Client needs Pt 1

An elderly client asks a nurse how to treat chronic constipation. What is the best recommendation the nurse can make? "Administer a phospho-soda enema when necessary." "Taking magnesium citrate when necessary will help." "Take a stool softener, such as docusate sodium (Colace), daily." "Use a tap-water enema weekly to evacuate the rectum."

"Take a stool softener, such as docusate sodium (Colace), daily." Explanation: Stool softeners taken daily treat chronic constipation by promoting absorption of liquid into the stool, creating a softer mass. Clients can take them on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or frequently can also lead to dependence of the bowel on an external source of stimulation. Tap water enemas should be used cautiously. The hypotonic nature of tap-water pulls the electrolytes from the body fluid and increases the risk for electrolyte imbalance.

The hospice nurse is caring for a client who is approaching death. The client has accepted death, is prepared to transition, but seems to forestall death. When asked by a new hospice nurse about forestalling death, which appropriate psychological event will the nurse relay to the new hospice nurse? anticipatory grieving nearing death awareness waiting for permission phenomenon central nervous system alterations

waiting for permission phenomenon Explanation: A dying client may accept death, but also realize that an important person is not ready to let go. The client tries to forestall death until the person gives permission - waiting for permission phenomenon. Central nervous system alterations occur from hypoxia of the brain. Anticipatory grieving is mourning the loss, whether by the client or family member, it is anticipating the change in life due to death. When the client has a premonition of the time or date of death, it is known as the nearing death awareness.

A visitor asks the nurse about entering the room of a client who has contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). The nurse explains the necessary precautions needed to visit the client. What statement by the visitor reflects understanding of the contact precautions teaching? "The mask will decrease the risk of my friend spreading MRSA." "The use of these masks and gloves will decrease the risk of me getting MRSA." "By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." "I will wash my hands after I go in the room and if I touch anything in my friend's room."

"By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." Explanation: Contact precautions for MRSA require gloves and gowns. A mask does keep respiratory secretions in isolation, but the client has MRSA and is on contact precautions. The visitor should wash hands before the visit and after the visit to decrease the spread of the MRSA.

A 20-year-old female client is asking questions about breast cancer. Which information should the nurse provide to this client? "It is important that you become familiar with your breasts so that you can detect any changes." "Every month before the start of your menstrual cycle, you should examine your breasts." "You should start wearing a bra without underwire that provides good support for your breasts." "Women should have their first screening mammogram before they are 40 years old."

"It is important that you become familiar with your breasts so that you can detect any changes." Explanation: American and the Canadian Cancer Society recommend that women become familiar with their breast tissue by looking at and feeling their breasts and reporting any changes to a health care provider right away. The American Cancer Society previously recommended that women perform breast self-examinations every month, 7 to 10 days after menses starts. Wearing a bra that is supportive without underwire and having a mammogram before 40 years of age are not causes of or recommendations for breast cancer screening.

The parents of a client with anorexia nervosa ask the nurse about the risk factors for this disorder. After reinforcement of the education plan by the nurse, which statement by the parents best indicates that it has been effective? "Risk factors include a high level of anxiety and disorganized behavior." "Risk factors include the inability to be still and emotional lability." "Risk factors include low self-esteem and problems with family relationships." "Risk factors include a lack of life experiences and opportunities to learn life skills."

"Risk factors include low self-esteem and problems with family relationships." Explanation: There are several risk factors for eating disorders, including low self-esteem, history of depression, substance abuse, and dysfunctional family relationships. Restlessness and emotional lability are symptoms of manic-depressive illness. Anxiety and disorganized behavior could be signs of a psychotic disorder. A lack of life experiences and an absence of opportunities to learn life skills may be a result of anorexia.

The nurse is assisting with the development of a plan of care for a client with generalized anxiety disorder (GAD). Which intervention is important to include? Assist the client to make plans for regular periods of leisure time. Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped. Encourage the client to engage in activities that increase feelings of power and self-esteem. Promote the client's interaction and socialization with others.

Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped. Explanation: One of the nurse's goals is to help the client with generalized anxiety disorder associate symptoms with an event, thereby beginning to learn appropriate ways to eliminate or reduce distress. A diary can be a beneficial tool for this purpose. Although encouraging the client to engage in activities that increase feelings of power and self-esteem; promoting interaction and socialization with others; and assisting the client to make plans for regular periods of leisure time may be appropriate, they are not the priority.

A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate? Tell the client that her milk is starting to come in because she's in labor. Perform a culture on the discharge, and inform the client that she might have mastitis. Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy. Complete a thorough breast examination, and document the results in the chart.

Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy. Explanation: After the fourth month of pregnancy, colostrum may be noticed. The breasts normally produce colostrum for the first few days after birth. Milk production begins 1 to 3 days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? It should begin early in the third trimester and end 1 month after delivery. It should begin before conception and end 3 months after delivery. It should begin at about 5 months' gestation and end at facility discharge. It should begin when the client learns she's pregnant and end after delivery.

It should begin before conception and end 3 months after delivery. Explanation: Ideally, childbirth education should begin before conception (or as soon after conception as possible) and continue for about 3 months after delivery. Beginning childbirth education later and ending it earlier wouldn't provide enough time for optimal preparation of the client and her partner.

A client who experienced a stroke has left-sided facial droop. During mouth care, the client begins to cough violently. What should the nurse do? Maintain the client on nothing-by-mouth status. Continue providing mouth care because the client's gag reflex is intact. Avoid providing mouth care. Make sure a tonsil suction device is readily available while providing mouth care.

Make sure a tonsil suction device is readily available while providing mouth care. Explanation: The client with facial droop has difficulty swallowing secretions during mouth care. Therefore, the nurse should have a tonsil suction device available to suction the client's mouth to avoid further coughing episodes and prevent aspiration. The client should undergo swallowing studies before a decision is made on whether to maintain nothing-by- mouth status. Continuing mouth care without the tonsil suction device places the client at risk for aspiration.

A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often? Once per year Twice per year Once, to establish a baseline Every 2 years

Once per year Explanation: The American Cancer Society (Canadian Cancer Society) recommends having a mammogram every year starting at age 40. Women at increased risk (those with a family history, genetic tendency, or history of breast cancer) should talk to their physicians about beginning screening earlier than age 40.

The parent of a neonate born with hypospadias is sharing feelings of guilt about this anomaly with a nurse. What is the best response by the nurse? "You should not feel guilty; there is nothing you could have done." "It is a waste of time to worry; you need to concentrate on taking care of your baby." "Maybe you need to talk to a specialist to see if it is hereditary." "Do you want to talk about how you have been feeling?"

"Do you want to talk about how you have been feeling?" Explanation: The nurse should encourage the parent to talk about how she has been feeling and allow her to be heard. This defect is not hereditary, nor is it carried by an autosomal recessive gene. The other two options belittle the parent's feelings.

