ADN Level 3 Final Exam

A client is taking metformin. To prevent lactic acidosis resulting from use of this drug, the nurse should instruct the client to report which of the following? Select all that apply. a) Dizziness b) Hyperventilation c) Headache d) Tingling in the fingertips e) Increased hunger f) Muscle discomfort

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Prostate cancer is predominant in what age group?

60- to 70-year-old age-group

The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? a) the elderly client diagnosed with a left fractured hip who is crying and is frightened about the surgery b) the school-aged client who has an open reduction and internal fixation of the right ulna with 1+ edema c) the middle-aged client who is 2 days postoperative for an emergency appendectomy and who has a rigid, hard abdomen d) the adolescent client who is 2 days postoperative for an emergency appendectomy and who his complaining of abdominal pain and rating it as an "8"

ANSWER = C A HARD, RIGID ABDOMEN INDICATES PERITONITIS, WHICH IS A LIFE-THREATENING EMERGENCY. THIS CLIENT SHOULD BE ASSESSED FIRST. a- this client is experiencing a psychosocial need, which, although important, is not priority over a physiologic problem b - 1+ edema would be EXPECTED in a client with a fractured ulna d - the client who is 2 days postop and c/o of and rating pain as an 8 should be assessed, but the pain is not life threatening and, therefore, does not take priority over the pt with probable peritonitis

The nurse is completing a head-to-toe assessment on a client diagnosed with breast cancer and notes a systolic murmur that the nurse was not informed of during report. Which action should the nurse implement first? a) notify the HCP about the new cardiac complication b) document the finding in the client's chart and tell the charge nurse c) check the chart to determine whether this is the first time a murmur has been identified d) ask the client whether she has ever been told she has an abnormal heartbeat

ANSWER = C although the client was not admitted for a cardiac problem, she may have had a murmur for a while, and the previous nurse did not pick it up or did not mention it in the report because it was a long-standing physiologic finding in this client. The nurse should research the chart for a current history and physical to determine whether the HCP is aware of the condition. a - notifying the physician should be done if this is a new finding; however, the nurse should investigate the finding further before notifying the HCP. b - this should be done, but assessing the client's situation is the nurse's priority. c -the nurse should NOT ask the client because this could scare or alarm the client needlessly.

The client who is 2 days postoperative for a left pneumonectomy has an apical pulse of 128 and a blood pressure of 80/50. Which intervention should the nurse implement first? a) notify the HCP immediately b) assess the client's incisional wound c) prepare to administer dopamine, a vasopressor d) increase the client's IV rate

ANSWER = D Increasing the IV rate will provide the client with circulatory volume immediately. Therefore, this is the first intervention. a - the HCP should be notified, but this is not the first intervention. The HCP will require other information, such as what the incision looks like and whether there is any bleeding that can be seen, before making any decisions. The nurse, therefore, should first provide emergency care to the client - in this case, support the client's circulatory system by increasing the IV rate - and then assess the pt before reporting to the HCP. b - the incisional wound should be assessed, but the priority is maintaining circulatory status because the client's vital signs indicate shock c - the client may require medication, such as dopamine, to increase the BP, but the client's circulatory system needs immediate support, which increasing the IV rate will provide. That, then, is the priority. **REMEMBER: IF THE CLIENT IS IN DISTRESS, DO NOT ASSESS! Situations as those in this question require the nurse to intervene to prevent the client's status from deteriorating. Before selecting "notify the HCP" as the correct answer, the test taker must examine the other 3 options. If information in any of the other options is data that will relieve the pt's distress, prevent a life-threatening situation, or provide info the HCP will need to make an informed decision, then the test taker should eliminate the "notify the HCP" option.

The nurse is reviewing a client's laboratory values and finds documentation of a phenytoin level of 32 mg/dL. Which signs and symptoms should the nurse monitor this client for? Select all that apply. a) Ataxia b) Confusion c) Tonic-clonic seizure d) Urinary incontinence e) Sodium depletion

Ataxia Confusion Explanation: A therapeutic phenytoin level is 10 to 20 mg/dL. A level of 32 mg/dL indicates phenytoin toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hy-ponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy

VERNIX CASEOSA

Trendeleburg's position

head lower than the heart

most common cancer in men

prostate cancer

A client has atrial fibrillation. The nurse should monitor the client for: a) heart block b) cerebrovascular accident c) ventricular fibrillation

Cerebrovascular accident. Explanation: Because of the poor emptying of blood from the atrial chambers, there is an increased risk for clot formation around the valves. The clots become dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication of atrial fibrillation.

Which of the following should the nurse do next after noting that an 8-month-old child's posterior fontanel is slightly open a) Document this as a normal finding. b) Question the mother about the child's labor and birth. c) Schedule an x-ray of the child's head. d) Check the child's head circumference.

Check the child's head circumference. Explanation: The posterior fontanel usually closes between 6 weeks and 2 months. Therefore, the nurse should measure the head circumference to determine if the child's head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures. This is not a normal finding because the posterior fontanel usually closes by age 2 months. Because the child is 8 months old, the labor and birth history probably would not be a significant factor. An x-ray (radiologic) examination is not necessary until other data are collected.

A client is confined to a wheelchair. To prevent a deep vein thrombosis (DVT), the physician has ordered anticoagulation. Which of the following will be most effective in preventing DVT? acetaminophen warfarin enoxaparin

Enoxaparin. Acetaminophen is an analgesic and antipyretic. Warfarin inhibits vitamin K-dependent activation of clotting factors II, VII, IX, and X, formed in the liver. Acetylsalicylic acid (ASA) is thought to exert its anti-inflammatory effect by inhibiting prostaglandin and other substances that sensitize pain receptors. In low doses, it interferes with clotting by keeping a platelet-aggregating substance from forming. Enoxaparin is a low-molecular-weight heparin that works by accelerating the formation of anti-thrombin III-thrombin complex and activates thrombin, preventing conversion of fibrinogen to fibrin

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? Hyperoxygenate. Suction the mouth. Suction the airway. Provide sedation.

Provide sedation. Hyperoxygenate. Suction the airway. Suction the mouth. Explanation: Increased agitation with suctioning will increase intracranial pressure (ICP), therefore sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned the suction catheter should be discarded.

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 beats per minute; and respiratory rate of 30 shallow breaths per minute. What should the nurse do first? a) Activate the Rapid Response Team (RRT). b) Call the neurosurgeon. c) Place the client in the Trendelenburg position. d) Consult the neurologic Clinical Nurse Specialist (CNS).

Rapid response teams (RRTs), or medical emergency teams, provide a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. Calling the neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk.

The nurse and UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places the gait belt around the client's waste prior to ambulating. 2. The assistant places the client on the abdomen with the client's head to the side. 3. The assistant places her hand under the client's right axilla to help the client move up in bed. 4. The assistant praises the client for attempting to perform activities of daily living independently.

ANSWER = 2 1. Placing a gait prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. 2. Placing the client in a prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures; therefore, this would not require the nurse to intervene. 3. This action is INAPPROPRIATE and would require IMMEDIATE intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client's back or using a lift sheet. 4. the client should be encouraged and praised for attempting to perform activities independently, such as combing hair or brushing teeth.

