EAQ Master Fundamentals

What is an important aspect of nursing care for a client exhibiting psychotic patterns of thinking and behavior? 1. Helping keep the client oriented to reality 2. Involving the client in activities throughout the day 3. Helping the client understand that it is harmful to withdraw from situations 4. Encouraging the client to discuss why interacting with other people is being avoided

1. Helping keep the client oriented to reality Keeping the withdrawn client oriented to reality prevents further withdrawal into a private world. A gradual involvement in selected activities is best. Helping the client understand that it is harmful to withdraw from situations is futile at this time. The psychotic client is unable to tell anyone why he is avoiding interaction with others.

A healthcare provider recently made the diagnosis that a client has glaucoma. The nurse is preparing to administer eyedrops to the client. Which ophthalmic solution is contraindicated for this client? 1. Timolol 2. Atropine 3. Pilocarpine 4. Epinephrine

2. Atropine Atropine, a mydriatic ophthalmic solution, is contraindicated for clients with glaucoma because it dilates the pupil, increasing intraocular pressure. Timolol, a beta blocker, decreases aqueous humor production; beta blockers are the preferred initial medications given to reduce intraocular pressure. Pilocarpine, a cholinergic, constricts the pupil, thereby increasing aqueous humor outflow. Epinephrine, an adrenergic agent, enhances aqueous humor outflow, thereby reducing intraocular pressure.

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, what should the nurse assess for? 1. Dry mouth 2. Tachycardia 3. Hypertensive crisis 4. Increased abdominal distention

2. Tachycardia Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemia and compensatory tachycardia. Dry mouth may occur with dehydration, but it is not as vital or immediate as signs of shock. Dry mouth is a subjective symptom that cannot be measured objectively. The fluid shift can cause hypovolemia with resulting hypotension, not hypertension. A paracentesis decreases the degree of abdominal distention.

The nurse teaches a client who is to undergo amniocentesis that ultrasonography will be performed just before the procedure to determine what? 1. Gestational age of the fetus 2. Amount of fluid in the amniotic sac 3. Position of the fetus and the placenta 4. Location of the umbilical cord and placenta

3. Position of the fetus and the placenta The position of the fetus and placenta is determined by means of ultrasonography to help prevent trauma from the needle during the amniocentesis. Although ultrasonography can be used to determine gestational age, this is not its purpose just before amniocentesis. Determining the amount of fluid in the amniotic sac is not the purpose of ultrasonography just before amniocentesis. The position of the placenta and fetus, not just the cord and the placenta, is needed for safe introduction of the needle.

When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), what must the nurse do? 1. Don clean gloves 2. Use barrier techniques 3. Put on a mask and gown 4. Wash the hands thoroughly

4. Wash the hands thoroughly Because this procedure does not involve contact with blood or secretions, additional protection to washing the hands thoroughly is not indicated. Donning clean gloves and using barrier techniques are necessary only when there is risk of contact with blood or body fluid. A mask and gown are indicated only if there is a danger of secretions or blood splattering on the nurse (for example, during suctioning).

A client with small-cell lung cancer is receiving chemotherapy. A complete blood count is prescribed before each round of chemotherapy. Which component of the complete blood count is of greatest concern to the nurse? 1. Platelets 2. Hematocrit 3. Red blood cells (RBCs) 4. White blood cells (WBCs)

4. White blood cells (WBCs) Antineoplastic drugs depress bone marrow, which causes leukopenia; the client must be protected from infection, which can be life threatening. RBCs diminish slowly and can be replaced with a transfusion of packed red blood cells. Platelets decrease as rapidly as WBCs, but complications can be limited with infusions of platelets.

A nurse administers lactulose to a client with cirrhosis of the liver. Which laboratory test change leads the nurse to determine that the lactulose is effective? 1. Decreased amylase 2. Decreased ammonia 3. Increased potassium 4. Increased hemoglobin

2. Decreased ammonia Lactulose destroys intestinal flora that break down protein and in the process give off ammonia. In clients with cirrhosis, ammonia is inadequately detoxified by the liver and can build to toxic levels. Amylase levels are associated with pancreatic problems. Increased potassium levels are associated with kidney failure. Hemoglobin is increased when the body needs more oxygen-carrying capacity, such as in smokers, or in high altitudes.

During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement? 1. An understanding of safer sex 2. An ability to assume self-responsibility 3. Ignorance related to correct condom use 4. Ignorance concerning the transmission of human immunodeficiency virus (HIV)

3. Ignorance related to correct condom use Vaseline (petroleum jelly) breaks down condom integrity and will increase the risk for condom failure. Using Vaseline instead of a water-soluble lubricant shows a lack of knowledge about condom use, a form of safer sex. Although the person is attempting to be responsible, there is a lack of knowledge and the behavior is unsafe. Condom use shows the client has some understanding about the transmission of HIV.

Which tocolytic agent inhibits prostaglandin activity and is given along with sucralfate to help manage preterm labor? 1. Nifidipine 2. Indomethacin 3. Calcium gluconate 4. Magnesium sulfate

2. Indomethacin Indomethacin is a nonsteroidal antiinflammatory agent that may cause gastric irritation so sucralfate is administered along with this drug. Nifidipine is a calcium channel blocker used to manage preterm labor. Calcium gluconate is used to reverse magnesium sulfate toxicity. Magnesium sulfate is used to manage preterm labor and pregnancy-induced hypertension.

Which drug is used to manage nonmetastatic gestational trophoblastic disease? 1. Oxytocin 2. Mifepristone 3. Dinoprostone 4. Methylergonovine

3. Dinoprostone Dinoprostone is a synthetic drug derived from naturally occurring prostaglandins. This drug is used to manage nonmetastatic gestational trophoblastic disease. Methylergonovine is used to treat postpartum hemorrhage. Oxytocin is used for labor induction. Mifepristone is used to induce an abortion.

The health care provider prescribes a low-fat, 2 g sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? 1. Chemically stimulate the loop of Henle 2. Diminish the thirst response of the client 3. Prevent reabsorption of water in the distal tubules 4. Cause fluid to move toward the interstitial compartment

3. Prevent reabsorption of water in the distal tubules

The nurse instructs the parents of a child with iron deficiency anemia that iron absorption may be enhanced by: 1. Giving the supplement with milk 2. Giving the supplement with citrus juice or fruits 3. Offering a chewable form once a day 4. Waiting until the child has a full stomach to administ3er

2. Giving the supplement with citrus juice or fruits The ascorbic acid in citrus fruits or juices enhances iron absorption

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? 1. Pulse rate 2. Tissue turgor 3. Specific gravity 4. Body temperature

2. Tissue turgor Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.

Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? 1. Carboprost tromethamine 2. Misoprostol 3. Nalbuphine HCl 4. Betamethasone

4. Betamethasone Betamethasone enhances fetal lung maturity when administered before a preterm birth. Carboprost tromethamine is a prostaglandin and nalbuphine HCl is a narcotic antagonist, neither of which is appropriate for administration in this case. Misoprostol is used for labor induction.