The nurse is caring for a client with posttraumatic stress disorder (PTSD) and the family informs the nurse that loud noises cause a serious anxiety response. Which explanation by the nurse would help the family understand the client's response? "Clients commonly experience extreme fear of normal environmental stimuli." "The response indicates another emotional problem needs investigation." "After a trauma, the client can't respond to stimuli in an appropriate manner." "Environmental triggers can cause the client to react emotionally."

"Environmental triggers can cause the client to react emotionally." Explanation: Repeated exposure to environmental triggers can cause the client to experience a hyperarousal state because there's a loss of physiological control of incoming stimuli. After experiencing a trauma, the client may have strong reactions to stimuli similar to those that occurred during the traumatic event. However, not all stimuli cause an anxiety response. The client's anxiety response is typically seen after a traumatic experience and does not indicate the presence of another problem.

After a nurse reinforces discharge education to the parents of a child with hypospadias, which statement by the parent indicates that additional education is needed? "I'll need to learn irrigation techniques." "It's important to keep the catheter free of kinks and blockages." "Proper catheter care helps prevent infection." "I should bathe my child in the tub daily."

"I should bathe my child in the tub daily." Explanation: A tub bath should be avoided to prevent infection until the stent has been removed. Parents are taught to care for the indwelling catheter or stent and how to perform irrigation techniques if indicated. They need to know how to empty the urine bag and how to avoid kinking, twisting, or blockage of the catheter or stent.

A nursing student is surprised that a young couple is seeking treatment for Infertility. When asked by the nursing instructor to define it in a 25-year-old couple, how does the student respond? "It is the couple's inability to conceive after 1 year of unprotected attempts." "It is the couple's inability to conceive after 6 months of unprotected attempts." "It is the couple's inability to sustain a pregnancy." "It is a low sperm count and decreased motility."

"It is the couple's inability to conceive after 1 year of unprotected attempts." Explanation: The determination of infertility is based on age. In a couple younger than 30 years old, infertility is defined as failure to conceive after 1 year of unprotected intercourse. In a couple age 30 or older, the time period is reduced to 6 months of unprotected intercourse.

An exercise stress test has been ordered for a 12-year-old child. Which statement by the child indicates the need for further instruction? "It will be important for me to eat the breakfast my mom makes for me before I take the test." "If I have any pain or difficulty breathing during the test, I need to let the nurse know." "The test should take only about 30 to 45 minutes." "I can eat after the test is finished."

"It will be important for me to eat the breakfast my mom makes for me before I take the test." Explanation: The exercise stress test will monitor the heart rate, blood pressure, and oxygen consumption during a period of activity. The child will be NPO (nothing by mouth) for at least 4 hours prior to the test. The remaining statements are correct.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. The client has questions about the paralysis. What information will the nurse tell the client about the paralysis? "You'll first regain use of your legs and then your arms." "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." "The paralysis caused by this disease is temporary." "It must be hard to accept the permanency of your paralysis."

"The paralysis caused by this disease is temporary." Explanation: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

To maintain a therapeutic environment with a client and his family, the nurse can use communication techniques such as clarification. Which statement is an example of the clarification technique? "How is it going?" "You say you aren't concerned, but you've asked me many questions on this same subject." "What do you mean when you say...?" "For now, I would like to concentrate on...."

"What do you mean when you say...?" Explanation: Asking the client what he means by a particular statement is an example of the clarification technique or validation seeking. Asking the client how things are going isn't a communication technique. Asking the client what he means is an example of confrontation; this technique calls attention to discrepancies in what the client is saying. Telling the client what the nurse would like to discuss is an example of focusing, which helps the client direct his thoughts.

A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate? "If you keep a positive attitude, you can do anything." "What makes you think you won't be able to walk again?" "What has your physician told you about your ability to walk again?" "Most likely you won't be able to, but we never know for sure."

"What has your physician told you about your ability to walk again?" Explanation: The nurse should respond by asking the client what he's already been told about his ability to walk again. After assessing the client's knowledge, she can better respond to the client's questioning. Option 1 provides the client with false hope, and option 2 may place the client on the defensive. Option 4 is an inappropriate response.

Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking? A breast-fed, 7-lb, 2-oz (3.2-kg) neonate who produces three stools and wets six diapers per day A bottle-fed, 7-lb, 4-oz (3.3-kg) neonate who drinks 23 oz of formula per day over the course of eight feedings A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day A breast-fed, 7-lb, 4-oz (3.3-kg) neonate who feeds on demand and averages ten feedings per day

A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day Explanation: A neonate with adequate nutrition voids six to eight times per day and has two or more bowel movements. A bottle-fed, 7-lb, 2-oz neonate who produces two stools and wets four diapers per day is at risk for imbalanced nutrition. Neonates need to be fed on demand, and breast-fed infants commonly feed every 2 hours. The 7-lb, 2-oz infant needs 17.5 to 21 oz of formula per day.

A client in college who has recently been diagnosed with human papillomavirus (HPV) infection comes to the health clinic and is anxious and tearful. Which nursing intervention would be most appropriate? Refer the client to a gynecologist. Ask the client to discuss concerns. Provide the client with reliable information about this condition. Discuss the dangers of multiple sex partners.

Ask the client to discuss concerns. Explanation: Encouraging the client to discuss concerns establishes a nonjudgmental, therapeutic relationship and would be the best initial response. Other interventions might be appropriate at some point. After a therapeutic relationship is established, the nurse should discuss the dangers of multiple sex partners in a nonjudgmental manner.

The nurse is admitting a client with abdominal pain, bloody stools, weakness, and dizziness when the client reports feeling the urge to have a bowel movement. What is the priority action by the nurse? Ask the client to wait for specimen collection. Assist the client onto the bedpan. Assist the client to the bedside commode. Have the client ambulate to the bathroom.

Assist the client onto the bedpan. Explanation: A client who is dizzy and weak is at risk for fall injury. Assisting the client with the bedpan would best meet the client's needs at this time without risking safety. If this client attempts to stand up without help, or walk to the bathroom alone, the client may fall and be injured. Asking the client to wait is not an appropriate intervention for toileting.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Crossing the client's ankles every 2 hoursterm-2 Putting slippers on the client's feet Placing hand rolls on the balls of each foot Attaching braces or splints to each foot and leg

Attaching braces or splints to each foot and leg Explanation: Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment. Slippers can't prevent footdrop because they're too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, which term-4promotes thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because they're too soft to support and hold the feet in proper alignment.

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? Avolition Perseveration Tangential Word salad

Avolition Explanation: Avolition refers to impairment in the ability to initiate goal-directed activity, lack of motivation, and inattention to needs such as personal hygiene and activities of daily living. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential behavior is exhibited when a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions.

The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first? Sit with the client for a few minutes. Call the physician immediately. Administer an analgesic. Inform the nurse-manager.

Call the physician immediately. Explanation: The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse-manager isn't necessary.

A client with osteoarthritis is refusing to perform independent daily care. Which approach would be most appropriate to use with this client? Explain that complete independence should be maintained. Inform the client that after care is completed, pain medication will be administered. Encourage the client to perform as much care as pain will allow. Perform the care for the client.

