle before going to bed. The nurse should do a comprehensive assessment of the client's risk for dental caries and educate the parents on how to prevent them from infancy.

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first?

A 40-year old who reports nausea, general anxiety, and is diaphoretic. Even though not complaining of chest pain, these symptoms should be treated as a potential MI. A cardiac workup should be performed immediately. Think Like A Nurse: Clinical Decision Making Nausea, general anxiety, and diaphoresis are non-specific manifestations of myocardial ischemia. The nurse should immediately consider obtaining a 12-lead ECG and cardiac markers. In addition to frequent vital signs monitoring, the nurse should also obtain baseline electrolyte panel and CBC, screen client for possible fibrinolytic therapy, establish an IV access, and implement the protocol for acute coronary syndrome (ACS). The nurse should also anticipate a portable chest X-ray for the client.

The nurse provides care for school age clients at summer camp. Which client in the infirmary does the camp nurse assess first?

A child with leukemia who was stung by a bee and reports feeling hot and itchy "everywhere". CORRECT- Generalized pruritus is a probable, meaning more likely than not likely, sign of an anaphylactic reaction, which can proceed quickly to loss of consciousness, angioedema, bronchiolar constriction, and pulmonary edema. This child may lose their airway within seconds if not treated. INCORRECT - Asthmatic airways have inflammation that contributes to airways becoming more reactive, and restlessness can indicate respiratory difficulty, boredom, or anything else. The infection causing the sore throat has likely triggered an asthma response. Although this is a potential airway problem, this not the priority client. Think Like A Nurse: Clinical Decision Making Generalized pruritus may signal an impending anaphylaxis. Therapeutic management of anaphylaxis focuses on rapid assessment and support of airway, breathing and circulation. After the nurse ensures airway patency and oxygenation of the potentially anaphylactic client, the client with headache and slurred speech should be evaluated next. In a camp setting, this might require calling 911. In a hospital setting, this might require activation of the rapid response team (RRT). The nurse may then evaluate the client who is potentially hypoglycemic and the client with asthma reporting a sore throat.

The nurse provides care for clients in the intensive care unit (ICU). A client diagnosed with a head trauma needs to be admitted. There are no empty beds. Which client does the nurse anticipate as being the most stable for a transfer to the step-down neurological unit?

A client diagnosed with a stroke 4 days ago who is exhibiting confusion After 4 days, the risk for this client having a second stroke is significantly reduced. Therefore, the focus of care is rehabilitation. This client can be transferred. A client with a head injury who is experiencing seizures is unstable and should not be transferred. Think Like a Nurse: Clinical Decision-Making When an intensive care unit reaches maximum capacity and a critically ill client requires admission to the unit, the nurse must think, "Which client on the unit is most clinically stable and can be safely transferred to a lesser level of care?" A client with known or suspected Neisseria meningitidis requires close monitoring in the intensive care unit. A client who develops a cerebrospinal fluid leak 1 day after transsphenoidal resection necessitates close monitoring for signs of bacterial meningitis and diabetes insipidus. A client with head injury and active seizure activity requires immediate intervention by specialized nursing staff to prevent further neurologic compromise. Four days after experiencing a stroke, a client with no further neurologic changes can safely be cared for in a lesser level of care.

The nurse assesses four assigned clients. Which assessment finding does the nurse immediately report to the health care provider?

A client diagnosed with chronic atrial fibrillation who reports blurred vision Amiodarone and digoxin may be used to treat atrial fibrillation. These medications may cause halos or blurred vision, which are signs of an adverse reaction and require immediate intervention. The CT scan oral contrast medium may contain a laxative to prevent constipation from the contrast. If not, the health care provider may prescribe a laxative to promote expulsion of the contrast dye. Think Like A Nurse: Clinical Decision Making Blurred vision can occur with a variety of health problems. However, the nurse needs to focus on the client diagnosed with atrial fibrillation. The nurse should mentally ask, "What would be causing the client with atrial fibrillation to have a vision change?" and "Is this an expected or unexpected manifestation?" The nurse should be aware that treatment for atrial fibrillation includes medications that regulate the heart rate and promote adequate ventricular functioning. The nurse should recognize that vision changes can signify medication toxicity and is not an expected finding. Because the client's symptom can be indicative of an adverse medication response, the health care provider should be immediately notified.

A group of clients are identified as at risk for pressure injury. For which client does the nurse initiate pressure injury prevention measures? (Select all that apply.)

A client in skeletal traction who is diaphoretic. A premature neonate with nasogastric feedings. The immobility imposed by skeletal traction combined with moist skin from diaphoresis puts this client at risk for a pressure injury. A preterm neonate does not have sufficient subcutaneous fat stores and is at risk for skin breakdown. The presence of an NG tube increases the neonate's risk, due to pressure from the tube and tape on delicate skin. INCORRECT— Skin that blanches does not indicate an ongoing problem with pressure. INCORRECT— After an umbilical hernia repair, this infant should be mobile and not at risk for pressure injuries. Think Like A Nurse: Clinical Decision Making For pressure injury risk factor assessment, it is recommended to use a structured approach that includes assessment of activity/mobility and skin status. Consider bedfast and/or chairfast individuals to be at risk of pressure injury development. Use of validated tools (appropriate to the population), such as the Braden score, is recommended. The nurse should recognize additional risk factors and use clinical judgment when using a risk assessment tool. Do not rely on the results of a risk assessment tool alone when assessing an individual's pressure injury risk.

The nurse determines that which client needs vitamin B6 (pyridoxine) supplementation

A client who is tuberculosis positive The client with tuberculosis is likely to be taking isoniazid (INH), a mainstay in prevention and treatment of tuberculosis, used in combination with other antitubercular drugs if the disease is active. Vitamin B6 is given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with this drug. The client with alcoholism needs supplementation with thiamine (vitamin B1). Thiamine deficiency is the primary cause of alcohol-related mental changes, such as Wernicke's encephalopathy and Korsakoff's syndrome for alcohol pt Think Like A Nurse: Clinical Decision Making The nurse is aware of medication side effects and proactively tries to prevent them. Many medications counteract or block needed nutrients. Isoniazid displaces B6. Each B vitamin is water-soluble and has specific and essential functions. B6 has many functions, but notably plays a role in synthesizing neurotransmitters necessary for nerve function. B6 supplementation is necessary to prevent serious side effects and potential adverse effects of antitubercular medications.

The nurse becomes concerned when which client makes the statement, "I've had leg spasms that kept me awake all night, and now I can't feel my hands and feet!"? (Select all that apply.)

A client with acute kidney injury and who has a urinary output of 4500 mL/24 hours. A client with acute pancreatitis due to medication toxicity. A client following surgery for removal of the thyroid gland. During the polyuric phase of acute kidney injury, calcium is excreted at a higher than normal rate, leading to hypocalcemia. 4) CORRECT - Acute pancreatitis leads to hypocalcemia, as calcium is bound with fatty acids. 5) CORRECT - The risk of damage to the parathyroid gland in thyroidectomy clients places them at risk for hypocalcemia. Cancers in the bone cause the bone to excrete calcium, which is absorbed in the bloodstream, leading to high serum calcium levels or hypercalcemia. Think Like A Nurse: Clinical Decision Making Leg spasms and paresthesias are symptoms of a low calcium level. The client with the polyuric phase of acute kidney injury is at risk for hypocalcemia because calcium is excreted in the urine output. Hypocalcemia occurs in acute pancreatitis because calcium binds to the fatty acids. With a thyroidectomy, the parathyroid glands can be damaged, which places the client at risk for hypocalcemia.

The psychiatric home care nurse plans visits for the day. The weather report states that the temperature will be 95 °F (35° C). Which client does the nurse see first?

A client with bipolar disorder who was discharged from the inpatient unit after starting lithium carbonate. Potentially the least stable patient due to recent hospitalization and taking Lithium, the bipolar client is monitored for response to lithium. Of particular concern at this time, because of the weather, is maintaining adequate sodium levels, as well as drinking appropriate amounts of water in order to prevent lithium toxicity. Think Like A Nurse: Clinical Decision Making The onset of action of lithium is fast, but the client may not achieve the desired effect for 5 to 6 days. Since the client is recently discharged from inpatient service, the nurse should visit this client first. Lithium may cause increased urination, leading to sodium and water loss. Given that the temperature is anticipated to be about 95°F (35°C), the client taking lithium is at risk for dehydration, if the client does not adequately consume fluids throughout the day.

The nurse admits four clients to the labor and delivery unit. Which client does the nurse see first?

A primigravida client with baseline fetal heart tones 136 bpm with decelerations to 116 bpm independent of contractions. This describes repetitive variable decelerations, which indicates an umbilical cord occlusion that needs to be resolved. There is an immediate risk to the safety of the fetus and this client is the priority. This describes early decelerations, which are caused by head compression and are considered to be normal. Think Like A Nurse: Clinical Decision Making The nurse monitors the fetal heart rate in relation to contractions to assess for fetal distress. Variable decelerations and late decelerations indicate distress, while early decelerations are considered positive indicators. The decelerations in fetal heart rate that have no relation to the contractions are considered variable decelerations and occur with occlusion of the umbilical cord. This client needs immediate intervention to ensure the viability of the fetus. The nurse understands the importance of immediately repositioning the client in an attempt to relieve cord compression, administering oxygen, and discontinuing oxytocin (if infusing).

The community health nurse, working with social services, reviews data on four families. Which client does the nurse evaluate first?

A school age client, small for age, whose parents are unemployed and are strict vegans A vegan diet (low in essential fats, complete proteins, iron, and B12) does not support growth needs during childhood. This child is at risk for malnutrition, a type of physical neglect. Physiological threats take precedent over other types of problems. Delinquent behavior, evidence of a psychosocial disturbance, may be suggestive of neglect, but it is not the priority. Think Like A Nurse: Clinical Decision Making Malnutrition for a school-age child is a cause for concern because it can lead to stunted growth or intellectual ability and other health issues. Community health nurses face the challenge of addressing the interplay of complex factors, such as the parents' unemployment, possible child neglect, and food insecurity. Managing malnutrition in the community involves identifying malnutrition using a universally validated screening tool and implementing appropriate care plans according to the degree of malnutrition. Early identification of at-risk clients is emphasized.

cranial nerves IX and X

A tongue depressor and flashlight. glossopharyngeal and vagus nerves, which control the client's ability to swallow and the gag reflex. A tongue depressor and flashlight are needed. Think Like a Nurse: Clinical Decision-Making Assessing the function of cranial nerves require that the nurse apply knowledge about anatomy and physiology. In addition, the nurse needs to know the function and assessment process for each cranial nerve being assessed. The cranial nerves IX and X control swallowing function and the gag reflex. To test these nerves, the nurse will need something to touch the back of the client's throat, such as a tongue depressor, and a flashlight to watch the uvula rise in the back of the throat when swallowing.

The nurse assesses a group of clients for risk of developing psoriasis. The nurse identifies which client as being low risk for developing psoriasis?

A young adult African American. The incidence of psoriasis is lower among darker-skinned races. Hormone changes have been linked to exacerbations of psoriasis. Think Like A Nurse: Clinical Decision Making The nurse should mentally review the pathophysiologic process of psoriasis along with the etiology and risk factors prior to identifying the client most at risk for the development of the disorder. The reasons for the development of psoriasis vary from being a genetic disorder to being an autoimmune reaction. The one factor that is linked to the development of the disorder is skin color. Psoriasis is more likely to occur in lighter-skinned clients of European descent than in dark-skinned clients. Regardless of the reason, psoriasis has periods of latency and exacerbation that have been linked to stress and hormone imbalances.

A client diagnosed with type 2 diabetes mellitus (DM) is treated for hypertension with propanolol. The history reveals that the client is diagnosed with glaucoma and is allergic to sulfa. Which prescribed medication requires an immediate intervention by the nurse?

Acetazolamide This medication is contraindicated. Clients with a sulfa allergy should not take acetazolamide, as an allergic reaction may occur. Think Like A Nurse: Clinical Decision Making The nurse should review the medication list and assess for those that may interfere with a current health problem or create a new one. Acetazolamide is contraindicated in clients with an allergy to sulfa. This is the medication that the nurse should question before administering to the client.

A client who had abdominal surgery 4 months ago experiences bloating, vomiting, cramping, and abdominal pain. Which does the nurse suspect as the cause of the client's symptoms?

Adhesions An adhesion is a band of scar tissue that forms between organs after a surgical procedure and can cause the symptoms of an intestinal obstruction. Think Like A Nurse: Clinical Decision Making The nurse is aware that the abdominal cavity contains several major organs and body systems. If the abdominal cavity is accessed for a surgical procedure, healing of the tissues can be complicated. At times, the body may over heal, which can result in an alteration in organ and tissue function. Organs and tissues may heal together or be drawn together with the formation of scar tissue, called adhesions. Adhesions shorten and tighten, pulling the structures that are connected by this scar tissue. In this scenario, the client's symptoms may appear like a new health problem, but are most likely caused by formation of adhesions that occurred from the previous surgery.

The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?

Administer bromocriptine as prescribed. NMS is a life-threatening complication. The nurse needs to manage fluid balance, reduce client temperature, and monitor for complications. The nurse should discontinue antipsychotic medications and administer bromocriptine (a medication to counteract the effects of NMS) and dantrolene as prescribed. Think Like A Nurse: Clinical Decision Making The nurse recognizes that this client is demonstrating symptoms of neuroleptic malignant syndrome, which can occur when taking an antipsychotic medication, such as haloperidol. Assessing the client's level of consciousness and continuing to monitor vital signs does not address the life-threatening problem at hand. Bromocriptine is the medication given to reverse the effects of this syndrome.

A client who received an intravenous dose of penicillin G develops restlessness, wheezing, and swelling of the lips and tongue. After applying oxygen via nonrebreather face mask, which action will the nurse take next?

Administer epinephrine 1:1000 intravenous push. The client is exhibiting symptoms of an anaphylactic reaction. The next action the nurse should take is to administer 0.3 to 0.5 mL of epinephrine 1:1000, by the subcutaneous, intramuscular, or intravenous route, which the nurse can repeat in 20 to 30 minutes if there is an indication. Epinephrine is the medication of choice for anaphylaxis as it can activate three types of adrenergic receptors and thus reverse the reaction to the antigen. This leads to increased blood pressure, decreased epiglottal edema, and decreased bronchoconstriction. The nurse should initiate an intravenous infusion of warmed 0.9% sodium chloride to help maintain vascular volume. Warming the solution helps prevent hypothermia that can result from the client receiving large amounts of intravenous fluids. However, airway issues are of greater priority. Think Like A Nurse: Clinical Decision Making Before implementing actions for this client, the nurse should stop and ask, "What is the reason for this client's symptoms and what can be done to help the client?" Since the symptoms began after receiving penicillin, the nurse should consider a previously unknown allergy to the medication. Actions should focus on supporting the client's airway and breathing. After oxygen is applied, the nurse needs to do something to minimize the symptoms and reduce throat swelling. The medication epinephrine is used to reverse the respiratory effects of an allergic response and should be given to this client immediately.

The nurse provides care for a client diagnosed with hypovolemic shock. Which action does the nurse take first?

Administer intravenous fluids. Hypovolemic shock results from severe dehydration. Administering fluids is the emergency treatment for this critical condition. Think Like a Nurse: Clinical Decision-Making The nurse is aware that restoring the client's fluid balance is the priority in this situation. The client with hypovolemic shock should receive normal saline or lactated Ringer solution to restore circulating volume and contribute to the client's homeostasis. If the client lost blood, red blood cell transfusion is indicated. The client's vital signs and urine output should be monitored frequently. If the client is an older adult, the nurse should monitor the client for risk of fluid overload during fluid resuscitation. The nurse should collaborate with the health care team in treating the reversible causes of the client's hypovolemia.

A child with failure to thrive has a positive sweat test. Which change does the nurse anticipate in this client's plan of care?

Administer replacement enzymes A positive sweat test is a positive finding for cystic fibrosis. Treatment for cystic fibrosis includes the administration of replacement enzymes. Think Like A Nurse: Clinical Decision Making The sweat test is considered the gold standard for diagnosing cystic fibrosis. The sweat test measures the amount of chloride in the sweat. For a child who has cystic fibrosis, the sweat chloride test results will be positive (showing a high chloride level) shortly after birth. Pancreatic enzymes and supplemental fat-soluble vitamins are prescribed to promote adequate digestion and absorption of nutrients, and optimize nutritional status. The nurse should keep in mind that in cystic fibrosis, therapeutic management is aimed toward minimizing pulmonary complications, maximizing lung function, preventing infecting, and facilitating growth.

The nurse provides care for the client diagnosed with acute pancreatitis. The nurse intervenes if the client makes which statement?

After I get better, I need to eat a high fat diet." "I'm glad I won't get sick like this again." "I'm glad my blood sugar will not be affected." This statement requires intervention by the nurse. Between acute attacks, the client needs a diet high in protein, high in carbohydrates, and low in fat. 3) CORRECT— This statement requires intervention by the nurse. The client may have flare-ups in the future or may develop chronic pancreatitis. 4) CORRECT— This statement requires intervention by the nurse. Transient hyperglycemia occurs in some clients with acute pancreatitis. If the damage from the pancreatitis episode is severe or recurrent, type 2 diabetes mellitus can occur. This statement does not require intervention by the nurse. The client remains NPO during the acute phase because pancreatic secretion is increased by food and fluid intake. As acute symptoms subside, oral feedings are gradually introduced. hink Like A Nurse: Clinical Decision Making Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy skills have been shown to be a stronger predictor of health status than age and educational level. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. It essential to teach the client about health maintenance activities about pancreatitis.

The nursing staff at the pediatric hospital discuss instituting a community education program regarding intellectual disabilities, particularly prevention. It is most beneficial for the nurses to emphasize which area?

Alcoholism treatment Alcohol is recognized as the leading cause of preventable intellectual disability. This is included in the fetal alcohol syndrome (FAS) complex of symptoms. Prenatal classes tend to focus on the parents in the last trimester of pregnancy, when any issues with the fetus may be already developed and no longer preventable or reversible. Think Like a Nurse: Clinical Decision-Making In many cases of intellectual disability, the exact cause is unknown. Prenatal exposure to alcohol or other drugs can be a cause. Prenatal errors in central nervous system development also may be responsible. Public health efforts to prevent intellectual disability should be geared toward adequate prenatal care that emphasizes abstinence from alcohol and other teratogens. In assessing clients with intellectual disability, the nurse should keep in mind that the most sensitive early indicator is delayed language development due to the extent of cognition required to understand and produce speech.

The nurse provides care to a client who is diagnosed with chronic cirrhosis due to long-term alcohol abuse. Which nursing assessment finding leads the nurse to suspect the client may also be experiencing early-stage hepatic encephalopathy?

Alternating periods of euphoria and lethargy Alternating periods of euphoria and lethargy are consistent with early-stage hepatic encephalopathy. Other manifestations of early-stage hepatic encephalopathy include a normal level of consciousness and reversal of day-night sleep patterns. Think Like A Nurse: Clinical Decision Making Hepatic encephalopathy is the neuropsychiatric manifestation of liver failure. Hepatic encephalopathy can occur in those with acute or chronic liver disease. Episodes can be triggered by infections, gastrointestinal (GI) bleeding, constipation, electrolyte problems, or certain medications. Grade 1 (early stage) encephalopathy manifests as trivial lack of awareness, euphoria or anxiety, a shortened attention span, and/or impaired performance of addition or subtraction. The underlying mechanism is due to a build up of ammonia in the blood. The nurse should anticipate giving the client lactulose and the antibiotic rifaximin (to reduce the GI flora responsible for ammonia production).

After abdominal surgery, the client reports abdominal gas pain. Which action is appropriate for the nurse to take?

Ambulate the client frequently. Ambulation promotes the return of peristalsis and facilitates the expulsion of flatus, reducing gas pains. Positioning on the right side, rather than the left side, aids in the release of gas in the colon. Think Like A Nurse: Clinical Decision Making Anesthesia and medications provided during a surgical procedure can adversely effect gastrointestinal functioning. If the client had abdominal surgery, the effects on the gastrointestinal tract are compounded by incision pain. Although uncomfortable, the presence of abdominal gas pain is a positive sign that indicates return of normal gastrointestinal functioning. To aid this client and relieve the discomfort, the nurse should assist the client to ambulate. Walking helps facilitate the expulsion of trapped flatus, relieving the discomfort.

he nurse in the outpatient clinic identifies which client as having the lowest risk for developing pneumonia?

An adult client diagnosed with mitral valve prolapse. Think Like A Nurse: Clinical Decision Making Before identifying the risk for developing pneumonia, the nurse should stop and ask the question, "Which physical conditions would precipitate the development of a lung infection?" Pneumonia can occur as an adverse effect of an upper respiratory infection, insufficient body protection from a disease process, after a surgical procedure, or because lifestyle actions cause undo stress to normal body immune processes. Of the clients being seen in the clinic, the one who has the least risk for the disease process is the one experiencing a problem with cardiac valve functioning.

The nurse provides care for four clients. Which client does the nurse recognize is at risk for experiencing sensory overload?

An elderly client admitted for emergency surgery. A sudden, unexpected admission for surgery may involve many experiences, such as lab work, X-rays, and signing surgical consent forms while the client is in discomfort. After surgery, the client may be in pain and possibly in a critical care setting. Listening to music at an increased volume is a normal activity for a person of this age. Think Like A Nurse: Clinical Decision Making The nurse should be aware that one health problem that can be controlled to some extent is that of sensory overload. The hospital environment does not necessarily support the person at risk for this health problem; however, recognizing in advance the client who is at risk helps the nurse identify interventions to minimize the effects. Of the clients in this scenario, the one most at risk is the older adult client. The nurse needs to consider this because of the acuity of the client's health problem (emergency surgery), along with any age-related concerns (impaired cognitive function), and the associated care needs (pain medication). Interventions to prevent sensory overload should be worked into the client's plan of care.

The nurse is in the home of an older adult client who is being visited by grandchildren. For which observation causes the nurse to intervene?

An infant who plays with a rattle that is cracked. Rattles have small beads inside that can be aspirated, presenting a choking risk for the infant. All rattles or toys that make noise should be inspected to ensure that they are intact. Think Like A Nurse: Clinical Decision Making This scenario has the nurse visiting an older adult client who has grandchildren in attendance. Prior to deciding if an unsafe situation exists, the nurse mentally asks, "Which observation can cause harm or injury?" Of the situations presented, the one that has the potential to cause the most harm is the infant playing with a rattle that is cracked. The objects inside of the rattle that cause the noise can come out through the crack and be swallowed or aspirated by the infant. This situation can be averted by taking the rattle out of the infant's hands and providing a safer toy. The nurse uses knowledge regarding normal growth and development expectations to rule out other safety concerns.

The school nurse educates preschool faculty and staff about hepatitis A. Which information does the nurse include in the teaching?

Anorexia is one of the most common symptoms of hepatitis A among children. Among pediatric clients, symptoms of hepatitis A often are flu-like in nature. Common symptoms of hepatitis A among young children include anorexia, fever, malaise, and lethargy. However, among children 6 years of age and younger, up to 70 percent of individuals who contract hepatitis A will be asymptomatic. Jaundice is relatively infrequent among pediatric clients who contract hepatitis A. Jaundice occurs in approximately 1 in 12 young children who experience acute viral hepatitis. Think Like a Nurse: Clinical Decision-Making Hepatitis A is a fecal-oral disease, and as such, it flourishes in areas with poor sanitation or where poor sanitation occurs, such as schools and day cares. The Centers for Disease Control and Prevention is a great resource for the public to obtain information about hepatitis A. This severe and contagious illness lasts weeks to months and includes flu-like symptoms such as fever, fatigue, and loss of appetite. Disease-specific symptoms include gray color stools, jaundice, and dark urine.

The health care provider removes the peripherally inserted central catheter (PICC) from a client. A portion of the catheter breaks off. Which action does the nurse take first?

Apply a tourniquet to the upper arm. The nurse will place a tourniquet close to the axilla. This prevents the catheter piece from advancing into the right atrium and acting as an embolism. After the tourniquet is applied, check for the presence of the radial pulse to ensure that arterial flow is not eliminated. The tourniquet will be kept in place until an x-ray is obtained and surgical retrieval attempted. Think Like A Nurse: Clinical Decision Making With proper placement, the distal end of peripherally inserted central catheter (PICC) lies near the heart in the superior vena cava. A catheter tip embolus may be the actual tip or a portion of the catheter. The original length of the PICC should be noted in the procedure documentation. If the entire catheter is not retrieved upon removal, the nurse may apply a tourniquet to the upper arm with the hope that the catheter embolus is lodged in the arm and not in a major vessel. The health care provider, rapid response team, and PICC insertion team should be notified of the adverse event. Documentation should be completed per the organizational policy.

A client seeks medical attention for cramping pelvic pain and saturating five sanitary napkins over a 2 hour period. Which questions are most important for the nurse to ask the client when conducting the health history of the current issue? (Select all that apply.)

Are you feeling dizzy?" "When was the first day of your last period?" "When did the bleeding start?" Dizziness is an adverse effect from blood loss. Asking about dizziness helps determine the effects bleeding has on the client. 2) CORRECT — Asking when the client experienced menstruation last is important to determine pregnancy potential and the possible loss of a pregnancy. Asking when the bleeding started is important to gather history of this event, as it will help determine the amount of bleeding the client is experiencing. Think Like A Nurse: Clinical Decision Making The nurse needs to assess the client to determine the potential cause for the bleeding. Questions should include when the bleeding started to determine the potential amount of blood loss and when the client's last menstrual period occurred in the event the client is experiencing a spontaneous abortion. Assessing the client for dizziness helps to determine if the blood loss is affecting total body fluid volume status.

The nurse prepares to discharge a client diagnosed with acquired immune deficiency syndrome (AIDS). The client is going to live with the parents so that they can assist with care. Which action does the nurse take first?

Ask the client about what kind of help is needed from the parents. The nurse should first determine the client's needs and then assess whether the parents are able to meet the client's needs. After assessment is complete, the nurse can begin implementation. Think Like A Nurse: Clinical Decision Making In considering how to best provide transitional care as the client transitions home, the nurse will first perform a gap analysis and identify the client's needs. The nurse will assess the client's needs, including the client's abilities to perform activities of daily living, before determining if the parents are able to provide care. Once the client's needs are identified, further planning and teaching can occur.

A pediatric client is admitted to the cardiology unit after experiencing sudden chest pain and dizziness. A diagnosis of supraventricular tachycardia (SVT) is made. If the client experiences another episode of chest pain and dizziness, which action does the nurse implement

Ask the client to stick the thumb in the mouth, close the mouth around it, and then blow on the thumb as if it were a trumpet. This is a form of the vagal or Valsalva maneuver, which can stop SVT. Blowing should occur for 30 to 60 seconds. Other possible vagal maneuvers include ice to the face, holding the breath and then bearing down, or massaging the carotid artery on only one side of the neck. If vagal maneuvers do not work, intravenous adenosine, an anti-dysrhythmic agent, may be given. Think Like a Nurse: Clinical Decision-Making The nurse needs to consider the age of the client and aim all teaching and interventions at the expected level of development and understanding. One mechanism to "break" the rhythm of supraventricular tachycardia (SVT) is to perform the Valsalva maneuver. The nurse is using a strategy that is age-appropriate for the client to elicit this maneuver. If the Valsalva maneuver is unsuccessful, medications may need to be administered.