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1. Gravida III with twins 2. Gravida V with endometriosis 3. Gravida II who had a 9-lb baby 4. Gravida I who has had an intrauterine fetal death

4. Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.

The nurse recognizes that the majority of congenital heart defects are treated with: 1. Diet 2. Exercise 3. Surgery 4. Medication

3. Surgery Surgery is generally required because the defects are structural so diet, exercise, and medication will not correct the defects.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to avoid to best prevent malaria? 1. Mosquito bites 2. Untreated water 3. Undercooked food 4. Overpopulated areas

1. Mosquito bites Malaria is caused by the protozoan Plasmodium falciparum, which is carried by mosquitoes. Avoiding untreated water, undercooked food, and overpopulated areas will not prevent protozoa from entering the bloodstream.

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client? 1. Penicillin therapy 2. Major tranquilizers 3. Behavior modification 4. Electroconvulsive therapy

1. Penicillin therapy Massive doses of penicillin may limit central nervous system damage if treatment is started before neural deterioration from syphilis occurs. Tranquilizers are used to modify behavior, not to treat general paresis. Behavior, not paresis, is treated with behavior modification. Electroconvulsive therapy is used to treat certain psychiatric disorders.

A stillborn infant was delivered a few hours ago. Aster the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? 1. I know how you feel 2. This must be hard for you 3. Now you have an angel in heaven 4. You're young. You can have other children

2. This must be hard for you Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. "This must be hard for you" is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present? 1. Headache 2. Pallor 3. Paresthesias 4. Blurred vision

3. Paresthesias Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

What signs and symptoms of withdrawal does the nurse identify in a postpartum client with a history of opioid abuse? 1. Paranoia and evasiveness 2. Extreme hunger and thirst 3. Depression and tearfulness 4. Irritability and muscle tremors

4. Irritability and muscle tremors The earliest sign of opioid withdrawal is central nervous system overstimulation. Paranoia and evasiveness are related to opioid drug abuse, not opioid withdrawal. Extreme hunger and thirst have no relation to opioid withdrawal; most postpartum women are hungry and thirsty. Depression and tearfulness are not specific to people who abuse opioids.

A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? 1. Milk 2. Steak 3. Chicken 4. Lima beans

4. Lima beans The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.

Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What instructions does the nurse reinforce for the client about this type of insulin? Select all that apply. A. It does not have a peak effect B. It is usually given once daily, at bedtime C. It usually has a 24-hour duration of action D. It may be mixed in a syringe with regular insulin E. Its onset of action comes 4 hours after administration

A. It does not have a peak effect B. It is usually given once daily, at bedtime C. It usually has a 24-hour duration of action Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2 hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other insulin.

What is the best method for the nurse to use when evaluating the amount of blood loss in a client with placenta previa? 1. Count or weigh perineal pads 2. Monitor pulse and blood pressure 3. Check hemoglobin and hematocrit values 4. Measure or estimate the height of the fundus

1. Count or weigh perineal pads An accurate measurement of the amount of blood loss may be obtained by counting or weighing pads. The vital signs will reflect the effects of the blood loss rather than the amount. Laboratory results demonstrate the effects of the blood loss rather than the amount. The fundus may be higher than expected because the low-lying placenta prevents the descent of the fetus into the pelvis, but the height cannot be used to estimate blood loss.

A practitioner prescribes Alprazolam (Xanax) 0.25 mg by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug should the nurse monitor the client? 1. Drowsiness 2. Bradycardia 3. Agranulocytosis 4. Tardive dyskinesia

1. Drowsiness Alprazolam (Xanax), a benzodiazepine, potentiates the actions of Γ-aminobutyric acid, enhances presympathetic inhibition, and inhibits spinal polysynaptic afferent pathways. Drowsiness, dizziness, and blurred vision are common side effects. Alprazolam may cause tachycardia, not bradycardia. Agranulocytosis is usually a side effect of the antipsychotics in the phenothiazine, not the benzodiazepine, group. Tardive dyskinesia occurs after prolonged therapy with antipsychotic medications; Alprazolam is an antianxiety medication, not an antipsychotic.

Which factors should the nurse consider when assessing an individual for a predisposition to violence, injury, or death? Select all that apply. 1. Poverty 2. Education 3. Work history 4. Drug involvement 5. History of physical abuse

1. Poverty 4. Drug involvement 5. History of physical abuse Poverty, drug involvement, and a history of physical abuse may predispose a client to violence, injury, or death. Assessing work history and education may help a nurse learn more about a client's risk factors, but they are not risk factors themselves.

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? Select all that apply. 1. Heat 2. Pallor 3. Edema 4. Decreased flow rate 5. Increased blood pressure

2. Pallor 3. Edema 4. Decreased flow rate The accumulation of fluid in the tissues between the surface of the skin and the blood vessels makes the skin appear pale. The accumulation of fluid in the interstitial compartment causes swelling. As the needle/catheter is dislodged from the vein, the drip rate of the IV slows or ceases. Heat is associated with phlebitis; the accumulation of room temperature IV fluid in the tissue makes the site feel cool. Increased blood pressure is a sign of circulatory overload; when an IV infusion has infiltrated, the intravascular fluid volume does not increase.

A woman who is infertile is diagnosed with primary ovarian failure. Which fertility drug regimen may be prescribed to treat infertility? 1. Clomiphene 2. Menotropins 3. Estrogens and progestins 4. Choriogonadotropin alfa

3. Estrogens and progestins Exogenous administration of estrogens or progestins is used to treat infertility associated with primary ovarian failure. The administration of clomiphene, menotropins, and choriogonadotropin alfa cannot stimulate the ovaries to increase the levels of estrogens or progestins.

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? 1. Restricting gross motor activity 2. Preventing further deterioration 3. Keeping the client oriented to time 4. Managing the client's unsafe behaviors

4. Managing the client's unsafe behaviors Clients with Alzheimer disease require external controls to minimize the danger of injury caused by lack of judgment. The staff should not prevent all gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration usually cannot be prevented in this disorder with nursing interventions; donepezil may help delay deterioration in some clients. It may not be possible to keep the client continuously oriented.

