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A male client reports little or no sexual desire, causing marital discord over the past year. What priority questions will the nurse ask the client to explore lack of sexual desire? Select all that apply.

"Did you experience this decreased desire before?"What are the current medications you are taking?""Do you have any medical conditions?" Clarifying the symptoms and their onset will provide an opportunity to gather useful information about the client's current condition. Many medications can have a profound effect on sexual desire as can some medical conditions. The client's sexual practices and marital history have no direct bearing on the client's lack of desire.

2/100900The family meeting began by the client's family demanding that the client "stop using marijuana at once, or there will be severe consequences, including no support to attend college." The drug, and the problems associated with its use, were explained to the family.What educational topic should the nurse address with this family during the next teaching session?

Address how the substance use has affected each member of the family. As the client continues to use a substance, it is common for the family members to develop anxiety, depression, anger, and physical symptoms to help them to cope with the distress. Talking about how things were for this client in the past may, or may not, be effective. Clients who use cannabis do not tend to become violent. It is unrealistic to expect an immediate and dramatic shift in a person's thinking about substance use.

The nurse is preparing to care for a postoperative thyroidectomy client who has just returned to the unit after surgery. What are the most important nursing interventions for this client? Select all that apply.

Have an emergency tracheotomy set on hand.Check behind the neck for bleeding.Monitor voice quality regularly.Observe for sudden increase in temperature, respiratory distress, and tetany. Postoperative thyroidectomy clients may need humidified oxygen and should be placed in the semi-Fowler's position. Vital signs will need to be monitored for any changes, and the client should be observed for bleeding behind the neck under the dressing. It is important to observe for signs of respiratory distress and to have tracheotomy equipment on hand. Monitor voice quality for injury to vocal chords. If the client develops postoperative thyroid storm/crisis, the temperature could rise as high as 106° F (41.1° C), and tetany may develop if the parathyroid glands were injured or removed.

A nurse is caring for a client whose cultural background is different from the nurse's. Which actions are appropriate? Select all that apply.

Nonverbal cues may have different meanings in different cultures. In one culture, eye contact is a sign of disrespect. In another culture, eye contact shows respect and attentiveness. The nurse should always respect the client's cultural beliefs, and ask if there are cultural or religious requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture. It isn't the client's responsibility to understand the nurse's culture. Culture influences a client's experience of pain.

A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply.

Provide small, frequent meals. Monitor weight gain.Encourage the client to keep a journal. Due to self-starvation, clients with anorexia can rarely tolerate large meals three times per day. Small, frequent meals may be tolerated better by the anorexic client, and they provide a way to gradually increase daily caloric intake. The nurse should monitor the client's weight carefully because a client with anorexia may try to hide weight loss. The client may be emotionally restrained and afraid to express feelings; therefore, keeping a journal can serve as an outlet for these feelings. An anorexic client is already underweight and should not be permitted to skip meals.

Which electrocardiogram (ECG) strip would the nurse expect to see from a child with bradycardia?

See screen shot image. Sawtooth — a. flutter. Chaotic — V. fibrillation. Bizarre — V. tachycardia.

Which non-pharmacologic interventions should be included in the plan of care for a client who has moderate rheumatoid arthritis? Select all that apply.

applying splints to inflamed joints. selecting clothing that has Velcro fasteners applying moist heat to joints. Supportive, non-pharmacologic measures for the client with rheumatoid arthritis include applying splints to rest inflamed joints, using Velcro fasteners on clothes to aid dressing, and applying moist heat to joints to relax muscles and relieve pain. Inflamed joints should never be massaged because doing so can aggravate inflammation. A physical therapy program including ROM exercises and carefully individualized therapeutic exercises prevents loss of joint function. Assistive devices should be used only when marked loss of ROM occurs.

During the admission assessment, the nurse focuses on the client's reflexes, muscle strength, coordination, eye movements, and mental status. What symptoms would the nurse identify as suggestive of vascular dementia? Select all that apply.

losing bladder control laughing inappropriately shuffling gait The typical symptoms of vascular dementia are confusion, memory deficits, wandering, shuffling gait, loss of bladder and bowel control, and inappropriate laughter. Leg swinging, head hyperextension, and joint deformities are not symptoms associated with vascular dementia.

What should the nurse include when prioritizing care for a client with advanced polycystic kidney disease (PKD)? Select all that apply.

pain management; prevention of infection; prevention of constipation; monitoring of electrolytes. Interventions for the client with PKD include pain management and prevention of infection, constipation, hypertension, and chronic kidney disease. Monitoring electrolytes is necessary because the disease often progresses to kidney failure, which a consequent effect on electrolyte levels. Cardiac arrhythmias would be atypical.