A nurse in the emergency department is performing triage on the following victims of an airplane crash. Prioritize the clients in the order in which they should be treated. 22-year-old with a 2-inch (5.1-cm) laceration to the left temple and slight confusion 22-year-old who is at 36 weeks of pregnancy and having contractions every 10 to 15 minutes 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26, and audible wheezing 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm

14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26, and audible wheezing 22-year-old with a 2-inch (5.1-cm) laceration to the left temple and slight confusion 22-year-old who is at 36 weeks of pregnancy and having contractions every 10 to 15 minutes 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm Explanation: The 14-year-old with asthma needs immediate, lifesaving interventions for the wheezing, and should be seen first. The confused 22-year-old should be seen next to assess for head injury; the location of the laceration could indicate a significant blunt force traumatic injury. The pregnant woman requires assessment but is not urgent unless other symptoms develop. The 75-year-old has non-urgent injuries and can wait safely for several hours

A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner should be involved in the client's care to: a) help the client cope with the anxiety associated with changes in body image. b) assess whether the client is a good candidate for surgery. c) evaluate the client's need for mental health intervention. d) assess suicidal risk postoperatively.

A - Many clients who undergo surgery for creation of an ileal conduit experience anxiety associated with changes in body image. The mental health practitioner can help the client cope with these feelings of anxiety. Mental health practitioners don't evaluate whether the client is a surgical candidate. None of the evidence suggests that urinary diversion surgery, such as creation of an ileal conduit, places the client at risk for suicide. Although evaluating the need for mental health intervention is always important, this client displays no behavioral changes that suggest intervention is necessary at this time.

After receiving a change-of-shift report at 7:00 AM, the nurse should assess which of these clients first? a) A 23-year-old with a migraine headache who has severe nausea associated with retching b) A 63-year-old with multiple sclerosis who has an oral temperature of 101.8 degrees F (38.8 degrees C) and flank pain c) A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast d) A 45-year-old scheduled for a craniotomy in 30 minutes who needs preoperative teaching

A 63-year-old with multiple sclerosis who has an oral temperature of 101.8 degrees F (38.8 degrees C) and flank pain Explanation: Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, the nurse should see that client first. The elevated temperature and flank pain suggest pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client.

A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it has been decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement would be appropriate to assist in alleviating the child's fear? a) "This aching and cramping is normal and temporary and will subside." b) "This normally occurs after the surgery and we will teach you ways to deal with it." c) "The pain medication that I give you will take these feelings away." d) "This pain is not real pain, and relaxation exercises will help it go away."

A. After amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Options 2, 3, & 4 are inappropriate to the child. Use therapeutic communication techniques. Note that the subject of the question relates to alleviating the child's fear. Options 2, 3, & 4 imply that this pain may be permanent. Review care of a child after amputation if you had difficulty with this question.

The client diagnosed with breast cancer who is positive for the BRCA gene is requesting advice from the nurse about treatment options. Which statement is the nurse's best response? 1. "If it were me in this situation, I would consider having a bilateral mastectomy." 2. "What treatment options has your health-care provider (HCP) discussed with you?" 3. "You should discuss your treatment options with your HCP." 4. "Have you talked with your significant other about the treatment options available to you?"

ANSWER = 2 1. This is boundary crossing because the nurse does not have breast cancer. The nurse should assess what information the client is really seeking and then explain the treatment or refer the client, as appropriate. 2. The nurse must assess what information the client actually needs. To do this, the nurse must know what treatment options have been suggested to the client. Assessment is the first step in the nursing process. 3. This may be needed after the nurse further assesses the situation, but this is not the first intervention. 4. The client needs information about treatment options from a designated HCP; the significant other would not have such information/suggestions.

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with pneumonia who has bilateral crackles 2. The client on strict bed rest who is complaining of calf pain 3. The client who complains of low back pain when sitting in a chair 4. The client who is upset because the food is cold all the time.

ANSWER = 2 1. A typical sign of pneumonia is bilateral crackles; therefore, this client would not be seen first. 2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should be assessed first. 3. The client experiencing low back pain when sitting in a chair should be assessed but not prior to the client with suspected DVT. 4. The nurse should address the client's concern about the food, but it is not a priority over a physiologic problem. When deciding which client to assess FIRST, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situation. After eliminating the expected options, the test taker should determine which situation is more life threatening.

A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed, and for I.V. Ringer's Lactate and hyperalimentation fluids. The nurse should do the following in order of priority from first to last: Start an infusion of hyperalimentation fluids. Administer Ringer's Lactate. Insert a nasogastric tube. Assist with ambulation to promote peristalsis.

Assist with ambulation to promote peristalsis. Administer Ringer's Lactate. Insert a nasogastric tube. Start an infusion of hyperalimentation fluids. Explanation: The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. I.V. fluid therapy can be done to correct fluid and electrolyte imbalances (sodium and potassium), and normal saline or Ringer's Lactate to correct interstitial fluid deficit. Nasogastric (NG) decompression of G.I. tract to reduce gastric secretions and nasointestinal tubes may also be used. Hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection.

If a mass casualty incident occurs near an acute care unit, which of the following is the nurse responsible for when implementing a disaster preparedness plan? a) An informal fan-out to contact and inform all registered nurses about the disaster and to elicit their help in assisting with the casualties b) A formal written plan of action for coordinating the response of the hospital staff and for designating how different areas will be used c) A formal plan to ensure that medical supplies and medications are available for the great number of casualties d) A designation of levels of casualty care and having nurses volunteer services at different levels

B - A formal written plan of action for coordinating the response of the hospital staff and for designating how different areas will be used Explanation: When a disaster occurs, a formal written plan of action is put into place. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan needs to focus on having health professionals and supplies available.

On entering the room of a client who has undergone a dilatation and curettage (D&C;) for a spontaneous abortion, the nurse finds the client crying. Which of the following comments by the nurse would be most appropriate? a) "Commonly spontaneous abortion means a defective embryo." b) "I'm truly sorry you lost your baby." c) "You should try to get pregnant again as soon as possible." d) "Are you having a great deal of uterine pain?"

B - The death of a fetus at any time during pregnancy is a tragedy for most parents. After a spontaneous abortion, the client and family members can be expected to suffer from grief for several months or longer. When offering support, a simple statement such as "I'm truly sorry you lost your baby" is most appropriate. Therapeutic communication techniques help the client and family understand the meaning of the loss, move less stressfully through the grief process, and share feelings. Asking the client whether she is experiencing a great deal of uterine pain is inappropriate because this is a "yes-no" question and doesn't allow the client to express her feelings. Saying that the embryo was defective is inappropriate because this may lead the client to think that she contributed to the fetus's demise. This is not the appropriate time to discuss embryonic or fetal malformations. However, the nurse should explain to the client that this situation was not her fault. Telling the client that she should get pregnant again as soon as possible is not therapeutic and discounts the feelings of the expectant mother who had already begun to bond with the fetus.