A nurse is counseling a pregnant woman with type 1 diabetes. What is the most important nursing consideration in the planning of care for this client? 1. Higher risk for fetal mortality 2. Possible need for cesarean birth 3. Expectation of lowered insulin needs 4. Requirement of intensive prenatal care

4. Requirement of intensive prenatal care There is a constant need for evaluation of the client's diabetic status, fetal maturity, and placental function. Fetal mortality in pregnancies in which diabetes is well managed is no higher than that in healthy pregnancies. Many clients with diabetes have vaginal births. Insulin requirements vary but are usually increased during the second and third trimesters of pregnancy.

Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching? 1. "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day." 2. "Any reconstituted solution must be discarded in 1 week." 3. "I can continue driving my car as long as I have the stamina." 4. "While taking this medicine I should be able to continue my usual activity."

1. "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day." Adequate fluid intake helps to flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment. Reconstituted solution may be stored in the refrigerator for 1 month. Confusion, dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such as driving or using machinery. Activity may have to be altered because fatigue and other flulike symptoms are common with this drug.

A client with mild preeclampsia is instructed to rest at home. She asks the nurse, "What do you mean by rest?" What is the most appropriate response? 1. "Tell me what you consider rest." 2. "Take three or four naps a day." 3. "Stay off your feet as much as possible." 4. "Would you like to know what I think it means?"

1. "Tell me what you consider rest." Responding by asking what the client considers rest reflects the client's statement and permits clarification, which will yield information that can be used in planning. Recommending three or four naps each day is too specific an interpretation of a rest requirement; there is more to maintaining rest than naps. There is also more to maintaining rest than staying off one's feet; this response is a vague interpretation of a rest requirement. What the nurse thinks rest means does not provide a clear picture of what the client interprets as rest.

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? 1. Decrease blood pressure 2. Increased oral temperature 3. Diminished peripheral pulses 4. Unequal bilateral breath sounds

1. Decreased blood pressure The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.

A pregnant client is admitted to the high-risk unit with uterine tenderness and some dark-red vaginal bleeding. Abruptio placentae is diagnosed. What priority evaluation should be included with vital signs, skin color, urine output, and fetal heart rate? 1. Fundal height 2. Obstetric history 3. Time of last meal 4. History of bleeding tendencies

1. Fundal height It is vital that a baseline measurement of the height of the fundus be obtained, because increasing size is a sign of concealed hemorrhage; with abruptio placentae, bleeding occurs behind the placenta. Obstetric history, time of the last meal, and history of bleeding tendencies are all appropriate assessment questions, but none is a priority at this time.

Which patient, diagnosed with arthritis, is at the greatest risk for developing activity limitations based on ethnicity? 1. Hispanic male 2. Caucasian male 3. Asian American female 4. Native American female

1. Hispanic male Hispanics and African Americans have a higher incidence of severe arthritic joint pain and arthritis-related activity limitations than other ethnic groups. Caucasian patients have a greater risk of developing arthritis; however, these patients are not at a great risk for arthritis-related activity limitations. Asian American women have an increased risk for developing lupus. Native American patients are at an increased risk for developing rheumatoid arthritis.

A common sign or symptom of patent ductus arteriosus and septal defects is: 1. Murmur 2. Chest pain 3. Hypotension 4. Headache

1. Murmur Murmurs are heard as the blood moves through the defective structures

What are the priority nursing interventions for a grieving client? Select all that apply. 1. Recording client details 2. Allowing the client to express feelings 3. Monitoring the psychologic behavior of the client 4. Counseling the family members about diet modifications 5. Respecting the feelings of the client and creating a comfortable environment

2. Allowing the client to express feelings 5. Respecting the feelings of the client and creating a comfortable environment The priority nursing interventions for a client in grief includes providing an environment that allows the client to express his or her feelings, such as anger, fear, and guilt. Respecting the client's privacy and need or desire to talk (or not) is important and helps create a comfortable environment. Recording client details is possible only when the client is stabilized. Monitoring the psychologic behavior of the client is a moderate priority. Counseling the client's family members about lifestyle modifications is the last priority because this is of low importance.

A delirious client sees a design on the wallpaper and perceives it as an animal. In the change-of-shift report, how should the nurse communicate what the client perceived? 1. A delusion 2. An illusion 3. A hallucination 4. An idea of reference

2. An illusion An illusion is a misperception or misinterpretation of an actual external stimulus. A delusion is a false belief that cannot be changed even by evidence; it is associated with psychosis. A hallucination results from an imaginary, not real, stimulus. An idea of reference is a belief that others are talking about the person.

A client with Hodgkin disease enters a remission period and remains symptom free for 6 months before a relapse occurs. The client is diagnosed at stage IV. What therapy option does the nurse expect to be implemented? 1. Radiation therapy 2. Combination of several chemotherapy agents 3. Radiation with chemotherapy 4. Surgical removal of the affected nodes

2. Combination of several chemotherapy agents A protocol consisting of three or four chemotherapeutic agents that attack the dividing cells at various phases of development is the therapy of choice at this stage; alternating courses of different protocols generally are used. Radiation, alone or in combination with chemotherapy, is used in stages IA, IB, IIA, IIB, and IIIA. Radiation with chemotherapy is recommended for use in stage IIIA. Surgical removal of the affected nodes is not a therapy for Hodgkin disease at any stage. The nodes may be removed for biopsy or irradiated as part of therapy.

What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound? 1. Monitoring urinary output 2. Decreasing external stimuli 3. Maintaining body alignment 4. Encouraging high intake of fluid

2. Decreasing external stimuli The slightest stimulation can set off a wave of severe, painful muscle spasms involving the whole body. Nerve impulses cross the myoneural junction and stimulate muscle contraction caused by exotoxins produced by Clostridium tetani. Monitoring urinary output is not a major nursing concern for clients with tetanus. Body alignment is not an important consideration for clients with tetanus. Oral intake of fluids may not be possible because of excessive secretions and laryngospasms.

A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" Which etiology should the nurse take into consideration when formulating a response? 1. Short episodes of standing 2. Defective valves within the veins 3. Compression of leg muscles on the veins 4. Formation of thrombophlebitis in the veins

2. Defective valves within the veins Varicose veins are dilated veins that occur as a result of incompetent valves. Varicosities may result from heredity factors, prolonged standing (which puts strain on the valves), and abdominal pressure on the large veins of the lower abdomen as occurs during pregnancy. Prolonged standing increases pressure on the valves within the veins. Compression of leg muscles on the veins limits venous pooling. Varicose veins increase the risk for thrombophlebitis; thrombophlebitis does not cause varicose veins.