The school nurse notes that an 8-year-old child experiences stomach aches that are relieved after the nurse contacts the parents at work. Which action is the most important for the nurse to take?

Ask the parents how the child behaves prior to school. he nurse needs to validate anxiety, especially separation anxiety. The child may be worrying about the parents and is relieved when the nurse talks to the parents. Think Like A Nurse: Clinical Decision Making The child is experiencing some form of separation anxiety. Finding out how the child behaves before leaving to go to school will help the nurse validate the source for the child's anxiety. It is premature to assume that the child is in danger and needs social service intervention.

he nurse notes that a client recovering from spinal anesthesia can feel the lower extremities, wiggle the toes, and move the legs. Which action will the nurse take next?

Assess blood pressure The ability to feel and move the toes and legs indicates motor blockade from the anesthetic is wearing off. However, blockage of the autonomic nervous system may still be present and cause hypotension. The nurse should assess the client for hypotension and gradually elevate the head of the client's bed. Think Like A Nurse: Clinical Decision Making The client recovering from spinal anesthesia who can feel and move the legs and toes indicates the anesthesia is no longer affecting the sensory and motor function of the lower extremities. However, the anesthesia could still have effects to the autonomic nervous system. Blood pressure should be assessed before raising the head of the bed. The assessment of bowel and breath sounds will not help identify if the client is experiencing autonomic nervous system effects of the anesthesia.

The nurse provides care to a client diagnosed with a pelvic fracture after a motor vehicle accident. The nurse notes that the client is agitated and attempting to get out of bed. The client has removed the IV and reports shortness of breath. The client's blood pressure is 90/58 mm Hg, respirations 28 breaths/minute, pulse 133 beats/minute, and O2 sat 78% on 3.5 L/minute of oxygen. Which action will the nurse perform? (Select all that apply.)

Assess breath sounds. Obtain arterial blood gases (ABG) Establish vascular access The client is responding to low oxygen levels; therefore, the nurse needs to assess to determine cause. 3) CORRECT— The client is responding to low oxygen levels; therefore, the nurse draws an ABG to further assess the client. The nurse needs to reestablish IV access to administer medications. Think Like A Nurse: Clinical Decision Making The client's symptoms indicate acute hypoxia, which may be caused by either a pulmonary or fat embolism. The nurse needs to intervene to ensure adequate oxygenation. Breath sounds should be assessed and arterial blood gases sent to help determine the cause for the symptoms. An intravenous access site is necessary for medication administration.

The nurse prepares to assess an infant. Which action is appropriate for the nurse to complete at the end of the assessment?

Assess ears and mouth Assessment of the ears and mouth is more traumatic and invasive and may cause the infant to cry. The nurse should perform auscultation and less aggressive assessments first while the client is calm and quiet The nurse should complete the assessment in a head to toe direction for genitalia area Think Like A Nurse: Clinical Decision Making Conducting a physical assessment on an infant can be challenging because of the client's size and activity. Before beginning, the nurse should categorize assessment activities into those that cause the least amount, and the most amount, of disruption to the client. The ones that cause the least amount of disruption should be completed first. These may include listening to heart, lung, and bowel sounds. As the assessment progresses, the nurse should conclude with those activities that are the most disruptive such as assessing the eyes, ears, and mouth.

When arriving for a home visit, the nurse learns that a toddler has just swallowed another family members ' medication. Which action will the nurse take first?

Assess the child The child should be immediately assessed before implementing any actions. The child might need cardiopulmonary resuscitation or treatment of other symptoms, such as seizure activity. Think Like A Nurse: Clinical Decision Making Developmentally, a toddler is curious and is interested in learning about the environment. Because of this, small objects, medications, and chemicals should be removed or secured in the environment to prevent the child from accidentally ingesting a potentially harmful substance. In this scenario, the toddler ingested another person's medication. The first action to take is to assess the toddler for adverse effects. Depending upon the findings, the nurse can suggest additional actions, the first of which is to contact the Poison Control Center for direction for treatment.

The nurse provides care for a client who had a hypophysectomy. The client reports being thirsty and having to urinate frequently. Which action does the nurse take?

Assess urine specific gravity. After this procedure, diabetes insipidus can temporarily occur because of an antidiuretic hormone deficiency. Glucose in the urine points to diabetes mellitus. Diabetes mellitus is not a complication of this procedure. Think Like A Nurse: Clinical Decision Making The nurse should first mentally review the type of surgery the client had, the reason for the procedure, expected manifestations, and any possible indications of complications. A hypophysectomy is the removal of a part or the entire pituitary gland, which controls specific hormones. One hormone is the antidiuretic hormone, which controls fluid balance. After surgery and due to the lack of this hormone, the client will have increased urine output, which is indicative of the complication diabetes insipidus. The nurse should expect to find low urine specific gravity due to high urine output and high serum sodium (hypernatremia) due to low fluid volume.

The nurse admits a preschool-age client diagnosed with dehydration. The client has a small retractable tape measure and continually extends and withdraws the tape. The nurse notes the client does not make eye contact and does not respond to questions, but does step on the scale when asked to do so. Which interventions will the nurse include in the client's plan of care? (Select all that apply.)

Assign the same nurse to the client's care each day. Use the client's name and speak directly to the client. Reward the client for positive behaviors, such as drinking acceptable fluids. Use developmentally-appropriate language to explain procedures to the client. - Continuity of caregivers is especially helpful in establishing trust with children. This client is showing characteristics of autism spectrum disorder, in which continuity of care is even more important. 2) INCORRECT - It is not necessary to take away the client's toy. Allowing the client to keep familiar items will help the child feel comfortable. 3) CORRECT - Using the client's name and speaking to the client establishes trust and gains the child's cooperation. 4) INCORRECT - Parents should not be asked to restrain their child. They may give comfort and support to the child, but staff should perform any restraint. 5) CORRECT - A choice of rewards often soothes young pediatric clients. 6) CORRECT - With any pediatric client, the nurse explains procedures in appropriate words for the child to understand and be able to anticipate what is occurring. Think Like a Nurse: Clinical Decision-Making The child's fixation on the movement of the tape measure and lack of eye contact could indicate a cognitive disorder consistent with autism spectrum disorder. The nurse should support the child's developmental level by establishing trust, talking directly to the child, rewarding acceptable behavior, and using words that the child understands. The nurse recognizes a deviation from expected behavior, and is able to draw conclusions about the client. The nurse can validate the client's condition through the medical record, the family, and/or the health care provider. The ability to recognize the client's developmental deficits allows the nurse to make appropriate plans for the client's care.

A gravida 1, para 0 client comes to the clinic for the first routine prenatal exam. The client expresses uncertainty about the date of the last menstrual period. Which assessment assists the nurse in determining the estimated date of delivery (EDD)?

Auscultation of the fetal heartbeat. The fetal heartbeat can be heard at 12 weeks and is a positive sign of pregnancy. The EDD can be established. Think Like A Nurse: Clinical Decision Making The nurse must be able to differentiate between presumptive, probable, and positive signs of pregnancy. When performing an assessment to determine the estimated date of delivery (EDD), diagnostic, or positive, signs of pregnancy are the most reliable. Positive signs of pregnancy include auscultating the fetal heartbeat, palpating fetal movement, and visualizing the fetus by ultrasound. The crown-rump length (CRL) measured in the first trimester (up to 13+6 weeks) is the most accurate sonographic method of determining the EDD.

The nurse instructs a client diagnosed with cholecystitis. The nurse determines that teaching is effective when the client selects which meal?

Barbecued chicken, green peas, lemonade. The client diagnosed with cholecystitis should consume a low-fat, low-carbohydrate, and high-protein diet. Barbecued chicken, green peas, and lemonade are all low-fat, low-carbohydrate, and high-protein foods. Think Like A Nurse: Clinical Decision Making To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. Diet is an essential component of managing gallbladder disease. The gallbladder stores bile. Inflammation or stones change how the stored bile is released, causing it to be released directly into the intestines instead of when it is needed to digest fat. Bile in the intestines causes a laxative effect. Fat without bile is mostly undigested and causes diarrhea, as well. The client must limit fat intake to avoid significant gastrointestinal discomfort.

At 2100, the nurse notes that the last client documentation was at 0900. The nurse on the previous shift did not complete or sign the documentation for that period of care. Which action by the nurse is correct?

Begin documenting on the line below the last entry in the nurses' notes, leaving no spaces. Documentation should be timely and accurate. Legally, the nurse begins documenting on the next available line, leaving no spaces. The previous nurse can create a late entry later. Think Like A Nurse: Clinical Decision Making The medical record is a legal document and should be treated as such. The current nurse has the responsibility to document care provided. The missing entry can be added later and identified as being "a late entry." There should not be any blank spaces left between documentation entries. The nurse cannot legally document care provided by another person.

The nurse provides care for a client diagnosed with mild preeclampsia. Which assessment data, identified by the nurse, supports this diagnosis? ( Select all that apply.)

Blood pressure of 150/96 mm Hg. ALT level 30 U/L (0.50 µkat/L). The criteria for mild preeclampsia include BP ≥ 140/90 mm Hg but ≤ 160/110 mm Hg. Liver enzymes remain normal with mild preeclampsia. Elevated liver enzymes are seen with severe preeclampsia (HELLP syndrome); the normal ALT level is 10-40 U/L (0.17-0.67 µkat/L). An adequate urine output is seen with mild preeclampsia; oliguria (≤ 30 mL/hr) is seen with severe preeclampsia. Think Like a Nurse: Clinical Decision-Making Before analyzing collected data, the nurse should mentally review the pathophysiologic process of eclampsia. The nurse should also apply knowledge that eclampsia is a condition experienced by some pregnant clients, which adversely effects blood pressure. Depending upon the blood pressure measurement, the client may have a mild, moderate, or severe case of eclampsia. Other tests used to determine the degree of eclampsia include liver enzymes. As the blood pressure rises, organs begin to experience the effects. The liver is particularly sensitive at this time and will reflect changes based upon the blood pressure. Since this client's blood pressure and liver enzyme results are not severe, the client's level of eclampsia would be categorized as being mild.

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.)

Burn injuries. Crush injuries. Major surgeries. Bowel ischemia. 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. 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.

The nurse provides care for an infant who may be infected with human immunodeficiency virus (HIV). Which laboratory study does the nurse expect the health care provider will prescribe to determine the presence of HIV in the infant?

CD4+ count. Infections in infants are confirmed with a CD4+ count, a virus culture of HIV, or polymerase. Western blot confirms the presence of HIV antibodies. Think Like A Nurse: Clinical Decision Making The nurse is aware a newborn may be exposed to the human immunodeficiency virus (HIV) in utero. Should exposure be suspected or confirmed by the diagnosis of the mother, a Western blot test will be done to confirm if the newborn has antibodies to HIV. However, the test may just indicate the newborn has antibodies from the mother. An additional test must be done to determine if the infant is positive for HIV. One test used to make this confirmation is the CD4+ count. Based upon the results of this test, further intervention will be prescribed.

The nurse notes that after a laboratory technician draws a blood specimen from a client that there are drops of blood on the floor and the wall next to the needle container. Which action does the nurse take first?

Call housekeeping to clean and disinfect the area The priority for the nurse is cleaning up the contaminated area in the client's room by contacting housekeeping to clean and disinfect the area. Think Like A Nurse: Clinical Decision Making The nurse identifies two concerns in this situation: a biohazard spill that poses a risk of contamination and an inappropriate action on the part of the lab technician that led to a spill. The nurse needs to address the immediate physical risk of contamination first. A blood spill needs to be immediately cleaned by the person or department with the appropriate cleansing materials. Contacting the housekeeping/environmental department to clean the spill is the best approach for the nurse to take.

fter reviewing the history obtained from a client, the nurse recognizes that which risk factors are associated with degenerative joint disease? (Select all that apply.)

Carpet installer. 78 years old. Minimal physical activity An occupation that causes increased mechanical stress to joints along with repetitive joint use is a risk factor associated with degenerative joint disease. 3) CORRECT— Increasing age is the primary risk factor for degenerative joint disease. 4) CORRECT— Inactivity increases the risk of degenerative joint disease.

The nurse provides care for the client diagnosed with chronic gastritis. The nurse intervenes if the LPN/LVN administers which medications to this client? (Select all that apply.)

Celecoxib Naproxen *those two above are NSAIDs* Use of nonsteroidal anti-inflammatory medications (NSAIDs) is a potential cause of gastritis. Since celecoxib is an NSAID, the nurse needs to intervene if the LPN/LVN attempts to administer this medication. Think Like a Nurse: Clinical Decision-Making Chronic gastritis is inflammation of the stomach. This disorder can be caused by medication, food, or ingestion of alcohol. Medications known to cause chronic gastritis include non-steroidal anti-inflammatory agents such as celecoxib and naprosyn. Both of these medications should be questioned before providing.

The nurse provides care to a client who is prescribed furosemide. Which meals will the nurse recommend as appropriate for this client? (Select all that apply.)

Cereal with a banana and orange juice. Baked potato topped with bean chili. Winter squash lasagna. Bananas and orange juice are high in potassium. 4) CORRECT — Potatoes and dry beans (those used in chili) are high in potassium. 5) CORRECT — Winter squash is high in potassium. Think Like A Nurse: Clinical Decision Making Furosemide is a potassium-wasting diuretic. The nurse educates the client about strategies for ensuring adequate dietary potassium intake. Potassium-rich foods include avocado, acorn squash, spinach, sweet potato, wild-caught salmon, pomegranate, and dried apricots and figs. In addition, the nurse teaches the client signs and symptoms of hypokalemia. Manifestations of hypokalemia include weakness, tiredness, nausea, vomiting, muscular cramping in the arms or legs, tingling or numbness, abdominal cramping, bloating, and constipation.

The nurse notes that an adolescent client without any previous health problems is prescribed intravenous and oral fluids to treat meningitis. For which serious complication does the nurse monitor this client?

Cerebral edema. Since the client has inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Think Like A Nurse: Clinical Decision Making The nurse should recall the pathophysiologic and infectious disease processes of meningitis. In this illness, the meninges are irritated with either a bacteria or virus. This irritation causes nuchal rigidity and photophobia as two major symptoms of the disorder. It is essential to keep in mind the location of the infection and the impact interventions will have on the client's status. The nurse should be aware of actions that contribute to increased intracranial pressure (IICP). One major cause of IICP is fluid overload. Since the client is prescribed both oral and intravenous fluids, the risk for IICP is high. The client needs close monitoring.

An older client with a history of smoking one pack per day for 50 years and consuming three beers per day demonstrates right middle lobe wheezing associated with a nonproductive cough, shortness of breath, and chest discomfort. Which prescription will the nurse implement first?

Chest X-ray. The client's symptoms suggest lung cancer and the wheezing is consistent with the associated constrictive airways. Pulmonary function tests evaluate lung capacity, which is done in constrictive diseases, such as asthma. Think Like A Nurse: Clinical Decision Making The nurse should anticipate that additional assessment is needed prior to receiving prescriptions from the health care provider. The nurse should consider the client's symptoms in relation to the physiology of the body; identifying the probability of respiratory system involvement, manifested by wheezing with a non-productive cough. Coupled with shortness of breath and chest discomfort, the indication is that "something" is occurring within the thoracic cavity. Assessment findings related to the client's history of smoking leads the nurse to recognize the most logical decision is to have the client's chest x-ray completed as a priority. The other diagnostic or laboratory tests can be completed after the chest x-ray.

The nurse delivers a change-of-shift report. Which information is important for the nurse to include in the report? (Select all that apply.)

Client's admitting diagnosis and relevant history. Client's emotional response to condition. Current intravenous (IV) solution and flow rate. Use of and response to as needed medications. The client's admitting diagnosis should be included. Any relevant medical history is also included. 2) CORRECT— The client's emotional response to the condition should be included. 3) CORRECT— The current IV solution and flow rate, when the current bag is scheduled to be completed, and the amount of solution remaining to be infused should be included. 4) INCORRECT - Descriptions of routines (in this case, routine morning care) or normal findings should not be included. 5) CORRECT— The use of and response to PRN (pro re nata, or as needed) medications should be included. Think Like A Nurse: Clinical Decision Making The hand-off report is completed in the presence of the client whenever possible so the client is aware of all aspects of the plan of care. The transfer of responsibility for the client should transition the client safely by including relevant information. Even data that is available in the medical record should be brought to the attention of the next nurse when relevant. Any significant events, abnormal lab results, vital sign trends, interventions that were successful, and work to be completed during the next 24 hours is communicated. A shared client environment, including client care areas with curtain dividers, presents challenges to privacy and confidentiality. Staff members should speak in low voices or confine conversations, away from the hearing distance of all individuals who are not members of the client's care team.

The oncology nurse provides care for a client diagnosed with lung cancer. Which symptoms, if exhibited by the client, most concern the nurse?

Confusion, weight gain, and urine output of 15 mL per hour. hese signs and symptoms indicate that the client is experiencing the syndrome of inappropriate anti-diuretic hormone (SIADH). Excessive ADH results in fluid retention and fluid overload. The most common cause of SIADH is cancer, especially lung cancer. These are expected manifestations of lung cancer. The pain comes partly from the tumor invading perivascular nerves. The blood-tinged sputum may come from bleeding from a malignant tumor. Think Like A Nurse: Clinical Decision Making Lung cancer is known for causing paraneoplastic syndromes, which involve damage to organs or tissues distant from the cancerous region. Tumors may produce hormones, enzymes, or other substances that can precipitate undesirable and dangerous physiologic responses. Tumors may also trigger the unnecessary release of hormones by other organs. Lung cancer can cause various secondary health alterations, including syndrome of inappropriate antidiuretic hormone (SIADH). Initial treatment is directed at the paraneoplastic syndrome and how it is expressed. Ultimately, eradication of the cancer is the only way to reverse the symptoms of a secondary syndrome.

The nurse teaches a group of clients about measures to control hypertension. Which points will the nurse include in the teaching session? (Select all that apply.)

Consume abundant fresh fruits, vegetables, and dairy products. Decrease intake of dietary sodium Stop smoking. The nurse should instruct the clients to consume a diet abundant in fresh fruits and vegetables and low-fat dairy (not dairy products high in fat content) to help control high blood pressure. 2) CORRECT - Avoiding heavily salted foods such as cured meats, sandwich meats, and potato chips, and not adding salt to food at the table is beneficial in lowering blood pressure. INCORRECT - Reducing alcohol consumption to two drinks or less per day for men and one drink per day or less for women helps lower blood pressure. 5) CORRECT - Smoking cessation reduces blood pressure. Think Like A Nurse: Clinical Decision Making Lifestyle changes are critical to preventing, halting, or even reversing hypertension and subsequent coronary artery disease. Smoking cessation and weight loss are key issues. A heart-healthy diet includes choosing fish or chicken over red meat, increasing fresh vegetables, and avoiding canned foods and frozen dinners, which often contain an entire day's allowance of sodium. Chronic health alterations that cause blood vessel damage, such as diabetes mellitus, high cholesterol, and hypertension, must be controlled to prevent end organ damage .

Which information will the nurse include when teaching the client about the self-management of an implantable cardioverter/defibrillator (ICD)? (Select all that apply.)

Continue taking antidysrhythmic medications until the health care provider directs otherwise. Do not wear tight clothing or belts over the ICD generator. Avoid activities that involve rough contact with the ICD. Report symptoms such as nausea, fainting, and weakness. Even after ICD placement, the client will need to continue taking antidysrhythmics until otherwise directed by the health care provider. 2) CORRECT- Tight clothing and a belt could cause irritation to the ICD generator. Rough activities, such as contact sports, may cause ICD electrodes to become dislodged. 5) CORRECT - Nausea, fainting, and weakness indicate low cardiac output and must be reported to the health care provider. 3) INCORRECT - There is no reason to notify the fire department about the client's ICD. The client should wear a medic alert bracelet. Think Like A Nurse: Clinical Decision Making After implantable cardioverter/defibrillator (ICD) implantation, the client typically is provided with a product brochure that includes key information on living with an ICD. The nurse can reinforce teaching, reminding the client to keep the incision dry for at least 4 to 5 days after insertion. The client should be informed of what signs and symptoms (e.g., redness, swelling, fever) to report to the health care provider. It is important that the client continue to take prescribed cardiac medications (e.g., antidysrhythmics) and follow up with the cardiologist for routine interrogation of the ICD. Before teaching, the nurse should first assess the client's baseline knowledge. The teach-back method is used to verify client's understanding.

A client admitted to the cardiac care unit after a myocardial infarction develops shortness of breath, tachycardia, and a cough with frothy, pink-tinged sputum. Which breath sound will the nurse expect when assessing this client?

Course rales. Course rales are expected with the pulmonary edema that accompanies a myocardial infarction Think Like a Nurse: Clinical Decision-Making The nurse uses knowledge of anatomy and physiology along with an understanding of the pathophysiology associated with the client's diagnosis. The nurse should conclude the client recovering from a myocardial infarction is at risk for developing heart failure. This is because of the damage to the cardiac tissue weakening the ability of the ventricles to pump blood effectively. Heart failure development will depend upon the location and extent of cardiac tissue ischemia. In heart failure, fluid is backed up in the vascular system and may enter the lungs. Fluid that enters the lungs will cause the client to develop pink-tinged sputum as evidence of pulmonary edema, and the breath sounds will reflect fluid in the lungs.

A client is prescribed pentamidine isethionate by the health care provider. Which observation best indicates to the nurse that the medication is effective?

Decreased crackles and dyspnea. Pentamidine is an anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients. The manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs. increase T cells= Pentamidine is an anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients. The manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs. Think Like A Nurse: Clinical Decision Making Pneumocystis jiroveci pneumonia (PJP), which was previously known as Pneumocystis carinii pneumonia (PCP), is the most common opportunistic infection among individuals diagnosed with HIV. This form of pneumonia may be lethal and does not respond to typical antifungal treatment. Pentamidine is administered as a nebulized or injectable medication. In the absence of other disease complications, therapeutic effects of pentamidine include decreased work of breathing, resolution of fever, diminishing cough, normalization of heart rate, and reduction or absence of pulmonary crackles or rhonchi. Pentamidine is associated with severe side effects.

A client with preeclampsia at 37 weeks' gestation receives a continuous intravenous infusion of magnesium sulfate. Which assessment finding causes the nurse the most concern?

Deep tendon reflexes 4+. The nurse should identify deep tendon reflexes greater than 2+ as an indication of increasing central nervous system irritability and an increased risk for seizures. The nurse should report this finding to the health care provider and might need to increase the infusion rate. INCORRECT - The expected therapeutic range for serum magnesium is 4 to 7 mg/dL. Think Like A Nurse: Clinical Decision Making The nurse should consider the action of magnesium, which is used to treat eclampsia or severe high blood pressure in the pregnant client. Intravenous magnesium acts as a smooth muscle relaxant, which results in vasodilation and reduced blood pressure. However, this relaxation can also adversely effect the musculoskeletal, respiratory and renal function. In reviewing the client's assessment findings, the nurse notes that all are within normal limits except for the deep tendon reflexes. Deep tendon reflexes that are +4 are indicative of severe clonus and suggest neurological irritability. This finding suggests that the magnesium is not effective and the client is at risk to develop seizures associated with eclampsia. The nurse should immediately contact the health care provider, monitor the blood pressure, and institute seizure precautions.

A client receives epoetin alfa for chemotherapy-induced anemia. For which medication complication will the nurse closely assess this client?

Deep vein thrombosis. It is important for the nurse to assess the client closely for signs of deep vein thrombosis or swelling, pain, and erythema of an affected limb as these are all adverse reactions associated with epoetin alfa therapy. Epoetin alfa is commonly prescribed for anemia associated with chronic kidney disease. Chronic kidney disease is not an adverse effect of the drug. Think Like A Nurse: Clinical Decision Making Erythropoietin, a glycoprotein that stimulates red blood cell production, is produced in the kidney. It stimulates the division and differentiation of committed erythroid progenitors in the bone marrow. Epoetin alfa has been noted to increase mortality and increase the risk for serious cardiovascular and thromboembolic events. To decrease these risks, the provider should use the lowest dose needed to avoid red blood cell transfusion. Epoetin alfa should be discontinued following the completion of a chemotherapy course. The nurse should collaborate with the health care provider to ensure that the client taking epoetin alfa receives deep venous thrombosis prophylaxis. The nurse should also anticipate monitoring the client's hemoglobin and hematocrit level.

A client with a history of diabetes mellitus (DM) and asthma takes high-dose corticosteroids. Which dermatologic complications will the nurse assess in this client? (Select all that apply.)

Delayed wound healing. Erythematous plaques on legs. Decreased subcutaneous fat over extremities. Erythematous plaques on the legs is related to diabetes mellitus. 5) CORRECT- Decreased subcutaneous fat in the extremities is related to both diabetes mellitus and corticosteroids. Think Like A Nurse: Clinical Decision Making Long-term steroid therapy may be prescribed for treatment of clients with various conditions, including chronic asthma or autoimmune disorders, such as lupus or rheumatoid arthritis. Both long-term systemic steroid therapy and Cushing syndrome result in multisystem effects of cortisol. Cortisol causes catabolism, altering the strength of tissues such as muscles and blood vessels. Collagen and elastic fibers in the epidermis are ruptured, resulting in decreased skin elasticity. While systemic steroid therapy does not typically cause changes in skin pigmentation, integumentary changes can include fragile skin, easy bruising, dry skin, acne, stretch marks, or infection. Topical corticosteroid cream misuse can cause integumentary effects such as skin thinning and telangiectasia .

A client diagnosed with a known history of substance abuse with opioids is recovering after a hysterectomy. Which actions will the nurse implement when providing care? (Select all that apply.)

Determines what type and amount of opioids the client uses. Administers opioids around-the-clock. 2) CORRECT — The nurse should evaluate the medication prescription to avoid the opioid that was abused. 3) CORRECT — The medication should be provided around-the-clock to maintain a steady opioid level and prevent symptoms of withdrawal. Think Like A Nurse: Clinical Decision Making Many postoperative clients will experience acute pain, which should be treated with an opioid medication. The nurse needs to be aware of difficulty with pain management because of the client's history of opioid abuse. The prescribed medication should be provided around the clock to reduce the risk of withdrawal symptoms. The type of opioid medication that the client abused should be evaluated so that the same medication is not used to treat postoperative pain; using the same medication can result in poor pain management with safe doses of the medication.

A client diagnosed with Addison disease comes to the emergency department experiencing nausea, vomiting, diarrhea, and abdominal pain. Which prescription does the nurse expect from the health care provider?

Dextrose 5% in normal saline IV solution and high-dose steroids. The client is exhibiting symptoms of Addisonian crisis, in which the client is hypotensive and experiences a severe deficiency of glucocorticosteroids. The nurse expects to administer isotonic fluid to increase fluid volume and to provide high-dose steroids to replenish the client. 2) INCORRECT - ACTH stimulates the adrenal cortex, but it does not help with Addisonian crisis. Clients with Addison disease have hyperkalemia rather than hypokalemia. Think Like A Nurse: Clinical Decision Making It is important for the nurse to recall the pathophysiology of Addison disease before anticipating which treatment is likely to be prescribed for this client. In this disease, the body does not have sufficient amounts of cortisol and aldosterone. Routine replacement of these hormones is required; however, when the body is stressed with another illness, the usual dosage is not sufficient. The deficit causes symptoms of acute Addisonian crisis to occur. The nurse should recognize that the client needs immediate care to balance electrolyte levels, replace fluids, and replenish hormones. The nurse will anticipate prescriptions to meet client needs.