The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that in this condition: a) the client has complete bilateral paralysis of the arms and legs b) the client has weakness on the right side of the body, including the face and tongue c) the client has lost the ability to move the right arm but is able to walk independently d) the client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

B. Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. Use the process of elimination. Note the strategic words complete right-sided and focus on the subject: hemiparesis. Recalling that hemiparesis indicates weakness and focusing on the strategic words will direct you to option B. Review the description of hemiparesis and care of the client with hemiparesis if you had difficulty with this question.

A nurse is assessing a client who recently experienced a stroke. The client has a left facial droop, hemiparesis of the upper left extremity, and diplopia. Which nursing intervention is most appropriate for this client? a) Assess the vagus nerve function before giving food or fluids. b) Match visual tasks with a verbal statement. c) Consistently place client care items in the same location. d) Encourage the client to write, rather than attempt to speak.

C - Consistently place client care items in the same location. Explanation: Clients with diplopia see two of the same object. Consistently placing items in the same location assists the client in locating the item. Based on the clinical presentation, the client most likely had a stroke located in the right middle cerebral artery. The speech center, Broca's area, is located in the left hemisphere of the brain and therefore, the client may have some slurred speech due to the facial droop, but not experience aphasia. The vagus nerve, which controls swallowing, is located in the brainstem. The client has double vision, therefore writing or observing visual cues would be difficult.

Which of the following is a common method of evaluating the urine output for newborns, infants, and toddlers who are not potty trained. a) Monitoring the amount of time for breast feeding b) Measuring the formula before the child ingests it c) Weighing the child before and after feeds d) Weighing the diaper before and after micturition

D - Weighing the diaper before applying it to the newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output. The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.

Craniocerebral injury in a child differs substantially from craniocerebral trauma in an adult. Which statement identifies a difference between children and adults that could produce a life-threatening complication for a child? a) Cerebral tissues in children are softer, thinner, and more flexible. b) Greater portions of a child's blood volume flows to the head. c) A child's skull can expand more than an adult's can. d) Hematomas in children can include subdural, epidural, and intracerebral.

Greater portions of a child's blood volume flows to the head. Explanation: If hemorrhage is associated with a head injury and it goes undetected, a child may experience hypovolemic shock because a large portion of a child's blood volume goes to the head. In children, cerebral tissues are softer, thinner, and more flexible — conditions that actually permit diffusion of the impact. Because a child's skull can expand more than an adult's can, a greater amount of posttraumatic edema can occur without evidence of neurologic deficits. Subdural, epidural, and intracerebral hematomas are the different types of head injury that can occur in children and adults

A nurse assigned to telephone triage returns a call from a parent whose teenager experienced a hard tackle during football last night. The parent reports, "He seemed dazed after it happened and the coach had him sit out the rest of the game, but he is fine now." What are the most appropriate instructions for the nurse to give? a) "If he seems fine now and had no other symptoms, it probably was not a concussion." b) "Take him immediately to the emergency department." c) "Watch him closely and call us back if you see any changes." d) "He cannot return to play until he has been evaluated by a health care provider."

"He cannot return to play until he has been evaluated by a health care provider." Explanation: Appearing dazed or stunned after a head injury is a symptom of a concussion. Concussion care includes removing the athlete from play and having the injury evaluated. Athletes should not return to play until they have been cleared by a health care provider. Concussions require ongoing monitoring. Because the client has no signs of deteriorating of neurologic function, that monitoring may best be provided by a consistent health care provider rather than through an emergency department.

Which of the following is the nurse's best rationale for positioning a client with decreased level of consciousness related to a head injury? a) Avoidance of impeding venous outflow b) Prevention of flexion contractures c) Decrease of cerebral arterial pressure d) Prevention of aspiration of stomach contents

A - Avoidance of impending venous outflow. Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase intracranial pressure. The other choices do not promote head trauma positioning and reduction/flow of cerebral fluid.

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate? a) "The vernix indicates a different gestational age than expected." b) "The vernix is difficult and painful to remove from a newborn." c) "The presence of vernix affects the newborn's immune system." d) "The vernix should be a thicker coating for a newborn."

A - Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.

Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? a) Asymmetric chest excursion. b) Nasal flaring. c) Rapid, shallow respirations. d) Slow, irregular respirations.

D - SLOW, IRREGULAR RESPIRATIONS Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a) diminished responsiveness. b) elevated temperature. c) decreasing blood pressure. d) pupillary changes.

a - diminished responsiveness Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply. a) Wrist pronation. b) Flexion of the arms and wrists with internal rotation. c) Opisthotonos. d) Plantar flexion of the feet. e) Stiff extension of the arms and legs.

• Wrist pronation. • Stiff extension of the arms and legs. • Plantar flexion of the feet. • Opisthotonos. Explanation: Decerebrate posture, which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? a) Helps the client to make a living will regarding future health care required. b) Protects the client's right to self-determination in health care decision making. c) Helps the client refuse treatment that he or she does not wish to undergo. d) Provides the client with in-depth knowledge about the treatment options available.

B - Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a) Hypertension and narrowing pulse pressure b) Rising blood pressure and bradycardia c) Hypotension and tachycardia d) Hypotension and bradycardia

B - rising blood pressure and bradycardia Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

An infant underwent surgery to remove a myelomeningocele. The infant has bulging fontanels. Which of the following is the nurse's best action? a) Calm the infant b) Teach parent about procedure c) Notify the healthcare provider d) Reposition infant

C - Bulging fontanels in an infant may indicated increased intracranial pressure, a possible postoperative complication. Calming the infant, teaching the parent, and repositioning the infant will not address the underlying problem of increased intracranial pressure within the skull. Calling the healthcare provider is indicated.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? a) Coma b) Apnea c) Infection d) High blood pressure

C - INFECTION The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? a) Turning. b) Coughing. c) Deep breathing. d) Passive range-of-motion (ROM) exercises.

Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.

The nurse walks into the room of a client who has a "do not resuscitate" prescription and finds the client without a pulse, respirations, or blood pressure. The nurse should first? a) Page the client's physician. b) Push the emergency alarm to call a code. c) Pull the curtain and leave the room. d) Stay in the room and call the nursing team for assistance.

D - stay in room and call nursing team for assistance The nurse should call to the nursing station to ask the nursing team for assistance. It is not necessary to page the physician because this is not an emergency, but the nurse will need to notify the physician of the client's death, and then also notify the family. A "code" should not be called because the client and family have designated a "do not resuscitate" status. Nursing personnel should begin postmortem care so that the family does not walk in unannounced to find their loved one deceased and looking disarrayed.

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? a) Placing him on mechanical ventilation b) Performing a lumbar puncture c) Giving him a barbiturate d) Elevating the head of his bed

Performing a lumbar puncture Explanation: The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery? a. administer half of the client's typical morning insulin dose as ordered b. administer an oral antidiabeteic agent as ordered c. administer an I.V. insulin infusion as ordered d. administer the client's normal daily dose of insulin as ordered

a - if the nurse administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren't effective for type 1 diabetes I.V. insulin infusions aren't necessary to manage blood glucose levels in clients undergoing routine surgery.

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base her next action on which understanding? a) The ordered route is inappropriate for administration of this drug. b) She should clarify the order with the physician. c) The order should specify the precise time to give the drug. d) The order is correct and valid.