A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon? 1. Eat a snack before going to bed 2. Measure the blood glucose level between 2 AM and 4 AM 3. Administer the prescribed bedtime insulin immediately before going to bed 4. Identify whether symptoms experienced in the morning are associated with either hyperglycemia or hypoglycemia

2. Measure the blood glucose level between 2 AM and 4 AM During the hours of sleep, the Somogyi effect may be caused by a decline in the blood glucose level in response to too much insulin. The resulting hypoglycemia stimulates counter regulatory hormones, which precipitate lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia and ketosis. Treatment involves decreasing the evening insulin. The dawn phenomenon is characterized by the release of counterregulatory hormones in the predawn hours, precipitating hyperglycemia on awakening. Treatment involves an increase in insulin. Eating a snack before going to bed should be done when insulin is taken before sleep, but it will not help to differentiate between the Somogyi effect and the dawn phenomenon. Administering the prescribed bedtime insulin immediately before going to bed depends on the insulin regimen prescribed by the health care provider and will not help to differentiate between the Somogyi effect and the dawn phenomenon. Both the Somogyi effect and the dawn phenomenon are characterized by hyperglycemia, not hypoglycemia.

Which behaviors are most likely to be observed in a client who is a victim of sexual abuse? Select all that apply. 1. Acting out 2. Promiscuity 3. Attention seeking 4. Public masturbation 5. Wariness of physical contact with adults

2. Promiscuity 4. Public masturbation A sudden emergence of sexually-related problems such as promiscuity and public masturbation may be observed in a client who has been a victim of sexual abuse. Acting out, attention seeking, and wariness of physical contact with adults are more likely to be observed in children who have been subjected to physical abuse, though not necessarily sexual.

A client who is in preterm labor at 34 weeks gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time? 1. Reduction of anxiety associated with preterm labor 2. Promotion of maternal and fetal well-being during labor 3. Supportive communication with the client and her partner 4. Helping the family cope with the impending preterm birth

2. Promotion of maternal and fetal well-being during labor Labor is continuing, and promotion of the well-being of both client and fetus is the priority nursing care during this period. Reduction of anxiety associated with preterm labor, supportive communication with the client and her partner, and helping the family cope with the impending preterm birth each address just one aspect of this client's needs and must be dealt with in the context of the priority need.

A client with the diagnosis of schizophrenia is given one of the antipsychotic drugs. The nurse understands that antipsychotic drugs can cause extrapyramidal side effects. Which effect may be irreversible? 1. Akathisia 2. Tardive dyskinesia 3. Parkinsonian syndrome 4. Acute dystonic reaction

2. Tardive dyskinesia Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is often irreversible, even when the antipsychotic medication is withdrawn. Akathisia (motor restlessness), parkinsonian syndrome (a disorder featuring signs and symptoms of Parkinson disease such as resting tremors, muscle weakness, reduced movement, and festinating gait), and dystonia (impairment of muscle tonus) can usually be treated with antiparkinsonian or anticholinergic drugs while the antipsychotic medication is continued.

A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first? 1. Evaluate the fetal heart rate 2. Turn the oxytocin infusion off 3. Place the client in the left-lateral position 4. Prepare the client for an emergency birth

2. Turn the oxytocin infusion off Because contractions are induced by the oxytocin, stopping the infusion should stop contractions and increase uteroplacental perfusion. Although evaluating the fetus's response is important, it is not the priority. Although placing the client in the left-lateral position is important, it is not the priority. There are no data to indicate that the client is ready to give birth.

A client is admitted with a marginal placenta previa. What should the nurse have available? 1. One unit of freeze-dried plasma 2. Vitamin K for intramuscular injection 3. Two units of typed and screened blood 4. Heparin sodium for intravenous injection

3. Two units of typed and screened blood A sudden, severe hemorrhage may occur because of the location of the placenta near the cervical os; blood should be ready for administration to prevent shock. Freeze-dried plasma is not used in this situation. Adults manufacture their own vitamin K, and an injection will not help prevent bleeding from the placenta. Heparin sodium is contraindicated in the presence of hemorrhage.

While caring for the foot of a client with diabetes, the client tells the nurse of severe pain and pus discharge from the foot. Which format of SOAPE includes this description? 1. Evaluation 2. Assessment 3. Objective information 4. Subjective information

4. Subjective information Subjective information is what the client states or feels. Evaluation is an appraisal of the response and effectiveness of the plan. Assessment refers to an analysis or potential diagnosis of the cause of the client's problem or need. Objective information is what the nurse can measure or actually describe.

In her 37th week of gestation, a client with type 1 diabetes has amniocentesis to determine fetal lung maturity. The lecithin/sphingomyelin ratio is 2:1, phosphatidylglycerol is present, and creatinine is 2 mg/dL. What conclusion should the nurse draw from this information? 1. A cesarean birth will be scheduled. 2. A birth must take place immediately. 3. The fetus need not be monitored any longer. 4. The newborn should be free from respiratory problems.

4. The newborn should be free from respiratory problems These test results confirm fetal lung maturity, and the neonate should be free of major respiratory problems. They do not indicate the need for a cesarean birth. There is no indication of fetal compromise; an immediate vaginal or cesarean birth is not necessary. Further fetal monitoring will be necessary in the future, as with any pregnancy.

A nurse is following a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as the highest priority for this client? A. Change in body image B. Increased risk for injury C. Increased risk of depression D. Lower level of physical activity

B. Increased risk for injury The client with diabetic neuropathy of the lower extremities has a diminished sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Therefore the highest priority nursing problem is increased risk for injury. Increased risk of depression and change in body image are more psychosocial in nature and, as such, are secondary needs. A lower level of physical activity may be a problem but is not the priority.

A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? A. Constipation B. Tall T waves C. Hyporeflexia D. Shallow respirations E. Prolonged PR interval F. Hyperactive bowel sounds

B. Tall T waves E. Prolonged PR interval F. Hyperactive bowel sounds Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.

Which antihistamine drug is considered nonsedating? 1. Zafirlukast 2. Montelukast 3. Fexofenadine 4. Chlorpheniramine

3. Fexofenadine Fexofenadine is a nonsedating antihistamine drug used to treat hypersensitivity reactions. Zafirlukast and montelukast are leukotriene inhibitors used to treat hypersensitivity reactions. Chlorpheniramine is an antihistamine with severe sedative effect.

Which patient population requires education on decreasing the risk for sexually transmitted infections (STIs)? 1. Hispanics 2. Caucasians 3. Pacific Islanders 4. African Americans

1. Hispanics Hispanics are four times more likely to contract all STIs when compared with Caucasians; therefore this patient population requires education on decreasing all types of STIs. The other groups (Pacific Islanders and African Americans) are not noted to have an increased risk for contracting all types of STIs.