Encourage the client to perform as much care as pain will allow. Explanation: A client with osteoarthritis should be encouraged to perform as much of her care as possible. The nurse's goal should be to allow the client to maintain her self-care abilities with help as needed. It's never appropriate to use pain medication as a bargaining tool.

A 22-year-old client with an external fixation device attached to his left thigh is unable to bear weight on his left leg. He asks a nurse if he can take a shower on his third postoperative day. After a review of the physician's orders, the nurse notes an order stating, "Client may shower ten (10) days after surgery." In order to meet the client needs, what appropriate action will the nurse take? Assist the client into the shower while he supports himself with one crutch. Wrap the device with plastic and then assist the client into the shower using a wheelchair. Explain that he is not permitted to shower, but the nursing assistant can help him with a sponge bath. Suggest that the client wait until he's able to bear weight on his left leg.

Explain that he is not permitted to shower, but the nursing assistant can help him with a sponge bath. Explanation: The client is permitted to shower while the external fixation device is in place if appropriate and approved by the physician. The client needs can be met by having the nursing assistant give him sponge baths. The fixator does not need to be protected from soap and water. Because the client cannot bear weight on his left leg, it's unsafe to assist the client into the shower while he supports himself with one crutch.

While reviewing the mental health chapter, which symptoms does the nursing student identify as the positive symptoms of schizophrenia? Somatic delusions, echolalia, and a flat affect Hallucinations, delusions, and disorganized thinking Waxy flexibility, alogia, and apathy Flat affect, avolition, and anhedonia

Hallucinations, delusions, and disorganized thinking Explanation: The positive symptoms of schizophrenia are distortions of normal functioning. Hallucinations, delusions, and disorganized thinking are positive symptoms of schizophrenia. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms reflect the diminution or loss of normal function.

According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage of development? Trust versus mistrust Identity versus role confusion Industry versus inferiority Initiative versus guilt

Industry versus inferiority Explanation: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence.

The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair? Parallel to the bed on the right side Perpendicular to the bed on the right side Parallel to the bed on the left side Parallel to the bed on either side

Parallel to the bed on the right side Explanation: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg.

A client, who has a new above-the-knee amputation, refuses to look at the residual limb and refuses family visits. When the nurse attempts to speak with the client about the surgery, the client replies, "I do not want to discuss it." Which nursing intervention is appropriate? Suggest a referral for a mental health examination. Avoid asking about the surgery to respect the client's wishes. Discuss the client's comments with the family. Provide support during the grieving process.

Provide support during the grieving process. Explanation: The nurse must recognize these are signs of grieving and should support the client during this process. This client has lost a limb and is in a depressed state of grieving. The five stages of grief are denial, anger, bargaining, depression, and acceptance. A referral for a mental health examination is not warranted because this is a recent surgery. This client should be encouraged to talk about the client's feelings. The nurse should respect the client's privacy and not discuss the client's comments with the family.

A nurse is assisting with an educational session for a group of women on the topic of urinary tract infection (UTI) prevention. Which information should the nurse expect to be included in this session? Take prescribed medications until the symptoms subside. Limit fluid intake to reduce the need to urinate. Wear only nylon underwear to reduce the chance of irritation. Report any urinary difficulty to the health care provider.

Report any urinary difficulty to the health care provider. Explanation: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. Clients should notify their healthcare provider so that microscopic urinalysis can be done and appropriate treatment can be initiated. Women should be instructed to drink 2 to 3 qt (1.9 to 2.9 L) of fluid per day to dilute the urine and reduce irritation on the bladder mucosa. The full course of antibiotics prescribed for UTIs must be taken, even if symptoms subside. Doing so helps to prevent recurrences. Women should avoid scented toilet tissue and bubble baths and should wear cotton (not nylon) underwear to reduce the chance of bladder irritation.

When teaching the parents of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which of the following descriptions should the nurse include? Burning or pain with urination Reports of a stiff neck History of febrile seizures Fever disappearing for longer than 24 hours, then returning

Reports of a stiff neck Explanation: A child with a fever and a stiff neck should be evaluated immediately for meningitis. All other symptoms should be addressed by the physician but can wait until office hours.

A 6-week-old infant is brought to the clinic for a well-baby visit. To check the fontanels, how should the nurse position the infant? Supine Seated upright Prone In the left lateral position

Seated upright Explanation: For the most accurate results, the nurse should seat the infant upright to assess the fontanels and should perform this assessment when the infant is quiet. Pressure from postural changes or intense crying may cause the fontanels to bulge or seem abnormally tense. When the infant is in a recumbent position, the fontanel is less flat than it is normally, creating the false impression that intracranial pressure is increased.

The nurse explains to a client with thyroid disease that the thyroid gland normally produces: T3, T4, and calcitonin. thyrotropin-releasing hormone (TRH) and TSH. TSH, T3, and calcitonin. iodine and thyroid-stimulating hormone (TSH).

T3, T4, and calcitonin. Explanation: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. TSH is produced by the pituitary gland to regulate the thyroid gland. TRH is produced by the hypothalamus gland to regulate the pituitary gland.

A nurse is reinforcing discharge instructions to the parents of a child who had a tonsillectomy. Which instruction is the most important? The child should drink extra milk. The child shouldn't drink from straws. Orange juice should be given to provide pain control. The mouth should be rinsed with salt water to provide pain relief.

The child shouldn't drink from straws. Explanation: Straws and other sharp objects inserted into the mouth could disrupt the clot at the operative site. Extra milk wouldn't promote healing and may encourage mucus production. Although drinking orange juice and rinsing with salt water will irritate the tissue at the operative site, irritation doesn't pose the same level of danger as clot disruption.

The nurse educator is discussing a case regarding a client with obsessive-compulsive disorder who tells the nurse that he or she must check the lock on his or her apartment door 25 times before leaving for an appointment. The nurse educator includes which information about what this behavior represents? The client's attempt to maintain the safety of his or her home The client's attempt to reduce anxiety The client's attempt to control his or her thoughts The client's attempt to call attention to himself or herself

The client's attempt to reduce anxiety Explanation: A compulsion is a repetitive act or impulse. Carrying out a compulsion helps a person reduce anxiety unconsciously. An obsessive-compulsive client doesn't want to call attention to himself or herself and can't control his or her thoughts. This client's priority is to reduce anxiety — not maintain the safety of the home.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? The nurse dries from forearms up toward fingers. The nurse keeps hands lower than elbows while washing. The nurse dries from finger tips down toward elbows. The nurse uses at least 3 to 5 mL of liquid soap.

The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate? Traction will help prevent skin breakdown. Traction helps with repositioning while in bed. Traction helps to prevent trauma and overcome muscle spasms. Traction allows for more activity.

Traction helps to prevent trauma and overcome muscle spasms. Explanation: Traction prevents trauma and overcomes muscle spasms. Traction doesn't help in preventing skin breakdown, repositioning the client, or allowing the client to become active.

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism? Wear a face mask when in close contact with the client. Administer ribavirin by nebulizer as prescribed. Educate the family about the differences between alcohol-based hand rubs and soap and water. Wear a gown, gloves, and goggles when providing personal care.