The nurse must clarify this order with the physician because meperidine is available in several dosage strengths, and 1 ml may contain varying amounts of the drug. A stat order need not specify a precise administration time. Meperidine is commonly given I.M. Because the order specifies the drug volume but not the dosage, the nurse shouldn't consider this order correct and valid.

An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: a) cerebral hyperemia b) intracranial hypotension c) increased myelination d) a slightly thicker cranium

a - Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension — not hypotension — places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable than an adult's, causing the child to receive a more severe injury

The primary health care provider orders carbamazapine extended release for a client with a cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube, and carbamazapine is on the hospital's "no crush" list. In order to administer the medication, the nurse should: a) Cut the medication into 4 pieces that can be placed in the feeding tube. b) Contact the primary care provider to change the order. c) Ask the pharmacist for an oral suspension. d) Dissolve the medication in 30 ml's of juice.

b - Contact the primary care provider to change the order. Explanation: The coating on an extended release medication helps assure slow absorption of the medication. If the nurse crushes the medication, the medication may enter the client's system too quickly and result in toxic levels. The only appropriate action is to contact the prescriber and ask that the order be changed. Cutting the medication or trying to dissolve a whole tablet would have similar results as crushing it. Carbamazapine comes as an oral suspension, but it is not extended release. Therefore, an order would be needed to address dosing if switching to this form.

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client? a. ineffective parenting related to the neonate's transfer to the intensive care unit b. impaired parenting related to the neonate's transfer to the intensive care unit c. deficient fluid volume related to severe edema d. fear related to removal and loss of the neonate by statute

b - because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of 'impaired parenting related to the neonate's transfer to the neonatal intensive care unit.' (another pertinent nursing diagnosis may be 'compromised family coping related to lack the opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.

The nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to assess in a 1-month-old infant? Select all that apply. a) Bulging fontanels b) Increased pulse c) Headache d) Irritability e) Decreased blood pressure f) High-pitched cry

• Bulging fontanels • High-pitched cry • Irritability Explanation: Signs and symptoms of increased ICP in a 1 month old include full, tense, bulging fontanels; a high-pitched cry; and irritability. With increased ICP, blood pressure rises while heart rate falls. The infant may have a headache, but the nurse cannot assess this finding in an infant.

A 10-year-old child is admitted to the hospital with clear drainage from the right ear after falling off a bicycle. The nurse is testing the fluid to determine if it is cerebrospinal (CSF) fluid. The mother asks what is the function of CSF. How would the nurse respond? Select all that apply. a) "CSF cushions the brain and spinal cord." b) "CSF produces cerebral neurotransmitters." c) "CSF acts as an insulator to maintain a constant spinal fluid temperature." d) "CSF removes waste products from the brain." e) "CSF acts as a barrier to bacteria."

• "CSF cushions the brain and spinal cord." • "CSF removes waste products from the brain." Explanation: CSF is primarily produced in the lateral ventricles of the brain. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue. The other options aren't functions of CSF.

The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which symptoms? Select all that apply. a) Bulging fontanel. b) Emesis. c) Headache. d) Irritability. e) Mood swings.

• Bulging fontanel. • Emesis. • Irritability. Explanation: Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.

The nurse is caring for an 8-year-old child with a head injury. Which of the following symptoms are important for the nurse to control to prevent an increase in intracranial pressure? Select all that apply. a) Pain b) Nausea c) Agitation d) Coughing e) Sedation

• Pain • Coughing • Agitation Explanation: Persistent and frequent coughing, pain, and agitation are all potential causes for increased intracranial pressure in the pediatric population. Sedation is used to reduce agitation and metabolic needs of the brain and therefore would not increase ICP in the pediatric population. Nausea may be a symptom of increased intracranial pressure, but does not cause it.

A parent brings an 8-month-old boy to the emergency department. The baby's vital signs are temperature 103.4° F (39.6° C), apical rate 122 beats per minute; respirations 30 breaths per minute. The baby is lethargic and difficult to arouse. A lumbar puncture is ordered. Which of the following actions should the nurse implement? a) Administer 1.0 L of oxygen using a pediatric mask b) Place the baby in a side-lying position avoiding flexion of the neck onto the chest c) Give the baby 60 mL of glucose water 30 minutes before the procedure d) Contact child protective services e) Obtain a blood glucose level immediately before the procedure

• Place the baby in a side-lying position avoiding flexion of the neck onto the chest • Obtain a blood glucose level immediately before the procedure Explanation: For a lumbar puncture, the nurse should place the infant in an arched, side-lying position to maximize the space between the third and fifth lumbar vertebrae. The nurse's hands should rest on the back of the infant's shoulders to prevent neck flexion, which could block the airway and cause respiratory arrest. The infant should be placed at the edge of the bed or table during the procedure, and the nurse should speak quietly to calm the infant. Cerebrospinal fluid (CSF) blood glucose level is two-thirds that of the plasma level. In bacterial meningitis, the glucose level of the CSF will be lower than two-thirds of the plasma level as bacteria feeds on the glucose. There is no indication that the infant is in distress, as the respiratory rate and apical heart rate are within the normal ranges for the infant's age. There is not sufficient evidence to notify child protective services.

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. a) Systolic blood pressure. b) Level of pain. c) Breath sounds. d) Cerebral perfusion pressure. e) Urine output.

• Systolic blood pressure. • Cerebral perfusion pressure. Explanation: The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

A client is admitted to the medical-surgical unit after undergoing intracranial surgery to remove a tumor from the left cerebral hemisphere. Which nursing interventions are appropriate for the client's postoperative care? Select all that apply. a) Place a pillow under the client's head so that the neck is flexed. b) Apply a soft collar to keep the client's neck in a neutral position. c) Maintain the client in the supine position. d) Turn the client on the right side. e) Place pillows under the client's legs to promote hip flexion and venous return.

• Turn the client on the right side. • Apply a soft collar to keep the client's neck in a neutral position. Explanation: The client should be turned on the right side, because lying on the left side would cause the brain to shift into the space previously occupied by the tumor. A soft collar keeps the neck neutral, allowing for adequate perfusion and venous drainage of the brain. Placing a pillow under the head flexes the neck and impairs circulation to the brain. Flexion of the hip increases intracranial pressure and, therefore, is contraindicated. Exclusive use of the supine position is not indicated.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a) hypoxia. b) visual disturbance. c) fever. d) gait alteration.

a - hypoxia Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)? a. "take an extra dose of digoxin if you miss one dose." b. "call the physician if your heart rate is above 90 beats/minute c. "call the physician if your pulse drops below 80 beats/minute." d. "take digoxin with meals."

b - the nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/ minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute - not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.

A client has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called: a. a first-degree laceration b. a second-degree laceration c. a third-degree laceration d. a fourth-degree laceration

c - birth may extend an episiotomy incision to the anal sphincter (a third degree laceration) or the anal canal (a fourth degree laceration). A first degree laceration involves the fourchette, perineal skin, and vaginal mucous membranes. A second degree laceration extends to the fasciae and muscle of the perineal body.