Which vaccination is given to young children to provide protection against tetanus and diphtheria but not pertussis? 1. Td 2. DT 3. DTaP 4. Tdap

2. DT DT is given to children to provide protection from both tetanus and diphtheria. Td is used as a booster dose to protect adolescents and adults from tetanus and diphtheria. DTaP is given to children to provide protection from tetanus, diphtheria, and acellular pertussis. Tdap is used as a booster dose to protect adolescents and adults from tetanus, diphtheria, and acellular pertussis.

Which blood disorder places a child at greatest risk for intracranial bleeding if head injury occurs? 1. Sickle cell anemia 2. Sickle cell trait 3. Iron deficiency anemia 4. Idiopathic thrombocytopenia purpura

4. Idiopathic thrombocytopenia purpura In idiopathic thrombocytopenia purpura, the platelet count is lowered and this increases the risk for bleeding, even if injuries are minor

When assessing an 85-year-old client's vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process? 1. A pulse rate irregularity 2. Equal apical and radial pulse rates 3. A pulse rate of 60 beats per minute 4. An apical rate obtainable at the fifth intercostal space and midclavicular line

1. A pulse rate irregularity Dysrhythmias are abnormal and are associated with acute or chronic pathologic conditions. An equal apical and radial pulse is expected; the radial pulse reflects ventricular contractions. The expected range in adults is 60 to 100 beats per minute. An apical rate obtainable at the fifth intercostal space and midclavicular line are the anatomical landmarks for locating the apex of the heart; they are unaffected by aging.

The nurse is teaching a client with diabetes about foot care. Which statements made by the client indicates the client understands which activities would be beneficial to prevent infection? Select all that apply. 1. "I will apply lotion to my feet daily" 2. "I will clean my feet with hot water" 3. "I will cut my nails close to the nail bed" 4. "I will soak my feet in water for at least 10 minutes before doing nail care" 4. "I will assess the skin on my feet for redness, abrasions, and open areas daily"

1. "I will apply lotion to my feet daily" 5. "I will assess the skin on my feet for redness, abrasions, and open areas daily" Applying lotion to the feet daily prevents dryness and thus prevents infection. The client with diabetes is at risk of infections due to delayed wound healing. Therefore, the client should assess for skin redness, abrasions, and areas of open wounds. The client with diabetes should not cut the nails; they should trim the nails. Trimming helps in preventing damage to tissues and thus reduces the risk of infection. Warm water should be used to clean the feet, not hot water. The client with diabetes is at risk of tissue ulceration because soaking causes maceration of the tissue. Therefore, the feet should not be soaked in water for 10 minutes before nail care.

A registered nurse is educating a licensed practical nurse (LPN) about promoting rest and sleep in sleep-deprived clients. Which statement made by the LPN indicates a need for further teaching? 1. "I won't allow visitors in the client's room." 2. "I'll carry out all procedures within a given time frame." 3. "I'll limit interruptions for vital sign checks during the night." 4. "I'll make sure that the client's room is kept at a comfortable temperature."

1. "I won't allow visitors in the client's room." The LPN should limit the number of visitors and the duration of visits but should not completely bar visitors from seeing the client. The LPN is right to plan to carry out all procedures within a short time frame to avoid disturbing the client repeatedly. The LPN is also right to plan to limit interruptions for vital sign checks during the night. The LPN also shows understanding by recognizing that the client's room should be maintained at a comfortable temperature to promote sleep.

While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet begun the bonding process. Which statement by the mother supports the nurse's conclusion? 1. "It's such a tiny baby." 2. "Do you think he'll make it?" 3. "Why does he need to be in an incubator?" 4. "My baby looks so much like my husband."

1. "It's such a tiny baby" By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.

A client with mild preeclampsia is told that she must remain on bed rest at home. The client starts to cry and tells the nurse that she has two small children at home who need her. How should the nurse respond? 1. "Let's explore your available current support and opportunities for child care." 2. "Are you worried about how you'll be able to handle this problem?" 3. "You can get a neighbor to help out, and your husband can do the housework in the evening." 4. "You can prepare light meals and the children can go to nursery school a few hours each day."

1. "Let's explore your available current support and opportunities for child care." Discussing with the client her options for managing child care helps addresses the problem directly while providing an opportunity for the client to examine her options. The therapeutic regimen includes bed rest and peace of mind; these can best be fulfilled if the children are cared for adequately. Asking whether the client is worried about how she will be able to handle this problem explores feelings but does not include a therapeutic regimen. Stating that the client can get a neighbor to help out and have the husband do the housework in the evening is giving a solution rather than exploring the situation with the client. Complete bed rest has been prescribed, which precludes getting up to cook, and the suggestion of nursery school for the children assumes that the client is able to afford it.

The nurse is caring for a pregnant woman with class II cardiac disease. The client has anemia with a hemoglobin level of 8 g/dL (80 mmol/L). What is the nurse's primary concern for this client? 1. Impending heart failure 2. Development of heart block 3. Appearance of atrial fibrillation 4. Imminent ventricular fibrillation

1. Impending heart failure Anemia reduces the capacity of the blood to carry oxygen and thus increases demands on the heart. Heart block is caused by a disturbance in the conduction of impulses, not the oxygen-carrying capacity of blood. Cardiac irregularity is not associated with anemia. Imminent ventricular fibrillation is a grave complication; adequate treatment should prevent this.

Before having sclerotherapy for varicose veins, a client asks the nurse why a solution is injected into the vein. How should the nurse respond? 1. "The solution causes the vein to scar and collapse. The vein is reabsorbed into local tissue and eventually fades." 2. "The solution cleans out plaque from within the vein, which allows for improved circulation and decreases varicosity." 3. "The solution anastomoses superficial veins to deep veins. Because the vein is no longer near the surface, it fades from view." 4. "The solution allows placement of an umbrella filter in the vein, which allows for improved circulation and decreases varicosity."

1. "The solution causes the vein to scar and collapse. The vein is reabsorbed into local tissue and eventually fades." Sclerotherapy effectively treats varicose and spider veins. It's often considered the treatment of choice for small varicose veins. Sclerotherapy involves injecting a solution directly into the vein. The sclerotherapy solution (generally a salt solution) causes the vein to scar and collapse, forcing blood to reroute through healthier veins. The collapsed vein is reabsorbed into local tissue and eventually fades. Plaque is considered an arterial rather than a venous problem. Superficial veins and deep veins normally are attached by communicating veins; sclerotherapy does not involve anastomosis. Placing an umbrella filter in the large affected veins prevents emboli from traveling to the lung; it is not a vein ligation and stripping.