The nurse in the outpatient clinic assesses a school-age child brought to the clinic because of a skateboarding accident. Which question does the nurse ask first?

Did you hit your head?" The priority is to assess for head injury. This question assists the nurse to determine whether a head injury has occurred. Think Like A Nurse: Clinical Decision Making While a comprehensive account of events surrounding an accident is ideal, in the initial nurse-client interaction, the nurse prioritizes and focuses the assessment. Skateboarding accidents have the potential to cause severe head trauma. The nurse first needs to know if the client has sustained head trauma in order to guide the plan of care. The nurse proceeds to ask about the height from which the fall occurred and whether the client was wearing a protective helmet.

A client is tested for suspected amyotrophic lateral sclerosis (ALS). Which early symptom will the nurse expect the client to exhibit?

Difficulty swallowing ALS affects the muscles of the throat and upper respiratory tract. The client will demonstrate dysphagia, which can cause aspiration. Other early symptoms include fatigue while talking, tongue atrophy, and weakness of the hands and arms. ALS causes facial fasciculations and not paresthesias. Think Like A Nurse: Clinical Decision Making Many of the early manifestations of amyotrophic lateral sclerosis (ALS) are related to impaired muscular coordination. Speech or swallowing difficulties, failure to accurately grasp a writing or eating utensil, gait impairments, or clumsiness may be initial symptoms. These symptoms progress rapidly over the course of less than five years, resulting in loss of all muscle control, including the muscles that control respiration. The nurse promotes client safety by offering anticipatory guidance and coping strategies to help compensate for declining muscular coordination.

The nurse provides care to an older adult client diagnosed with right-sided paralysis caused by a cerebrovascular accident (CVA). Which sign is most important for the nurse to post in the client's room?

Do not use the right arm for lifting." Because the paralyzed muscles cannot offer resistance, the shoulder can be easily dislocated if the arm is used for lifting. This is a common injury in clients with paralysis, and the sign will help prevent it from occurring. Think Like A Nurse: Clinical Decision Making The nurse needs to consider the client's health problem prior to planning interventions. Because of the pathophysiological process of a cerebrovascular accident, the client will demonstrate paralysis of one side of the body. For this client, the right side of the body is affected. Because sensory and motor function is absent, the affected side of the body must be protected from harm and accidental injury. The nurse needs to communicate that the right side of the body should not be used when repositioning the client.

The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best?

Do what is asked. Make the environment quiet and keep your distance until your spouse is less upset." The client is probably having PTSD flashbacks. When a combat veteran has a flashback, the veteran is psychologically in a war zone, reliving a trauma as if it were occurring now, and may misidentify people as a threat. The client's spouse should be directed to maintain a safe distance and limit stimuli. A calm, slow approach is useful when a client is diagnosed with PTSD, but approaching the client and talking slowly and calmly should not be done during a flashback Think Like A Nurse: Clinical Decision Making The nurse recognizes the client is experiencing a psychiatric condition as a result of being in combat. This frequently occurs, but can be difficult for the family to handle and accept. The nurse explains the psychiatric issue to the spouse and then emphasizes the need to maintain personal safety. The client is psychologically reliving a traumatic event, which could cause the client to act out. The environment should be kept as calm and quiet as possible to reduce environmental stressors and reduce stimuli once the episode passes. The nurse provides information about assistance and support programs for the client and family.

While interviewing a young adult, the nurse learns that the individual has a history of frequent nosebleeds that require health care intervention. Which question by the nurse assesses risk factors for this condition?

Do you use nasal sprays for allergies? he frequent use of nasal sprays to relieve allergic symptoms can result in vasoconstriction that causes atrophy of nasal membranes. This results in the decreased integrity of blood vessels in the nose and leads to frequent nosebleeds that are difficult to resolve. Aspirin is a platelet anti-aggregant and may prolong bleeding, but it does not cause nosebleeds. Think Like a Nurse: Clinical Decision-Making Nosebleeds are common and are often related to dry mucous membranes. Chronic exposure to a dry environment may cause drying of the mucous membranes. Frequent or prolonged nosebleeds require further assessment and potential intervention. The client might try application of a thin coat of water-based lubricating ointment in the nares to enhance moisture or use of a saline nasal spray, alternating with the anti-allergy spray. Using a humidifier in the home can also reduce nose bleeds.

While working at a local food processing plant, a flying object penetrates an employee's right eye. The employee is admitted to an emergency department. After administering pain medication, which question is most important for the nurse to ask?

Do you wear glasses?" This question helps determine whether material other than the known object penetrated the eye. If the client wears glasses, pieces of glass may have also penetrated the eye along with the flying object. Think Like A Nurse: Clinical Decision Making The nurse needs to consider if there is additional information that will be important or impact the care that is designated for this client. The client should be assessed for anything that could be in the eye besides the foreign material that was first indicated. Further assessment could inform the nurse and health care provider that the client's eye may have eye glass material or a contact lens present at the site of injury.

A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the nurse places the client's hand over the head, it remains in that position. Which action is appropriate for the nurse to implement?

Document the findings as waxy flexibility. The client is demonstrating waxy flexibility, which is a form of abnormal posturing seen in catatonic schizophrenia. Waxy flexibility can be described as a loss of animation and a tendency to remain motionless when placed in a position Think Like a Nurse: Clinical Decision-Making The nurse is responsible for conducting a head-to-toe assessment for each assigned client at least once per shift. The nurse must have knowledge of the client's diagnosis to determine which data is expected, and unexpected, in order to provide care. The client diagnosed with catatonic schizophrenia is likely to exhibit wavy flexibility (a body part will stay in the position in which it is placed). This is an expected finding. Therefore, the appropriate action by the nurse is to document the information in the client's medical record. Unexpected findings require the nurse to notify the health care provider in addition to documentation in the medical record.

The health care provider prescribes ciprofloxacin for the client. Which instruction is most important for the nurse to include about this medication?

Drink plenty of fluids until this medication is complete Increased fluid intake is essential because it prevents crystalluria and kidney stone formation. This complication can lead to surgery, hospitalization, or other medical intervention.Milk or yogurt should not be consumed as this decreases the absorption of ciprofloxacin. Using these products between doses is acceptable. Think Like A Nurse: Clinical Decision Making Fluoroquinolones such as ciprofloxacin are known to cause acute renal failure due to interstitial nephritis. The crystals of this agent precipitate under alkaline urine and provoke renal failure through intratubular precipitation. Conservative measures, that include hydration with standard IV fluid formulations and avoidance of alkalinization of the urine, can reverse this condition if applied in time. The nurse should also keep in mind that taking ciprofloxacin is one of the risk factors for C. difficile infection. The nurse should monitor the client for diarrhea and put the client in prophylactic isolation until proven the diarrhea is not due to C. diff.

The nurse provides care for a client at 14 weeks ' gestation and who is diagnosed with a UTI. The client reports that her usual daily intake of fluid is 1 cup of decaffeinated coffee and a 4-ounce glass of orange juice in the morning, a 12-ounce glass of skim milk with lunch and dinner, and a 12-ounce can of caffeine-free diet cola in the midafternoon. It is most important for the nurse to make which suggestion?

Drink two 8-ounce glasses of water before 5 p.m. The recommended fluid intake is 1500 to 2000 mL/day. This client 's fluid intake is approximately 1440 mL/day. Adding water, which is preferable to juices and sodas to manage weight gain in pregnancy, would increase the client 's fluid intake to 1920 mL/day. Decaffeinated beverages are acceptable in pregnancy as long as they do not dominate the fluid intake. It is more important for this client to add water to the daily intake. Think Like A Nurse: Clinical Decision Making Pregnancy is a risk factor for urinary tract infection (UTI) partly because hormonal changes make the tissues of the urinary tract vulnerable to infection. To prevent and manage UTI, the client should drink at least eight glasses of water a day. Common antibiotics such as amoxicillin, erythromycin, and penicillin, are considered safe for pregnant women. The nurse should teach the client that the majority of urinary symptoms are due to pregnancy-related changes in the urinary system. Past history of UTI, sexual activity, lower socioeconomic group, and multi-parity are significant risk factors for UTI.

The nurse prepares a client for a barium enema. Which instruction is most important for the nurse to include?

During the test, it is crucial that you take slow, deep breaths through your mouth. For the test to be successful, a client must retain the barium. As barium is introduced, a client may have the urge to defecate. Slow, deep breathing will help ease the discomfort and urge to defecate. Think Like A Nurse: Clinical Decision Making The nurse has a responsibility to provide information to the client regarding how to tolerate diagnostic testing in order to assure successful test outcomes. A barium enema is a diagnostic test that uses barium as a contrast medium to identify structures and areas of pathology within the large intestines. Because the contrast medium is introduced via an enema, the client may become uncomfortable. A natural reaction to having a feeling of fullness in the rectum and descending colon is to bear down. The nurse should counsel the client to take slow deep breaths when the barium is being introduced to reduce the feeling of rectal fullness.

The nurse on the medical/surgical unit reviews lab results. The nurse notes that a client's serum albumin level is 2.5 g/dL (25 g/L), fasting blood sugar is 110 mg/dL (6.1 mmol/L), potassium is 4.2 mEq/L (4.2 mmol/L), and sodium is 140 mEq/L (140 mmol/L). It is most important for the nurse to assess for what finding?

Edema. The client has hypoalbuminemia. The normal serum albumin is 3.5-5.5 g/dL (35-55 g/L). An albumin deficit decreases oncotic pressure, and fluids shift from the vascular area to tissue, which causes edema. Think Like A Nurse: Clinical Decision Making The nurse reviews the lab values and identifies the client's albumin level as low. The nurse evaluates each assessment finding to identify whether it is associated with hypoalbuminemia. One reason for the development of edema is a low total body protein level. An adequate albumin level is required for fluid to stay in the vasculature. When this level decreases, fluid will shift to body tissues, causing edema. The nurse should assess the client's dietary intake, explore reasons why the client is not eating (if applicable), and collaborate with the dietitian to develop a healthy, balanced meal plan for the client.

The nurse supervises the care of a client receiving enteral feedings through an NG tube. Which observations indicate to the nurse that the care being provided by the nursing assistive personnel (NAP) is appropriate for this client? (Select all that apply.)

Elevates the head of the bed 30 degrees. Warms the feeding to room temperature. Clamps the proximal end of the feeding tube at the end of the feeding. Elevating the head of the bed prevents aspiration and indicates appropriate care by the NAP. 3) CORRECT— Warming the feeding to room temperature prevents cramping and indicates appropriate care by the NAP. Clamping the proximal end of the feeding tube at the end of the feeding prevents air from entering the stomach and indicates appropriate care by the NAP. Think Like A Nurse: Clinical Decision Making When supervising client care, the nurse first considers the scope of practice of the care provider. The nursing assistive personnel (NAP) is able to provide nasogastric tube feedings if the skill has been deemed appropriate and safe to provide to a stable client. However, the NAP cannot perform assessment or evaluation, such as checking the amount or pH of the gastric aspirate. The nurse then considers the safety of the actions provided by the NAP. When administering a nasogastric tube feeding, the head of the bed should be elevated to prevent aspiration. Warming the feeding to room temperature prevents gastric cramping and distress. And clamping the nasogastric tube at the conclusion of the feeding prevents air from entering the gastrointestinal tract. These actions are appropriate for NAP to perform.

The nurse provides care for a client in the second trimester of pregnancy. Which assessment finding does the nurse attribute to the normal blood volume increase in pregnancy?

Elevation in client's heart rate of 10 to 15 beats Cardiac output increases in pregnancy because more blood is pumped from the heart with each contraction. The pulse rate increases by 10 to 15 beats/min to accommodate the additional blood volume. Think Like A Nurse: Clinical Decision Making The nurse is aware that the body undergoes major changes during pregnancy. When caring for a client who is pregnant, the nurse needs to recall the physiologic processes that are occurring, both within the client and with the fetus. As the fetus grows, the client's body needs to accommodate the fetal metabolic processes. One of these processes is fetal blood flow. The client's total blood volume increases over the course of the pregnancy, which is reflected in the client's heart rate. An increase of 10 to 15 beats per minute is an expected finding.

The nurse is assessing a client who is at 10 weeks' gestation. Which assessment finding does the nurse expect to see?

Enlargement of the client's breasts Hypertrophy of mammary glandular tissue and increased vascularization, pigmentation, and size and prominence of nipples and areolae are caused by hormonal stimulation and begin early in the first trimester. Melanocyte-stimulating hormone from the anterior pituitary cause the appearance of the linea nigra. Striae gravidarum, or stretch marks appear in 50 to 90% of pregnant women during the second half of pregnancy, between 20 to 40 weeks. hink Like A Nurse: Clinical Decision Making Each stage of pregnancy is associated with predictable physiological and psychological changes. The nurse offers anticipatory guidance on these matters to reassure the client, to explain the anticipated changes, to differentiate expected changes from issues that need to be brought to the health care provider's attention, and to offer useful and evidence-based strategies for relief. For example, douching is avoided in pregnancy and is not used in response to increased vaginal discharge. Anemia can often be offset by increasing iron-rich foods, but the client should alert the health care provider about unreasonable fatigue and dizziness. Nocturnal leg cramps can be eased with positioning, dietary changes, and applying warm packs to the legs.

The nurse teaches a new mother who is breastfeeding about the stool that the newborn will eliminate. Which information will the nurse include?

Expect 3 to 6 small, soft, orange-yellow stools each day The stool of a breastfed infant is orange-yellow, soft, and small with an even consistency. The mother should expect up to 6 stools a day. The number of stools decreases with age. The color changes with the introduction of solid foods. Think Like A Nurse: Clinical Decision Making Before teaching the client about the type of stool the newborn will eliminate, the nurse should mentally recall the physiological processes associated with breastfeeding and the infant. The infant is not ingesting solid food and is being sustained on breast milk. Because breastmilk is more easily digested by the infant, the appearance and consistency of the bowel movements are affected. The nurse should include this information when teaching, and remind the client that the number of stools will decrease with time, and that the consistency and color will change as solid foods are introduced.

The nurse counsels the parents of school-age children. One of the parents asks the nurse how they should teach their children about human sexuality. Which response by the nurse is best?

Find out what your children know before answering their questions." The nurse should suggest that parents first assess their child's knowledge. Children often have misinformation about human sexuality. If the misinformation is not identified and corrected, the child will incorporate the misinformation into the parent's answer. Think Like A Nurse: Clinical Decision Making The nurse should follow the nursing process and suggest that the parent ask what the child knows or "has heard" about human sexuality. The suggestion is for the use of assessment. Assessing the child provides the parent with a valid starting point. It is necessary to assess whether the child has been exposed to incorrect information. After the child's basic knowledge has been determined, the parent can then proceed with teaching the child about human sexuality and answering any questions.

diabetes mellitus.

Frequent urination, excessive thirst, and excessive hungry

A client diagnosed with lung cancer gains 4.4 lb (2 kg) overnight and has a serum sodium of 122 mEq/L (122 mmol/L) and potassium of 4.5 mEq/L (4.5 mmol/L). Which intervention does the nurse expect to be prescribed for this client?

Furosemide 40 mg IV push. Lung cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH), which is an abnormal secretion of antidiuretic hormone. This health problem results in increased water absorption and dilutional hyponatremia. Diuretics are used to promote fluid loss. Think Like A Nurse: Clinical Decision Making The nurse recalls complications that can occur with lung cancer and how those complications may be manifested. Knowledge of pathology and experience will help the nurse to identify that this type of cancer can cause the development of the syndrome of inappropriate antidiuretic hormone (SIADH). With SIADH, the client develops dilutional hyponatremia due to the accumulation of excess body fluid. The weight gain and sodium level support this diagnosis and treatment begins with providing diuretics, as prescribed. This removes excess fluid and helps the body naturally readjust the sodium level. Additional treatment may include a fluid restriction.

The nurse provides care for a client who is human immunodeficiency virus (HIV) positive and has been taking anti-retroviral therapy (ART) for 15 years. Which health maintenance activity does the nurse teach this client related to the adverse effects of long term ART?

Have your lipid profile checked." Long-term ART leads to hyperlipidemia and cardiovascular disease, possibly due to chronic stress. Immunization for the flu is appropriate for general health. It is not related to the adverse effects of long-term ART. Think Like A Nurse: Clinical Decision Making Antiretroviral therapy (ART) has saved many lives, but it is not without its drawbacks. Adherence to the medication regimens is difficult due to significant and unpleasant side effects and the price of the medication. ART also leads to negative metabolic effects. For example, hypertriglyceridemia, dyslipidemia, and insulin resistance are common adverse affects of this therapy, resulting in an increased risk of myocardial infarction. With advances in ART, HIV and AIDS are now chronic illnesses, allowing the client time to develop significant cardiac disease as a comorbidity.

The nurse performs a physical examination on a newborn. Which assessment finding does the nurse report to the health care provider?

Head circumference of 40 cm An average head circumference of a newborn ranges from 32-36 cm. An increase in size may indicate hydrocephalus or increased intracranial pressure. The nurse must alert the health care provider of this assessment finding. The chest circumference is 1-2 cm less than the head. An average head circumference of a newborn ranges from 32-36 cm. This is an expected finding. Think Like A Nurse: Clinical Decision Making A head-to-toe physical examination is performed for all newborns within an hour of birth. Head circumference is measured during this initial assessment to provide baseline information. The expected newborn head circumference is between 32 and 36 cm (12.6 and 14.1 inches). Since the newborn's head circumference in this scenario is 40 cm (15.7 inches) and outside of the normal parameters, the nurse must notify the health care provider. One possible cause of increased head circumference is hydrocephalus.

The nurse provides care to a male client. The health care provider (HCP) prescribes IV infusion of 1000 mL 0.9% sodium chloride (NaCl) over 8 hours. Which assessment findings cause the nurse to hold administration of the IV fluid and clarify the HCP's prescription? (Select all that apply.)

Hematocrit is 38% (0.38 Proportion of 1.0). Urine output is 2200 mL/day. Urine specific gravity is 1.008. Normal hematocrit is 42 to 52% (0.42 to 0.52 Proportion of 1.0) in men, and 35 to 47% (0.35 to 0.47 Proportion of 1.0) in women. In the absence of bleeding, decreased hematocrit may indicate fluid volume excess. Further evaluation is needed prior to administering additional fluid. 3) CORRECT - Normal adult urine output is 800 to 2000 mL/day. Excessive urine production may indicate fluid volume overload. Administration of additional fluid should be questioned. 4) CORRECT - Normal urine specific gravity is 1.010 to 1.030. A decrease in urine specific gravity is reflective of dilute urine and may indicate excess fluid volume is present. Administration of additional fluid should be questioned. Think Like a Nurse: Clinical Decision-Making Before administering the prescribed IV fluid, the nurse reviews recent assessment data and becomes concerned. A low hematocrit level in the absence of bleeding could indicate hemodilution or excess body fluid. Another issue is that the client is experiencing a urine output of 2200 mL/day, when the normal amount should be between 800 to 2000 mL/day. The extra urine could be the body's attempt to expel excess fluid. The last indication is the urine specific gravity. A level of 1.008 indicates dilute urine, which occurs with excess body fluid.

The nurse notes the health care provider prescribed a diet consisting of increased amounts of fresh fruits and vegetables, chicken, and whole grain breads for an adult male client. Which finding does the nurse expect to see on the client's medical record?

Hematocrit of 40% (0.40) and hemoglobin of 11.2 mg/dL (112 g/L). The normal hematocrit for a male is 42 to 52% (0.42 to 0.52). The normal hemoglobin for a male is 13 to 18 mg/dL (130 to 180 g/L). These lab values indicate anemia, for which a diet high in protein, iron, and vitamins is advised. The prescribed diet will provide high amounts of protein, iron, and folic acid. Think Like A Nurse: Clinical Decision Making The nurse will review client laboratory results by noting normal ranges and any client deviations. The nurse should anticipate which prescriptions will address any abnormal lab values. In this scenario, the nurse evaluates the diet prescribed and recognizes that it provides protein, iron, and folic acid. The nurse recognizes that this diet may be prescribed for anemia. The client's hemoglobin and hematocrit levels are low, which could indicate iron-deficiency anemia for which the diet is appropriate.

A client receives a prescription for clopidogrel. Which laboratory results are important for the nurse to monitor based on this new prescription? (Select all that apply.)

Hemoglobin. Hematocrit. CORRECT— Clopidogrel is an oral antiplatelet medication that interferes with platelet aggregation. Adverse effects include hemorrhage, bleeding, hematuria, and hemoptysis. A decreased hemoglobin may indicate bleeding. 2) CORRECT— A decreased hematocrit may indicate bleeding. 3) INCORRECT - Clopidogrel suppresses platelet aggregation, but it does not decrease platelet count. 4) INCORRECT - A prothrombin time (PT) along with an INR is useful for monitoring warfarin effectiveness. 5) INCORRECT - aPTT used to monitor effectiveness of heparin. Think Like A Nurse: Clinical Decision Making Hemostasis refers to the cessation of bleeding from a damaged blood vessel. Coagulation, which is one step in the complex process of hemostasis, refers to blood clot formation. The coagulation cascade, which involves a complex series of chemical reactions between clotting factors, results in formation of the fibrin protein. Treatment of the client who experiences hypercoagulation may include administration of medications that (a) affect platelet function or (b) selectively target one or more mechanisms involved in the clotting cascade. Antiplatelet medications, such as clopidogrel, decrease the platelets' tendency to stick to one another and require monitoring of the client's bleeding time. Anticoagulant medications, such as warfarin, heparin, and fondaparinux sodium, alter the function of clotting factors and require monitoring of international normalized ratio (INR), prothrombin time (PT), or activated partial thromboplastin time (aPTT).

The nurse provides care for a client scheduled for an adrenalectomy to treat pheochromocytoma. For which symptom will the nurse monitor the client first?

Hypertension Hypertension is the classic sign of pheochromocytoma. The client's blood pressure should be closely monitored. Think Like a Nurse: Clinical Decision-Making Hypertension has often been characterized as "the silent killer" and there can be a physiologic reason for the development of this health problem. The nurse is aware one reason for secondary hypertension to develop is the presence of a pheochromocytoma, which is a tumor within the adrenal gland. This tumor alters adrenal gland hormone secretion, which causes hypertension. While clients with pheochromocytoma may present with thirst, increased urinary output, and increased blood glucose, these symptoms are unlikely to result in immediate harm to the client. The severe hypertension found in pheochromocytoma may result in stroke or myocardial infarction.

The nurse provides care to an older adult client. Which age-related change causes the nurse to carefully monitor the client's fluid and electrolyte balance?

Hyponatremia An increase in antidiuretic hormone and atrial natriuretic peptide, and a decrease in renin and aldosterone, lead to decreased sodium reabsorption and increased water retention by the kidneys, which can cause low sodium or hyponatremia. Think Like A Nurse: Clinical Decision Making Some bodily functions change as a result of aging, and it is important for the nurse to understand what changes can occur and how the changes will present. The nurse should mentally ask, "What normal change related to age can be detrimental to this client's health?" The nurse needs to be aware the kidneys undergo major function changes with aging, which occur because of fluctuating hormone levels that control electrolyte and fluid balance. The most notable change is with the sodium level that can be corrected by monitoring fluid intake.

A client receives aminophylline 0.7 mg/kg/hr by continuous IV infusion into the left arm. Which adverse effects are important for the nurse to assess during the infusion?

Hypotension and cardiac arrhythmias. FOR IV meds Observe client receiving IV administration of medication closely for hypotension, arrhythmias, and convulsions until serum levels stabilize within therapeutic ranges. Think Like A Nurse: Clinical Decision Making The nurse must be aware of adverse effects of any medication prescribed to a client. If the nurse is unaware of adverse effects, or administering a medication not routinely prescribed, the nurse must research the medication using a current, and appropriate, resource. The medication prescribed in this scenario can adversely effect cardiovascular function and precipitate seizure activity. With this knowledge, the nurse will conclude that while the medication is infusing, the nurse should closely monitor the client for any changes in the cardiac, and neurologic, system.

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?

I have been drinking more fluids to keep from getting dehydrated, but I am urinating less than I thought I would." 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. 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.

The nurse instructs a client on how to collect a 24-hour urine specimen for a creatinine clearance test. Which statement by the client would cause the nurse to intervene?

I will go to the lab after I work out in the gym." Creatinine is a waste product of muscle breakdown. A client should not engage in strenuous exercise during, or just before, the test. Think Like A Nurse: Clinical Decision Making Pre-procedure considerations and teaching are an important nursing function. For any test, consider if the client needs to be "nothing by mouth," or NPO, for a period of time, can or cannot perform certain activities, should avoid over-the-counter (OTC) medications, or must withhold taking prescription medications before the test. Factors that interfere with this test include dehydration, contrast dye for tests, stress, urinary tract infections, and exercise.

A pediatric client presents with flushed skin, generalized itching, nausea, wheezes, and inspiratory stridor after being stung by a bee. Which medication prescriptions will the nurse expect to implement for this client? (Select all that apply.)

IM epinephrine. IV diphenhydramine IV methylprednisolone. Nebulized albuterol treatment CORRECT — The nurse expects to implement this medication prescription. Intramuscular (IM) epinephrine is appropriate for anaphylactic shock because it causes peripheral vasoconstriction and bronchodilation. 2) CORRECT — The nurse expects to implement this medication prescription. Intravenous (IV) diphenhydramine is appropriate for anaphylactic shock because it blocks histamine release. 3) INCORRECT - An IV bolus of lactated Ringer solution is appropriate for hypovolemic shock. However, this is not evident as this time. 4) CORRECT — The nurse expects to implement this medication prescription. Intravenous (IV) methylprednisolone is appropriate for anaphylactic shock because it treats inflammation and elevates blood pressure if needed. 5) CORRECT — The nurse expects to implement this medication prescription. A nebulized albuterol treatment is appropriate for anaphylactic shock because it opens the airways and promotes oxygenation. Think Like a Nurse: Clinical Decision-Making The client is demonstrating signs of an anaphylactic reaction to an insect sting. The nurse should always be alerted after an insect bite and closely monitor the client for signs of an allergic reaction. Because this is a medical emergency, the nurse must be prepared to administer medications that will reverse the reaction. Medications the nurse will have available and prepare to administer include epinephrine for bronchodilation, diphenhydramine to block the release of histamine, and methylprednisolone to treat inflammation.

The nurse in the outpatient clinic provides care for a client diagnosed with peptic ulcer disease and gout. Which health care provider prescription does the nurse question?

Indomethacin 50 mg four times daily." Indomethacin is a nonsteroidal anti-inflammatory that is used cautiously in clients with peptic ulcer disease. Think Like a Nurse: Clinical Decision-Making The nurse must monitor for medication interactions, as well as be alert to medications prescribed for one condition that may exacerbate another health alteration. For the client diagnosed with both gout and peptic ulcer disease, the nurse is concerned when the health care provider prescribes a medication that may help gout but also may cause gastrointestinal (GI) bleeding. The health care provider may choose to discontinue this medication, substitute a similar medication, administer this medication with a GI protective medication, or provide additional teaching regarding adverse effects. The nurse is responsible for recognizing this issue and advocating for the client's safety.