The nurse is administering medications for clients on a medical unit. Which medication should the nurse administer first? 1. The narcotic pain medication to a client complaining that his pain is an "8". 2. A loop diuretic to a client diagnosed with heart failure who has 3+ pitting edema. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

ANSWER = 3 1. A pain medication is important to administer in a timely manner, but its administration is not priority over a medication that must be administered on time to prevent respiratory complications. 2. For a client experiencing expected symptoms of a disease, such as pitting edema, administration of a loop diuretic has a 30-minute leeway - that is, it can be administered 30 minutes before to 30 minutes after the scheduled dosing time. 3. Anticholinesterase medications administered for myasthenia gravis must be administered on time to preserve muscle functioning, especially the functioning of the muscles of the upper respiratory tract. This is the priority medication. 4. Clients who have called for medications should be attended to, but this client would not receive an antacid for heartburn before the client diagnosed with myasthenia gravis or the client in pain.

The client diagnosed with lung cancer has a hemoglobin and hematocrit (H&H) of 13.4 mg/dL and 40.1, a WBC count of 7800, and a neutrophil count of 62%. Which action should the nurse implement? 1. Place the client in reverse isolation. 2. Notify the NCP. 3. Make sure no flowers are taken into the room. 4. Continue to monitor the client.

ANSWER = 4 1. The client's lab work does not indicate an increased risk for infection. The client does not need to be placed in reverse isolation. 2. The lab work is within normal limits. The nurse does not need to notify the HCP. 3. The client is not at an increased risk for infection; therefore, the client may have flowers in the room. 4. This client's lab work is within normal limits. The nurse should continue to monitor the client.

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a myocardial infarction who has an elevated troponin level. 2. The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds. 3. The client diagnosed with end-stage liver failure who has an elevated ammonia level. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.

ANSWER = 4 1. The nurse would expect the client diagnosed with a myocardial infarction to have an elevated troponin level; thus the nurse would not assess this client first. 2. Because the client's PTT of 68 seconds is 1.5 times the normal range, it is considered therapeutic and would not warrant the nurse's assessing this client first. 3. The nurse would expect a client with end-stage liver failure to have an elevated ammonia level. 4. The therapeutic range for Dilantin is 10-20 mg/dL. This client's higher level warrants intervention because the serum level is above the therapeutic range. The test taker must know normal laboratory data.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? a) "For breakfast I will choose pineapple juice, a bran muffin, and milk." b) "Today I can have apple juice, chicken broth, and vanilla ice cream." c) "I can have oatmeal, custard, and tea." d) "I will have orange juice, farina, and coffee."

B - A bland, full-liquid diet may include some fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as orange juice, coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, "I look horrible! Will it ever look better?" Which of the following responses by the nurse would be most appropriate? a) "After it heals and you're dressed, you won't even know you had surgery." b) "Would you like to meet Ms. Paul? She looks just great and she had a mastectomy, too." c) "Don't worry. You know the tumor is gone, and the area will heal very soon." d) "You're shocked by the sudden change in your appearance as a result of this surgery, aren't you?"

D - When a client appears shocked by her appearance after surgery, such as after having a mastectomy, the nurse should help her express her feelings and offer the supportive care that she needs at this time. Telling the client that her disfigurement will not show when she is dressed dismisses her concerns and blocks expression of her feelings. Telling the client not to worry avoids the issues. Having the client meet someone who has had breast surgery is often helpful but is better done later, when the client is convalescing and accustomed to the appearance of the operative site. The client needs support now when the dressings are removed, not later.

The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father's bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner's planned visit? a) Ensuring that the care team does not impose their beliefs on the family or the complementary practitioner. b) Identifying whether the family would prefer to pursue alternative or conventional treatment for their father. c) Taking measures to prevent cultural conflict when the practitioner comers to the hospital. d) Ensuring any complementary therapies are safe when combined with his prescribed therapy.

D - While it is important for the nurse and the other members of the care team to ensure that stereotypes or cultural imposition do not exist, the priority in all aspects of care is safety. Consequently, potential interactions between the complementary therapies and conventional hospital treatments are a priority. The family should not be required to forgo conventional treatment to pursue some aspects of culturally based, complementary care.

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? a) Logrolling or turning as a unit when turning. b) Keeping the neck in a neutral position. c) Elevating the head of the bed to 30 degrees. d) Keeping the client flat on one side or the other.

Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies.

A client has been admitted to the neurosurgical unit after a motor vehicle accident that resulted in a closed head injury. The client is currently unconscious. The nurse has completed the initial assessment. Place the following interventions in order of priority. Use all options. Assess level of consciousness. Maintain a patent airway. Administer intravenous fluids. Protect skin integrity. Prevent urinary incontinence.

Maintain a patent airway. Assess level of consciousness. Administer intravenous fluids. Prevent urinary incontinence. Protect skin integrity. Explanation: Maintaining a patent airway is the most important intervention for this client due to the nature of the injuries. The client is unconscious; however, assessing the level of consciousness is the next priority so any changes can be determined. Intravenous fluids are the next priority to maintain adequate hydration. A Foley catheter would need to be inserted to prevent incontinence. Protecting skin integrity would be the last in the order of immediate priority needs.

the comatose victim of the car accident is to have a gastric lavage. Which of the following positions would be most appropriate for the client during this procedure? a. lateral b. supine c. trendelenburg's d. lithotomy

a - an unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration. Positioning the client supine carries a major risk of airway obstruction from the tongue, vomit, or nasopharyngeal secretions. Trendeleburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema. The lithotomy position has no purpose in this situation.

a nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: a. monitoring of arterial oxygen saturation (SaO2) b. arterial blood gas (ABG) studies c. chest auscultation d. chest x ray

d - chest x ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has re-expanded sufficiently.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nursing student notes confusion, a petechial rash, and meningeal irritation. The nursing instructor asks what are considered signs of meningeal irritation. Which signs and symptoms does the student include in his or her explanation? Select all that apply. a) Low cerebrospinal fluid (CSF) pressure b) Cerebral edema c) Increased intracranial pressure (ICP) d) Brudzinski's sign e) Nuchal rigidity

• Brudzinski's sign • Nuchal rigidity Explanation: Brudzinski's sign and nuchal rigidity indicate meningeal irritation, as in meningitis. Other signs of meningeal irritation include Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure.

The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse keep in mind when administering this dose? Select all that apply. a) Cephalosporin potentiates the effects of heparin. b) Double check the dose with another nurse. c) It should be administered in the anterior area of the iliac crest. d) The onset is immediate. e) Use a 27G, 5/8-inch (1.6-cm) needle.

• It should be administered in the anterior area of the iliac crest. • Use a 27G, 5/8-inch (1.6-cm) needle. • Cephalosporin potentiates the effects of heparin. • Double check the dose with another nurse. Explanation: Older adults may have little subcutaneous tissue, so the area around the anterior iliac crest is a suitable site for these clients. The nurse should use a 27G, 5/8-inch (1.6-cm) needle. Cephalosporin and penicillin potentiate the effects of heparin. Two nurses should check the dose because a dose error could cause hemorrhage. The onset of heparin is not immediate when given subcutaneously.

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality? a) Sodium b) Potassium c) Chloride d) Calcium

A - Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

Which finding would be most indicative of hydrocephalus in an infant? a) A pulsating fontanel. b) Increased blood pressure. c) Sunsetting eyes. d) A positive glabellar reflex.