As the nurse helps a postpartum client change her perineal pad, the client comments, "I wish you didn't have to look at the pad. It's so embarrassing for me." What is the best response by the nurse? 1. "This seems to be uncomfortable for you; however, I have to estimate the amount of blood loss to identify any potential problems." 2. "There can be more blood loss than you might realize. We can determine how much you've lost with a formula." 3. Examining the pad is a common practice that helps us keep you safe. It's a necessary part of the job, and I don't mind." 4. "Looking at your pad is a procedure we follow to determine the extent of your bleeding so we can give you the necessary care."

1. "This seems to be uncomfortable for you; however, I have to estimate the amount of blood loss to identify any potential problems." Recognizing the client's discomfort and informing the client of the need to estimate the amount of blood loss acknowledges her feelings and provides an explanation for the intervention. Blood loss can be estimated from the pad count, the degree of saturation, and the time taken for the saturation to occur; an estimate of loss can give the nurse an opportunity to prevent complications caused by hemorrhage. Informing the client that the blood loss can be calculated does not identify the client's feelings; also, this statement may be alarming. Telling the client that examining the pad is a common practice or policy does not acknowledge the client's feelings; it is a general response that does not educate the client about why this assessment is necessary.

Which child(ren) need(s) an iron supplement? Select all that apply. 1. A 5-month-old infant who is exclusively breastfed 2. A healthy toddler with age-appropriate eating habits 3. A 16-year-old girl who is trying to lose weight 4. A preterm infant with low birth weight 5. A 10-month-old infant who eats commercial infant cereal

1. A 5-month-old infant who is exclusively breastfed 3. A 16-year-old girl who is trying to lose weight 4. A preterm infant with low birth weight A breastfed infant should start iron supplements at 4 months of age. Preterm infants have less iron reserve to begin with, so they also need supplements. A 16-year-old girl who is dieting will have iron deficiency related to menstruation, so she should also have supplements. It is recommended that a toddler obtain the necessary iron by eating lean meats, legumes, and fortified cereal. The 10-month-old is eating commercial infant cereal, which is the best solid food source of iron

The nurse is preparing to educate a group of clients about health promotion to prevent head and neck cancer. Which clients are of highest priority for education? Select all that apply. 1. A client who chews tobacco 2. A client who has multiple sex partners 3. A client who uses condoms when having sex 4. A client with a history of alcohol abuse for 5 years 5. A client who brushes with a soft bristle toothbrush

1. A client who chews tobacco 2. A client who has multiple sex partners 4. A client with a history of alcohol abuse for 5 years Tobacco, alcohol, and human papilloma virus (HPV) are the major causes of neck cancer. The nurse should counsel the client who chews tobacco and educate regarding the importance of oral hygiene. The nurse should advise the client to stop chewing tobacco to reduce the risk of head and neck cancer. The nurse should educate the client with multiple sex partners about protecting against human papilloma virus (HPV), which is a risk factor for cancer. The nurse should place a high priority on health promotion in a client with a history of alcohol abuse for 5 years because it is one of the major risk factors for head and neck cancer. The client should use condoms when having sex with potentially infectious partners to prevent HPV infections that can lead to head and neck cancer. A client should maintain proper oral hygiene by brushing his or her teeth regularly with a soft bristle brush and flossing.

A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which client does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. 1. A client with septicemia 2. A client with mild preeclampsia 3. A client with diabetes mellitus who delivered a 10-lb baby 4. A client who had a cesarean section because of abruptio placentae 5. A client who delivered 12 hours ago and has lost 475 mL of blood

1. A client with septicemia 4. A client who had a cesarean section because of aprubto placentae DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage. A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC.

Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process? 1. Promoting vasodilation 2. Cleansing perineal tissue 3. Softening the incision site 4. Tightening the rectal sphincter

1. Promoting vasodilation Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. What is a priority nursing intervention? 1. Administer the prescribed antipyretic and notify the charge nurse or primary health care provider 2. Obtain the respirations, pulse, and blood pressure; recheck the temperature in one hour 3. Assess the amount and color of urine; obtain a specimen for a urinalysis 4. Note the consistency of respiratory secretions and obtain a specimen for culture

1. Administer the prescribed antipyretic and notify the charge nurse or primary health care provider Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia can then be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure and rechecking the temperature in one hour is necessary. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply. 1. Airborne 2. Contact 3. Droplet 4. Hazardous Wastes 5. Standard

1. Airborne 2. Contact 3. Standard Contact precautions are used for patients with known or suspected infections transmitted by direct contact or contact with items in the environment. Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Varicella can be transmitted by airborne and contact. Droplet precautions are used for patients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that my travel 3 feet, but are not suspended for long periods. Standard precautions are used with every client. Nurses should treat all body excretions, secretions, and moist membranes/ tissues, excluding perspirations as potentially infectious. Contact and airborne precautions must be used

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply. 1. Airway 2. Breathing 3. Circulation 4. Give comfort measures 5. Facilitate family presence 6. Exposure or environmental control

1. Airway 2. Breathing 3. Circulation 6. Exposure or environmental control The primary survey focuses on airway, breathing, circulation (ABC), and environmental control. These are surveyed during emergency assessments in a primary survey to identify life-threatening conditions and to analyze the appropriate interventions. Giving comfort measures and facilitating family presence are performed in a secondary survey of emergency assessment followed by a primary survey.

A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene to prevent these behaviors from causing the other clients to feel what? 1. Angry 2. Dependent 3. Inadequate 4. Ambivalent

1. Angry A person with a condescending, superior attitude typically evokes feelings of anger in others and will increase their anxiety. It is unlikely that a condescending, superior attitude will produce feelings of dependency, inadequacy, or ambivalence in others.

A woman who is HIV positive delivers an infant. The health care provider prescribes testing for the newborn, and the nurse prepares to take which action? 1. Ask the laboratory to perform virologic testing 2. Obtain blood from the umbilical cord to send to the laboratory 3. Perform a heelstick to obtain a specimen for a Western blot assay 4. Perform a fingerstick to obtain a specimen for an enzyme-linked immunosorbent assay (ELISA)

1. Ask the laboratory to perform virologic testing Traditional HIV antibody measurement by ELISA or Western-blot assay is not accurate in infants younger than 18 months because of the persistence of maternal antibodies. Because of the potential for maternal contamination during delivery, umbilical cord blood should not be used for testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up testing, depending on the initial results.