Wear a face mask when in close contact with the client. Explanation: RSV infection necessitates droplet precautions, including the use of a facemask. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection.

A 10-month-old infant with bacterial meningitis was just started on antibiotic therapy. Which nursing action is especially important in this situation? Administer oral gentamicin. Encourage the child to drink 3,000 mL of fluid per day. Wear a mask while providing care. Flex the child's neck every 4 hours to maintain range of motion.

Wear a mask while providing care. Explanation: With bacterial meningitis, respiratory isolation must be maintained for at least 24 hours after beginning antibiotic therapy. Wearing a mask is an important part of respiratory isolation. Moving the child's head to maintain range of motion would cause pain because his meninges are inflamed. Gentamicin is never administered orally. Encouraging 3,000 mL of fluid would cause overhydration in a 10-month-old infant and place him at risk for increased intracranial pressure.

A client is in the first stage of labor. Her cervical dilation has progressed from 4 to 7 cm. The nurse understands that the client is most likely in which phase? transition phase active phase latent phase preparatory phase

active phase Explanation: Cervical dilation occurs more rapidly during the active phase than any of the previous phases. The active phase is characterized by cervical dilation that progresses from 4 to 7 cm. The preparatory, or latent, phase begins with the onset of regular uterine contractions and ends when rapid, cervical dilation begins. Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.

A client has been prescribed a diet that limits purine-rich foods. Which would the nurse teach the client to avoid eating? milk, ice cream, and yogurt bananas and dried fruits anchovies, sardines, kidneys, sweetbreads, and lentils wine, cheese, preserved fruits, meats, and vegetables

anchovies, sardines, kidneys, sweetbreads, and lentils Explanation: Anchovies, sardines, kidneys, sweetbreads, and lentils are high in purines. Bananas and dried fruits are high in potassium. Milk, ice cream, and yogurt are rich in calcium. Wine, cheese, preserved fruits, meats, and vegetables contain tyramine.

A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: as the infant plays. as the mother rocks the infant. as the mother feeds the infant. as the infant sleeps.

as the mother feeds the infant. Explanation: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for instance, the mother may interact with the infant at a distance. Rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance.

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, doing this helps the child achieve: industry. trust. initiative. autonomy.

autonomy. Explanation: According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. An infant is at the stage of trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt.

A nurse has started working in a long-term-care facility. During the evaluation of an older adult client, the nurse should expect which finding? change in the structure of the eyes decreased facial hair in female clients increased facial hair in male clients quick wound healing

change in the structure of the eyes Explanation: Multiple structural changes occur in the eyes of older adult clients. Women commonly have increased facial hair, whereas men have decreased facial hair. Wound healing is slowed due to nitrogen loss.

A client with dependent personality disorder is working on goals for self-care. Which short-term goal statement would be the initial goal? perform all self-care activities independently complete self-care activities in a minimal amount of time write a daily schedule for each day of the week determine activities that can be performed without help

determine activities that can be performed without help Explanation: Each of the statements would be appropriate for inclusion in the plan of care. The initial goal, however, will be the determination of activities. The other goal statements may be included but not first. By determining activities that can be performed without assistance, the client with dependent personality disorder can then begin to practice them independently. If the nurse only encourages a client to perform self-care activities independently, nothing may change. Writing a daily schedule doesn't help the client focus on what needs to be done to promote self-care. The amount of time needed to perform self-care activities isn't important. If time pressure is put on the client, there may be more reluctance to perform self-care activities.

When plotting height and weight on a growth chart, which observation by the nurse would indicate that a 4-year-old child has a growth hormone deficiency? upward shift of 1 percentile or more upward shift of 5 percentiles or more downward shift of 2 percentiles or more downward shift of 1 percentile or more

downward shift of 2 percentiles or more Explanation: When the health care provider evaluates the results of plotting height and weight, upward or downward shifts of 2 percentiles or more in children older than age 3 may indicate a growth abnormality.

A client is admitted to the emergency department with chest discomfort, diaphoresis, and nausea. Suspecting possible myocardial infarction (MI), the nurse would anticipate that the health care provider will prescribe which diagnostic test to quickly determine myocardial damage? electrocardiogram cardiac catheterization echocardiogram cardiac enzymes

electrocardiogram Explanation: Electrocardiogram is the quickest, most accurate, and most widely used tool to diagnose MI. Cardiac enzymes also are used to diagnose MI, but the results can't be obtained as quickly. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease.

The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is: instructing the client not to get out of bed without assistance. keeping the bed in the lowest possible position. placing the call light for easy access. keeping the bedpan available so that the client doesn't have to get out of bed.

keeping the bed in the lowest possible position. Explanation: Keeping the bed in the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when assistance is required, the bed must first be in the lowest position. The client may not require a bedpan.

A student nurse is preparing to administer an injection to a client. The instructor asked the student questions related to the administration of the injection. The student did not hear the questions, her muscles became tense, and her hands sweaty. The student nurse may be experiencing which level of anxiety? panic severe moderate mild

moderate Explanation: Experiencing moderate anxiety is demonstrated by selective inattention. Perceptual field has narrowed, causing the inability to focus on what the instructor is saying.

A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should: palpate the bladder above the symphysis pubis. be unable to palpate the bladder. feel that the bladder is smooth. palpate the bladder at the umbilicus.

palpate the bladder above the symphysis pubis. Explanation: Eight hours is a long time not to have voided. Typically, the kidneys produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder should be full of urine and palpable above the symphysis pubis. If the bladder isn't full after 8 hours, the client's kidneys may be malfunctioning or the client may be dehydrated.

The nurse is caring for a client on isolation precautions. The nurse exits the room and proceeds to take off the personal protective equipment (PPE). Which option identifies how the nurse should correctly remove the PPE? remove gloves, mask, and gown remove mask, gown, and gloves remove gown, gloves, and mask remove gloves, gown, and mask

remove gloves, gown, and mask Explanation: The nurse should remove the gloves first, followed by the gown and then the mask. This sequence prevents contamination from the gloves and gown to other parts of the body.

The nurse is caring for a preschool-age child who sustained burns in a house fire. The child is prescribed morphine every 4 hours for pain. Which parameter is most important when monitoring a child who's receiving morphine? blood pressure temperature respirations pulse

respirations

The nurse is discussing cocaine, amphetamines, and caffeine with a client. How would the nurse classify these substances? analgesics opiates stimulants anticholinergics

stimulants Explanation: Cocaine, amphetamines, and caffeine are all stimulants. Acetaminophen is an analgesic. Oxycodone is an opiate. Atropine is an anticholinergic.

A client with paranoid personality disorder is discussing current problems with a nurse. Which nursing intervention has priority in the care plan? ask the client to focus on ways to interact with others suggest the client clarify thoughts and beliefs about an event encourage the client to look at sources of frustration urge the client to discuss the use of defense mechanisms

suggest the client clarify thoughts and beliefs about an event Explanation: Clarifying thoughts and beliefs helps the client avoid misinterpretations. Clients with a paranoid personality disorder tend to be aggressive and argumentative rather than frustrated. They tend to mistrust people and don't see interacting with others as a way to handle problems. The client's priority must be to interpret his thoughts and beliefs realistically, rather than discuss defense mechanisms. A paranoid client will focus on defending himself rather than acknowledging the use of defense mechanisms.