The nurse is reviewing a client's medication list and providing instruction on how to take each medication. Which medication should not be taken with grapefruit juice? Select all that apply.

simvastin fexofenadine buspirone erythromycin Digoxin is a cardiac glycoside and levothyroxine is a thyroid preparation. Neither drug interacts with grapefruit.

2/10/2017 0800 A client was admitted for intracranial hemorrhage four days ago. Morning laboratory results demonstrate a low serum sodium of 121 mEq/L, a low serum osmolality of 256 mOsm/kg, a high urine osmolality of 588 mOsm/kg, and a high urine sodium of 89 mmol/L. Vital signs are stable. Urine output is high, averaging greater than 100 cc/hr. Which nursing interventions should the nurse include when planning care for a client with cerebral salt wasting (CSW) syndrome?

sodium and fluid replacement Cerebral salt wasting syndrome is a volume-depleted and sodium-wasting state, requiring fluid replacement with isotonic solutions to prevent further deterioration. Its presentation is similarly to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is treated with free water restriction. Synthetic vasopressin replacement is used to treat central diabetes insipidus.

A 33-year-old client reports never having an orgasm. The client's partner is upset about being unable to meet the client's needs. Which interventions should the nurse implement? Select all that apply.

Ask the client if intercourse is enjoyable and if the client feels there is a problem. Assess the couple's sexual history and their perception of the problem. In this case it is important to assess both partners to determine the perception and extent of the problem. When assessing the client, the nurse should be professional and matter-of-fact while discussing sexual activity and associated pleasure or possible difficulties. Assessing the couple's perception of the problem will help define it, and assist the couple and the nurse in understanding it. Most individuals can be taught to reach orgasm if there is no underlying medical condition. It is unethical and improper to direct the client to fake an orgasm with a sexual partner. A nurse cannot make a medical diagnosis such as sexual aversion disorder.

The nurse is teaching a client recovering from a femur fracture repair to walk with crutches using a four-point gait, beginning with the left foot. Prioritize the steps of this nurse's instructions.

Assume tripod position, bearing weight on the handgrips. Move the right crutch forward 4 to 6 inches (10 to 15 cm). Move the left foot forward to the level of left crutch. Move the left crutch forward 4 to 6 inches (10 to 15 cm). Move the right foot forward to the level of right crutch.

The nurse is teaching a female client about postmenopausal bone loss. What will the nurse include with the teaching? Select all that apply.

Be active three times a week with weight-bearing exercises.Sun exposure can be beneficial, but sunscreen should be used. Stool softeners do not increase peristalsis, so they do not impair calcium absorption or precipitate bone loss. The nurse should encourage natural vitamin D production by promoting sun exposure, but must balance this benefit with the risk for skin cancer development by recommending sunscreen. Exercising with weight-bearing activities does prevent bone loss; however, while swimming and cycling are good for cardiovascular health, the lack of weight-bearing means they do not directly reduce bone loss. Calcium channel blockers do not affect serum calcium levels. Smoking and secondhand smoke may cause bone loss; being in the house with a smoker is a risk factor that is not adequately controlled by going to a different floor or room.

The nurse is caring for a client with histrionic personality disorder. The client's family member asks, "How do I handle the drama that occurs with my family member?" What information should the nurse provide this family? Select all that apply.

Do not argue or try to rationalize things with the person." "State your responses in a non-emotional manner." "Remember to give positive feedback whenever possible." "Maintain a serious and personal interest in the person."

The nurse has just admitted a client to the telemetry floor with reports of acute chest pain radiating down the left arm. Which laboratory studies should the nurse order to evaluate myocardial damage? Select all that apply.

creatinine phosphokinase (CK-MB)/troponin T and troponin I/myoglobin

A nurse is talking to a client who delivered her baby 5 days ago, and suspects that the client is having the postpartum blues. Which client behavior is suggestive of this problem? Select all that apply.

Postpartum blues are a transient mood alteration that arises during the first 3 weeks postpartum and are typically self-limiting. They affect 50% to 80% of postpartum clients. Postpartum depression, a more severe mood alteration, is seen in approximately 20% of clients. It involves changes that occur within a few days after birth, and may last for a few days to more than one year. Crying, difficulty sleeping, and mood swings are commonly seen in clients with postpartum blues, while the inability to care for the infant and voicing feelings of worthlessness are more indicative of postpartum depression.