C - sunsetting eyes Sunsetting eyes, or downward deviations of the irises, are a sign of hydrocephalus. A positive glabellar reflex, or blinking in response to taps on the forehead, and a pulsating fontanel are normal findings. Hydrocephalus in the newborn manifests as hypotension.

A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? a) Client exhibits akathisia only while sitting. b) Client exhibits bradyphrenia during the nursing assessment. c) Client exhibits a shuffling gait with stooped posture. d) Client experiences a decrease in dystonia.

Client experiences a decrease in dystonia. Explanation: Extrapyramidal effects and antipsychotic-induced muscle rigidity are caused by a low level of dopamine. Dopamine receptor agonists reduce extrapyramidal symptoms such as bradyphrenia or slowed thought processes, akathisia or meaningless movements such as marching in place, or dystonia or abnormal muscle rigidity or movements.

A client concerned about being diagnosed with type 2 diabetes tells a nurse, "My mother suffered with diabetes for many years and finally died of kidney failure in spite of treatment. Why should I try if I'm going to go through the same thing?" What is the nurse's most appropriate response? a) "There are no guarantees about how diabetes will progress." b) "It sounds like your mother's diabetes wasn't under very good control." c) "Your mother didn't get the proper treatment." d) "Are you worried that you'll have the same experience as your mother?"

D - Asking if the client feels he'll have the same experience as his mother gives him an opportunity to vent underlying anxiety. There's nothing to indicate that his mother's diabetes wasn't under good control or that she had substandard care. Saying there's no guarantee about how diabetes will progress doesn't appropriately address the client's concerns and may increase his anxiety. After the nurse has addressed the client's anxiety, she can more easily address more-specific teaching needs.

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness? a) Limited spontaneous movement; sluggish speech b) Remains in a deep sleep; responsive only to vigorous and repeated stimulation c) No motor or verbal response to noxious (painful) stimuli d) Can be roused with stimulation

D - The child is obtunded if he can be roused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic.

The neonoate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a. peripheral acrocyanosis b. bradycardia c. lethargy d. jaundice

c - lethargy in the neonate may be seen with hypoglycemia because of a glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia - not bradycardia - is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

The nurse assesses for complications in a newborn infant born with assistance of forceps. Which of the following findings would indicate a need for further assessment? Select all that apply. a) Reduction of movement in one of the infant's arms b) Loss of sensation in one the infant's arms c) Redness and edema on the side of the infant's face d) Lifting causes the infant to cry e) Ecchymosis on the neck

• Lifting causes the infant to cry • Reduction of movement in one of the infant's arms • Loss of sensation in one the infant's arms Explanation: A reported neonatal complication from use of forceps is Erb's palsy. Symptoms that would alert the nurse to Erb's palsy include paralysis and reduced sensation of the affected limb. Crying while lifting could indicate that the infant's clavicle is broken, another complication of a forceps birth. Redness, areas of ecchymosis, and edema are all expected after a forceps birth.

A client has left-sided paralysis. The nurse should document this condition as left-sided: a) hemiplegia. b) paraplegia. c) quadriplegia. d) monoplegia.

A - Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

Nursing care management of the child with bacterial meningitis includes which of the following? Select all that apply. a) Administer intravenous (IV) antibiotics. b) Perform neurologic checks every 4 hours. c) Give IV fluids at 1 ½ times maintenance. d) Decrease environmental stimuli. e) Administer IV anticonvulsants.

• Administer intravenous (IV) antibiotics. • Decrease environmental stimuli. • Perform neurologic checks every 4 hours. Explanation: Antibiotics are indicated for the treatment of bacterial meningitis. Clients with bacterial meningitis often have increased ICP. It is necessary to maintain adequate hydration. However, infusing fluids at 1 ½ times maintenance can increase ICP, further risking neurologic damage from cerebral edema. Most children with meningitis are sensitive to sound, lights, and stimulation. Decreasing environmental stimuli and keeping the room dim and quiet are essential. Frequent neurologic checks are necessary to monitor any changes in the child's level of consciousness. Anticonvulsants are not indicated unless the child experiences seizures as a result of the meningitis.

A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles (1,207 km) away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with: a) Transportation and money for the boys. b) Decision-making abilities. c) Support systems and coping strategies. d) Denial as a primary coping mechanism.

C - The client's resources for coping with the emotional and practical needs of herself and her family need to be assessed because usual coping strategies and support systems are often inadequate in especially stressful situations. The nurse may be concerned with the client's use of denial, decision-making abilities, and ability to pay for transportation; however, the client's support systems will be of more importance in this situation.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the unlicensed personnel to assist with implementing the nursing plan of care by a) Placing a commode at the bedside and instructing the client in its use. b) Ordering adult diapers for the client so she will not have to worry about incontinence. c) Requesting an indwelling urinary catheter to avoid incontinence. d) Padding the bed with extra absorbent linens.

A - A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? a. firm fundus at the symphysis b. white, thick vaginal discharge c. striae that are silver in color d. soft breasts without milk

a - by 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a non-pregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle feeding mother).

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which of the following? a) A full breakfast as desired without coffee, tea, or energy drinks. b) No food or fluids. c) A liquid breakfast of fruit juice, oatmeal or smoothie. d) Only coffee or tea if needed.

A - Full breakfast as desired without coffee, tea, or energy drinks. Beverages containing caffeine, such as coffee, tea, cola drinks, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be NPO.

Which of the following goals is collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? a) To maintain joint flexibility. b) To reduce ataxia. c) To build muscle strength. d) To improve muscle endurance.

A - TO MAINTAIN JOINT FLEXIBILITY The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective.

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants? a) Encourage parents to be present during the treatment. b) Tell the infant that it will be over within a minute. c) Provide the infant with soft toys or a feeding bottle. d) Ask a child specialist to be present during treatment.

A - When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child

A client is transported to the emergency department with an acute respiratory infection. Vital signs are T 102 F (38.8 C), P 110 bpm, R 32 breaths/min. Circumoral cyanosis is noted, and the oxygen saturation is 86%. What should be the immediate actions by the nurse caring for this client? Select all that apply. a) Encourage deep breathing and coughing. b) Place the client in high Fowler's position. c) Initiate oxygen at 6 L/min via nasal cannula. d) Maintain side lying with one pillow. e) Encourage pursed-lip breathing.

B and C - High Fowler's and oxygen - The immediate needs of this client are oxygenation. Due to the cyanosis and decreased oxygen saturation, placing the client in high Fowler's and initiating oxygen will immediately improve gas exchange. Encouraging deep breathing and coughing, and maintaining in a side-lying position, will not improve breathing and will exacerbate the situation. Pursed-lip breathing would be appropriate for a client with COPD.

A client with a diagnosis of cancer is frequently disruptive and challenges the nurse. This behavior may be caused by: a) The one-time crisis from learning of the diagnosis. b) The usual trajectory of a short-term illness. c) Uncertainty and an underlying fear of recurrence. d) A history of a behavioral illness.

C - Cancer clients report that the lifelong fear of recurrence is one of the most disruptive aspects of the disease. The trajectory of the disease is unpredictable and can be intertwined with many short- and long-term illnesses related to cancer and the treatment modalities. A diagnosis of cancer challenges the individual and the family with a series of crises rather than a time-limited episode. There are no data to indicate that the client has an underlying behavioral disorder.