The nurse is collecting data on a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. Which action should the nurse perform first? draw blood for laboratory analysis begin cardiac monitoring give nasal oxygen take vital signs

take vital signs Explanation: The first step of nursing process is data collection. Taking vital signs would determine hemodynamic stability, and monitoring heart rhythm may be indicated based on data collected. Giving nasal oxygen and drawing blood require a health care provider's order and should not be part of a screening evaluation.

The nurse is reinforcing teaching about aspirin therapy with a client diagnosed with transient ischemic attacks (TIA). Which statement made by the client indicates understanding? "I need to take aspirin regularly to prevent headaches." "Taking aspirin regularly will reduce my risk of having severe pain." "Aspirin will help prevent me from having a stroke." "If I take aspirin, I am less likely to develop a bleed in my brain."

"Aspirin will help prevent me from having a stroke." Explanation: Aspirin is taken prophylactically to prevent cerebral infarction secondary to embolism and thrombosis. Headache is not common in TIAs. Aspirin can increase the chances of intracranial hemorrhage, especially if the dose is excessive. Aspirin can help reduce specific types of pain, but will not reduce the risk of having severe pain

The nurse is reinforcing education for an adolescent that is concerned about acne on the face. Which statement made by the teen indicates a need for further reinforcement of education? "My breakouts are caused by eating fatty foods." "I wash my face with soap and water every morning and night." "I use topical retinoids as prescribed at night on my skin." "Stress and hormones worsen my breakouts."

"My breakouts are caused by eating fatty foods." Explanation: The common skin condition on the adolescent is acne. Acne is a skin condition that occurs when hair follicles become plugged with oil and dead skin cells. Acne is not exacerbated by eating fatty foods. This information would need clarification. Treatment for acne is washing the face with soap and water and using topical retinoids. Stress and fluctuating hormones can cause acne breakouts.

Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective? "I'll find out what problems others have so I won't repeat them." "As long as I live, I won't abide by social rules." "I don't have problems in social relationships; I never really did." "Sometimes I can see what causes relationship problems."

"Sometimes I can see what causes relationship problems." Explanation: Progress is shown when the client addresses behaviors that negatively affect relationships. Clients with paranoid personality disorder struggle to understand and express their feelings about social rules. Knowing other people's problems isn't useful; the client must focus on his own issues. Clients with paranoid personality disorder tend to have impaired social relationships and are very uncomfortable in social settings. By not recognizing the problem, the client indicates that he is in denial.

The nurse is caring for a client on a regimen of four medications to treat tuberculosis (TB). The nurse discovers that the client is not taking all of the prescribed medications. What is appropriate for the nurse to say to the client? "TB resistance can develop if you don't take your medications properly." "It is important to take your medications as instructed." "Why aren't you taking all of your medications? Are the side effects bothersome?" "Taking many medications can be difficult. Tell me about the difficulties you're having."

"Taking many medications can be difficult. Tell me about the difficulties you're having." Explanation: Acknowledging that a multi-drug regimen can be difficult conveys empathy. Asking the client to discuss the specific difficulties promotes active participation. The nurse can then provide more education and help remove potential obstacles to compliance, such as lack of finances. TB resistance development and the importance of taking medication as instructed are important but not the priority. Asking if the side effects are bothersome is important but not the priority response.

A 15-year-old girl visits the neighborhood clinic seeking information on how to prevent pregnancy. How should the nurse respond to her request? "Have you've told your parents you're sexually active?" "What precautions are you taking now when you have sex?" "What would you like to know?" "Let's discuss what your friends are doing to keep from getting pregnant."

"What precautions are you taking now when you have sex?" Explanation: An approach that requests only the information necessary to answer the teenager's question is nonthreatening, nonjudgmental, and may enhance the adolescent's willingness to talk about her experiences. This enables the nurse to better evaluate the teenager's needs. The nurse should ask only about the precautions currently being taken. Asking the adolescent what she would like to know assumes that she knows what she needs to know. The birth control precautions her friends are taking are irrelevant at this time. Asking the teen if her parents know she is having sex may make her defensive and fearful of seeking help.

During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What should be the nurse's initial response? "When people are under stress, they may see things or hear things that others don't. Is that what just happened?" "I'm having a difficult time hearing you. Please look at me when you talk." "There is no one else in the room. What are you doing?" "Who are you talking to? Are you hallucinating?"

"When people are under stress, they may see things or hear things that others don't. Is that what just happened?" Explanation: This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship. Directing the client to look at the nurse wouldn't address the obvious issue of the hallucination. Confrontational approaches, such as in options 3 and 4, are likely to elicit an uninformative or negative response.

A nurse knows that gender is part of one's identity. Which event signifies when gender is first ascribed? A child receives sex-specific toys. A neonate is born. A child receives sex-specific clothing. A child attends school.

A neonate is born. Explanation: As soon as a neonate is born, gender is ascribed. In the hospital, a neonate is given either a pink or blue name band, card, or blanket. Sexual identity is reaffirmed throughout the school years. Gender identification is perpetuated throughout life with sex-specific clothing and toys.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? Giving the feedings at room temperature Decreasing the rate of feedings and the concentration of the formula Placing the client in semi-Fowler's position while feeding Changing the tube feeding administration set every 24 hours

Decreasing the rate of feedings and the concentration of the formula Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping, so this intervention should have already been performed. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Changing tube feeding administration sets every 24 hours prevents bacterial growth; it doesn't decrease the client's discomfort.

A client who is 36 weeks pregnant appears anxious and tells the nurse that she will never be able to handle labor and delivery. What is the appropriate action by the nurse? Assess the client for intimate partner violence. Document this common concern during the third trimester. Discuss the concern with the client's partner. Obtain a referral order for psychotherapy.

Document this common concern during the third trimester. Explanation: It is common for clients to verbalize feelings of anxiety and concern over the impending labor and delivery during the third trimester of pregnancy, so the nurse simply needs to document the finding. There is no indication that the client needs psychotherapy. All clients should be screened for intimate partner violence but there is no indication that this client needs screening more than another client. Discussing the client's concerns with her partner would not help the client.

A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? Droplet precautions Standard precautions Contact precautions Airborne precautions

Droplet precautions Explanation: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use droplet precautions. This includes wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask. Contact precautions are used to reduce the spread of microorganisms by direct client contact or by contact with items in the client's environment. Examples of illnesses requiring contact precautions include Clostridium difficile infection, diphtheria (cutaneous), and scabies. Airborne precautions are instituted for clients known or suspected to have serious illnesses transmitted by airborne droplet nuclei, including tuberculosis, measles, and varicella. Standard precautions should be used for all clients when exposure to blood or other body fluids is likely.