The nurse notices that a client who practices Judaism has a lunch tray containing beef, green beans, salad, vanilla pudding, and milk. Which action by the nurse is most appropriate?

Inform the client that an alternate meal will be requested. For clients practicing Judaism, dietary laws based on biblical and rabbinical regulations forbid the consumption of dairy and meat products during the same meal. The nurse should obtain an alternate meal on a new tray. Think Like A Nurse: Clinical Decision Making The nurse needs a solid understanding about the cultural and religious practices of clients. If the nurse is unaware of the practices, the nurse has a responsibility to learn through either research or communication with the client/family. Judaism is common in many regions and the nurse needs to know that the client who adheres to strict Judaism dietary laws will not consume meat and dairy products in the same meal. The nurse should mentally ask, "How can I best meet the needs of this client?" The answer is to inform the client that an alternate meal tray is being prepared and will be provided as soon as it arrives.

The nurse plans a presentation to discuss the concept of malpractice. The nurse covers which elements required to be present in a malpractice case? (Select all that apply.)

Injury. Causation. Duty. Breach of duty. Injury is one of the four required elements in malpractice cases. 3) CORRECT— Causation (nurse conduct causes injury) is one of the four required elements in malpractice cases. 4) CORRECT— Duty (legal relationship between nurse and client) is one of the four required elements in malpractice cases. 5) CORRECT— Breach of duty is one of the four required elements in malpractice cases. hink Like A Nurse: Clinical Decision Making Malpractice occurs when a nurse fails to act as a competent nurse normally would act in the same situation and this results in client injury. Failing to enact immediate steps in response to an emergency, using equipment incorrectly, and administering medication without following prescribed parameters or protocols are all instances of potential malpractice. Examples of negligence in nursing might include failing to call for the code team in response to a client who demonstrates agonal respirations or administering digoxin to a client whose heart rate is 48 beats per minute.

A client is admitted to the emergency department following a motor vehicle accident. The client reports seeing sudden black dots and flashes of light and states that it feels as if a curtain is being closed over the right eye. Which action does the nurse take based on this data? (Select all that apply.)

Instruct the client not to get out of bed. Have the client lie on the right side Prevent the client from eating or drinking. This client is reporting manifestations of a detached retina. Bed rest prevents further detachment of the retina. 2) CORRECT - Lying on the affected side prevents further detachment of the retina. The client should be NPO in anticipation of surgery to correct detachment of the retina Think Like A Nurse: Clinical Decision Making Clients with retinal detachment report light flashes, floaters, and a "cobweb," "hairnet," or ring in the field of vision. The nurse should anticipate visual acuity measurement as the first diagnostic procedure. The detached retina can be directly visualized using ophthalmoscopy or slit lamp microscopy. The nurse should prepare the client for surgery following a standard protocol.

The nurse provides care for a client who experienced a severe eye injury related to an acid splash. The nurse administers proparacaine hydrochloride before each eye examination. Which action is most important for the nurse to take

Instruct the client not to touch the eye Rubbing or touching the eye when the eye is anesthetized may cause corneal damage. Instructing the client not to touch the eye ensures client safety and is the highest priority. Think Like A Nurse: Clinical Decision Making The nurse considers the safety risks inherent in this client situation. Proparacaine hydrochloride is an anesthetic used prior to ophthalmologic examinations. Once the medication is instilled, the nerve endings of the eye are blunted, reducing the ability of the eye to react to pain or pressure. The nurse knows that this places the client at higher risk for eye damage if the eye is touched or rubbed, an action that the client experiencing eye irritation may be more likely to do. The nurse prioritizes teaching the client about not touching the eye to minimize this safety hazard.

A client states to the nurse, "I was just bitten by a tick." The client asks to be tested for Lyme disease. Which action does the nurse implement based on this information?

Instruct the client to return in 4 weeks for testing. It takes 1 to 2 months after the tick bites to get a reliable result because of the antibody formation process. Think Like A Nurse: Clinical Decision Making The Centers for Disease Control and Prevention (CDC) currently recommends a two-step process when testing blood for evidence of antibodies against the Lyme disease bacteria. The first step uses an enzyme immunoassay (EIA) or, rarely, an indirect immunofluorescence assay (IFA). If this first step is negative, no further testing of the specimen is recommended. If the first step is positive or indeterminate, the second step is performed. The second step uses the "Western blot" test. Results are considered positive only if the EIA/IFA and the immunoblot are both positive. The nurse teaches the client local skin care of the erythema migrans seen on the skin due to the tick bite.

The clinic nurse provides care for a client who reports a sore throat and fever. A throat culture indicates group A beta-hemolytic Streptococcus infection. Urinalysis reveals protein and numerous RBCs. Antibiotics are prescribed. The client is leaving soon for a 6-week international conference. Which action should the nurse take next?

Instruct the client to schedule an appointment before leaving the country. Follow-up appointments before leaving and upon return are required to determine the client 's kidney status due to the symptoms of acute glomerulonephritis. Think Like A Nurse: Clinical Decision Making The client is experiencing strep throat. One adverse effect of this bacterial infection is acute glomerulonephritis, which affects the kidney's ability to function appropriately. The protein and red blood cells in the client's urine indicate that some degree of kidney function is being harmed by the infection. The client should be seen by a health care provider prior to leaving the country to evaluate kidney function and determine additional interventions to preserve kidney function in the long-term.

A parent asks the nurse when an infant can begin to eat solid foods. The nurse assesses the infant's readiness to begin eating solid foods. Which assessment finding indicates to the nurse that the parent should wait to introduce solid foods?

Intact tongue extrusion reflex. Absence of the tongue extrusion reflex indicates readiness to begin solid foods. If the tongue extrusion reflex remains, solid foods should be delayed until it is extinguished - Drooling is present when an infant is ready to begin solid foods. Think Like A Nurse: Clinical Decision Making The techniques used to assess an infant's developmental level are different from those used to assess an older child or adult. The nurse will need to use knowledge or assessment and evaluation that is specific to the infant's development and maturity. The nurse will rely on the presence or absence of reflexes, which serve as a guide to the infant's growth and development. The presence or absence of the tongue extrusion reflex is used to determine if the infant is developmentally prepared to ingest solid food. If the reflex is present, the infant will push food placed in the mouth out, indicating that solid food should not be offered. Once the reflex disappears, solid food can be introduced at the rate and type recommended for the client's age and by the health care provider.

The prenatal client asks the nurse why she is going to receive Rho(D) immune globulin during her pregnancy. Which information does the nurse include in the response?

It prevents your body from having an immune reaction against your infant's blood. Rho(D) immune globulin prevents the mother from forming antibodies to a developing fetus's Rh-positive blood. Sensitization may occur during pregnancy, birth, abortion, or amniocentesis. Think Like A Nurse: Clinical Decision Making Maternal-fetal differences in Rh incompatibility are treated prophylactically with Rh immune globulin (RhoGAM) during pregnancy and treated again after pregnancy depending on the newborn's blood. A mother with Rh negative blood will develop an immune response to a fetus with Rh positive blood. This only impacts mothers with Rh negative blood; a mother with Rh positive blood will not develop an immune response regardless of the fetal Rh factor. The mother's body identifies the child as foreign, just as it would an influenza infection, and mounts a defense to protect the maternal body. If the mother is allowed to create an immune response to this child, subsequent children are at risk of miscarriage, illness, or death.

The nurse schedules a client for a myelogram. Which teaching will the nurse provide to prepare the client for this test? (Select all that apply.)

Jewelry and metal objects will need to be removed. An informed consent form will need to be signed. Food and fluids will be restricted for 4 to 8 hours before the procedure. The procedure will take about 45 minutes. INCORRECT - A health care provider will perform the procedure. 2) CORRECT- Jewelry and metal objects from the chest area need to be removed. 3) CORRECT- An informed consent is required because the procedure is invasive. 4) CORRECT- Preparation for a myelogram includes restricting food and fluids for 4 to 8 hours before the procedure. 5) CORRECT- The procedure takes about 45 minutes to complete. Think Like A Nurse: Clinical Decision Making Nurses must be knowledgeable of pre-, intra-, and post-test implications. Usually, the nurse can access this information using resources provided by the hospital or organization. Client teaching, preparation, and safety are the nurse's obligations. The client undergoing a myelogram must not have taken medications that affect blood clotting, including aspirin, unless directed to do so by the health care provider. The client should expect the procedure to take about an hour. The dye that is injected into the subarachnoid space is heavier than cerebrospinal fluid (CSF). It is essential that the client not lie completely flat for several hours to a day after the procedure.

The nurse manager is planning an in-service to address confidentiality issues. Which measure is appropriate for the nurse manager to include as a way to prevent confidentiality violations?

Keep ambulatory clients and visitors away from the nursing station as much as possible. The nursing station is a center of activity in terms of in-person and telephone conversations, paperwork, and computer screens, all of which may include confidential information. Ambulatory clients, or visitors waiting for their needs to be addressed, can easily be exposed to confidential information. This action is very useful in terms of interdisciplinary collaboration and, if done correctly, in terms of involving the client. However, in terms of confidentiality, it can be a problem if there is more than one client in a room and also if discussions are held outside client rooms in hallways. Think Like A Nurse: Clinical Decision Making A shared client environment, including client care areas with curtain dividers, presents challenges to privacy and confidentiality. Staff members should speak in low voices or hold conversations away from the hearing distance of all individuals who are not members of the client's care team. Signage reminding staff to adhere to regulations related to privacy and confidentiality also may be helpful.

The nurse plans care for a client diagnosed with left-sided paralysis and slurred speech. Which direction is most important for the nurse to provide to an unlicensed assistive personnel (UAP)?

Keep the head of the bed elevated to 30 degrees. Elevating the head of the bed facilitates venous drainage from the brain and reduces intracranial pressure. It is best to also maintain the head in a midline neutral position. Think Like A Nurse: Clinical Decision Making The nurse considers the outcome of each action and utilizes the ABCs to prioritize. The client has left-sided paralysis and slurred speech, which are symptoms of a stroke. It is important to keep the head of the bed elevated for a client with a stroke to reduce intracranial pressure and prevent aspiration, and to ensure unrestricted venous outflow from the cranium and meet circulatory and airway needs. The nurse needs to recognize which direction to the unlicensed assistive personnel (UAP) is related to client safety and reduces risk for harm. Directing the UAP to keep the head of the bed elevated for this client is within the scope of practice of the UAP.

An older adult client with pneumonia has a temperature of 101.2o F (38.44o C), pulse of 112 beats/min, respirations of 22 breaths/min, and BP of 90/50 mm Hg. For which findings will the nurse notify the health care provider? (Select all that apply.)

Lactic acid level 5.0 mEq/L (0.555 mmol/L) Blood pressure of 90/50 mm Hg. A normal lactic acid level is 0.5 to 2.2 mEq/L (0.0555 to 0.2442 mmol/L). Elevated levels indicate inadequate oxygenation in the body or the presence of shock. A drop in blood pressure indicates potential shock, which could be life-threatening in the client with pneumonia. Think Like A Nurse: Clinical Decision Making Pneumonia is a bacterial or viral infection in the lungs. Symptoms include elevated temperature and a change in respirations, in addition to upper and lower respiratory congestion. An elevated lactic acid level that occurs in a client with pneumonia can indicate inadequate oxygenation. This finding also is seen in the early stages of shock. Low blood pressure occurs in shock as the body fluid is being shunted to other organs. Because pneumonia is an infection, an elevated white blood cell count, rapid heart rate, and an elevated oral temperature are expected.

The nurse positions an unconscious client. In which location will the nurse place a trochanter roll?

Lateral aspect of the hip to the midthigh The roll should be placed at the lateral aspect of the hip to the midthigh. The hip joint lies between these points. The hip tends to rotate externally when the client is positioned supine. If the hip is in correct alignment, the patella faces upward. Think Like A Nurse: Clinical Decision Making Maintenance of correct body alignment in unconscious clients is a nursing challenge. To prevent the legs from rolling outward, a trochanter roll may be used. The nurse should keep in mind to turn the client into a 30-degree side lying position and use the hand to determine if the sacrum is off the bed. In addition, the nurse should ensure that the heels are free from pressure on the bed. Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size, and weight of the individual when choosing a support surface. Synthetic sheepskin pads, cutouts, and ring or donut-type devices should not be used to elevate heels or be used to prop a body part.

The nurse provides care for a client who has undergone the repair of a gynecologic fistula. Which interventions will the nurse include in the client's immediate post-operative nursing care? (Select all that apply.)

Maintain urinary catheter. Warm sitz baths. Perineal hygiene. Increase oral fluids. The urinary catheter usually stays in place for 7 to 10 days to avoid stress on the repaired areas and to prevent infection. 2) CORRECT — Sitz baths should be taken three to four times each day to promote healing. 3) CORRECT — Perineal hygiene is of great importance to reduce the risk of infection. 4) INCORRECT - Bladder training is not done until several days after surgery, after the urinary catheter is removed. 5) CORRECT — Increasing oral fluids helps increase urine output to keep the urinary catheter irrigated. Think Like a Nurse: Clinical Decision-Making Fistulas of the gynecologic organs are a potential complication of gynecologic malignancy. They may occur as a consequence of advanced-stage disease or surgical or radiation therapy. For example, in vesicovaginal fistula, the abnormal communication between the urinary bladder and the vagina results in the continuous involuntary discharge of urine into the vagina. The nurse anticipates the need to assist the client with perineal hygiene, pain management, and body image disturbance. Depending on the extent of the fistula, surgery might be required. The nurse reinforces routine pre-operative and post-operative teaching.

The nurse provides care to a client who sustained severe crush injuries of both legs during a motor vehicle crash. The client is diagnosed with rhabdomyolysis. The nurse anticipates the health care provider will prescribe which intervention for the client?

Mannitol Administration of mannitol, an osmotic diuretic, is an appropriate intervention for the client diagnosed with rhabdomyolysis. Rhabdomyolysis is characterized by the release of massive quantities of myoglobin from damaged muscle cells, as well as the release of intracellular potassium (K +) due to cell lysis. Mannitol is administered to promote excretion of substances, including myoglobin and potassium. Think Like A Nurse: Clinical Decision Making The nurse gives the client with rhabdomyolysis mannitol to reduce edema and compartment syndrome as a result of crush injuries. To monitor effectiveness, the nurse anticipates an increased urine output (in crush injury, a urine output of 300 mL or more is recommended, and volumes of up to 12 liters/24 hours may be required). In rhabdomyolysis, intravenous hydration coupled with diuresis is thought to decrease the risk of myoglobin-associated acute tubular damage and acute kidney injury. Alkalinizing the urine with bicarbonate-containing fluids to a urine pH greater than 6.5 may reduce the aggregation of myoglobin in the kidney.

A preschool-age client is recovering from a tonsillectomy and adenoidectomy. The client is discharged home with the parents. Which instructions will the nurse give to the parents? (Select all that apply.)

Monitor the child for continuous swallowing. Administer pain medication such as acetaminophen, as needed. Monitor the child for restlessness and difficulty breathing Deep breathing and coughing could precipitate bleeding. so no, I chose that one but its not the correct answer Think Like A Nurse: Clinical Decision Making Post-tonsillectomy, the nursing interventions are focused on assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding. Discharge teaching may include reinforcing adherence with antibiotics, when to notify the health care provider (e.g., signs of difficulty breathing), and improving fluid and food intake. Water, apple juice, and grape juice, are well tolerated post-operatively. Soft foods such as ice cream, sherbet, yogurt, pudding, and applesauce are easy to swallow and excellent sources of nutrients. Other soft, easily chewed foods are also excellent. The client is advised to avoid hot or spicy foods, or foods that are hard and crunchy. The client may take pain medicine an hour before meals to reduce pain while eating.

The nurse assesses a client with a serum sodium level of 138 mEq/dL (138 mmol/L), potassium level of 3.8 mEq/dL (3.8 mmol/L) and calcium level of 7.8 mg/dL (1.95 mmol/L). For which client symptom does the nurse assess? (Select all that apply.)

Muscle cramps. Chvostek sign.

The nurse provides care for a client in the first trimester of pregnancy. The client experiences nausea. Which information does the nurse provide to the client? (Select all that apply.)

Nausea may be linked to the mother's acceptance of the pregnancy. Nausea should diminish by the 14th week of pregnancy. Eating a dry carbohydrate immediately upon arising is recommended Avoid fried, spicy, and greasy foods Ambivalence about, or rejection of, the pregnant state may cause nausea. 2) CORRECT - Nausea begins about 4 weeks after the last menstrual period, and usually improves by the end of the 14th week of pregnancy. Nausea is associated with an increase of human chorionic gonadotropin (hCG) levels in early pregnancy. 3) CORRECT - Eating a dry carbohydrate upon waking up in the morning may help decrease nausea. 4) INCORRECT - Eating more protein at night may help with nausea. 5) CORRECT - Avoiding fried, spicy, and greasy foods can help. Think Like A Nurse: Clinical Decision Making The nausea ("morning sickness") that many women experience during the first trimester of pregnancy is the result of hormonal changes. Human chorionic gonadotropin (hCG), is produced at higher levels during the first trimester than at any other time during pregnancy. The nurse explains to the client the difference between typical "morning sickness" and hyperemesis gravidarum, which is a complication of pregnancy that is characterized by severe nausea and vomiting over an extended period. Before teaching, the nurse should first assess the client's baseline knowledge. The teach-back method is used to verify the client's understanding.

The nurse provides care for an infant who tested positive for phenylketonuria (PKU). The nurse determines which action is the priority for this infant?

Offer the infant formula without phenylalanine. The infant with PKU lacks the enzyme necessary to convert phenylalanine to tyrosine. Phenylalanine is a type of protein. In infants with PKU, phenylalanine accumulates in the tissues and leads to mental deficiencies. Infants with PKU are fed a formula that is low in phenylalanine, but contains the minerals and vitamins required by the infant. Think Like A Nurse: Clinical Decision Making It is important for the nurse to know that phenylketonuria (PKU) is a genetic disorder in which the individual cannot convert phenylalanine to tyrosine. The nurse then needs to think about the specific needs of the infant, which is nutrition, and how to manage the condition. The nurse knows that because of the PKU genetic disorder, any foods containing phenylalanine should be avoided. A formula that does not contain phenylalanine is required. The nurse identifies the most important issue by using Maslow, which is that food is a basic need.

The home care nurse visits an older adult client with a recent history of a cerebrovascular accident (CVA) resulting in a neurogenic bladder. The client is incontinent and has developed repeated urinary tract infections (UTI). Which action by the nurse is most appropriate?

Perform an intermittent catheterization for residual urine. Even though a client with a neurogenic bladder is incontinent, the bladder may not be empty completely. Residual urine can cause a UTI. Think Like A Nurse: Clinical Decision Making A neurogenic bladder occurs when the nerves that control urination are damaged or injured. The result is an inability to void or urinary retention. Incontinence with a neurogenic bladder occurs when the volume of urine in the bladder is so great, excess urine is released. Since the client is experiencing repeated urinary tract infections, the most likely cause is excess urine in the bladder. The client's bladder needs to be drained and bladder distention closely monitored to reduce the risk of future infections.

The nurse provides care to a client who underwent abdominal surgery. Assessment of the client's abdominal incision reveals that three staples have dislodged and the wound edges are separating. The nurse will implement which action? (Select all that apply.)

Place a sterile saline dressing over the wound. Place the client in a semi-Fowler's position with knees bent. Following abdominal surgery, in the event of wound dehiscence, the wound should be covered with a sterile towel or a sterile dressing that has been moistened with saline. To prevent further separation of the wound closure, the client should be positioned to decrease abdominal muscle strain. Knee flexion decreases abdominal muscle strain. Deep breathing, coughing, and other activities that may increase intraabdominal pressure are to be avoided, as additional strain on the abdominal muscles may lead to dehiscence, which involves protrusion of a portion of the bowel through the open wound. Think Like A Nurse: Clinical Decision Making Dehiscence is described as the separation of the edges of an abdominal wound. Nursing actions include covering the wound with a sterile dressing moistened with sterile saline. The client should also be placed in a bent knee position to reduce tension on the abdominal muscles and incision.

The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate?

Prepare a schedule of activities and monitor the client's participation in the activities. The client displays symptoms of depression. For the client with depression, a regular daily routine of scheduled activities provides structure and decreases the amount of problem solving required. Participating in activities will increase self-esteem and assist the client to engage with others. Think Like A Nurse: Clinical Decision Making Cognitive deficits are frequently comorbidities to mental illness. The client does not display the ability to make decisions. While the client might benefit from rest periods and being offered choices, the nurse will initially schedule the client's activities to ensure the client is getting optimal treatment benefit. Clients with depression will not always willingly engage in activities and so the nurse must arrange this.

The nurse provides care for a comatose client. The nurse is unable to elicit a reaction after applying the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub. Which action does the nurse take next?

Press a pencil to a finger or toe of each limb When assessing a client 's response to pain, begin with the least noxious stimulation (speak to client) and proceed to more painful stimulation such as the trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub that are central stimulation. If there is no response to central stimulation demonstrating brain function, apply peripheral stimulus to the extremities. A client 's finger or toe should be braced on the nurse 's thumb and a pencil placed sideways on top of the nail bed at the base of cuticle and pushed down hard. Use peripheral assessment only on extremity that did not move. First, complete the assessment. Failure to respond to painful stimuli indicates the brain is not responding, it but does not indicate a client has arrested. Think Like A Nurse: Clinical Decision Making The nurse needs to be knowledgeable about the skills used for physical assessment. The nurse understands that coma is a change in level of consciousness in which the client does not interact with the environment. In this state of consciousness, the client is unable to react to painful stimuli. When assessing the degree of response to pain, the nurse should begin with this least pain-causing approach and progress to the action, which is known to cause the most amount of pain.

(CAT) scan without the use of contrast dye.

Problems being in a closed space. A CAT scan provides a three-dimensional assessment of the body part to be scanned using an enclosed machine. If a client is claustrophobic, the scan may cause severe anxiety.

The nurse reviews teaching material for use during upcoming community clinic pediatric appointments. Which instruction is most appropriate for the nurse to provide to an older school-age client and the parent?

Proper nutrition Because of the threat of obesity and a diet-conscious society, children begin to diet. The nurse should teach the importance of body-building nutrients and regular physical activity. Think Like A Nurse: Clinical Decision Making The nurse needs to analyze the available teaching materials and select the items that address the growth and development of the school-age client. A client of this age has yet to reach the period of rapid body growth that occurs in adolescence. During this time, the client's metabolism is stabilized, which can lead to an increase in body weight. It is essential that teaching about healthy nutrition occurs at this time, since life-long eating habits and patterns are established during the school-age years. The client is developmentally able to assist with meal preparation and should be supported when making healthy food choices.

The nurse assesses a client with a colostomy. Which stomal appearance indicates a prolapse has occurred?

Protruding. A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma. A stoma that is dark and bluish in color indicates ischemia. Think Like A Nurse: Clinical Decision Making When preparing to care for a client with a colostomy, the nurse should mentally ask, "What characteristics are expected when assessing the stoma?" A normal stoma is nearly flush with the abdominal skin and is pink to beefy red in color. The skin around the site should be intact. The nurse identifies evidence of a problem if a portion of the colon can be seen protruding through the stoma. This is called a prolapse and must be immediately reported to the health care provider for evaluation and intervention.

acquired immunodeficiency syndrome (AIDS) and cutaneous Kaposi sarcoma, confirms this new diagnosis

Punch biopsy of the cutaneous lesions.

The nurse provides care for a client diagnosed with hyperthyroidism. Which intervention does the nurse include in the plan of care for this client?

Quiet environment. This client is in a hypermetabolic state, so a physically and mentally restful environment is helpful. Think Like A Nurse: Clinical Decision Making The nurse in this scenario will use knowledge acquired during the study of anatomy and physiology. Before planning care for this client, the nurse should mentally review the pathophysiologic process of hyperthyroidism and the associated manifestations. Hyperthyroidism causes a hypermetabolic state. The nurse understands the body functions are increased and commonly include such manifestations as an elevated body temperature, rapid heart rate, restlessness, and weight loss. Until treatment becomes effective, actions to counterbalance the internal stimulation are initiated. In this scenario, the nurse will provide a calm quiet environment.

A client is admitted to the emergency department (ED) with respiratory compromise. Which assessment finding does the nurse document as indicative of a pneumothorax?

Rapid respirations. This describes tachypnea, a symptom of pneumothorax. Think Like A Nurse: Clinical Decision Making The nurse must be able differentiate a pneumothorax from other respiratory issues. Since the client is exhibiting symptoms of a pneumothorax, the nurse should anticipate care to support the client's altered respiratory function. The nurse should immediately notify the health care provider, assess the client's vital signs, administer supplemental oxygen, and prepare the client for an immediate, or STAT, chest x-ray. The client will likely be very anxious, so it is important for the nurse to provide emotional support and encourage relaxation techniques.

The nurse provides care for a client diagnosed with rheumatic fever. Which information is priority for the nurse to obtain when completing the client's health history?

Recent symptoms of pharyngitis. Rheumatic fever typically begins 1-6 weeks after having pharyngitis or strep throat. It is priority to determine if the client had symptoms of pharyngitis when completing the client's health history Although it is important to determine if the client is experiencing chest pain with activity, it is priority to identify if the client had symptoms of pharyngitis. Rheumatic fever develops following pharyngitis. Think Like A Nurse: Clinical Decision Making The nurse knows that rheumatic fever, which affects the heart, is a reaction to the microorganism that causes strep throat. The nurse needs to first assess if the client experienced strep throat or pharyngitis over the last few weeks, and if so, whether the client finished the full course of prescribed antibiotics.

The nurse screens clients at a health fair for vitamin B 12 deficiency. Which clients will the nurse determine as needing vitamin B 12 supplementation? (Select all that apply.)

Recently diagnosed with pernicious anemia. Follows a strict vegan diet Takes metformin (Glumetza) for type 2 diabetes mellitus. Had a gastrectomy 2 years ago Pernicious anemia is a risk factor for vitamin B 12 deficiency because the stomach does not secrete intrinsic factor with this health problem. A vegan diet is a risk factor for vitamin B 12 deficiency because this vitamin is found in animal muscle meats. Metformin is a risk factor for vitamin B 12 deficiency because it interferes with the absorption of the vitamin. 6) CORRECT- A gastrectomy is a risk factor for vitamin B 12 deficiency because there is no stomach to secrete intrinsic factor. Think Like a Nurse: Clinical Decision-Making The nurse should be aware that clients with health problems or who experience situations that affect the function of the stomach, or the stomach lining, are at risk for developing a vitamin B 12 deficiency. Client situations that may necessitate the need for supplementation of this vitamin include those with pernicious anemia, those who have had a gastrectomy, individuals who are prescribed metformin, and anyone who consumes a diet low in animal meat. The nurse should recognize that clients with these conditions are likely candidates to receive vitamin B 12.

The nurse provides care for a client receiving lithium therapy. Which instruction is important for the nurse to include in client teaching?