A nurse works in a school with preadolescent students. One of the students has just returned to school after the death of a grandmother. The nurse tries to assess the student's response to the loss. Which statement is most appropriate for the nurse to use with the student? a) "Would you like to tell me about your grandmother? I bet she was very special." b) "I'm here for you any time you need to talk to me about your grandmother." c) "When I lost my grandmother, I felt very sad. Is that how you are feeling?" d) "I understand that you recently lost your grandmother. Is that correct?"

C - Maintaining the therapeutic relationship is important, and some self-disclosure followed by refocusing on the client is therapeutic and may encourage engagement in the conversation. The other options are not helpful in assessing the student's response to the loss

During the postoperative period after a modified radical mastectomy, the client confides in the nurse that she thinks she got breast cancer because she had an abortion and she did not tell her husband. The best response by the nurse is which of the following? a) "You might feel better if you confided in your husband." b) "Cancer is not a punishment; it is a disease." c) "I can have the social worker talk to you if you would like." d) "Tell me more about your feelings on this."

D - The nurse should respond with an open-ended statement that elicits further exploration of the client's feelings. Women with cancer may feel guilt or shame. Previous life decisions, sexuality, and religious beliefs may influence a client's adjustment to a diagnosis of cancer. The nurse should not contradict the client's feelings of punishment or offer advice such as confiding in the husband. A social worker referral may be beneficial in the future, but is not the first response needed to elicit exploration of the client's feelings.

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-services programs. This is an example of which type of report? a. incident report b. nurse's shift report c. transfer report d. telemedicine report.

a - an incident report, also termed a variance report or occurrence report, is a tool healthcare agencies use to document anything out of the ordinary that results in or has the potential to result in harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns and initiating in-service programs to prevent further problems. A nurse's shift report is given by a primary nurse to the nurse replacing him or her by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link healthcare professional immediately and enable nurses to receive and give critical information about clients in a timely fashion.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? a) Protects the client's right to self-determination in health care decision making. b) Helps the client refuse treatment that he or she does not wish to undergo. c) Helps the client to make a living will regarding future health care required. d) Provides the client with in-depth knowledge about the treatment options available.

A - Informed Consent protect's the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, BUT, the MOST IMPORTANT function is to encourage shared decision making. Informed consent does not help the client to make a living will.

The most common issue associated with sleep disturbances in the hospitalized client with cancer is: a) Psychological. b) Cultural. c) Nutritional. d) Social.

A - Most hospitalized persons are at risk for sleep disturbances. Psychological issues (such as anxiety and depression) and pain are related to sleep deprivation. Social, nutritional, and cultural issues are not necessarily associated with sleep disturbances.

Forty-eight hours after undergoing a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. Assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with a recommendation for: a) A dose of morphine. b) A dose of furosemide. c) A computerized tomography scan. d) A fluid bolus of normal saline.

A computerized tomography scan. Explanation: The infant is exhibiting signs and symptoms of increased intracranial pressure (ICP) caused by a shunt malfunction. A CT scan, shunt series X-ray, and tapping the shunt are performed to diagnose a shunt malfunction. Irritability results from the increased ICP, not postoperative pain. The infant has increased ICP; a fluid bolus will further increase it. The increased ICP is caused by a shunt malfunction and will not be relieved by Lasix. Surgical intervention is necessary to correct a shunt malfunction.

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barre syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

ANSWER = 1. 1. Because the client is having an evolving stroke, the client is experiencing a worsening of signs and symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse. 2. A transient ischemic attack by definition lasts less than 24 hours; thus, this client should be stable at this time. When the test taker is deciding which client should be assigned to the most experienced nurse, the MOST critical and UNSTABLE client should be assigned to the most experienced nurse.

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? a) Anticipate the client will exhibit some degree of expressive or receptive aphasia. b) Place the wheelchair on the client's left side when transferring him into a wheelchair. c) Provide close supervision because of the client's impulsiveness and poor judgment. d) Support the right arm with a sling or pillow to prevent subluxation.

C - Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.

A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband's accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. Which of the following nursing interventions is the most appropriate at this time? a) Reassure her that the important fact is that she is here now. b) Describe her husband's medical treatment since admission. c) Allow her to verbalize her feelings and concerns. d) Explain to her that her husband's condition is stable.

C - Verbalizing feelings and concerns helps decrease anxiety and allows the wife to move on to understanding the current situation. Describing events or explaining equipment is appropriate when the person is not distraught and is ready to learn. Explaining the client's medical status is appropriate when the person is not distraught. Reassuring the family member does not allow verbalization of feelings and discounts her feelings.

The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate at this time? 1. Inpatient rehabilitation unit 2. Home health-care agency 3. Long-term care facility 4. Outpatient therapy center

ANSWER = 1 1. This client should be referred to an inpatient rehabilitation facility for intensive therapy before deciding on long-term placement (home with home health care or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time. 2. A home health-care agency may be needed when the client returns home, but the most appropriate referral is to a rehabilitation center where intensive therapy can take place. 3. A long-term care facility may be needed at some point, but the client should be given the opportunity of regaining as much as lost ability as possible at this time. 4. The outpatient center would be utilized when the client is ready for discharge from the inpatient center.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that: a) only low doses of opioids are safe; higher doses may cause respiratory depression. b) clients with terminal cancer may develop tolerance to opioids. c) a client who can fall asleep isn't in pain. d) pain medication should be given only when a client requests it.

B - Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

A client is admitted to the rehabilitation unit after a cerebrovascular accident (or brain attack). The client is bedridden and aphasic. When assessing the client's emotional response to the illness, what would the nurse most want to explore? a) Ability to understand the illness b) Past experiences and coping abilities c) Willingness to participate in rehabilitation d) Frustration with changes in lifestyle

B - It is very important to explore a client's past challenges and coping abilities. This information will help the nurse understand the client's resiliency and know how best to support the client. The client's emotional state would not be assessed by the other options.

A client has been injured in a snowmobile accident and is airlifted to the trauma center with a neck injury. The nurse needs to implement which of the following interventions if the injury is at the C4 level? Select all that apply. a) Measures to control hyperthermia and reduce the metabolic rate b) Assessment of level and extent of paralysis c) Mechanical ventilation to prevent hypoxemia and hypercapnia d) Catheterization to relieve urinary retention to prevent autonomic dysreflexia e) A tracheotomy to maintain a patent airway

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A client is admitted after the police found he had been sleeping in his car for 3 nights. The client says, "My wife kicked me out and is divorcing me. It wasn't my fault I was fired from work. My wife and boss are plotting against me because I am smarter than they are." He then pounds the table and says, "I'm not staying here, and you can't stop me." Which of the following should be included in the client's plan of care? Select all that apply. a) Assault and escape precautions. b) Appropriate housing. c) Anxiety and anger management. d) Suspiciousness and grandiosity issues. e) Collateral information from his wife and boss. f) Divorce counseling.

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A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply. a) Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site. b) Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. c) Verbally ask the client to state his name, surgical site, and procedure. d) Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports. e) Show the client an anatomic model of the surgery site.