The nurse is assisting with the development of a plan of care for a client with generalized anxiety disorder (GAD). Which intervention is important to include? Encourage the client to engage in activities that increase feelings of power and self-esteem. Promote the client's interaction and socialization with others. Assist the client to make plans for regular periods of leisure time. Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped.

Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped. Explanation: One of the nurse's goals is to help the client with generalized anxiety disorder associate symptoms with an event, thereby beginning to learn appropriate ways to eliminate or reduce distress. A diary can be a beneficial tool for this purpose. Although encouraging the client to engage in activities that increase feelings of power and self-esteem; promoting interaction and socialization with others; and assisting the client to make plans for regular periods of leisure time may be appropriate, they are not the priority.

A client who is 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse provide which information that at 16 weeks' gestation the client's fetus will most likely present? Be able to suck and swallow Have open nostrils Open the eyes Have audible heart sounds

Have audible heart sounds Explanation: Fetal heart tones are usually audible with a fetoscope between 16 and 20 weeks' gestation. The fetus can suck and swallow at about 20 weeks' gestation. The eyes are open at approximately 28 weeks' gestation. The nostrils are open at about 21 to 28 weeks' gestation.

A nurse is discussing skin turgor evaluation of an elderly client with her peers. While doing so, the nurse should include which information with her colleagues? Inelastic skin turgor is a normal part of aging. Dehydration causes the skin to appear edematous and spongy. Overhydration causes the skin to tent. Normal skin turgor is moist and boggy.

Inelastic skin turgor is a normal part of aging. Explanation: Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do? Put a heating pad on the area to reduce inflammation. Inform the physician immediately. Squeeze the nipple to check for drainage. Check the area after her next menses.

Inform the physician immediately. Explanation: The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after her next menses to inform the physician of the breast lump because prompt treatment may be necessary. The client doesn't need to place a heating pad on the area because it would have no effect on a breast lump.

A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next? Massage the fundus. Give methergine orally. Perform vaginal examination. Obtain vital signs.

Massage the fundus. Explanation: After delivery of the placenta, the fundus is normally firmly contracted at the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus. Fundus above the umbilicus may indicate boggy uterus. Massaging the fundus will activate contraction and aid involution. Methergine can be given; however, it is not the initial action. It can be given if the massage does not alleviate the problem. Vaginal examination is not the initial action. Vital signs are needed but this is not the initial or priority action in this case.

The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation? Check for peripheral vision. Observe for pupil constriction and convergence while focusing on an object coming toward the client. Have the client follow an object upward, downward, obliquely, and horizontally. Touch the cornea lightly with a wisp of cotton.

Observe for pupil constriction and convergence while focusing on an object coming toward the client. Explanation: Accommodation refers to convergence and constriction of the pupil while focusing on a nearing object. Touching the cornea lightly with a wisp of cotton describes evaluation of the corneal reflex. Having the client follow an object upward, downward, obliquely, and horizontally refers to cardinal fields of gaze. Checking for peripheral vision refers to visual fields.

A client with chronic anxiety disorder reports chest pain. Which nursing intervention is most appropriate? Administer prescribed anti-anxiety medication. Obtain vital signs. Stay with the client. Reassure the client that the episode will pass.

Obtain vital signs. Explanation: Although the client with chronic anxiety disorder may have somatic symptoms, physiologic causes for chest pain must be thoroughly assessed. Reassuring the client would be acceptable only after ruling out a physiologic cause for the symptoms. Staying with the client may be therapeutic, but obtaining vital signs would take precedence. Administering anti-anxiety agents might mask signs of cardiac problems.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? Administering frequent oral feedings Administering an analgesic once per shift, as prescribed, to prevent drug addiction Encouraging frequent visits from family and friends Positioning the client on the side with the knees flexed

Positioning the client on the side with the knees flexed Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and prescribed, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

Which steps should the nurse follow to insert a straight urinary catheter? Put on gloves, prepare the equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6". Prepare the client and the equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows. Create a sterile field, drape the client, clean the meatus, and insert the catheter only 6". Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. Explanation: Option 3 describes all the vital steps for inserting a straight catheter. Option 1 is incorrect because the nurse must prepare the client and equipment before creating a sterile field. Option 2 is incorrect because the nurse put on gloves before creating a sterile field and performing the other tasks. Option 4 describes the procedure for inserting an indwelling catheter, rather than a straight catheter.

A mother asks the nurse how to handle her 4-year-old child, who recently started wetting his pants after being completely toilet trained. The child just started attending nursery school 2 days a week. Which principle should guide the nurse's response? The child experiences growth while regressing, regrouping, and then progressing. The child returns to a level of behavior that increases his sense of security. The child forgets previously learned skills. The parents may prefer less mature behaviors.

The child returns to a level of behavior that increases his sense of security. Explanation: The stress of starting nursery school may cause the child to regress to a level of behavior that increases his sense of security. A child's skills remain intact, although increased stress may prevent the child from using these skills. Growth occurs when the child doesn't regress. Parents rarely desire less mature behaviors.

A client with paranoid personality disorder responds aggressively to something another client said during a psychoeducational group session. Which rationale explains the likely underlying cause of the client's response to the interaction? The client was attempting to handle emotional distress. The client is impulsive and was acting out frustrations. The client took the statement as a personal criticism. The client doesn't want to participate in the group.

The client took the statement as a personal criticism. Explanation: Clients with paranoid personality disorder tend to be hypersensitive and take what other people say as a personal attack on their character. The client's participation in group therapy would be minimal because the client is directing energy toward emotional self-protection. Clients with a paranoid personality disorder tend to be rigid and guarded rather than impulsive and rebellious. The client with a paranoid personality disorder is acting to defend himself, not handle emotional distress.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? Using a peri bottle to clean the perineum after each voiding or bowel movement Spraying water from peri bottle into the vagina Cleaning the perineum from back to front after a bowel movement Changing perineal pads every 8 hours

Using a peri bottle to clean the perineum after each voiding or bowel movement Explanation: Cleaning with a peri bottle (squirt or spray bottle) should be performed after each voiding or bowel movement. The perineum should be cleaned from front to back, to avoid contamination from the rectal area. To keep the perineum clean, perineal pads must be changed when they are soiled. Water from the peri bottle isn't sterile and should never be directed into the vagina.

A client newly diagnosed with type 2 diabetes is admitted to the metabolic unit for treatment initiation and education. Which information should the nurse reinforce to this client as a goal for treatment? an eye examination every 2 years, until age 50 exercise and a weight-reduction diet smoking reduction but not complete cessation maintenance of blood glucose levels between 180 and 200 mg/dL

exercise and a weight-reduction diet Explanation: Type 2 diabetes is commonly related to obesity; therefore, weight reduction may normalize blood glucose levels. Weight reduction should be achieved by a healthy diet and exercise to increase carbohydrate metabolism. Blood glucose levels should be maintained between 80 and 100 mg/dL to prevent the development of diabetic complications. Clients with type 1 or 2 diabetes should not smoke because of the increased risk of cardiovascular disease. A funduscopic examination should be done yearly to identify early signs of diabetic retinopathy.