Regular diet with normal sodium and adequate fluid intake. The client who is taking lithium needs to maintain a regular diet with adequate fluid intake (approximately 2-3 L/day). Lithium is a salt preparation, and its retention within the body is directly related to the body's sodium and fluid balance. The client should avoid sodium depletion because lithium replaces sodium in the cells, precipitating lithium toxicity. Think Like A Nurse: Clinical Decision Making The nurse knows that lithium toxicity poses a high risk to client safety and provides teaching to minimize the risk to the client. The body recognizes lithium as a salt and may use lithium to replace sodium stores in the body. Because of this, the client taking lithium must maintain a stable daily intake of sodium. Adequate fluid intake is necessary to ensure adequate excretion of lithium when it is metabolized.

The nurse presents a teaching session to a postpartum client who just delivered her first newborn. When educating the client about breastfeeding, which action does the nurse implement?

Remain with the client and newborn during the breastfeeding. The nurse should remain with the client to assess effectiveness of the newborn's suck, swallow, and gag reflex. Observation of the breastfeeding sessions offers an excellent opportunity to evaluate effectiveness of the feeding and provide additional teaching. Think Like A Nurse: Clinical Decision Making Observation of a newborn breastfeeding from the mother offers clues to the nurse about what further instruction might be required and opportunities to praise the new mother's efforts. Techniques and tips can be offered during this time, if needed. This is also an opportunity for the nurse to observe maternal-infant bonding behaviors and to offer the significant other, if present, ways in which to participate.

A client with a previous history of transfusion-related acute lung injury (TRALI) requires another transfusion of red blood cells (RBCs). Which intervention will the nurse use to prevent a recurrence of TRALI?

Request for leukocyte-reduced red blood cells. The reaction of anti-leukocyte antibodies between donor and recipient leads to TRALI. Leukocyte-reduced RBCs reduces the risk of TRALI recurrence. upplemental oxygen will not prevent TRALI, nor is it used routinely in a RBC transfusion. Think Like a Nurse: Clinical Decision-Making Leukoreduction is a process in which the white blood cells are intentionally reduced in red blood cells (RBCs) to diminish the risk of adverse reactions. The nurse knows this is typically requested when transfusing a client with a known history of transfusion reaction. Blood transfusion safety requires the nurse to confirm the client's identification and the health care provider prescription with another licensed practitioner. The nurse is aware that clients with a previous history of transfusion reactions are at higher risk for adverse transfusion reactions. Generally, diphenhydramine, acetaminophen, and hydrocortisone are given to prevent a reaction in clients at high risk for reaction.

A client who uses a triphasic birth control pill calls the clinic with reports of dull pain in the left lower extremity. The pain started after a routine 4-mile run and has continued. Which action does the nurse take first?

Request that the client come to the clinic immediately Deep vein thrombosis (DVT) is an adverse effect of birth control pills. This client has symptoms of thrombosis and must be evaluated urgently. This action must be taken first to ensure proper diagnosis. Think Like a Nurse: Clinical Decision-Making Triphasic birth control pills have constant or changing estrogen concentrations and varying progestin concentrations throughout the cycle. The nurse should inform the client about the dangerous side effects of birth control pills using the mnemonic ACHES; A - abdominal pain (severe); C - chest pain; H - headaches (severe); E - eye disorders; and S - severe leg pain or lower leg swelling. Signs and symptoms of deep vein thrombosis (DVT) require prompt evaluation and treatment.

The nurse assesses an older adult client for infection. Which nursing assessment is most important based on this data?

Respiratory rate achypnea, along with confusion and tachycardia, are the most reliable signs of infection in older adult clients. 3) INCORRECT - Older adult clients are less likely to have an leukocytosis in response to an infection. More than 20% of older adult clients with infection present without leukocytosis. Think Like A Nurse: Clinical Decision Making When providing care for an older adult client, the nurse must remember that clinical manifestations of infection may not present in the usual manner. The older adult client often exhibits a change in the level of consciousness or tachypnea when developing an infection. Therefore, the nurse closely monitors the client's respiratory status as an indicator of probable infection. Nurses need the knowledge to distinguish the impact client age has on clinical manifestations of the disease process.

The nurse provides care for a child with suspected sickle cell disease. Which laboratory result does the nurse expect to be increased in sickle cell disease?

Reticulocyte count. These counts are elevated in children with sickle cell disease because the lifespan of their sickled red blood cells is shortened. Think Like A Nurse: Clinical Decision Making The nurse should mentally review the pathophysiology of sickle cell disease . This disease causes red blood cells to assume a sickle shape, which alters oxygen-carrying capacity and enhances the ability of the cells to become trapped in capillaries, causing pain. The sickling of the red blood cells enhances the lysis of circulating red blood cells. In response to red blood cell destruction, the body accelerates the process of creating new replacement cells, which are released into the bloodstream before maturity. Because of the disease process, the laboratory result most likely to validate the disease would be a high reticulocyte count.

The nurse reviews the documentation by a student nurse after a routine physical on a healthy adult. The nurse determines that the student nurse properly inspected the client's anterior chest if which entry is found in the client's chart?

Ribs with symmetric interspaces and 90-degree costal angle." Inspection of the anterior chest includes shape and configuration of the chest, facial expression, level of consciousness, color and condition of skin, and quality of respirations. Expansion is palpated over posterior chest wall. Think Like A Nurse: Clinical Decision Making The first step in physical assessment of the chest is inspection. Rib location, interspaces, and costal angle would all be observed. Diaphragmatic excursion is assessed through the use of percussion. Chest expansion is assessed through palpation. Breath sounds are assessed with auscultation.

The nurse prepares to administer an influenza vaccine to the client. Upon review of the client's history, which medications cause the nurse to question the administration of the vaccine? (Select all that apply.)

Rimantadine. Zanamivir. The nurse needs to question if the vaccine should be administered, for giving the influenza vaccine with an antiviral may decrease the efficacy of the vaccine. Think Like A Nurse: Clinical Decision Making The influenza vaccination is prepared with an inactivated form of the flu virus. Once the medication is injected, the body creates antibodies against the virus to prevent disease if exposure to the virus occurs. Since the flu is caused by a virus, the effectiveness of antiviral medication, such as rimantadine and zanamivir, may be effected. The nurse should contact the prescribing health care provider.

The nurse observes the unlicensed assistive personnel (UAP) perform mouth care on an older adult client admitted to the hospital with fever of unknown origin. Which action performed by the UAP requires an intervention by the nurse?

Rinsing the client 's mouth with a glycerin-based mouthwash. A mouthwash with glycerin causes dehydration and irritation of the oral tissues. The nurse should intervene and provide the UAP and client with a non-glycerin mouthwash. Think Like a Nurse: Clinical Decision-Making The nurse is responsible for supervising the care provided by the unlicensed assistive personnel (UAP). Prior to delegating to the UAP, the nurse must assess the UAP's knowledge, skill, training, and scope of practice. After delegating a task, the nurse needs to assess the UAP's understanding of the instructions. The nurse evaluates each action by the UAP for safety concerns. Glycerin swabs or mouthwash dehydrate oral tissues, leading to breakdown in the mucous membranes. The UAP should be directed to use agents that are non-irritating and non-drying when assisting a client with mouth care.

The client taking sitagliptin asks the nurse for breakfast suggestions from the hospital menu. Which foods will the nurse recommend? (Select all that apply.)

Scrambled egg with salsa, whole wheat toast, and fruit jelly. Whole grain cereal with sliced banana and 1% milk. Yogurt with blueberries and almonds, and hot tea with lemon. 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

The nurse provides care for a client diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which data does the nurse expect upon assessment?

Serum sodium of 115 mEq/L (115 mmol/L) Because of water retention, a dilutional hyponatremia occurs. The normal sodium is 135 -145 mEq/L (135-145 mmol/L). Treatment includes restricting fluid intake to 500 -600 mL/24 h, administering diuretics, daily weights, and an accurate intake and output. and it will cause tachycardia, so the answer that I chose is wrong because the heart rate is in the normal range Think Like A Nurse: Clinical Decision Making The nurse considers the pathophysiology and clinical manifestations of the syndrome of inappropriate antidiuretic hormone (SIADH). With this health problem, malfunctioning of antidiuretic hormone secretion causes water to be retained to the extent that the body sodium level is diluted. A high level of serum sodium usually associated with fluid retention is not expected. Laboratory testing will reveal a low sodium level despite the client experiencing evidence of fluid retention. Treatment begins with withholding fluids and providing medication to remove excess fluid from the body.

The nurse provides care for a client diagnosed with dementia. The nurse instructs the nursing assistive personnel (NAP) about bathing the client. Which strategies will the nurse identify as appropriate for the client? (Select all that apply.)

Sing or talk to the client throughout the activity. Expose only one area at a time while bathing. Organize all supplies before starting the bath. Bathe the client slowly and explain each action. This strategy, continuous communication, can help the client relax and be more cooperative. 2) CORRECT— This strategy will help keep the client warm and provides privacy.An organized and efficient bath process prevents an interruption to retrieve a missing item needed for the bath. 5) CORRECT— Moving slowly and explaining each touch can help the client relax and prevent agitation and possible injury. Think Like A Nurse: Clinical Decision Making Clients diagnosed with dementia may experience confusion, fear, anger, and paranoia. Caregiver actions can dissipate the negative reactions or intensify them. The client with dementia usually responds best to unhurried, calm, tolerant care. When frightened, rushed, or startled, such clients may become aggressive or uncooperative. Simple and clear communication is best. Adding soothing music or music from the client's generation can be comforting. Clients respond well to activity or thought redirection.

The nurse provides care to a client who is comatose. Which observation requires intervention by the nurse?

Skin over the ischial tuberosities appears blanched The absence of normal red tones in the skin indicates tissue ischemia due to reduction of blood flow. This area should not be massaged; however, the client does need to be repositioned to take the body weight off of this area. Think Like A Nurse: Clinical Decision Making Since 2016, pressure injury is used to describe what was formerly referred to as pressure ulcer. The nurse should consider bedfast and chairfast clients to be at risk for development of pressure injury. As part of routine and ongoing care, the nurse should inspect all the skin upon admission as soon as possible (but within 8 hours); inspect the skin at least daily for signs of pressure injury, especially nonblanchable erythema; and assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows, and beneath medical devices. When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature, and tissue consistency compared to adjacent skin. Moistening the skin assists in identifying changes in color.

The nurse teaches a group of pregnant clients about the risks of drinking alcohol during pregnancy. Which potential long-term effects of fetal alcohol syndrome does the nurse include in the teaching? (Select all that apply.)

Slowed physical growth. Facial abnormalities. Learning disabilities. Slowed physical growth and developmental delays are potential effects of fetal alcohol syndrome. 2) CORRECT — Facial deformities are potential effects of fetal alcohol syndrome. 3) INCORRECT - Respiratory depression is not associated with fetal alcohol syndrome. 4) CORRECT — Learning disabilities are a potential effect of fetal alcohol syndrome. Think Like A Nurse: Clinical Decision Making Fetal alcohol syndrome (FAS) or fetal alcohol spectrum disorders (FASDs) are due to alcohol abuse during pregnancy. Clinical assessment of FAS includes microcephaly, small palpebral (eyelids) fissures, abnormally small eyes, maxillary hypoplasia, epicanthal folds (fold of skin of the upper eyelid over the eye), thin upper lip, short upturned nose, altered palmar crease pattern, short birth length, low birth weight, narrow forehead, mental retardation, and cardiac defects. The nurse should perform a comprehensive assessment and be vigilant in monitoring the newborn for neonatal abstinence syndrome.

The nurse provides care for a client with a history of chronic urinary tract infections who is experiencing urolithiasis. Which type of urinary stone does the nurse suspect the client has developed?

Struvite. Struvite stones are referred to as infection stones because they form in urine that is alkaline and rich in ammonia. Uric acid stones occur in clients with gout. Calcium oxalate stones result from increased calcium intake or conditions that raise serum calcium concentration Cystine stones are rare and occur in clients with a genetic defect that results in decreased renal absorption of the amino acid cysteine. Think Like A Nurse: Clinical Decision Making When considering the type of kidney stone that this client may be developing, the nurse should ask, "What occurs in the body with a chronic urinary tract infection?" Applying knowledge of pathophysiology, the nurse recognizes that with this type of infection, the urine is most likely rich in alkaline and ammonia, which supports bacterial growth. The type of stone that forms has to survive and thrive in this alkaline, ammonia-rich environment. The stone that develops easily in this environment is a struvite stone.

The nurse provides care for a toddler-age client. Which toy or activity is most age-appropriate?

Stuffed animals. Stuffed animals are age-appropriate for toddler growth and development. Other age appropriate toys for this age group are push-pull toys, low rocking horses, and dolls. Think Like A Nurse: Clinical Decision Making The nurse will use knowledge related to growth and development to determine appropriate toys for a toddler-age client. Toddlers (18 to 24 months) begin to enjoy playing "pretend." This is the time to introduce dress-up clothing, dolls, kitchen sets, and toy cars, trucks, and school buses. The nurse should always be aware of client safety and carefully screen toys for safety concerns. Toddlers at this stage are full of energy and eager to explore everything around them. They love all kinds of physical activities, like pulling, pushing, lugging, knocking down, emptying and filling. Toddlers are curious and enjoy touching and investigating everything they see.

The nurse prepares to move a client from bed to chair using a hydraulic lift. Which action is appropriate for the nurse to take?

Suspend the client in the sling above the bed prior to moving the lift. The hydraulic lift supports weight safely and will not tip over. Suspending the client briefly above the bed prior to moving away from it provides reassurance and increases the client's feelings of security. Think Like A Nurse: Clinical Decision Making Among nursing personnel, most musculoskeletal disorders occur as a result of client handling. In particular, back and shoulder injuries can result in long-term impairment and debilitation. Proper use of assistive handling equipment, such as a hydraulic lift, reduces the risk of injury to both the nurse and the client. Education and training are key to effectively using assistive devices. If the nurse is uncertain about any aspect of how to correctly use the lift, an experienced colleague should be consulted. Most facilities require two individuals to work as a team when operating a hydraulic lift.

A client requests information on nonpharmacologic methods of birth control. In planning the client's care, which method is most effective and needs to be included when providing education?

Symptothermal method. The symptothermal method combines cervical mucus evaluation and basal body temperature evaluation. Any time a method of birth control can be used in combination with another, the rate of effectiveness increases. Therefore, this method is the most effective. Think Like A Nurse: Clinical Decision Making Barrier methods, such as the condom, sponge, cervical cap, or diaphragm, spermicide, the copper IUD, and natural family planning, are all hormone-free methods of birth control. However, it is important that the nurse reviews with the client the effectiveness rates of these birth control methods, as well as encourages the client to discuss the methods that are best for their personal situation with their health care provider. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse should always use the teach-back method.

he older adult client has a medical history that includes hypertension. A public health nurse visits this client regularly. Which finding does the nurse expect for this client?

Temperature 96.8°F (36°C), pulse 80 beats/min, respirations 20 breaths/min, blood pressure 160/90 mm Hg. The temperature is usually lower in the older adult client due to decrease in basal metabolic rate. The BP is expected with a history of hypertension, particularly since there is no indication the client is being controlled with an anti-hypertensive. Think Like A Nurse: Clinical Decision Making The nurse anticipates several changes to vital signs when providing care to an older adult client. Risk for hypertension increases with age due to atherosclerosis. Older adults are also more prone to orthostatic hypotension with position changes. Respiratory rate usually does not change with age. However, lung function decreases slightly due to ossification of intercostal cartilage. Older adults have diminished vital capacity and rely more on accessory abdominal muscles during respiration. The temperature of older adults is at the lower end of the normal range. In an older client, fever is present when a single oral temperature is over 100°F (37.8°C).

The nurse makes rounds on the medical unit to assess the care given by the nursing assistive personnel (NAP). Which observation requires an intervention by the nurse?

The NAP prepares to take an oral temperature on a client recovering from a rhinoplasty. Rhinoplasty compromises the ability of the client to breathe through the nose due to the packing in both nostrils. If the client has to keep the mouth closed for an oral temperature measurement, the client cannot breathe. Think Like A Nurse: Clinical Decision Making The nurse should evaluate and monitor the NAP's competency periodically. This will ensure the provision of high-quality and safe client care. Given that the client is unable to breathe through the nose due to the packing in both nostrils, the nurse should inform the NAP during the handoff report how the temperature can be taken (e.g., via the axilla). If the NAP is unfamiliar with caring for clients with rhinoplasty, the nurse should encourage the NAP to ask questions.

The nurse performs an assessment of a 2-year-old client. The nurse expects which findings? (Select all that apply.)

The child kicks a ball without falling. The child builds a block tower of six blocks. The child uses two-to-three-word phrases. The ability to jump with both feet is more likely seen in a 2 1/2-old, though a 2-year-old client can run fairly well. 2) CORRECT— This child should be able to kick a ball and pick up an object without falling over. 3) INCORRECT - Riding a tricycle requires gross motor skills more appropriate to a 3-year-old client. 4) CORRECT— This child should be able to build a block tower, turn doorknobs, and unscrew lids. 5) CORRECT— The 2-year-old child often has a 300-word vocabulary. Therefore, two-to-three-word phrases are anticipated. 6) INCORRECT - The 2-year-old child is only expected to state the first name. Think Like A Nurse: Clinical Decision Making Before assessing a 2-year-old client the nurse should stop and ask, "What behavior should I expect to assess in this client?" The nurse will use the concepts of growth and development. The nurse needs to understand a client of this age continues to develop and the musculoskeletal and neurologic systems will reflect this in certain behaviors. This client will be able to walk and run without assistance. Motor coordination of the hands is improving; however, the risk for injury and harm becomes greater. The client's voice and comprehension skills continue to develop and the client will be able to communicate needs and engage in conversation with a few words.

The nurse provides care for a client after electroconvulsive therapy (ECT). Which observation is of concern to the nurse?

The client reports a backache. A backache is not an expected effect of ECT. Due to convulsions that may occur during ECT, a fracture could occur in a vertebrae. Less severe, but also of concern, is muscle soreness related to effects of succinylcholine, which causes depolarization of muscles. The use of muscle relaxants before ECT usually prevents these adverse effects. Assess the severity, duration, and location of the client's pain and report the findings to the health care provider. Think Like A Nurse: Clinical Decision Making First, the nurse needs to review expected symptoms, and then consider which symptom is least expected or may indicate a bigger problem. In evaluating which symptom is of highest concern, the nurse considers which one indicates a risk of harm to the client. Backache is not expected after electroconvulsive therapy and could indicate a spinal injury. This could be caused by strain placed on the spine because of lying supine for the procedure or indicate a vertebral fracture or sprain as a consequence of seizure activity that may occur. The finding should be reported for further assessment and treatment.

The nurse provides care for a client who had a subtotal thyroidectomy 12 hours ago. Which finding does the nurse report to the health care provider?

The client reports numbness around the mouth and fingertips Hypocalcemia and tetany may occur if the parathyroid glands are removed, damaged, or if their blood supply is impaired during thyroid surgery. These occurrences can result in decreased parathyroid hormone levels. Ask the client hourly about tingling around the mouth or of the toes and fingers. Assess for muscle twitching as a sign of calcium deficiency. Calcium gluconate or calcium chloride for intravenous (IV) use must be available for administration in an emergency situation Think Like a Nurse: Clinical Decision-Making After a subtotal thyroidectomy, the nurse will perform typical interventions such as monitoring for hemorrhage and preventing infection. Because of the surgical location, laryngeal nerve damage and respiratory distress due to inflammation are also of serious concern. The nurse teaches the client to alert the nurse of anything unusual, whether it seems significant or not. Parathyroid glands are important in calcium regulation, are located near the thyroid gland, and are often injured during surgery. Initial indications of low calcium include toe tingling, lip numbness, and muscular twitches. This requires immediate intervention.

The nurse in the outpatient mental health clinic develops a plan of care for a client diagnosed with bulimia. The nurse determines that which goal is most important?

The client will identify symptoms of electrolyte imbalance. The client needs to know the life-threatening complications of illness, especially hypokalemia, so that help can be sought immediately for symptoms to prevent death. Abstaining from binging is the ultimate long term goal, and these behaviors take time to change. The client needs to be able to seek help for life-threatening metabolic imbalances to live long enough to meet this goal. Think Like A Nurse: Clinical Decision Making Health teaching is essential in preventing complications. The client is taught to self-monitor for early signs of electrolyte imbalances. Clients are often asymptomatic, particularly those with mild hypokalemia. Weakness and fatigue are the most common manifestations of hypokalemia. Severe hypokalemia may manifest as bradycardia with cardiovascular collapse. Arrhythmias and acute respiratory failure from muscle paralysis are life-threatening complications that require immediate diagnosis. Clients should be provided with printed educational materials or web-based resources.

The nurse in the pediatric clinic performs a physical assessment on an adolescent male client. Which finding by the nurse requires an immediate intervention?

The client's scrotum appears enlarged and red. The nurse palpates a thickened and swollen spermatic cord. 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.

The client with emphysema is brought to the emergency department by the family. The nurse notes that the client is short of breath and ashen. The client's respiratory rate is 36 breaths/min. Oxygen is started per nasal cannula at 2 L/min. Which observation most concerns the nurse?

The client's skin color is pink within the first 20 minutes of oxygen delivery. The COPD client who has hypercapnia, which is likely in advanced or exacerbated emphysema, is at risk for oxygen-induced hypoventilation because stimulus for breathing is low oxygen level, not high CO2 level as in other people. Signs of hypoventilation will appear in the first 30 minutes of oxygen administration. Color will improve due to the increase in PaO2 levels, going from gray or ashen to pink before becoming apneic or going into respiratory arrest. Think Like A Nurse: Clinical Decision Making For clients without chronic respiratory illness, turning from ashen to pink is a reassuring finding. In the client with chronic obstructive pulmonary disease (COPD), this quick return of color is followed by lethargy and decreased level of consciousness, followed by significant respiratory difficulties. The nurse considers oxygen as a drug that has the potential to cause adverse effects. Supplemental oxygen for this client is titrated slowly and the nurse looks for small and continued improvement of oxygenation.

A 6-month-old infant is brought to the wellness clinic by parents for a routine visit. Which observation requires follow up by the nurse for evaluation of a possible developmental delay?

The infant abducts the extremities and fans the fingers when there is a noise. The Moro reflex, which is an involuntary startle response, is strongest during first 2 months after birth. This reflex should disappear after approximately 4 months of age. Follow up is indicated, as a persistent Moro reflex may be indicative of altered neurological development. Think Like A Nurse: Clinical Decision Making Many reflexes are present at birth. The rooting and suck reflexes help the newborn adapt to extrauterine life by learning how to suckle. Other primitive reflexes, such as the tonic neck reflex, seem to have no purpose other than to indicate an intact neurological system. Newborn reflexes may persist in certain conditions such as cerebral palsy or may reappear in conditions such as stroke. Which reflexes persist or reappear can indicate which part of the neurological system is affected.

Which client does the nurse determine is at risk for injury when planning care?

The infant client who is receiving prescribed intramuscular injections in the dorsogluteal site The dorsogluteal site involves a high risk for sciatic nerve injury or piercing of a major blood vessel. This site is small and poorly developed in infants and children and is not used for intramuscular injections. This is a safety issue. Catheters can be sterile (single use) or clean (multiple use). Instruct clients to wash and rinse the catheter and their hands with soap and water before and after catheterization. This client is not at risk for injury. Think Like a Nurse: Clinical Decision-Making The nurse has a responsibility to understand correct administration of IM medication and the impact that client age has on the process. In giving IM injection to infants, the needle is inserted at 90-degree angle into the anterolateral thigh muscle (vastus lateralis muscle). There are no data to document the necessity of aspiration. However, if performed and blood appears after negative pressure, the needle should be withdrawn and a new site selected. These vaccines are administered via IM route: DTaP, DT, Td, Hib, hepatitis A, hepatitis B, influenza, and pneumococcal conjugate vaccine (PCV7).

The nurse receives a report on clients who reside on the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (Select all that apply.)

The nurse assessed a suicidal client every 15 minutes. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. The nurse allowed a suicidal client to remain in street clothes. The nurse initiated a signed PRN prescription for physical restraints. The suicidal client must have one-on-one supervision at all times. The client could attempt suicide in a 15-minute interval. CORRECT - Seclusion is never punitive. This intervention is only to be used to achieve the goal of client and others ' safety. 4) CORRECT - All clothing and personal belongings are secured to minimize the potential for self-harm. Clients are placed in hospital gowns only. 5) CORRECT - Restraints are never a PRN prescription. The nurse uses alternative measures prior to the use of restraints (such as reorientation, family involvement, frequent assistance with toileting). Think Like a Nurse: Clinical Decision-Making The Joint Commission requires all health care providers to implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. The scenario described offers several opportunities for the oncoming nurse to verify the clients ' plans of care, to reinforce adherence to protocol and procedure, and to ensure delivery of evidence-based practice. Situational crisis calls for the application of TeamSTEPPS ®, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety. This evidence-based framework aims to improve communication and collaboration among health care team members by promoting effective use of information, personnel, and resources for the purpose of achieving optimal client outcomes.

The nurse observes staff providing care to assigned clients. Which observation indicates to the nurse that care is appropriate?

The nurse wears clean, non-sterile gloves when removing an indwelling urinary catheter. Sterile gloves are required when inserting the urinary catheter. However, clean, non-sterile gloves can be worn when removing the catheter. Gloves are not required for a stage 1 pressure injury, as the skin is reddened, but still intact. Think Like a Nurse: Clinical Decision-Making Clean gloves should be worn when removing an indwelling urinary catheter due to the risk of coming into contact with the client's bodily fluids. The use of sterile gloves when unnecessary is considered a misappropriation of supplies.

The nurse prepares to administer the polio vaccine by intramuscular injection to a child. The parent says "I am afraid my child will get polio from the vaccine." Which response by the nurse is best?

The vaccine cannot cause polio because it contains killed virus particles The polio vaccine administered by the intramuscular route contains inactivated (or killed) polio virus. The organism causes an immune response, but is incapable of reproducing and causing infection. Think Like A Nurse: Clinical Decision Making Health promotion and disease prevention activities include monitoring and providing required vaccinations at the appropriate times. The use of vaccinations may cause anxiety for some parents because of a lack of knowledge of how the vaccine works and what the vaccination is intended to do. The parent who is concerned that a vaccination will cause a disease needs information about the contents of the vaccine and the expected response once the vaccine is administered. The person receiving the vaccination may also be concerned and the nurse should provide teaching prior to administering the vaccination. The nurse should maintain knowledge about the mechanism of immunity associated with various vaccines.

The nurse instructs a client about how to use crutches. Which observation indicates to the nurse that teaching is successful?

The weight of the body is transferred to the hands and the arms. The arms should be bent at a 35-degree angle. The body weight should be placed on hands and arms. Think Like A Nurse: Clinical Decision Making Using crutches can be challenging and the nurse must keep this in mind before teaching a client how to use the devices. The nurse should ask, "Does this client have the physical strength to use crutches?" and "Is this the safest method of ambulation for this client?" Crutches are usually measured by the physical therapy department to ensure proper height for the client; however, the nurse should recognize that crutches that rest in the axillae are too tall, and if the client is leaning forward, the crutches are too short. The client needs to be able to equally grasp the handles on both crutches so that the weight of the body is equally distributed. Using crutches should be comfortable and the client should be able to ambulate safely, protecting the injured lower limb, and maintaining stability with the arms and hands.

The nurse provides care for the client diagnosed with septic shock. Which observation most concerns the nurse?