A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors? 1. Bipolar disorder, manic phase 2. Antisocial personality disorder 3. Obsessive-compulsive disorder 4. Chronic undifferentiated schizophrenia

1. Bipolar disorder, manic phase This kind of hyperactive behavior is typical of the manic flight into reality associated with mood disorders. The behaviors are more indicative of a mood disorder than a personality disorder. Ritualistic, not manic, behavior is indicative of obsessive-compulsive disorder. A flat affect and apathy are more indicative of a schizophrenic disorder.

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe? 1. Calcium 2. Magnesium 3. Bicarbonate 4. Potassium chloride

1. Calcium These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.

Which action performed by the client with diabetes would increase the risk of sepsis during foot care? 1. Cleansing cuts with iodine 2. Trimming the nails after shower 3. Wearing leather shoes while walking 4. Cutting toenails even with a rounded contour

1. Cleansing cuts with iodine The client with diabetes should clean cuts with warm water and mild soap, but not with iodine. The nails may become soft after a shower, so the client should trim the nails after the shower, which reduces the risk of injury and infection. The client should wear leather shoes rather than vinyl shoes while walking. The client should cut the toenails even with a rounded contour.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select al that apply. 1. Clients have a right to refuse treatment 2. Nurses are required to answer clients truthfully 3. The health care provider should have been notified 4. The client had insufficient knowledge to make such a decision 5. Legally prescribed medications are administered despite a client's objections

1. Clients have a right to refuse treatment 2. Nurses are required to answer clients truthfully 3. The health care provider should have been notified Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. Client's questions must always be answered truthfully. The health care provider should be notified when a client refuses an intervention so that an alternate treatment plan can be formulated. This is done after the nurse explores the client's reasons for refusal. The client had a discussion with the nurse that indicated that the client had sufficient information to make the decision to refuse the medication. The client has a right to refuse treatment; this right takes precedence over the health care provider's prescription.

The nurse is caring for a postpartum client with preeclampsia being managed with a magnesium sulfate infusion. What is the priority nursing assessment? 1. Counting respiratory rate 2. Obtaining blood pressure 3. Eliciting deep tendon reflexes 4. Monitoring urine output

1. Counting respiratory rate Magnesium sulfate is continued for 24 hours after delivery and requires careful monitoring for toxicity. Checking the blood pressure, testing the deep tendon reflexes, and monitoring urine output are all appropriate assessments in a client receiving this medication; however, monitoring the respiratory rate is the priority.

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure? 1. Dilation of blood vessels 2. Decreased response of chemoreceptors 3. Decreased strength of cardiac contractions 4. Disruption of cardiac accelerator pathways

1. Dilation of blood vessels Paralysis of the sympathetic vasomotor nerves after administration of a spinal anesthetic results in dilation of blood vessels, which causes a subsequent decrease in blood pressure. Chemoreceptors are sensitive to pH, oxygen, and carbon dioxide tension; they are not related to hypotension and are not affected by spinal anesthesia. The strength of cardiac contractions is not affected by spinal anesthesia. The cardiac accelerator neurons in the medulla regulate heart rate; they are not related to hypotension and are not affected by spinal anesthesia. Topics

A healthcare provider prescribes divalproex for a client with the diagnosis of bipolar I disorder, manic episode. What side effects of this medication might the client report during a follow-up visit? 1. Dizziness, nausea, and vomiting 2. Photosensitivity, agitation, and restlessness 3. Abdominal cramps, tremor, and muscle weakness 4. Weight gain, drowsiness, and diminished concentration

1. Dizziness, nausea, and vomiting Divalproex, an anticonvulsant, causes gastric irritation and should be taken with food; it is available in an enteric-coated form. It may cause nausea, vomiting, indigestion, hypersalivation, diarrhea or constipation, anorexia or increased appetite, dizziness, headache, and confusion. Photosensitivity, agitation, and restlessness are all common side effects of phenothiazines. Abdominal cramps, tremor, and muscle weakness are signs and symptoms of lithium toxicity. Weight gain, drowsiness, and diminished concentration are common side effects of tricyclic antidepressants.

A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse? 1. Finding the client's contacts 2. Interviewing the client's parents 3. Instructing the client about birth control measures 4. Determining the reasons for the client's promiscuity

1. Finding the client's contacts Gonorrhea is a highly contagious disease transmitted through sexual intercourse. The incubation period varies, but symptoms usually occur 2 to 10 days after contact. Early effective treatment prevents complications such as sterility. The parents may be unaware that their child has gonorrhea. Most birth control measures do not protect against the transmission of sexually transmitted infections. Contracting venereal infection is not necessarily indicative of promiscuity.

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? 1. Do not change positions suddenly. 2. Light-headedness is a common adverse effect that need not be reported. 3. The medication may cause a sore throat for the first few days. 4. Schedule blood tests weekly for the first 2 months.

1. Do not change positions suddenly Vasotec (enalapril) is classified as an ACE Inhibitor. ACE stands for angiotensin-converting enzyme. Vasotec is used to treat high blood pressure (hypertension) and congestive heart failure. It can also be used to treat a disorder of the ventricles. Angiotensin is a chemical that causes the arteries to become narrow. ACE inhibitors help the body produce less angiotensin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure. Clients should be advised to change position slowly to minimize orthostatic hypotension. A healthcare provider should be notified immediately if the client is experiencing light-headedness or feeling like he or she is about to faint, as this is a serious side effect. This medication does not cause a sore throat the first few days of treatment. Presently, there are no guidelines that suggest blood tests are required weekly for the first two months.

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation? 1. Electroconvulsive therapy 2. Short-term psychoanalysis 3. Nondirective psychotherapy 4. High doses of anxiolytic drugs

1. Electroconvulsive therapy Electroconvulsive therapy, which interrupts established patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable depression that does not respond to antidepressant medication. The client's depressed mood limits participation in psychotherapy; feelings precipitated by therapy may lead to suicidal acting out. Psychotherapy is directed toward helping the person learn new coping mechanisms and better ways of coping with problems; the depressed client needs direction to accomplish this. Antianxiety medications are usually not prescribed for clients with depression.

A client is found to have a borderline personality disorder. What is a realistic initial intervention for this client? 1. Establishing clear boundaries 2. Exploring job possibilities with the nurse 3. Initiating a discussion of feelings of being victimized 4. Spending 1 hour twice a day discussing problems with the nurse

1. Establishing clear boundaries Individuals with borderline personality disorder are impulsive and have difficulty identifying and respecting boundaries in relation to others. Exploration of this topic in a meaningful manner can be done only after an ongoing relationship has been established. Feeling victimized is a frequent theme among clients with this disorder; however, they rarely have the insight to initiate discussion of these feelings and usually show resistance when the topic is broached. An individual with a borderline personality disorder may not be able to spend this length of time having a meaningful discussion with the nurse; usually they are too impulsive to engage in consistent work until a therapeutic relationship has been established.