A 55-year-old male client wishes to be proactive about health issues. To help ensure early identification of prostate cancer, the client should: get a transrectal and transabdominal ultrasound every 5 years. have a blood urea nitrogen (BUN) and creatinine assessment every year. have a yearly digital rectal exam and prostate-specific antigen (PSA) test. perform monthly testicular self-examinations, especially after age 50 years.

have a yearly digital rectal exam and prostate-specific antigen (PSA) test. Explanation: The incidence of prostate cancer increases after age 50 years. Digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA testing, which assesses a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations will not identify changes in the prostate gland due to its impalpable location in the body. A transrectal and transabdominal ultrasound and a BUN and creatinine evaluation are usually done after diagnosis to identify the extent of disease and potential metastases.

Which short-term goal is most appropriate for the client with paranoid personality disorder who has impaired social skills? discuss anxiety-provoking situations obtain feedback from other people address positive and negative feelings about self identify personal feelings that hinder social interaction

identify personal feelings that hinder social interaction Explanation: The client must address the feelings that hinder social interactions before developing ways to address impaired social skills. Feedback can be obtained only after action is taken to improve or change the situation. Discussion of anxiety-provoking situations is important but doesn't help the client with impaired social skills. Addressing the client's positive and negative feelings about himself won't directly influence impaired social skills.

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care? providing mouth care maintaining current weight encouraging ambulation promoting bowel rest

promoting bowel rest Explanation: Promoting bowel rest is the priority during an acute exacerbation. This is accomplished by decreasing activity and initially putting the client on nothing-by-mouth (NPO) status. Weight loss may occur, but the priority is bowel rest. Crohn's disease is a type of inflammatory bowel disease (IBD). It causes inflammation of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition.

A nurse is providing care for a client with multiple myeloma. Which resource may best help the client adapt to the disease? pastoral care hospice care support group family

support group Explanation: Support groups consist of clients with the same diagnoses who share experiences of the disease with each other. Sharing experiences may help the client with multiple myeloma understand disease-related problems and give the client a forum in which to vent feelings, which are usually similar to those of the group. The client's family and clergy, although supportive, cannot share similar disease experiences. Hospice care is usually implemented late in the disease, at the end of life.

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? "If it had been your emergency, I would have made the other client wait." "I know it's frustrating to wait. I'm sorry this happened." "Can we talk about how this is making you feel right now?" "I really care about you and I'll never let this happen again."

"Can we talk about how this is making you feel right now?" Explanation: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option 1 wouldn't address the client's anger. Option 2 is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option 4, because such matters are outside the nurse's control.

A client confides to a nurse, "I have urges and desires to have sex with children." What should the nurse's most appropriate response be? Inform child protective services about the client and the thoughts the client reported. Question the client, "Are you able to control your thoughts about sexual relations with children?" Ask the client, "Have you ever acted on these desires?" Explain that these thoughts are unacceptable and intensive therapy is need.

Ask the client, "Have you ever acted on these desires?" Explanation: If a client reports a desire for pedophilia, then it is important to assess if the client ever acted upon these thoughts; the best predictor of future behaviors is past behaviors. Humans may have sexual fantasies but it is their behavior by which they are judged. No human thoughts are unacceptable, but therapy is required if the client is dystonic. Informing child protective services is premature; the nurse has not obtained information whether the client has acted on these thoughts.

Which intervention might safely prevent constipation in a client who has end-stage ovarian cancer and requires high doses of opioids to control pain? Instructing the client to avoid consuming alcohol Telling the client to avoid taking over-the-counter medications Informing the client that taking laxatives routinely might help Explaining the importance of increasing the intake of fiber and fluids

Explaining the importance of increasing the intake of fiber and fluids Explanation: The nurse should explain the importance of increasing the intake of fiber and fluids to prevent constipation. Avoiding alcohol won't prevent constipation; however, the client should be cautioned about its use with opioids. The client should be instructed to consult with her physician before taking over-the-counter medications. The client should also be cautioned against taking laxatives routinely because they can lead to dependency.

A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which nursing consideration is most important for the nurse to be aware of when providing care for this client? Use of a stethoscope to auscultate the fistula is contraindicated. The client feels best immediately after the dialysis treatment. The client should not feel pain during initiation of dialysis. Taking a blood pressure reading on the affected arm can cause clotting of the fistula.

Taking a blood pressure reading on the affected arm can cause clotting of the fistula. Explanation: Pressure on the fistula or extremity can decrease blood flow and precipitate clotting in a client who has had surgery to form an arteriovenous fistula. Auscultation of a bruit in the fistula with a stethoscope is one way to determine patency. Typically, clients feel fatigued immediately after hemodialysis because of the rapid change in fluid and electrolyte status. Although the area over the fistula may have some decreased sensation, the needle stick can still be painful for the client.

The nurse is having a conversation with a depressed client. The client states, "Do you think I should tell my family how I feel?" What is the most therapeutic response by the nurse? "Of course you should. Honesty is the best policy." "Do you think you should tell your family?" "I am not sure they would understand, but you could try." "I think you should sit them down and talk with them about this."

"Do you think you should tell your family?" Explanation: By responding with "Do you think you should tell your family?" the nurse is demonstrating the therapeutic communication technique of reflecting. This allows the client to initiate the action, and the nurse is not providing an answer to the conflict. The other responses give advice, which is a nontherapeutic communication technique.

The nursing instructor asks the nursing student why should an infant be quiet and seated upright when the nurse checks his or her fontanels. Which is the best response? "The infant can breathe more easily when sitting up." "The mother will have less trouble holding a quiet, upright infant." "Lying down can cause the fontanels to recede, making assessment more difficult." "Lying down and crying can cause the fontanels to bulge."

"Lying down and crying can cause the fontanels to bulge." Explanation: Lying down and crying can cause the fontanels to bulge, giving the nurse inaccurate data. The nurse should sit the child upright and try to keep him or her calm and quiet. The fontanels should look almost flush with the scalp and surface, and slight pulsation should be visible. The fontanels should feel soft and either flat or slightly indented.

A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply. Droplet Contact Neutropenic Standard Airborne

Contact Standard Explanation: The purpose of isolation is to prevent the spread of infection to other clients. Contact isolation is normally used for GI infections and diarrhea as well as wound infections with drainage or draining abscesses. In addition to contact isolation, standard precautions should be observed with this client. Droplet precautions are used for clients with suspected or known infection caused by organisms transmitted by infectious droplets, as in pertussis. Airborne precautions should be instituted for clients suspected or known to be infected with tuberculosis. Neutropenic precautions are instituted to protect the client with a low white blood cell count from infection.

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first? Perform a complete physical assessment of the client. Help determine the most appropriate contraceptive method for the client. Obtain a thorough health history from the client. Explore her own personal beliefs and feelings about contraception.