There is blood at a venipuncture site and around an intravenous catheter. The bleeding is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem. Sepsis is the most frequent cause of DIC. Think Like a Nurse: Clinical Decision-Making Disseminated intravascular coagulation (DIC) is an adverse effect of septic shock. This complication causes bleeding, which would occur at the intravenous catheter insertion site. Early signs of shock include full and bounding pulses and a rapid respiratory rate. Signs that shock is progressing include cool, clammy, and pale skin.

The nurse provides care for a client scheduled for surgery the following morning. The preoperative prescriptions include NPO after midnight. No medications are prescribed to be withheld before surgery. Which medication causes the nurse to question its administration prior to surgery? (Select all that apply.)

Triamterene 50 mg given every morning for hypertension. Dabigatran 75 mg given daily for atrial fibrillation. Diuretics are withheld prior to surgery, as they increase the client's risk for hypovolemia and hypokalemia. Anticoagulants are withheld prior to surgery in order to prevent excessive bleeding intraoperatively. Except for diuretics, cardiac medications, especially those prescribed for hypertension, are not withheld prior to surgery. Think Like A Nurse: Clinical Decision Making Adjustments to medication doses and schedule are typically prescribed before surgery. Since this did not occur with this client, the nurse should question administering medications that can adversely affect the client's physiological status. Diuretics should not be given before surgery since fluid and electrolyte balance may be affected. Anticoagulants should not be given before surgery since blood coagulation will be affected.

The nurse provides care for a client reporting anorexia, belching, heartburn, and a sour taste in the mouth. The health care provider (HCP) prescribes a number of tests. Which test does the nurse recognize as being time sensitive when scheduling?

Upper gastrointestinal (GI) flouroscopy The barium radiography that is used in an upper gastrointestinal flouroscopy can interfere with other tests; therefore, this test is the most time sensitive of the tests presented. It may interfere with x-rays, ultrasound, proctoscopy, colonoscopy, and any other test using iodine. Therefore, the upper GI flouroscopy is scheduled after any of these tests. Think Like a Nurse: Clinical Decision-Making When scheduling diagnostic tests, the nurse should be aware of any planning or preparation needed so that the results are valid. The nurse needs to apply knowledge of the individual tests in order to schedule the sequence correctly. The goal is to arrange the tests so that one does not interfere with the remaining testing. When analyzing the list of diagnostic tests in this scenario, the one with the largest implication for planning is the upper gastrointestinal series. This test uses barium as a contrast medium, which interferes with direct visualization of intestinal structures and mutes sound waves. Because of this, the abdominal ultrasound and colonoscopy should be scheduled and completed before the upper gastrointestinal series.

A client with a history of hypertension experiences a subarachnoid hemorrhage, head laceration, and ulnar fracture from a motor vehicle crash. Which finding indicates to the nurse that the client's condition is deteriorating? (Select all that apply.)

Urine output 5000 mL in 24 hours. Radial and apical pulse 120 beats per minute. Diminished pupillary response. A head injury can cause diabetes insipidus. A urine output of 5000 mL is extremely high, which is characteristic of diabetes insipidus. Think Like A Nurse: Clinical Decision Making The client experiences a subarachnoid hemorrhage. This means there is bleeding in the brain, which displaces cerebral tissue and causes increased intracranial pressure (ICP). Elevated ICP can be assessed by a change in pupillary response. Elevated ICP can cause malfunction of the pituitary gland and diabetes insipidus, which results in high urine output. A rapid heart rate is a symptom of hypovolemia or low blood volume, which can occur if significant blood is accumulating in the brain.

The nurse provides care to a client receiving sulfamethoxazole-trimethoprim (SMZ-TMP). Which observation indicates that the client is experiencing a common side effect of this medication?

Urticaria A mild to moderate rash is the most common side effect of SMZ-TMP, which is a urinary tract anti-infective.- Aminoglycosides are ototoxic. SMZ-TMP is not an aminoglycoside. Think Like A Nurse: Clinical Decision Making The nurse is responsible for monitoring clients who are prescribed medications for both side effects and adverse reactions. While side effects are bothersome and may affect adherence, adverse reactions can be life-threatening. Adherence is particularly important for the client who is prescribed antibiotics such a sulfamethoxazole and trimethoprim (SMZ-TMP) as not completing the complete prescribed course can lead to drug resistance. The most common side effect for SMZ-TMP is a mild to moderate rash. The client should be educated regarding this information and provided with instruction on how to treat the rash if it occurs and when to notify the health care provider.

The nurse provides care to a client who is believed to have developed tuberculosis. The nurse implements which steps when collecting the client's sputum specimen? (Select all that apply.)

Use a suction catheter to obtain the specimen if needed Offer oral care before collecting the sputum specimen. Send the specimen to the laboratory immediately. If the client is unable to cough effectively, pharyngeal suctioning may be used to obtain a sputum specimen. Oral care should be routinely offered to the client, including prior to collection of the sputum specimen. Good oral hygiene may help prevent contamination of the specimen by microorganisms in the oral cavity. 4) CORRECT- It is critical that specimens be sent immediately to the laboratory to promote accuracy of the analysis. Advising the client to spit into the collection container may result in the collection of saliva instead of sputum. The client should be advised to first breathe deeply and then cough up sputum to provide the sample for analysis. Think Like A Nurse: Clinical Decision Making Sputum consists of material coughed up from the respiratory tract. It includes saliva, sinus secretions, and normal bacteria. For the client diagnosed with a respiratory infection, sputum also contains purulence composed of white blood cells, debris, and mucus. Clear sputum is seldom sufficient to perform a culture. Bloody-streaked sputum occurs with advanced tuberculosis disease. Dark green or yellow sputum may indicate a respiratory infection. For the client with tuberculosis, dark green or yellow sputum is an expected finding.

The nurse monitors a client for the early signs and symptoms of dumping syndrome. Which assessment findings indicate to the nurse that this complication has occurred? (Select all that apply.)

Vertigo. Tachycardia. Profuse sweating. Pallor. Vertigo is an early manifestation that occurs 5 to 30 minutes after eating. 3) CORRECT -Tachycardia is an early manifestation that occurs 5 to 30 minutes after eating. 4) CORRECT - Profuse sweating is an early manifestation that occurs within 5 to 30 minutes after eating. 5) CORRECT - Pallor is an early manifestation that occurs 5 to 30 minutes after eating. Think Like a Nurse: Clinical Decision-Making Rapid gastric emptying occurs when sugar or food moves too rapidly from the stomach into the small bowel. Refined sugar quickly absorbs water, resulting in the characteristic symptoms of dumping syndrome. Osmotic fluid shifts and hypoglycemia triggers vasomotor and gastrointestinal symptoms. Hypoglycemia results from taking in too much carbohydrate and a quick, overactive insulin response by the pancreas, resulting in that carbohydrate being used incorrectly. Minimizing consumption of simple carbohydrates is helpful when aiming to control symptoms of dumping syndrome. Some clients might find that fluids and foods should not be consumed together. The nurse will be both a teacher and resource person to the client with dumping syndrome.

dopamine

Vital signs. Dopamine is indicated for correction of hemodynamic instability as a result of shock. Monitoring vital signs provides the most appropriate information regarding the effects of the medication. Think Like A Nurse: Clinical Decision Making Dopamine affects the myocardium by increasing heart rate and cardiac contractility. At low doses (less than 2 mcg/kg/min), dopamine increases renal blood flow. At typical doses (3 to 10 mcg/kg/min), dopamine improves heart function and increases blood pressure. At high doses (greater than 10 mcg/kg/min), vasoconstriction increases blood pressure. At doses higher than 20 mcg/kg/min, peripheral circulation becomes compromised by vasoconstriction as the body attempts to maintain cardiac output. The nurse monitors the client carefully for therapeutic and adverse effects. Additionally, the nurse titrates the medication dose according to facility protocol and the health care provider prescriptions to balance an adequate blood pressure with other client needs.

The nurse prepares to obtain a blood pressure measurement from a client. Which action does the nurse take?

Wrap the cuff 2.5 cm (1 in) above the antecubital space. The nurse should make sure the bladder of the cuff is over the brachial artery in order to compress it during measurement. Therefore, the nurse should be sure to place the cuff is 2.5 cm (1 in) above the antecubital space. The nurse should position the client's arm at the level of the heart to ensure an accurate reading. If the arm is elevated above the level of the heart, gravity can cause an inaccurately low reading. If the arm is below the level of the heart the reading can be inaccurately high. Think Like a Nurse: Clinical Decision-Making The nurse should recognize and practice correct technique when measuring a client's vital signs. Prior to obtaining the blood pressure measurement, the nurse should recall considerations and actions that provide the most accurate measurement of cardiovascular functioning. The equipment required for this measurement includes a cuff, a sphygmomanometer, and stethoscope. Of the items required for this measurement, the cuff is applied first, the stethoscope is placed second, and the valve of the sphygmomanometer is closed prior to inflation. The nurse knows that selection of the right size cuff is important to avoid false readings.

The client is placed on cephalexin prophylactically after surgery. Which foods will the nurse encourage the client to eat?

Yogurt and acidophilus milk. Yogurt and acidophilus milk will help maintain normal intestinal flora, which may be altered by cephalexin. The nurse should encourage the client to eat these foods. Think Like A Nurse: Clinical Decision Making When reviewing the client's prescribed medications, the nurse would ask, "Are there medications here with side effects that should be addressed?" An antibiotic such as cephalexin can adversely effect the number and functioning of normal gastrointestinal flora. The client needs to ingest foods that restore the flora, such as yogurt and acidophilus milk. Foods high in fiber or protein will not help return the balance of normal intestinal flora

uric acid renal calculi diet

avoid High-purine.

fluorescein angiography

determines the amount of pressure within my eyes.

Signs of allergic reaction to the Hib vaccine

hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine.

elevated serum alpha-fetoprotein (AFP)

indicate a neural tubal defect

butorphanol

pain med

risk of developing gastric cancer

risk of developing gastric cancer The presence of H. pylori in the stomach increases the risk for gastric cancer. H. pylori causes peptic ulcer disease. Think Like a Nurse: Clinical Decision-Making General factors that increase an individual's cancer risk include obesity, tobacco use, chronic stress, and consumption of a high-nitrate diet. Alcohol consumption is also a factor that generally increases the risk for developing cancer, though research suggests the degree of risk depends of the amount and frequency of alcohol intake. Certain types of cancer are associated with risk factors that are disease specific. For gastric cancer, additional risk factors include a history of H. pylori infection, pernicious anemia, or Epstein-Barr virus. Genetic alterations that are usually associated with other cancer types, but also occur with gastric cancer, include BRCA1, BRCA2, and hereditary nonpolyposis colorectal cancer (HNPCC).

hemophilia

the most frequent site of bleeding is into muscles and joints. Repeated bleeding episodes cause changes in bone and muscles, which can lead to crippling knee and joint deformities. Think Like a Nurse: Clinical Decision-Making The knee is the most frequent joint that can bleed in a client with hemophilia. Chronic bleeding causes joint deformity and alters the ability to ambulate and maintain independence. Joint deformities do not commonly occur in epilepsy, cystic fibrosis, or celiac disease.

pernicious anemia

vitamin B 12 injections.

The nurse plans discharge care for the client diagnosed with recurrent cancer and lymphedema. Which client statements alert the nurse to a need for home health services? (Select all that apply.)

"Sometimes I don't get to the bathroom in time." My hands always shake when I try to pick things up." "My dentures don't fit so I don't wear them, but I eat just fine." "I can't feel a thing in my feet. It's been that way for a while." CORRECT— A home health referral could benefit this client by assessing for durable medical equipment that might assist the client in using the bathroom. If incontinence is a problem, the client may need assistance with personal care. 3) CORRECT— This client may need assistance preparing meals, and managing medication administration. Home health care can provide accurately assess and provide appropriate referrals. 4) CORRECT— Although the client says, "I eat just fine," a dietary referral will ensure the client has the home resources and ability to eat a balanced diet. The fact that the dentures don't fit may indicate the client has lost significant weight. 5) CORRECT— A home health referral will determine if this client has safety needs in the home because of numbness in the feet. Slippery or uneven surfaces could be dangerous for this client. 6) INCORRECT - A home health referral is not necessary as long as the client is able to meet hygiene needs in other ways besides tub baths, such as showering or sponge baths. Think Like A Nurse: Clinical Decision Making Referral for home health services requires assessment and documentation of the client's needs. The nurse should collaborate with the case manager or social worker in determining which services may be required. Use standardized tools (e.g., Katz Index of Independence in Activities of Daily Living) to assess and document activities of daily living limitations that may be required.

The nurse provides care for clients in the emergency department. Four clients come in at the same time. Which client does the nurse see first?

A 6-month-old with vomiting and diarrhea. This client is at significant risk for dehydration and electrolyte imbalances due to the small body mass, inability to compensate effectively, and loss from both upper and lower GI sources. This client is the priority. The average healthy young adult 's body can adequately compensate for dehydration over the short term. The client may require an injection of an anti-emetic to stop the vomiting. Think Like A Nurse: Clinical Decision Making Dehydration occurs more readily in infants and young children than it does in adults. The risk is increased in infants and young children because they have an increase in extracellular fluid percentage and a relative increase in body water compared with adults. A 6-month-old with vomiting and diarrhea should be assessed first by the nurse. Nursing goals for this client are restoring fluid volume and preventing hypovolemic shock. Provide oral rehydration to children with mild to moderate dehydration. The nurse should anticipate administering IV fluids for clients with severe dehydration.

Ménière disease

Clients with Ménière disease require a low-sodium diet to decrease fluid retention (endolymphatic fluid, which is clear, intracellular fluid located in the labyrinth of the inner ear). Many Chinese restaurants use MSG and soy sauce, both of which are high in sodium. Fast-food places and products also have a tendency to be high in sodium. The symptoms of Ménière disease are caused by fluid in the inner ear. The client should be instructed to implement actions to reduce the accumulation of excess fluid, which includes avoiding foods that have a high-sodium content. The client should be instructed to read food labels to determine the amount of sodium in the product. Commercial salt substitutes are not as effective as using spices and herbs to enhance the flavor of foods that are low in sodium. Foods that are processed or canned should be avoided because of the high-sodium content.

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?

"Has the client had any recent skin infections? " 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 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.

The nurse plans teaching for a client receiving quinapril. The nurse determines that further teaching is needed when the client makes which statements? (Select all that apply.)

"I should increase my intake of broccoli and bananas. " "I should use a salt substitute to season meals. " This client statement indicates the need for additional teaching. Quinapril is an ACE inhibitor that blocks the release of aldosterone, which promotes potassium retention. The client should avoid or limit foods high in potassium, such as broccoli and bananas. This client statement indicates the need for additional teaching. Salt substitutes contain potassium, and this client will want to limit potassium while taking the ACE inhibitor. Think Like a Nurse: Clinical Decision-Making Prior to administering any newly prescribed medication, the nurse should provide teaching about the mechanism of action, expected effects, necessary precautions, and adverse effects. The nurse should recognize the medication is an angiotensin-converting enzyme (ACE) inhibitor, and understand the mechanism of action alters the removal of excess potassium from the body. The nurse needs to explain the need to avoid foods, supplements, or seasonings that contain potassium. It is important for the nurse to realize that lifestyle factors, such as dietary intake, can potentiate the adverse effects of medications.

The nurse assists a new novice nurse to provide care for a client with a magnesium level of 0.8 mEq/L (0.4 mmol/L). The nurse intervenes if the novice nurse makes which statements? (Select all that apply.) "

"I should look for a short QT interval on the EKG." I may have to administer calcium gluconate." "Taking magaldrate has contributed to the client's problem." This statement requires intervention. The client is experiencing hypomagnesemia, which causes a prolonged, not a short, QT interval. The normal magnesium level is 1.5 to 2.5 mEq/L (0.75 to 1.25 mmol/L). This statement requires intervention. Calcium administration would be considered if the client had hypermagnesemia, not hypomagnesemia. Therefore, calcium would not be used. Therapeutically, calcium binds to excess magnesium. This statement requires intervention. Magaldrate, an antacid, can cause hypermagnesemia, not hypomagnesemia. A positive Chvostek sign occurs due to the accompanying hypocalcemia that occurs with hypomagnesemia. Think Like a Nurse: Clinical Decision-Making Hypomagnesemia is uncommon among healthy individuals. Most often, hypomagnesemia occurs in relation to health alterations (e.g. alcoholism, Crohn disease, or poorly-controlled diabetes mellitus). Medications may also contribute to the development of hypomagnesemia (e.g. digoxin and certain antibiotics, such as aminoglycosides). Symptoms of hypomagnesemia are related to the lack of magnesium necessary to support muscle, nerve, and enzyme functions. Magnesium has transport functions for potassium and sodium, which are necessary for cardiac muscle and nerve function.

he nurse discusses breastfeeding with a new mother. Which client statements require the nurse to intervene? (Select all that apply.)

"I wash my nipples with soap between feedings." "I use breast pads with plastic lining." This statement requires intervention. Soap causes drying and removes protective oils. Apply breast milk to nipples after feedings because breast milk has healing properties. This statement requires intervention. Breast pads with plastic lining retain moisture and can increase the risk for yeast infection. Think Like A Nurse: Clinical Decision Making The nurse is aware that, for first-time mothers, breastfeeding can be challenging because the mother may not have established adequate techniques before leaving the hospital. The nurse needs to be competent in lactation education, or to refer the client to a breastfeeding specialist. Breastfeeding can be initiated within the first hour of life, if the newborn is stable. Instructions to mothers include hand hygiene before breastfeeding, but it is typically not necessary to wash the nipples before feeding, and clear water is used to avoid the drying effects of soap. The nurse can show various positions for breastfeeding that are comfortable for the mother. The mother must become proficient with latching and unlatching to increase fluid intake to improve milk production. The nurse should use the teach-back method in all educational encounters with clients.

The nurse completes dietary teaching with a client who has chronic kidney failure. The nurse determines more teaching is needed when the client makes which statement? (Select all that apply.)

"I will eat more oranges and other foods with vitamin C." "I should increase dairy products in my diet." "I should add protein powder to my fruit smoothies." Citrus fruits are high in potassium and should be avoided, as kidneys cannot excrete excess potassium. Other foods that are high in potassium include dried fruits, avocado, tomato, potatoes, and bananas. This statement indicates that additional teaching is needed. Dried fruits, including raisins and prunes, are high in potassium, so don't take as well Think Like A Nurse: Clinical Decision Making In renal failure, the client is at high risk for hyperkalemia, hypernatremia, and hyperphosphatemia. Potassium, which is present in high levels in citrus fruits and dried fruits, needs to be restricted. Phosphorus is restricted because of the delicate balance of this electrolyte with calcium. Protein is restricted because of the inability to eliminate uric acid, a byproduct of protein metabolism, through the kidneys. Sodium, which is in processed foods, is restricted to prevent fluid overload and edema.

The nurse prepares to discharge a newborn home with the parents. Which statement by one of the parents indicates to the nurse a need for further teaching about newborn care?

"I will notify my health care provider about absence of breathing for 10 seconds. It is normal for a neonate to have periods of apnea. Apnea lasting longer than 20 seconds should be reported to the health care provider. Think Like a Nurse: Clinical Decision-Making Infant apnea is diagnosed for any unexplained episode of the cessation of breathing that lasts 20 seconds or longer or when a shorter respiratory pause is associated with other symptoms (e.g. bradycardia, cyanosis, pallor, and the occurrence of marked hypotonia). While apnea is fairly common in preterm infants, it is rare among full-term healthy infants. When apnea occurs for full-term infants, it is usually an indication of an underlying pathology. The nurse should offer reassurance to parents by explaining the difference between true apnea and periodic breathing (pauses in respiration that last less than 10 seconds). Periodic breathing is not dangerous and no intervention is required.

The nurse provides care to a client placed in halo vest traction who sustained an injury two days ago. Which statement by this client is of the most concern to the nurse?

"It hurts when I chew. " If pain with jaw movement occurs 24 to 48 hours after halo traction is applied, it may indicate that the skull pins have slipped onto the thin temporal plate. Notify the health care provider immediately. The health care provider tightens the skull screws 24 to 48 hours after a halo is applied, and this can cause discomfort. Offer an analgesic as prescribed. hink Like A Nurse: Clinical Decision Making The nurse is responsible for knowing about the client's treatment. It is most important for the nurse to recognize expected and unexpected manifestations by using the principles of assessment. A halo traction vest is used to stabilize the cervical spine column after an injury occurs to the vertebra in this region. The pins of the traction are inserted into various areas, one of which is the skull. If the client is complaining of jaw pain with chewing, it is likely that one of the pins has moved into the thin temporal plate area. The health care provider should be notified immediately since the pin needs to be removed or repositioned to ensure the integrity of the halo traction and reduce the risk of any additional damage or injury to the client.

The nurse provides care to an adult client with newly-diagnosed rheumatoid arthritis (RA). Which information does the nurse include in the client's discharge instructions?"

"Move your joints as much as you can each day. " With RA, pain often decreases with joint use. By contrast, with osteoarthritis (OA), joint use typically causes joint pain to worsen in intensity. To reduce the risk of joint injury, the client diagnosed with RA should aim to slide objects to the desired location rather than lifting them. Think Like a Nurse: Clinical Decision-Making Goals of rheumatoid arthritis (RA) treatment include reducing or eliminating pain, decreasing inflammation around the joints, stopping joint damage, and maintaining a desired quality of life. Surgery, medications, and complimentary therapies such as diets, vitamins, or acupuncture may be used, but the client should be aware of the limits of each therapy's effectiveness. For example, acupuncture does not affect the joint condition, but may reduce pain, and, therefore, be of use. The nurse encourages exercise promoting flexibility, range of motion, and general strengthening to best help this client.

The nurse provides discharge planning for a group of clients. For which client does the nurse request a health care provider's referral for home health care services?

A client diagnosed with heart failure who underwent diuresis 4 days earlier. The client is at risk for complications related to heart failure and altered fluid balance. As such, requesting a referral for home health services is warranted to ensure the client's safety. Skilled nursing care will include assessing the client for decreased circulating volume, hypotension, tachycardia, and signs or symptoms of hypokalemia. Clients who undergo cardiac catheterization typically do not require an overnight hospital stay unless complications develop. The client is not likely to require home health care services. Discharge instructions should include instructing the client not to bend, strain, or lift heavy objects for 24 hours. The client should observe the puncture site for bleeding, swelling, or new bruising, and seek medical treatment if complications develop or any worsening in the client's condition is noted. Think Like a Nurse: Clinical Decision-Making Readmission of clients with heart failure is common and costly. Government incentives to reduce readmissions are provided, and hospitals with high readmissions rates can lose nearly 3% of their Medicare reimbursement. Discharge planning of heart failure clients should include provision for home health care services. Other interventions shown to lower readmissions include partnering with community physicians, having nurses responsible for medication reconciliation, arranging for follow-up visits before discharge, having a process in place to send all discharge or electronic summaries directly to the client 's primary care provider, and assigning staff to follow up on test results after the client is discharged.

A client with a history of alcoholism and cirrhosis of the liver is admitted to the medical unit for ascites management. Which prescribed substance will the nurse administer first?

Albumin. Albumin is a hyperosmotic protein solution. It is given to pull fluid back into the blood vessels. Once the fluid has been moved into the bloodstream, diuretics can then promote excess fluid excretion. Think Like A Nurse: Clinical Decision Making The nurse needs to understand the manifestations of the client's diagnosis of cirrhosis. The nurse also needs to know the actions of prescribed medications, how it will affect the client's symptoms, and what the expected outcome will be. Albumin is a form of protein used to pull fluid back into the general circulation and decrease the symptom of ascites. This is the prescription that the nurse should implement first. After the infusion, the diuretic can be given to help remove excess fluid from the blood stream.

The nurse provides care for clients in a long-term care facility. A client is diagnosed with Legionnaire disease. Which action by the nurse is appropriate?

Ask for maintenance on the institution's hot water tank. Legionnaire disease is caused by Legionella pneumophila, which is found in warm, stagnant water such as hot water tanks and is spread by the aerosolized route from the environmental source to the client. Maintenance on the hot water heater is required to eliminate the source. There is no direct evidence that Legionnaire disease can be spread between humans. No precautions other than standard precautions are recommended. Think Like A Nurse: Clinical Decision Making The nurse assesses the environment of clients and evaluates for any safety risks present. Legionnaire disease is caused by a microorganism that proliferate in warm standing water. Since this disease was diagnosed in a client who resides in a long-term care facility, all of the hot water tanks need to be cleaned and flushed to clear the microorganism out of the facility's water system. This prevents other clients from becoming infected. Clients should be monitored for symptoms of Legionnaire disease, such as fever, body aches, and cough. Clients who are 50 years of age and older, clients who smoke, clients with chronic lung disease, clients with immunodeficiency, and clients with underlying diseases (i.e. diabetes, renal disease, hepatic disease) are at highest risk for infection with Legionnaire disease.

The nurse provides care for a client with a fractured right femur in skeletal traction. Before administering care to the pin sites, it is most important for the nurse to take which action?

Assess the appearance of the pin sites. Carefully examine each pin site for drainage or redness. The nurse ensures the pins are in the correct placement before beginning pin care. While it is important for the nurse to assess the client's pain level and medicate, if necessary, prior to pin care, assessing the pin sites for infection is the priority. If the pins have moved or have become infected, the nurse will not perform pin care at this time. Think Like a Nurse: Clinical Decision-Making The condition of the pins and the surrounding tissue should be assessed for type and amount of drainage and skin color before beginning pin care. The condition of the pins should be assessed before gathering the supplies, since different supplies may be needed if the sites appear infected or inflamed. Assessing for pain is appropriate, but addresses a psychosocial need. Assessment of the site condition addresses a physical need and should be done first.

The nurse answers the call light of a client reporting a severe headache 30 minutes after undergoing a lumbar puncture. Which action does the nurse take first?

Assess the puncture site. Headaches are a common side effect of a lumbar puncture procedure. However, assessing for leakage of cerebrospinal fluid or the presence of a hematoma is required to determine if further intervention is indicated. Think Like A Nurse: Clinical Decision Making Spinal headache is a common but extremely painful side effect of a lumbar puncture. Pain medication and blood pressure measurement may be appropriate following assessment for obvious cerebrospinal fluid (CSF) drainage or hematoma formation. Reinforcing instructions to remain flat in bed may be appropriate but is not the priority. Treatment of persistent headache following lumbar puncture may include administration of an epidural blood patch by the health care provider, during which a sterile sample of the client's blood is injected at the level of the lumbar puncture in an effort to occlude the dural puncture site and stop the leakage of CSF.

he nurse assesses a client who had a thyroidectomy. The nurse notes that the client has a weak voice and hoarseness. Which nursing action does the nurse take?

Assure the client that this is a temporary condition. These symptoms can result from trauma during the surgery and usually resolve in time. 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.

The nurse provides care for an African-American client diagnosed with hypertension in a cardiac unit. Which medication prescription does the nurse question for this client?

Atenolol Atenolol is a beta-adrenergic inhibitor (beta blocker) that slows heart rate and decreases cardiac contractility and cardiac output, thereby lowering blood pressure. Beta blockers are less effective in African Americans than they are in Caucasians and should be questioned in an African-American client with hypertension Think Like A Nurse: Clinical Decision Making Some medications are more or less effective than others in clients. In the African-American client, beta blockers are less effective and the prescription should be questioned before providing the medication to the client. Vasodilators, thiazide diuretics, and calcium channel blockers are equally effective in African-American clients and can be safely provided without questioning.