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A nurse observes a nursing assistant bending over a bed as she helps an obese client sit up. The nurse discusses her observations with the nursing assistant to reinforce the need for proper body mechanics. Which response indicates that the nursing assistant understands these principles? Select all that apply. a) "I should ask the client to help as much as possible." b) "I should bend at the knees, keep my back straight, then pull the client up." c) "After letting the bed up,grasp the drawsheet, and pull the client up." d) "I need to keep my elbows straight and use my thigh muscles to bear the weight." e) "I need to keep my back straight and lift with my thigh muscles."

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After reinforcing the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statements would demonstrate her understanding of when to call the physician's office? Select all that apply. a) "If the baby seems to be more active than usual." b) "If I notice the veins in my legs getting bigger." c) "If I have a pounding headache that doesn't go away." d) "If the leg cramps at night are waking me up." e) "If I get up in the morning and feel dizzy, even if the dizziness goes away." f) "If I see any bleeding, even if I have no pain."

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The nurse manager in a labor and birth unit is making rounds on a client in early labor. Which of the following indicate that safety procedures are being implemented for this client? Select all that apply. a) Continuous fetal monitoring. b) Mother lying flat on back, if comfortable. c) Client reports pain is tolerable. d) IV rates at ordered level. e) Bed in low position. f) Client satisfied with support system present.

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A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? a) Stressing the importance of following the physician's instructions after surgery. b) Reassuring the client by telling her that surgery is a common procedure. c) Providing the client with information about what to expect postoperatively. d) Telling the client it is normal to be afraid.

C - Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow her physician's orders will not necessarily decrease anxiety.

Which of the following is the most important consideration when performing tracheotomy suctioning? a) Fluid intake should be limited to reduce the amount of secretions produced. b) Oxygen should be provided after each suctioning episode if desaturation occurs. c) The client should be hyperoxygenated, then suctioned for the duration of 10 to 15 seconds. d) Suctioning should be done routinely and frequently to prevent accumulation of secretions.

C - The most important aspect is to ensure the client is hyperoxygenated to increase oxygen saturation levels. Then suctioning should be limited to 10-15 seconds. This helps to prevent desaturation so that breathing is not compromised. It is not enough to apply oxygen if desaturation occurs. Suctioning should be done when necessary, not as a routine. Fluid intake is increased to help liquefy the secretions.

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion? a) Having the client express sadness that the relationship is ending b) Reviewing what's been accomplished during the relationship c) Introducing new issues to the client d) Referring a client to support groups

C - The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.

A nurse is caring for a child recently diagnosed with cerebral palsy, and the parents of the child ask the nurse about the disorder. The nurse bases her response on the understanding that cerebral palsy is: a) An infectious disease of the central nervous system b) An inflammation of the brain as a result of a viral illness c) A congenital condition that results in moderately to severe retardation d) A chronic disability characterized by impaired muscle movement and posture

D. Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infection process of the CNS. Encephalitis is an inflammation of the brain that occurs as a result of a viral illness or CNS infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation. Use the process of elimination. Eliminate options 1&2 first, noting that they are comparable or alike. Next, note the relationship between the words "palsy" in the question and "impaired muscle movement" in D.

A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests? a) Albumin level. b) Reticulocyte count. c) Red blood cell count. d) Direct and indirect bilirubin levels.

A - Serum albumin levels help determine whether protein intake is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake.

A nurse is assessing available support systems for a client in the community mental health clinic. The client is divorced, has no siblings, and both parents died last year. The client has contact with once-supportive former in-laws; however, the client describes a strained relationship since the divorce. With regard to the relationship with the in-laws, what knowledge does the nurse use to plan care? a) Low-quality support relationships often negatively affect coping in a crisis. b) Strong social support is of relatively little importance as a coping factor. c) The in-laws offer the only opportunity to obtain social support for the client. d) The relationship with the in-laws can enhance the client's sense of control.

A - Strong social support enhances mental and physical health, providing a significant buffer against distress. Relationships of low-quality support are known to impact a person's coping effectiveness negatively.

The 7:00 P.M. to 7:00 A.M. nurse has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The male client who has just been brought to the floor from the emergency department (ED) with no report of complaints. 2. The female client who received pain medication 30 minutes ago for pain that was a level "8" on a 1-to-10 pain scale. 3. The male client who had a cardiac catheterization in the morning and has been allowed to use the bathroom one time. 4. The female client who has been turning on the call light frequently and stating that her care has been neglected.

ANSWER = 1 1. This client may or may not be stable. He may have "no complaints" at this time, but the nurse must assess this client first to determine that whatever the complaint was that brought him to the ED has stabilized. This client should be seen first. 2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated, and the nurse can evaluate the amount of pain relief after making sure that the ED admission is stable. 3. This client has been back from the procedure long enough to be allowed bathroom privileges; therefore, this client does not need to be seen first. 4. Psychological issues are important, but not more so than a physiologic issue, and the client admitted from the ED may have a physiologic problem. The test taker should use some tool as a reference to guide in the decision-making process. In this situation, Maslow's Hierarchy of Needs should be applied. PHYSIOLOGIC needs needs have priority over psychosocial ones.

A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an intravenous (IV) line of D5 1/2 NS + 20 meq KCL/L running at 60 ml/hr. Vital signs are a temperature of 100.4 (38 degrees C), heart rate of 120, respiratory rate of 28, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for: a) Rectal acetaminophen. b) IV lorazepam. c) IV fosphenytoin. d) Rectal diazepam.

B - IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter, stopping seizure activity. If an IV line is not available, rectal diazepam is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.

A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby's coming!" To help the client remain calm and cooperative during the imminent birth, which of the following responses by the nurse is most appropriate? a) "You're right, the baby is coming, so just relax." b) "I'll explain what's happening to guide you as we go along." c) "Your doctor will be here as soon as possible." d) "Please don't push because you'll tear your cervix."

B - The client is experiencing a precipitous birth. The nurse should remain calm during a precipitous birth. Explaining to the client what is happening as the birth progresses and how she can assist is likely to help her remain calm and cooperative. Maintaining eye contact is also beneficial. Telling the client that she is right and to just relax is inappropriate because the client may not be able to relax because of the strong urge to push the fetus out of the birth canal. Telling the client not to push because she may tear the cervix can instill fear, not cooperation. Saying that the primary health care provider will be there soon may not be an accurate statement and is not reassuring if the client is concerned about the birth.

The primary health care provider has ordered intravenous mannitol for a child with a head injury. The best indicator that the drug has been effective is: a) Decreased intracranial pressure. b) Increased urine output. c) Improved level of consciousness. d) Decreased edema.

a - decreased ICP Mannitol is an osmotic diuretic used to reduce intracranial pressure. The use of the drug is controversial and should be reserved to cases which do not respond to other treatments or when brain herniation is likely. Children this sick should be on intracranial pressure (ICP) monitoring. The best indicator that the drug has produced the desired results is a reduction in the ICP. Improved levels of consciousness should follow reduced ICP. While the drug will cause increased urine output, that measurement in and of itself does not indicate successful treatment. Because the drug is being used for head injuries, not to improve urine output in acute renal failure, the child may not have visible edema.