Explore her own personal beliefs and feelings about contraception. Explanation: The nurse must first explore her own personal beliefs and feelings about contraception to detect biases; if biases exist, the nurse must refer the client to another health care professional. Only after exploring personal beliefs and feelings does the nurse obtain a thorough health history, perform a complete physical assessment, and help determine the most appropriate contraceptive method.

The nurse is caring for a client who is blind. Which is the best way for the nurse to assist with ambulation? Have the client walk down the hall with his or her hand along the wall. Have the aide push the client in a wheelchair. Have the client take the nurse's arm, with the nurse walking slightly ahead of the client. Have the client walk beside the nurse, with the nurse's hand on the client's back.

Have the client take the nurse's arm, with the nurse walking slightly ahead of the client. Explanation: Having the client take the nurse's arm, with the nurse walking slightly ahead of the client, allows the client to have more of a feeling of control. Having the client walk beside the nurse with the nurse's hand on the client's back does not provide physical support. Having the client walk down the hall with his or her hand along the wall does not provide balance and stability. Having the client walk down the hall with his/her hand along the wall does not facilitate independence or self-esteem in the client.

A client undergoing a brain computed tomography (CT) scan because of continual migraine headaches is placed in the CT scanner and suddenly reports having palpitations, shortness of breath and shaking. What is the client most likely experiencing? Myocardial infarction (MI) Allergic reaction Hypoglycemic episode Panic attack

Panic attack Explanation: Considering that the client's symptoms have occurred after entry into the CT scanner, they most likely signal a panic attack, which is a period of intense fear or discomfort that develops abruptly and peaks in 10 minutes. An allergic reaction would have a precipitating cause and might also include a cutaneous reaction or edema. An MI usually involves chest pain or cardiac compromise. Hypoglycemia rarely causes shortness of breath, but would need to be ruled out by obtaining the client's blood glucose level.

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? Monitoring the client's platelet and leukocyte counts Recommending that the client discontinue chemotherapy Checking regularly for signs and symptoms of stomatitis Providing a solution of hydrogen peroxide and water for use as a mouth rinse

Providing a solution of hydrogen peroxide and water for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen peroxide and water for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer viscous lidocaine or systemic analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality? The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit. At the client's request, the CCU nurse updates the client's spouse on their condition. The CCU nurse notifies the on-call provider about a change in the client's condition.

The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress. Explanation: The ED nurse is no longer directly involved with the client's care, and has no legal right to information about the client's present condition. Anyone directly involved in their care (such as the telemetry nurse and the on-call provider) has the right to information about the client's condition. Because this client asked the nurse to update their spouse, doing so doesn't breach

Which finding is considered normal in the neonate during the first few days after birth? Weight loss of 25% Birth weight of 4½ to 5½ lb (2,000 to 2,500 g) Weight loss, then return to birth weight Weight gain of 25%

Weight loss, then return to birth weight Explanation: Babies lose approximately 10% of their birth weight during the first 3 or 4 days until breast-feeding is established because they lose excess extracellular fluids and meconium and they have limited oral intake. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

A client comes to the emergency department reporting chest discomfort and tingling of the fingers. The electrocardiogram shows a heart rate of 136 beats/minute and no other changes; respirations are 28 and shallow. Which nursing intervention has the greatest priority? helping the client to calm down obtaining a detailed medical history maintaining the client's IV fluids apply O2 at 3 L via nasal cannula

apply O2 at 3 L via nasal cannula Explanation: The client is exhibiting anxiety and the nurse should assist the client to calm down. Feelings of panic and/or fear, cold or sweaty hands and/or feet, shortness of breath/hyperventilation, heart palpitations, numbness or tingling in the hands or feet, nausea, and dizziness are signs and symptoms of panic from anxiety. Anxiety can adversely affect the client's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the client. The other nursing interventions are valid, but they are not the priority in this situation.

A nurse is assisting with the care of a neonate and is preparing to administer erythromycin ointment to the neonate's eyes shortly after birth. Which condition is the nurse preventing by administering this medication to the neonate? ophthalmia neonatorum diabetic retinopathy strabismus cataracts

ophthalmia neonatorum Explanation: Eye prophylaxis is administered to the neonate immediately, or soon after birth, to prevent ophthalmia neonatorum (conjunctivitis contracted during birth from passage through the birth canal). Erythromycin ointment is not given to prevent cataracts, diabetic retinopathy, or strabismus. Cataracts are opacities of the lens of the eye in children with congenital rubella, galactosemia, or cortisone therapy. Diabetic retinopathy occurs in clients with diabetes when the retina bleeds into the vitreous humor causing scarring, after which neovascularization occurs. Strabismus is neuromuscular incoordination of the eye alignment.

A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client? further education personal development conflict resolution career development

personal development Explanation: True recovery involves changing the client's distorted thinking and working on personal and emotional development. Before the client pursues further education, conflict resolution skills, or career development, it's imperative to devote energy to emotional and personal development.

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? "The pulse can't be checked accurately if the arteries are palpated at the same time." "Checking both carotid arteries at the same time may cause transient hypertension." "Checking both carotid arteries at the same time may impair cerebral circulation." "Checking both carotid arteries at the same time may cause severe tachycardia."

"Checking both carotid arteries at the same time may impair cerebral circulation." Explanation: The carotid arteries must be palpated one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia (not tachycardia) could lead to cardiac arrest. Palpating both carotid arteries at the same time doesn't cause hypertension.

The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate? "Your child is extremely fragile, and visitations are not recommended." "Let's have your child communicate by phone calls with friends and family members instead." "While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery." "We should not have visitors for another few days to best protect your child from infection."

"While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery." Explanation: Prevention of infection after any surgical procedure is important. After a week, the child's risk for infection, while still present, is lessened. If all visitors are free of infection, a visit would be fine.

A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." What is the priority action by the nurse? Help the client accept her new role. Encourage the client to work faster. Reassure the client that her feelings will soon pass. Help the client break down large tasks into smaller ones.

Help the client break down large tasks into smaller ones. Explanation: If a client feels overwhelmed by the additional tasks brought on by her new role as a mother, the nurse should help her break down large tasks into smaller, more manageable ones. Encouraging her to work faster or reassuring her that her feelings will soon pass wouldn't address her needs. The nurse can't help the client accept her new role if the client feels overwhelmed.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Institute isolation precautions. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Obtain a sputum specimen for enzyme immunoassay testing.

Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A postpartum client is scheduled for discharge tomorrow. The nurse is reinforcing discharge instructions with the client. The nurse determines that the client understands the information when stating that she will report which finding to her health care provider? episiotomy discomfort temperature of 99.2° F (37.3° C) whitish vaginal discharge 2 weeks after birth redness, warmth, and pain in a breast

redness, warmth, and pain in a breast Explanation: Signs of mastitis include a reddened, warm, painful area on the breast, as well as fever, headache, and flu-like symptoms. If these symptoms occur, the client should contact her healthcare provider for treatment. Episiotomy discomfort may persist for up to 6 weeks after birth. A temperature of 99.2° F is not significant unless it persists. A whitish vaginal discharge, lochia alba, normally occurs 2 weeks after birth.