The nurse provides care to a client receiving an epinephrine infusion following a cardiac arrest. Which assessment findings demonstrate that treatment is effective? (Select all that apply.)

Blood pressure 130/67 mm Hg . Apical heart rate 99 beats/min Capillary refill less than 2 seconds. Epinephrine is a vasopressor and is used off-label to help maintain an adequate blood pressure. A BP within normal limits indicates the treatment is effective. 2) CORRECT - Epinephrine is a vasopressor and is used off-label to help maintain an adequate heart rate and rhythm. An apical pulse within normal limits indicates the treatment is effective. A capillary refill of less than 2 seconds indicates normal tissue perfusion and adequate cardiac output. Think Like A Nurse: Clinical Decision Making Epinephrine is a vasopressor that is used to maintain cardiovascular function. Vasopressors act on the blood vessels and induce vasoconstriction to raise blood pressure. Evidence that treatment has been effective includes a blood pressure within normal limits, a heart rate within normal limits, and capillary refill of less than 2 seconds.

A client returns to the unit following a pyelolithotomy through a flank incision. Which assessment finding does the nurse expect?

Breath sounds that are clear on both sides. This is an expected outcome. While the client post-pyelolithotomy is at risk for pleural effusion and lung puncture due to the site of the surgery, the expected outcome is clear breath sounds. Think Like A Nurse: Clinical Decision Making The client had surgery to remove a kidney stone. The nurse needs to be aware of certain findings, postoperatively, that are expected, and others that may indicate the development of complications. Clear breath sounds indicate adequate oxygenation and ventilation. Because of the location of the incision, the client may hesitate to take deep breaths. The nurse must encourage the client to turn, cough, and take deep breaths to decrease the likelihood of developing complications post surgery, such as pneumonia, atelectasis, or pleural effusion.

The nurse finds a client restless, cyanotic, and clutching the throat between the thumb and fingers. Which actions are appropriate for the nurse to implement? (Select all that apply.)

Call for help Deliver abdominal thrusts. Ask if the client can speak. The client exhibits signs of upper airway obstruction. Therefore, the nurse should call for help in case the client becomes unresponsive, requiring resuscitation After verifying the presence of complete airway obstruction, the nurse should stand behind the client, with arms wrapped around the waist. With one hand against the abdomen and the other grasping the opposite wrist, the nurse performs a rapid, upward thrusting motion until the foreign body dislodges or the client loses consciousness. 5) CORRECT- The nurse should ask if the client can speak or cough. If the client can do either, the client has a partial airway obstruction. The client should be encouraged to cough to dislodge the foreign body. Think Like A Nurse: Clinical Decision Making Choking occurs when a foreign object lodges in the throat or trachea, blocking the airway. In adults, a piece of food is often the culprit. Young children often swallow small objects. The universal sign for choking is hands clutched to the throat. The nurse or bystander should immediately call for help (e.g., call 911 in the community). A trained first responder may perform abdominal thrusts (i.e., Heimlich maneuver). To perform the Heimlich maneuver, the nurse stands behind the person. Place one foot slightly in front of the other for balance. Wrap arms around the waist. Tip the person forward slightly. If a child is choking, kneel down behind the child. Make a fist with one hand. Position it slightly above the person's navel. Grasp the fist with the other hand. Press hard into the abdomen with a quick, upward thrust, as if trying to lift the person up. Perform between six and ten abdominal thrusts until the blockage is dislodged.

he nurse provides care to a client receiving total parenteral nutrition (TPN). Which intervention will the nurse include in the care plan for this client?

Change the solution bag every 24 hours. For clients receiving TPN, solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity and the amount of glucose in the solution. The catheter used to administer TPN is not flushed with water prior to starting the infusion. A gastric tube is flushed with water prior to starting nutritional support Think Like A Nurse: Clinical Decision Making At times, a client is unable to orally ingest food or the gastrointestinal tract is unable to digest and absorb nutrients. In this situation, total parenteral nutrition will be used (TPN). Total parenteral nutrition is a mixture of nutrients that is provided intravenously to support the client's nutritional needs. The nurse is aware the base solution is typically high in dextrose in which vitamins and minerals have been added. Because if the high amount of glucose, there is a risk for bacteria to flourish within the solution. To minimize the client's risk of contracting an infection from the TPN solution, the solution should be changed every 24 hours. This includes the solution bag and tubing.

The nurse reviews care needed by several clients with open wounds. Which clients will the nurse delegate to the LPN/LVN? (Select all that apply.)

Client with pressure injuries on both heels receiving daily wound care with an alginate dressing Client with osteomyelitis of the jaw receiving daily sterile dressing changes. Client with a stage 3 sacral pressure injury that is due for weekly wound measurements. Client with a surgical incision on the left hip requiring daily gauze dressing changes. Think Like A Nurse: Clinical Decision Making LPN/LVNs are supervised by a nurse. Functions of the LPN/LVN are regulated by state law and outlined in each state's nurse practice act. For LPN/LVNs, appropriate tasks include administering oral and intravenous medications; collecting specimens such as blood, urine, and sputum; measuring the client's vital signs; and changing wound dressings. Typically, the LPN/LVN is assigned stable clients. Prior to delegation or assignment of tasks to the LPN/LVN, the nurse is responsible for ensuring the LPN/LVN's experience and expertise are sufficient to ensure safe, effective client care. LPN/LVNs can collect client data, but only the nurse can analyze and interpret data. Each specific organization also has policies that specify the role and function of the LPN/LVN.

The nurse provides care to several clients receiving chemotherapy. Which clients require immediate follow up by the nurse? (Select all that apply.)

Client with stomach cancer with a blood pressure of 132/80 mm Hg, pulse 96 beats per minute, respirations 20 breaths per minute, and temperature 100.4°F (38°C). Client with prostate cancer who is vomiting and has decreased urinary output. Client with breast cancer with new onset of facial swelling. The client with stomach cancer has an elevated temperature and should be assessed and the health care provider notified immediately. Neutropenia is a common adverse effect of chemotherapy and puts the client at risk for a life-threatening infection. 5) CORRECT - The client with prostate cancer is showing signs of dehydration, and vomiting will only exacerbate the problem. The nurse should assess the client and notify the health care provider immediately. 6) CORRECT - Swelling of the face and eyes and distention of neck and chest veins are signs of superior vena cava syndrome. The nurse should assess for this obstructive emergency and notify the health care provider immediately. Fatigue is expected with chemotherapy Think Like A Nurse: Clinical Decision Making The nurse has a group of clients who are each very ill and in need of prompt nursing care. The nurse determines which clients are experiencing expected side effects and symptoms, and which symptoms, if left untreated for roughly an hour, are most likely to lead to client injury. The client with low urine output is continuing to lose fluids, which will lead to hypotension and other sequelae. Neutropenic, febrile clients can progress to septic shock within minutes to a few hours. The client with facial edema is facing an airway, breathing, and circulation crisis if the nurse does not intervene.

Which is the first measure for the charge nurse to implement during a low-census client care shift?

Contact the hospital supervisor with staffing information. Excess staff may be floated to another unit that requires additional personnel. Only the supervisor will have this information. The charge nurse may not make unit staffing changes without consideration of the rest of the hospital. Think Like a Nurse: Clinical Decision-Making Every hospital has established processes on how to monitor client census and adjust staffing. The nurse in charge is expected to communicate openly with the nursing supervisor (or equivalent direct report) to report low census. An appropriate goal is to ensure that adequate skilled workforce is available to meet the clients' needs. Floating staff members to other units depends on local union and labor regulations.

The home care nurse receives a phone call from the caregiver for a client diagnosed with AIDS. The caregiver reports having the flu and is afraid of giving the client an infection. Which action does the nurse take first?

Determine if there is someone else available to provide care for the client. The priority is to prevent the client's exposure to infection. The nurse should first determine whether another healthy caregiver can provide care in place of the caregiver with the flu. This will protect the client from exposure to the flu. Think Like A Nurse: Clinical Decision Making The situation posed in the question represents a serious safety risk to the client with acquired immune deficiency syndrome (AIDS). The nurse must assess the situation and determine the best course of action. Ideally, the caregiver should not provide care to the client and should be sequestered from the client. If possible, another caregiver should be identified as a temporary substitute. If this is not possible, then the nurse should instruct the caregiver on infection control measures and also contact the health care provider to discuss the possibility of prescribing anti-influenza medication (e.g. oseltamivir phosphate) prophylactically for the client.

The nurse provides care for a client receiving a full strength tube feeding. Which complication is the nurse likely to assess in this client?

Diarrhea Intolerance of the feeding solution or the feeding rate most often result in runny stools. Vomiting can occur if the feeding is administered too quickly, but is not something the nurse expects to occur. Think Like a Nurse: Clinical Decision-Making Solutions for tube feedings are manufactured containing different amounts of nutrients and electrolytes. The nurse should be aware that full strength feedings have a high osmolality and may contain sorbitol, both of which will pull water into the intestine. The nurse is aware that increased water in the intestine may trigger diarrhea. To counteract and decrease the high osmolality of a full strength enteral feeding solution, the solution should be diluted with a predetermined amount of water. The strength of the enteral feeding solution may be increased as the client becomes more tolerant.

A client comes to the clinic and reports general sadness, exhaustion, and a loss of interest in activities. The client is interested in taking St. John's wort. Which medications, currently prescribed to the client, cause the nurse to be concerned? (Select all that apply.)

Digoxin. Nifedipine. Simvastatin. Escitalopram. Think Like A Nurse: Clinical Decision Making To assess for potential medication interactions, the nurse obtains the client's full medication history, which includes asking about supplements such as herbs, vitamins, and essential oils. The Food and Drug Administration (FDA) does not recommend use of St. John's wort for the treatment of any mental or physical condition. St. John's wort is an unregulated supplement that may interact with many medications. The client should be advised to discuss the use of supplements, herbs, and essential oils with the health care provider.

A school-age client with eye inflammation tells the school nurse that the parents refuse to take the student to a health care provider for medical attention. Which action will the nurse take first?

Discuss the condition of the child's eyes with the parents. The nurse needs to collect objective data and not just base care upon the child's report. The parents should be contacted first to learn more about the situation, including the possible cause of the condition. he nurse should not provide care until learning what is causing the client's inflammation. It could be an infection or related to a surgical procedure. Think Like A Nurse: Clinical Decision Making Caring for young clients can be challenging and the nurse always needs to validate information with the client's parent/guardian. Health problems that appear minor may actually be quite severe. In the case of a school-age client with eye inflammation, the nurse needs to apply the process of assessment in order to collect more information. Even though the client reports that the parents do not want to take the client for care, the nurse needs to validate this information prior to making a recommendation. The nurse should contact the parents, report the condition of the client's eye, provide rationale for medical attention, and suggest the parents seek care for the client.

A nurse provides care for a client who gave birth to a neonate 24 hours ago. The client and the newborn both have the AB negative blood type. Which action does the nurse implement based on this data?

Document the client and newborn's blood types. The nurse can document the findings, as no further action is required. Think Like A Nurse: Clinical Decision Making One situation that is of utmost importance during pregnancy and after delivery is the compatibility of blood types between the mother and baby. If the mother is of one blood type and the baby another, there is a risk that the mother will develop antibodies to the baby's blood type, which will place the fetus of any future pregnancies at risk. Since the mother and baby both have the same blood type and Rh factor, the mother does not need medication to prevent the development of antibodies. The blood types of both mother and baby should be documented in the medical record.

The nurse provides care to a client receiving thrombolytic therapy for a blood clot in the lower extremity. Which assessment findings indicate that treatment is effective? (Select all that apply.)

Dorsal pedal pulses +1 bilaterally. Affected foot slightly pink. Client reports feeling pinpricks on the great toe. The presence of +1 dorsal pedal pulses bilaterally indicates adequate blood flow to both legs and feet; therefore, current treatment is effective. Think Like A Nurse: Clinical Decision Making Evaluation of the therapeutic effectiveness of a medication is an essential nursing skill. When evaluating the effectiveness of a medication for a blood clot, the nurse looks for the reversal or absence of blood clot symptoms. A deep vein thrombosis (DVT) causes absent pulses distal to the clot, edema, erythema, and pain or absence of sensation. Evidence of circulation restoration is a positive sign that the prescribed thrombolytic is working.

The community health nurse obtains and evaluates laboratory test results for four clients. Which lab results most concern the nurse?

Elevated serum anti-streptolysin O (ASO) titer This result indicates glomerulonephritis. The condition results in damage to glomerulus caused by an immunological reaction that results in proliferative and inflammatory changes within the glomerular structure. The infection can be a serious threat to the client's health. Think Like A Nurse: Clinical Decision Making The nurse will use the nursing process to evaluate the significance of laboratory results. When values are outside the parameters of normal, the nurse needs to review possible causes to assist with planning client care. The serum anti-streptolysin O (ASO) titer is a blood test used to evaluate the amount of inflammation in kidney glomeruli. Renal inflammation can occur as a complication of the beta-hemolytic streptococcus bacteria. An elevated value indicates the presence of glomerulonephritis, which needs to be treated immediately with antibiotics. If left untreated the client can develop renal failure. The nurse will need to carefully follow medical prescriptions and monitor the client for a change in status or complications.

The nurse receives report on a client admitted to the unit with a new diagnosis of abdominal aortic aneurysm (AAA). When teaching the client measures to reduce the risk of complications associated with AAA, which instruction does the nurse include?

Encourage the increase of fluid intake and dietary fiber Increasing intake of fiber and fluid prevents constipation and the need for straining with bowel movements. This increased intra-abdominal pressure presents a risk of rupture. The modified Trendelenberg position is contraindicated because it increases pressure in the aortic artery, which may increase the risk of rupture. Think Like A Nurse: Clinical Decision Making The client with an abdominal aortic aneurysm (AAA) must be taught to avoid all types of straining and any activities that increase systemic blood pressure. Avoiding constipation, and the associated straining that may occur during a bowel movement, is an important part of the client's plan of care. An unrepaired AAA can obstruct sections of the intestines, resulting in constipation. Performing the Valsalva maneuver to forcefully defecate a hard or firm stool causes sudden pressure changes across the abdominal aortic wall, potentially causing a life-threatening rupture.

The nurse obtains a history on a middle-age adult client who has come in for a gynecological examination. The client shares with the nurse that having intercourse is painful. Which action does the nurse take first?

Explore the client's personal menstrual history. The client is probably experiencing dyspareunia caused by perimenopause or menopause. The nurse should assess the client's menstrual status before determining the appropriate course of action. his may occur as part of a larger discussion on sexuality. Initially, the assessment should be targeted at identifying the cause. Think Like A Nurse: Clinical Decision Making The client is describing experiencing dyspareunia. The nurse will follow the nursing process and assess the underlying cause first before developing a diagnosis and then a plan of action. Because of the client's age, the client could be experiencing symptoms of menopause, which includes vaginal dryness. The nurse needs to first assess if the client is continuing to menstruate prior to offering suggestions to reduce the pain of intercourse.

The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for the nurse to take which action?

Give the client a brief orientation to the unit. The client experiencing depression will benefit from a brief orientation to the unit upon admission. A more in depth orientation can occur at a later time. Think Like A Nurse: Clinical Decision Making Routine admission procedure to the psychiatric unit includes orientation to the unit. However, the nurse should keep information simple and not overwhelm the client. The nurse should be cognizant of possible low self-esteem of the client and changes in self-care behavior. The nurse should be alert for signs of self-destructive behavior, help client to reduce anxiety and decisiveness, and support self-esteem.

The nurse reviews laboratory reports for a client diagnosed with acute kidney injury who will begin prescribed hemodialysis treatment later today. The client is prescribed 3000 units epoetin alfa subcutaneous three times a week. Which laboratory report requires immediate notification of the health care provider?

Hemoglobin 12 g/dL (120 g/L). Healthy kidneys produce a hormone called erythropoietin (EPO). This hormones causes the bone marrow to make red blood cells, which then carry oxygen throughout the body. With acute kidney injury, the kidneys do not make enough EPO. As a result, the bone marrow makes fewer red blood cells, causing anemia. A hemoglobin of 12 g/dL (120 g/L) indicates anemia and is associated with a higher risk of thromboembolic events such as a stroke, myocardial infarction, and heart failure. An increase in serum potassium is expected with acute kidney injury and is being addressed by dialysis. Think Like a Nurse: Clinical Decision-Making Evidence gathered during epoetin alfa injection trials indicated clients should experience a gradual and minimally necessary rise in hemoglobin levels while on this medication to avoid increased clot risk. The nurse considers the difference between hemoglobin and hematocrit. Hematocrit is a measure of the volume of red blood cells (RBCs) in the total blood volume, which includes plasma, RBCs, white blood cells (WBCs), and platelets. Hematocrit is measured as a percentage. Hemoglobin is a measure of the amount of hemoglobin in the blood. An increased hemoglobin level may be due to increased production of RBCs. An elevated RBC count is associated with an increased risk of clot formation.

The nurse provides care for a client diagnosed with prerenal acute kidney injury. The nurse recognizes that which cause likely led to this diagnosis?

Hypovolemia The nurse needs to recognize that decreased cardiac output or hypovolemia is the cause of prerenal acute kidney injury. Think Like A Nurse: Clinical Decision Making For the client diagnosed with acute kidney injury (AKI) secondary to hypovolemia, the nurse understands the importance of fluid volume replacement and trending of the client's creatinine levels. The nurse knows to closely monitor the client's urine output, blood pressure, and daily weight. Teach the client that with adequate and early treatment, renal function should improve rapidly in the first 5 to 25 days.

The nurse in the community mental health center talks individually with a client with generalized anxiety disorder and who has been attending center programs for 4 months. Which statement made by the client best indicates that the anxiety is resolving?

I am sleeping 7 hours a night and my dreams are calm." Sleeping well indicates major resolution of anxiety, as the sleeping and dreaming both reflect and affect body, mind, and spirit and are not conscious processes. In anxious states, there is a disturbed sleep pattern, sleep deprivation, and fatigue. Intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep. Think Like A Nurse: Clinical Decision Making Evaluating effectiveness of treatment for generalized anxiety disorder requires the use of validated tools to evaluate presence or absence of symptoms such as excessive worrying, relentlessness, and changes in sleeping and eating habits, among others. The nurse should also advocate for screening the client for related mental health issues, such alcohol and drug use, if relevant to the client's clinical scenario. Nail-biting and skin-picking are manifestations of anxiety, the latter possibly even leading to skin excoriation. Stopping these behaviors indicates that some control is being exerted during the anxious state.

The nurse evaluates comprehension of teaching provided to a client scheduled for surgery. Which client response is the most important for the nurse to report to the health care provider?

I hope they keep the operating room cool. My grandfather died during surgery when he got very hot." The statement about keeping the operating room cool may indicate a risk for malignant hyperthermia, which is a genetic predisposition disorder transmitted as an autosomal dominate trait. It is a life-threatening complication of general anesthesia. Symptoms include tachycardia, dysrhythmias, tachypnea, hyperthermia, and hypotension. It is treated with dantrolene sodium. Think Like A Nurse: Clinical Decision Making The client's statement about a family member dying during surgery because of a fever indicates a genetic risk for malignant hyperthermia. The health care provider should be notified immediately with this information. Having feelings of claustrophobia and finalizing a will before surgery indicates a high level of anxiety. The nurse should address anxiety, but does not need to report this to the health care provider. Asking about near-death experiences during surgery could indicate the client has a fear of dying, however, this does not need to be reported to the health care provider.

The nurse assesses the client diagnosed with seizures, migraines, and type 1 diabetes mellitus (DM). Which client statement requires follow up by the nurse? (Select all that apply.)

I see fireflies around my head." "I can't seem to wake up today." "My hands won't stop shaking." This client statement requires follow up by the nurse. Flashing lights may indicate aura before the seizure or a migraine. 2) CORRECT— This client statement requires follow up by the nurse. Hypersomnia or fatigue may indicate hyperglycemia, an adverse effect of poorly managed type 1 DM. 3) CORRECT— This client statement requires follow up by the nurse. Tremors may be associated with hypoglycemia, an adverse effect associated with type 1 DM. Postictal confusion and sleepiness is common Think Like A Nurse: Clinical Decision Making The client with seizures, migraines, and diabetes mellitus has significant nursing management needs, and symptoms of complications may overlap and cause confusion. Additionally, this client may be on multiple medications that also have interaction potential. The client's glucose must be tightly controlled. The brain is very sensitive to glucose levels and changes in stimulation of the central nervous system is avoided in the client with migraines or seizures.

A client diagnosed with myasthenia gravis prepares for discharge to living at home with an adult child. The nurse reviews with the adult child necessary home modifications, as well as ambulation issues. Which statement by the adult child indicates that further teaching is necessary?

I will go forward in and out of elevators, pushing my parent's wheelchair carefully in front of me." The nurse should instruct that when the wheelchair is being pushed, it should be backed into and out of elevators to ensure safety. This action allows the larger back wheels to roll over the uneven door opening easily. Rolling the smaller front wheels first will cause the chair to tip forward. Think Like A Nurse: Clinical Decision Making Although wheelchair use is generally simple and intuitive, education is essential to preventing client injuries. The nurse educates the client and family members about basic safety strategies, including locking the brakes and folding the footplates prior to entering and exiting the wheelchair. Instructions also include avoiding placing heavy loads on the back of a wheelchair and making sure the wheel spokes are free from contact with loose objects or lap coverings. The client and family members should be advised to avoid going up or down steep inclines or slopes.

The nurse plans care for a client with Grave disease. The nurse intervenes when the client drinks which fluid?

Iced tea 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.

The nurse plans discharge instructions for a client taking atorvastatin. Which health promotion information does the nurse include when teaching this client?

Increase intake of fiber Increasing fiber in the diet can reduce cholesterol levels by up to 10%. An annual physical is part of general health maintenance. It is not specific to clients with hyperlipidemia. Think Like A Nurse: Clinical Decision Making Before providing teaching to the client, the nurse should recall the purpose and mechanism of action for the prescribed medication. Atorvastatin is an anti-cholesterol medication, which is used to reduce the amount of lipids in the blood. However, the nurse is aware that medication is only one factor in the management of hyperlipidemia. To maximize the client's therapeutic response to the medication and aid in the promotion of this client's health, the nurse should introduce other actions the client can take to reduce blood lipid levels. One such way is to increase the amount of fiber in the diet, since fiber binds with ingested fat and helps eliminate the fat from the body before it is metabolized.

The nurse in the prenatal clinic assesses a client at 38 weeks' gestation. The client reports that she is unable to get comfortable. Which statement by the nurse is appropriate?

Inform the client that low-heeled shoes might help back discomfort. Because the client is at 38 weeks' gestation, there are changes in the curvature of the sacrum. Low-heeled shoes (or orthopedic shoes) may relieve back discomfort. Tell the client to lie on her back on a hard surface with her feet elevated.This position compresses the vena cava and decreases blood supply to the fetus. Think Like A Nurse: Clinical Decision Making Musculoskeletal pain is common during pregnancy. This is due to weight gain, posture changes, hormonal changes, muscle separation, and stress. Simple activities the client can do to relieve and prevent back pain include using legs to squat rather than bend over when picking up something from the ground, wearing low-heeled shoes, and wearing support hose. When sitting, the client is advised to use foot support and a pillow behind the back. The nurse should also explore and rule out other causes of back pain such as uterine contractions, urinary tract infection, and musculoskeletal disorders.

A client seeks medical attention after having bleach splashed in the eyes. Which action will the nurse perform first?

Irrigate the client's face and eyes Bleach is an alkaline substance that can penetrate the scleral membrane and cause permanent eye damage. The alkaline should be immediately removed to limit the amount of damage to the eye. The client's other systems are not at risk. A comprehensive physical assessment does not need to be done. Think Like A Nurse: Clinical Decision Making The nurse needs to recognize that bleach is a caustic substance capable of causing serious damage the to client's eyes. The nurse should consider the urgent need for action in order to protect the client and reduce the risk for harm. The nurse needs to skip the assessment phase of the nursing process and eliminate any intervention that does not address urgency of the situation. The best first approach is to begin flushing the eyes with copious amounts of water to stop the burning process. This should continue until further medical attention is obtained for evaluation and treatment. The scenario requires that the nurse remember, "When in distress, do not assess."

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

Let me explain about the two main kinds of hearing loss. 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). 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.

The nurse reviews the prescription for hormone therapy for a client with prostate cancer. Which goal of treatment will the nurse identify as important when planning care for this client?

Limit the amount of circulating androgens. Limiting the amount of circulating androgens is the desired outcome because prostate cells depend on androgen for cellular maintenance. Think Like a Nurse: Clinical Decision-Making When providing care for a client with prostate cancer, priority nursing interventions include encouraging communication. The client will have concerns about altered physical functions, including sexual and urinary. The nurse teaches bladder control strategies such as reducing caffeine intake and performing perineal exercises. The client will need teaching regarding prescribed anticancer therapies and their side effects. Anti-androgen medications stop testosterone and dihydrotestosterone (DHT) from stimulating prostate cancer cell growth. Side effects are directly related to the lack of normal levels of male hormones in the body.

The nurse observes a nursing assistive personnel (NAP) transfer a client with right-sided paralysis using a hydraulic lift. For which action will the nurse intervene?

Lowers the bed before the transfer is initiated The bed should be raised so the NAP uses proper body mechanics during the transfer. A lowered bed increases the NAP's risk for injury. Think Like A Nurse: Clinical Decision Making The risk for back and other injuries is associated with manual lifting tasks. Coordinated musculoskeletal movement is necessary when positioning or transferring clients. Before transferring or lifting, the nurse should assess the weight to be transferred or lifted, determine the assistance needed, and gather available resources needed for the activity. Use the assistance of a lift team, if one is available in the facility. Other important key points in maintaining proper body mechanics include maintaining good posture; use of appropriate force; push, instead of pull; and rotating tasks.

A client returns for a re-evaluation of primary lymphedema affecting the left leg and ankle. Which statement by the client most concerns the nurse?

My leg hurts, and it is red and warm to the touch." Redness, warmth, and pain of the affected leg can indicate infection, a condition for which patients with lymphedema are at high risk. Infection poses an immediate risk of physical harm to the client and is the highest priority concern. Think Like a Nurse: Clinical Decision-Making The nurse considers what is expected for lymphedema. Lymphedema is the accumulation of lymph in the soft tissue of the affected region. The swelling causes stretching of the skin, along with compression of muscle, blood vessels, and nerves. The nurse collaborates with other members of the interdisciplinary team to manage the expected findings. Redness and warmth are unexpected findings with lymphedema, though. With reduced blood circulation, reduced lymphatic flow, and compression of muscles, the nurse suspects that the client either has cellulitis or a deep vein thrombosis (DVT). The client's symptoms warrant immediate evaluation by the health care provider.

The nurse in the outpatient clinic receives a phone call from a client with type 1 diabetes mellitus. The client reports a blood glucose level of 200 mg/dL (11.1 mmol/L) at 0700. Which instruction to the client is most appropriate?

Obtain a blood sugar at 0300 and report the results to the clinic. Assess the blood glucose level to determine if the hyperglycemia is caused by the Somogyi effect, which is characterized by a normal or elevated blood glucose at bedtime, hypoglycemia between 0200 and 0300, and a rebound hyperglycemia in the morning. Think Like A Nurse: Clinical Decision Making The Somogyi effect is typically seen with the use of NPH insulin. If the client is suspected of experiencing the Somogyi effect, the client will be asked to perform a fingerstick glucose test between 0200 and 0300. No changes to the insulin coverage should be made until it is determined necessary to avoid profound hypoglycemia in the early morning hours. The nurse should instruct the client to keep a record of all blood sugar level findings. The client should also have a hemoglobin A1C checked three to four times a year for clients with type 1 diabetes mellitus.

The nurse provides care to an infant client who is diagnosed with heart failure. Which assessment by the nurse best detects fluid retention in the client?

Obtaining daily weights. The earliest sign of fluid retention is weight gain. Counting the number of wet diapers is done to assess hydration. Think Like A Nurse: Clinical Decision Making Infants with heart failure often exhibit subtle signs such as difficulty feeding and tiring easily. The nurse should pay close attention to parents' statements such as, "The baby drinks a small amount of milk and stops, but then wants to eat again very soon after," "The baby seems to perspire a lot during feedings," or "The baby seems to be more comfortable sitting up than lying down." Although the earliest sign of fluid retention is weight gain, the nurse should keep in mind that, in general, weight gain is a late sign of heart failure

A child diagnosed with status asthmaticus, receiving oxygen 50% per an air-entrainment mask, has a pulse of 120 beats/min, respirations 26 breaths/min, and a temperature of 98.6°F (37.0°C). Which observation causes the nurse the most concern?

Oxygen saturation is 85% The oxygen saturation of 85% translates to a PO 2 < 60 mm Hg on the oxygen-hemoglobin dissociation curve. This is a clinical indicator of hypoxemia. Therefore, this is most concerning observation. Think Like a Nurse: Clinical Decision-Making The nurse will apply the integrated concepts related to the ABCs when managing the client in this scenario. Before analyzing assessment data, the nurse recalls the pathophysiological process of asthma, and specifically of status asthmaticus. In a situation involving asthma, the usual treatment approaches are not always effective to relieve the client's symptoms. This client is receiving 50% oxygen through an effective delivery method, and the nurse should expect the client's oxygenation level to be greater than 85%. Therefore, the nurse immediately reports the data to the health care provider for additional evaluation and intervention.

An LPN/LVN reports to the nurse that a client admitted with persistent chest pain is experiencing moderate, spastic lower abdominal pain, nausea, and some vomiting. Which action does the nurse take first

Perform a comprehensive abdominal assessment. Abdominal pain is not usually associated with myocardial infarction. The nurse should assess for GI issues. The nurse should assess the abdomen prior to notifying the health care provider. Nausea and vomiting are side effects of many medications, but the nurse should first assess the client's abdomen to detect any abnormal findings. Think Like A Nurse: Clinical Decision Making The gastrointestinal symptoms are not consistent with the reason for the client's reason for seeking medical attention. It is not a nursing function to determine if newly developing symptoms are related to an existing condition. The nurse is not a diagnostician, and a complete abdominal assessment needs to be completed prior to notifying the health care provider with the symptom and associated findings. The client's new symptoms are considered a change in status.

The nurse provides care for a client diagnosed with acute gallbladder inflammation. Which menu selection by the client requires intervention by the nurse? (Select all that apply.)

Pizza with a side salad and ranch dressing. French onion dip and pita chips. Cheese omelet and fried potatoes. Pizza and most salad dressings are high in fat and should be avoided by the client with an inflamed gallbladder. French onion dip is high in fat and should be avoided 6) CORRECT- Cheese and fried foods are high in fat and should be avoided. hink Like A Nurse: Clinical Decision Making The gallbladder makes and stores bile, which aids in the digestion of fat. When the gallbladder is inflamed, fat metabolism will be compromised. Dietary changes for the client with an inflamed gall bladder include ingesting low-fat foods such as skim milk, protein powder, baked potato, bread, and tapioca gelatin.

The nurse instructs a client about the care of a new colostomy. Which information does the nurse include? (Select all that apply.)

Place tissue on stoma when changing the appliance. Cut the skin barrier 1/8 inch larger than the stoma. Empty the pouch of stool before removing the appliance. Check stoma for color, size, and shape. The client should place tissue on the stoma when changing the appliance, for this will absorb stool and prevent stool from contacting the skin. 4) CORRECT— The client needs to cut the skin barrier no more than 1/8 inch larger than the stoma. This will allow the stoma to expand and prevent stool from contacting peristomal skin. 5) CORRECT— The client needs to empty the pouch of stool before removing the appliance. This will prevent contact of stool to the client's skin. 6) CORRECT— The client needs to check the stoma for color, size, and shape. This will ensure adequate blood flow to the stoma. Think Like A Nurse: Clinical Decision Making The nurse is aware a new colostomy can be overwhelming to a client and teaching needs to be provided in short increments. Each episode of teaching should be focused, provide an opportunity for the client to ask questions, and include the opportunity for the client to provide a return demonstration on the needed care. The client will need to know how to protect the skin around the stoma and the collection device, how to assess the stoma appearance every time the appliance is changed, and how the ostomy appliance should be managed. The nurse would also assess the client for psychosocial concerns such as appearance, odor, sexuality, and the disease process leading to the colostomy.

The nurse instructs the parent of a toddler about appropriate foods for a 2-year-old. Which suggestion is most important for the nurse to make?

Provide the child with finger foods. The toddler is working to develop autonomy in this stage. Finger foods offer the child the necessary independence for this stage. The toddler needs carbohydrates for energy. The nurse should recommend a balanced diet. Think Like A Nurse: Clinical Decision Making The nurse needs to be knowledgeable about the growth and development of a client who is 2 years of age. It is perfectly normal for this client to test and exert independence when ever possible. The nurse should encourage the parent to support this behavior during mealtimes by providing the client with foods that can be independently eaten. Finger foods are the best choice for the parent to provide.

A client diagnosed with an intact immune system is treated for herpes zoster. Which observations indicate to the nurse that this client's care is appropriate? (Select all that apply.)

Prescribed acyclovir by mouth. Assigned nurse has a positive history for chicken pox. Performs slow, rhythmic breathing. Acyclovir is an antiviral medication that is prescribed to decrease pain and slow the progression of the disease. The nurse with a positive history for chicken pox means the worker has immunity to the varicella virus. Susceptible health care workers should not enter the room if a caregiver who is immune is available. Slow rhythmic breathing encourages relaxation to help the client cope with the discomfort. Airborne precautions are not necessary. Standard precautions are recommended for localized herpes zoster and nonimmunocompromised clients. Think Like A Nurse: Clinical Decision Making Caring for a client with herpes zoster may be challenging because of the symptoms and length of time it takes to resolve. The illness occurs when something within the body activates the virus that has been laying dormant since the client experienced chicken pox decades earlier. Because it is the same virus that causes chicken pox, only care providers who have experienced chicken pox should care for the client. When herpes zoster occurs, the client will develop a characteristic rash that can be traced along a nerve root or band. The rash is extremely painful despite being treated with antiviral medication. Both pharmacologic and nonpharmacologic pain management interventions are used to promote comfort in the client with this health problem.

The nurse provides care for a client who sustained a fractured right femur. The client has a cast applied. Which type of exercise does the nurse assist the client to perform?

Quadriceps setting of the right leg. Isometric exercise contracts the muscle without movement of the affected joint. This exercise will help maintain strength of the leg. Think Like A Nurse: Clinical Decision Making The nurse is aware that isometric exercises while wearing a cast are important in preventing complications such as poor circulation and swelling. The exercises should be performed at least three times a day. The simplest exercise is to have the client wiggle the toes. Isometric, non-weight-bearing exercises, where the muscles are made taut and then relaxed in a repetitive manner, help in maintaining the strength of the leg muscles and in preventing weakness and atrophy. The nurse might consider offering the client pain medication prior to performing the exercises, or recommending the client perform the exercises after receiving medication for injury-related pain.

An adolescent client sustains a spinal cord injury at the level of L1 in a motor vehicle accident (MVA). The adolescent returns to school after rehabilitation and tells the school nurse, "I am determined to lead a normal life. " To assist the adolescent to achieve this goal, which action by the school nurse is most appropriate?

Reinforce teaching about the Cred é maneuver Applying manual pressure to the bladder aids in emptying the bladder completely and helps reduce risk for infection. Performing the Cred é maneuver at the same times every day can result in bladder control. The nurse can make sure protective undergarments are available if needed. It is the client 's goal is to lead a normal life, and continence would contribute to this goal achievement. Federal requirements provide for a public toilet that provides privacy to manage personal hygiene. Think Like A Nurse: Clinical Decision Making The nurse should understand that the client's spinal cord injury is at L1, which affects bladder function. One action to help meet the client's goal of leading a normal life is to help the client regain as much control as possible over bladder function. This can be accomplished by teaching the client the Crede method, or manually applying pressure over the bladder to expel urine. If performed at regular intervals, the client can regain control of urinary function and reduce the risk of urinary tract infections.

The nurse provides care to a client who reports pain at an IV site. The nurse notes tenderness and redness at the insertion site and redness proximally along the vein. Which intervention does the nurse implement?

Remove the IV and apply a warm, moist compress. Signs and symptoms of phlebitis include pain and tenderness at the IV insertion site and redness along the affected vein. Management of phlebitis includes removal of the IV catheter and application of a warm, moist compress to the affected area. Think Like A Nurse: Clinical Decision Making Prior to implementing any action for this client, the nurse mentally asks, "What do the symptoms indicate about the intravenous site?" Redness at the site and along the vein, accompanied by discomfort, indicates the development of phlebitis. The nurse has an obligation to reduce risk and prevent injury. The IV fluid, or medication, infusion causing the vein irritation needs to be stopped. Next, the IV catheter is immediately removed and warm compresses applied to the site. Another IV catheter can be placed in an alternative site once the affected site is treated.

The nurse provides care for clients at the student health clinic. Which data cause the nurse to suspect the student is using cocaine?

Reports of insomnia, rhinorrhea, and facial pain These signs and symptoms are associated with cocaine use by inhalation. The nose is the most common route for administration of cocaine, which causes rhinorrhea and facial pain. Think Like A Nurse: Clinical Decision Making The nurse understands there may be various conditions that can be caused by a multitude of symptoms. The nurse needs to consider the population that is receiving care, and focus on known risk factors. The nurse knows that cocaine is a psycho-stimulant and causes vasoconstriction. Adverse effects of inhaled cocaine include facial pain, rhinorrhea, and insomnia. Other substances can cause a variety of symptoms to include nausea, vomiting, abdominal pain, fatigue, dilated pupils, and anorexia.

The client is diagnosed with heart failure. The nurse receives a new prescription to administer IV chlorothiazide. The nurse questions this prescription based on which laboratory value? (Select all that apply.)

Serum sodium = 128 mEq/L (128.0 mmol/L). Serum calcium = 12 mg/dL (3 mmol/L). Serum pH = 7.48: Thiazide and loop diuretics produce metabolic alkalosis because of urinary loss of hydrogen. Therefore, the nurse questions this prescription. Think Like A Nurse: Clinical Decision Making Chlorothiazide is a thiazide diuretic that increases the excretion of sodium, decreases the excretion of calcium, increases the secretion of potassium, and promotes urinary loss of hydrogen. Because of this, the laboratory values that support questioning this medication include serum sodium, serum calcium, and serum pH. The medication can be safely given for the elevated potassium level.

An infant is prescribed amoxicillin trihydrate 20 mg oral suspension every 8 hours by mouth. Which instruction will the nurse provide to the client 's parent?

Shake the medication before giving it. The medication particles are not totally dissolved in a suspension. The medication needs to be shaken before preparing a dose. Maximum absorption of amoxicillin trihydrate occurs on an empty stomach. Think Like A Nurse: Clinical Decision Making For a client with a newly prescribed medication, focus instructions on the medication 's administration procedures, therapeutic effects, and adverse effects. Include instructions to shake amoxicillin to ensure delivery of the prescribed dose needed to treat the client 's condition. For the infant client, it is essential to instruct the parents to never mix a medication with formula or food unless specifically instructed to do so. This can alter the medication 's action, the client might not consume the entire dose, or the client may begin refusing the food or formula.

The nurse assesses a client diagnosed with the acute stage of the human immunodeficiency virus (HIV) infection. Which finding will the nurse expect to observe when providing care to this client?

Temporary decrease in CD4+ T cells. The symptoms of the acute stage of infection occur 2 to 3 weeks after initial infection and last for 1 to 2 weeks. This decrease occurs temporarily and then quickly returns to baseline. Fever and night sweats occur in the symptomatic infection stage of the disease. Think Like A Nurse: Clinical Decision Making The nurse needs to be aware of the acute manifestations of the human immunodeficiency virus (HIV). Symptoms may occur 2 to 3 weeks following exposure. After initial exposure to the virus, the body is unable to ward off the infection, which causes a drop in the CD4 blood cells. Within a few weeks, the body adjusts to the virus and the CD4 level rebounds. This rebounding can be sustained if appropriate medication intervention with antiretroviral agents is implemented. Testing plays a role in disease prevention by identifying clients who are positive for the HIV virus before they infect others.

An older adult client is prescribed ambulation with a walker after total hip arthroplasty surgery. Which statement is the best for the nurse to make to this client?

Tennis balls with a cross cut can be applied over the walker tips." Cross-cut tennis balls are applied over the walker tips to make sliding easier. This statement is appropriate for the nurse to make to the client. Flexion of the hip greater than 90 ° should be avoided in a client recovering from hip arthroplasty surgery to prevent dislocation of the prosthesis. Think Like A Nurse: Clinical Decision Making The nurse needs to ensure that the client can safely use the walker to ambulate. Cross-cut tennis balls have been found effective to make sliding the legs of the walker easier. Hip flexion should be restricted to a 90-degree angle to prevent accidental dislocation of the hip prosthesis. Frequently used items should be placed at waist-height to prevent bending.

The nurse assists in the care provided by the LPN/LVN for client who had a mastectomy. The client has a wound drainage evacuator in place. Which observation concerns the nurse?

The LPN/LVN releases manual pressure on the drainage evacuator after the plug is in place, and the unit rapidly inflates. Rapid reinflation indicates an air leak is present. If this occurs, the nurse should compress the unit again and check the plug for a secure fit. Think Like A Nurse: Clinical Decision Making The drainage evacuator device should remain deflated after the plug is in place and manual pressure released. Should the device inflate, either the plug was not secure or the device has a leak. The nurse should compress the device again and re-secure the plug. The nurse should periodically assess and document the amount and characteristics of the drainage.

The nurse provides care for a pediatric client who is 18 months of age during a wellness visit. The nurse assesses the child's growth and development. Which assessment finding causes the nurse to be concerned?

The child does not speak 15 words. A cause for concern for a child age 18 months is an inability to speak 15 words. Think Like a Nurse: Clinical Decision-Making Behaviors and skills are expected to develop within a certain time frame during infancy and childhood. Examples include physical abilities, social behaviors, emotional responses, cognitive abilities, and communication skills. Each developmental task is usually given a wide range of 3 to 6 months during which the milestones should be reached. The range accounts for the client's individualized characteristics. When milestones are not reached on time, the nurse is concerned that the client may have a developmental delay caused by a pathophysiological process. While monitoring the client is often the first step, lack of progress signals the need for intervention.

The nurse supervises hospice care for a client who practices orthodox Judaism. Which observation best indicates to the nurse that the care of this client is appropriate?

The client has a continuous intravenous morphine infusion Pain management is appropriate for many clients at the end of life. Some members of the orthodox Jewish faith may wish for all of the following from caregivers at the end of life: facilitating lucidity, maximizing function, pain management, providing peace, and respecting dignity. Therefore, pain management with a continuous morphine infusion is considered appropriate care. End-of-life care in the Islamic religion requires the dying to face east towards Mecca. Think Like a Nurse: Clinical Decision-Making When providing culturally sensitive care at the end of life, the nurse must be aware of his or her own personal beliefs, values, and behaviors regarding pain and pain management. The nurse must also be open to the cultural effects regarding how clients perceive and react to pain. To develop an effective and caring relationship with the client from a different culture, the nurse respects the client, respects the client's response to pain, and avoids stereotyping.

The nurse assesses the newly-admitted client. Which data indicate the client is at risk for having a latex allergy? (Select all that apply.)

The client has an allergy to avocado The client has undergone multiple surgeries. The client is employed as a health care worker. Think Like A Nurse: Clinical Decision Making Most institutions are replacing latex products with nonlatex products whenever possible. The nurse is aware though true latex allergies resulting in anaphylaxis are not common and life-threatening. Every potential latex allergy is taken very seriously. Repeated exposure to latex is one risk factor. People with multiple existing allergies are at increased risk too, due to a hypervigilant immune response. The nurse is alert that allergies to apples, bananas, carrots, celery, kiwi, melons, papaya, and tomato are risk factors. The nurse needs to remember latex is found in gloves, syringes, vial stoppers, stethoscopes, IV tubing, catheters, tape, and other medical supplies and equipment.

The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?

The client is experiencing blindness without an identified physical cause. Conversion disorder is diagnosed when the client presents with neurologic symptoms such as blindness, deafness, or paralysis that cannot be explained by medical evaluation. Think Like a Nurse: Clinical Decision-Making The nurse understands that a conversion reaction is the development of a neurologic symptom without an identifiable reason. The client demonstrating blindness as a conversion reaction will have intact optic cranial nerve function, but will be blind. Additionally, a client diagnosed with a conversion reaction may report muscle paralysis, again, without an identifiable cause.

A client receives treatment for recurrent venous thromboembolism (VTE) of the right leg. Which observation most concerns the nurse?

The client removes compression stockings during the day Compression stockings are used to decrease venous stasis, which will reduce the risk of recurrence of VTE and of enlargement of the venous thrombus. They are to be left in place except for bathing. edematous is an expected finding in VTE. The nurse should continue to monitor. There is another physical concern that is a higher priority. Think Like a Nurse: Clinical Decision-Making The nurse evaluates each client statement and considers whether it poses a risk to the client. Compression stockings in the treatment of venous thromboembolism (VTE) are to reduce pooling of blood in the extremities. These stockings are to be worn continuously except for routine bathing and skin care. Teach the client that compression stockings should not be rolled down, cut, or otherwise altered because this action could lead to arterial ischemia, edema, skin breakdown, and VTE. Unless contraindicated, instruct the client to flex and extend the feet, knees, and hips at least every 2 to 4 hours while awake to promote circulation.

An older adult client is admitted to the hospital from a long-term care facility. The nurse establishes a nursing diagnosis of decreased fluid volume related to poor intake and fever. Which symptoms most concern the nurse?

The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg. An increased pulse rate with thready quality, decreased blood pressure, and elevated temperature indicate that the client may be experiencing hypovolemic shock related to decreased fluid volume. This is a priority concern. Think Like A Nurse: Clinical Decision Making The nurse recognizes that a rapid heart rate and dropping blood pressure indicates low fluid volume. The client also has a fever, which is contributing to fluid losses, as well. This client needs immediate fluid replacement and diagnostic testing to determine the cause for the elevated temperature. The nurse should anticipate that the health care provider will likely order a battery of diagnostic tests, including a complete blood count (CBC), basic metabolic panel (BMP), blood cultures, and urinalysis.

The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate?

The client's use of language. The cognitive viewpoint of depression sees it as stemming from errors in thinking, which may be negative, illogical, and/or irrational. Language is used in thought as well as in speech. Speech and writing are used to express thoughts, and thereby are indicators of the client's automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions Think Like a Nurse: Clinical Decision-Making The premise of cognitive therapy centers on the assumption that an individual's mood and thought patterns are directly related. Negative, dysfunctional thinking has an impact on an individual's mood, self-concept, behaviors, and physical well-being. Goals of cognitive therapy include educating an individual about identifying negative thought patterns, evaluating the validity of the thought patterns, and replacing negative thoughts with healthier patterns of thinking.

The nurse monitors a client who is recovering from coronary artery bypass graft (CABG) surgery. Which finding most concerns the nurse?

The jugular veins are distended, but the lung sounds are clear. ugular vein distention is a symptom of cardiac tamponade. Cardiac tamponade is a potential complication after a CABG caused by blood accumulating around the heart (from bleeding and nonpatent mediastinal tubes) and compressing the myocardium, atria, and ventricles. This is an expected finding after a CABG since the heart has been accessed through the sternum. The client will be treated with pain medication Think Like A Nurse: Clinical Decision Making One post-operative complication after coronary bypass grafting is the development of cardiac tamponade or the accumulation of fluid within the pericardial sac. Jugular vein distention occurs because fluid within the pericardial sac exerts pressure on the heart, atrium, and ventricles. The absence of fluid in the lungs is consistent with this complication.

The nurse provides care for a client after a thoracotomy. The client has a chest tube drainage system in place. Which observation most concerns the nurse?

The level of the fluid in the water-seal chamber does not move The fluid in the water-seal chamber should fluctuate with the respirations of the client, rising with inspiration and falling with expiration. The absence of fluctuation indicates either that the lung has re-expanded (which is desired) or that there is an obstruction of the chest drainage tubes (which is not desired). The most common cause of tubing obstruction is the client lying on the tubing. Other causes are kinking, dependent loops, clots, or fibrin. Think Like a Nurse: Clinical Decision-Making Assessing the effectiveness of the chest tube drainage system begins with client assessment. Expected client assessment findings include alert and oriented, normal respiratory effort, normal skin color, normal pulse rate, and little to no change in breath sounds since the last assessment. Next, the nurse troubleshoots the equipment, assessing the insertion site, tubing position and condition, the collection container, and the suction regulation equipment if applicable. In this way, the nurse systematically works from the client to the equipment, eliminating one potential problem at a time.

Heimlich/abdominal thrust maneuver

The maneuver is used to dislodge food or other foreign bodies in the throat. The Heimlich/abdominal thrust maneuver uses the remaining air in the lungs to expel a foreign body. Think Like a Nurse: Clinical Decision-Making When a client is choking, ask the client, "Can you speak?" If the client can speak, the nurse knows the client has a partial airway obstruction; in that case, stay with the client, encourage the client to continue coughing, and monitor the cough effectiveness. If the client is unable to speak, the nurse knows the client has a complete airway obstruction, thus requiring the nurse to perform the Heimlich maneuver.

The nurse is caring for a male client who has been reporting chest discomfort for the past 30 minutes. The nurse is orienting a new nurse. The nurse determines care provided by the new nurse is appropriate if which observations are made? (Select all that apply.)

The nurse administers morphine sulfate 4 mg IV. The nurse asks if movement makes the pain worse. The nurse obtains an electrocardiogram. The nurse asks the client if medications are taken for impotence. Administering morphine sulfate for chest pain decreases the preload, afterload, pain, and client's anxiety level. Therefore, this observation by the new nurse is appropriate. 2) CORRECT- Asking about characteristics of pain and factors that exacerbate pain can help identify other possible causes of pain besides cardiac (eg, pleurisy, costochondritis). This action by the new nurse is appropriate for chest pain. An electrocardiogram helps to diagnose or rule out myocardial infarction and ischemia. This action by the new nurse is appropriate for chest pain. 5) CORRECT- For chest pain, the administration of nitrates should be considered. However, the nurse would not administer nitrates for chest pain if the client takes sildenafil, vardenafil, or tadalafil for impotence, which can cause a fatal drop in blood pressure. This action by the new nurse is appropriate for chest pain. Aspirin prevents platelet aggregation and reduces incidence of death. However, the typical dose is 160 to 325 mg and not 648 mg. Think Like A Nurse: Clinical Decision Making Chest discomfort is a classic symptom of a myocardial infarction. The nurse should obtain an electrocardiogram to evaluate electrical activity of the heart. Morphine is appropriate, as it will reduce the cardiac workload. Characteristics and exacerbating factors should be included when assessing the quality of the client's discomfort. Since nitrates may be prescribed to treat a myocardial infarction, it is appropriate for the nurse to assess if the client routinely takes any medications for erectile dysfunction because this could cause a drop in blood pressure.

The nurse provides care for clients in the outpatient clinic and receives four phone calls. Which call does the nurse return first?

The parent of a toddler calls to report that their child swallowed a nickel. The nurse should immediately evaluate to determine if the toddler is having respiratory difficulty due to airway obstruction. The parent of a toddler calls to report that their child has a rash and sore throat= The rash and sore throat probably describe a Streptococcus A infection or virus. This is not emergent unless the client is having respiratory difficulty. Think Like A Nurse: Clinical Decision Making A child who swallowed a nickel requires further evaluation for possible airway or gastrointestinal obstruction. Foreign body aspiration is common in infants and toddlers and can be life-threatening. The nurse should anticipate sending the child for an X-ray. Once the child is stabilized, the nurse can discuss with the parents methods for avoiding aspiration or swallowing of foreign bodies.

The nurse supervises the care of a client who just had a short leg cast applied. Which observations demonstrate to the nurse that care is appropriate? (Select all that apply.)

The staff handles the cast using the palms of the hands. The affected limb is elevated to the level of the heart. The nurse compares the toes of the casted leg with the opposite leg. The staff places a fan in the client's room. The use of the palms of hands by caregivers prevents the development of pressure areas under the cast. 3) CORRECT— Elevating a cast at or above the heart promotes better circulation and decreased edema in the dependent part. 4) CORRECT— The nurse assesses for neurovascular functioning in the unaffected leg and compares it to the circulation, motion, and sensation in the casted extremity. 5) CORRECT— A fan increases the circulation of air in a client's room, which facilitates drying of the cast. Think Like a Nurse: Clinical Decision-Making The nurse evaluates each statement about care provided. The nurse remembers that the goal is to have a dry, intact cast that securely maintains bone alignment, but does not restrict circulation. With this in mind, the nurse chooses to assess circulation and to use gravity to prevent edema. The nurse selects actions that assist with drying and will prevent damage to the cast. Teach the client to not get the cast wet (when applying an ice pack, cover the cast with a cloth), do not remove any padding, and do not insert objects inside the cast.

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.)

Thick, dark skin on bilateral lower extremities. Varicose veins in the right leg. Pain in the lower extremities while sitting. Crater-like lesions on the lower extremities. 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. 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.

The nurse provides care to a client diagnosed with chronic heart failure (HF) and an acute bacterial infection. The client's medications include furosemide 40 mg PO daily and aspirin 81 mg PO daily. Which new prescriptions cause the nurse to seek clarification from the health care provider? (Select all that apply.)

Vancomycin 3 g IV piggyback every 12 hours. Digoxin 0.25 mg PO daily The combination of vancomycin with furosemide, which is a loop diuretic, increases the client's risk for ototoxicity. 4) CORRECT - The combination of digoxin and with furosemide, which is a loop diuretic, increases the client's risk for digoxin toxicity. 5) INCORRECT- Clopidogrel is not contraindicated for the client who takes furosemide. Clopedigrel is also not contraindicated for the client who takes low-dose aspirin. Think Like A Nurse: Clinical Decision Making Heart failure is characterized by fluid within the pulmonary vasculature and peripheral body structures. Treatment typically includes diuretics and aspirin. Vancomycin can cause ototoxicity, which is enhanced if given with furosemide. The client is at risk for digoxin toxicity if digoxin is taken with furosemide. Potassium chloride is used to replace the loss of potassium, which can occur when taking furosemide. Enalapril and clopidogrel do not adversely interact with furosemide or aspirin and can be safely taken.

dissociative disorder

one type of multiple personality disorder