The child has a hemoglobin (Hgb) value of 8 g/dL. Which symptom would the nurse expect to see at the hemoglobin level? 1. Fatigue 2. Pallor 3. Glossitis 4. "Spoon" fingernails

1. Fatigue The clinical signs and symptoms of mild to moderate anemia (hemoglobin: 6-10 g/dL) are often vague and nonspecific and include irritability, weakness, decreased play activity, and fatigue. When hemoglobin falls below 5 g/dL, the child will have anorexia, skin pallor, pale mucous membranes, glossitis, concave or "spoon" fingernails, inability to concentrate, tachycardia, and systolic murmurs

What are the psychological signs and symptoms experienced by clients with sleep deprivation? Select all that apply. 1. Fatigue 2. Disorientation 3. Hyperexcitability 4. Diminished reasoning 5. Slowed response time

1. Fatigue 2. Disorientation 3. Hyperexcitability Fatigue, disorientation, and hyperexcitability are psychological symptoms experienced by sleep-deprived individuals. Diminished reasoning and slowed response time are physiologic, symptoms of sleep deprivation.

A nurse has been caring for a suicidal client for 3 weeks on an in-patient unit. One morning the client greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long." What does the client's behavior and statement indicate? 1. Increased risk of suicide 2. Increased level of anxiety 3. Positive response to treatment 4. Resolution of suicidal ideation

1. Increased risk of suicide A sudden lifting of mood may indicate an increased risk for suicide; the client may now have the emotional energy to make the decision to act on suicidal ideas or, having decided to commit suicide, feels that the problems will soon be gone. The anxiety level usually decreases when the client makes a decision; this may indicate that the decision is to commit suicide. The client's statement "I'm not going to have problems for very long" may indicate continuing suicidal thoughts, not a positive response to treatment or resolution of suicidal ideation.

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. When planning care for this client, the nurse recalls what about confusion? 1. It occurs with a transfer to new surroundings 2. It will be unchanged despite reality orientation 3. It is a common finding and is expected with aging 4. It results from brain changes that make interventions futile

1. It occurs with a transfer to new surroundings A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.

During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1. Lethargy 2. Ambivalence 3. Emotional lability 4. Increased appetite 5. Long periods of sleep

1. Lethargy 2. Ambivalence 3. Emotional lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.

A client with type 2 diabetes mellitus and hypertension is discharged from the hospital and is advised to go into long-term care. The client cannot afford a long-term care facility. What source would help the client to receive long-term care services? 1. Medicaid 2. Private pay 3. Preferred provider organizations (PPOs) 4. Health maintenance organization (HMOs)

1. Medicaid Medicaid provides benefits of home health services to poor people and low-income people.

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mmHg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1. Monitoring deep tendon reflexes 2. Assessing urine output every 8 hours 3. Maintaining a dark, quiet environment 4. Using a pump to regulate the medication 5. Having calcium gluconate available at the bedside 6. Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min

1. Monitoring deep tendon reflexes 3. Maintaining a dark, quiet environment 4. Using a pump to regulate the medication 5. Having calcium gluconate available at the bedside Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the primary healthcare provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary healthcare provider.

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping due to afterbirth pains? 1. Multipara who has vaginally delivered three children 2. Primipara whose newborn weighed 7 lb 3. Multipara with effectively controlled diabetes 4. Multipara whose second child was small for gestational age

1. Multipara who has vaginally delivered three children A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.

A nurse in the birthing suite has just admitted four clients. Which client should the nurse anticipate may require a cesarean birth? 1. Multipara with a shoulder presentation 2. Multipara with a documented station of "floating" 3. Primigravida with a fetus presenting in the occiput posterior position 4. Primigravida with a twin gestation with the lowermost twin in the vertex presentation

1. Multipara with a shoulder presentation A shoulder presentation in a multipara is indicative of a transverse lie, and this necessitates a cesarean birth. It is not uncommon for the fetus of a multipara to be high at the beginning of labor; early engagement occurs more often with a primigravida. With an occiput posterior position the labor may be longer, but usually the mother can give birth vaginally. If the first twin is in the vertex presentation, a vaginal birth will be attempted with a double setup; if possible, the birth of the second twin also will be attempted vaginally.

What should an older client be instructed to do to ensure antibody-mediated immunity? Select all that apply. 1. Obtain a shingles vaccination 2. Receive a tetanus booster injection 3. Obtain the pneumococcal vaccination 4. Receive annual testing for tuberculosis 5. Receive an annual influenza vaccination

1. Obtain a shingles vaccination 2. Receive a tetanus booster injection 3. Obtain the pneumococcal vaccination 5. Receive an annual influenza vaccination Because older adults are less able to make new antibodies in response to the presence of new antigens, they should receive the shingles vaccination. Because older adults may not have sufficient antibodies present to provide protection when they are re-exposed to microorganisms they have already generated antibodies against, booster shots are encouraged. The pneumococcal and influenza vaccinations help to create antibodies in response to new antigens. Testing for tuberculosis addresses cell-mediated immunity for the older client.

A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. What is important for the nurse to consider when administering potassium chloride intravenously to this client? 1. Oliguria is an indication for withholding intravenous (IV) potassium 2. Rapid infusion of potassium prevents burning at the IV site 3. Clients with severe deficits should be given IV push potassium 4. Average IV dosage of potassium should not exceed 60 mEq in 1 hour

1. Oliguria is an indication for withholding intravenous (IV) potassium Potassium chloride should not be given unless renal flow is adequate; otherwise, the potassium chloride will accumulate in the body, causing hyperkalemia. Rapid infusion may cause severe pain at the infusion site and precipitate cardiac arrest. Potassium chloride must be well diluted or it will precipitate cardiac arrest. 60 mL/hr is too high a dosage; the IV dosage should not exceed 20 mEq of potassium chloride per hour.

Which oxytocic drug may help to control uterine bleeding post-delivery and promote milk ejection? 1. Oxytocin 2. Mifepristone 3. Dinoprostone 4. Ergot alkaloids

1. Oxytocin Oxytocin is used to induce labor, control uterine bleeding after delivery, and promote milk ejection during lactation. Mifepristone is generally used to induce abortion. Dinoprostone induces labor but has no effect on milk ejection or uterine bleeding. Although ergot alkaloids control uterine bleeding after delivery, they do not cause milk ejection during lactation.

Which interventions are included in the care plan of a postpartum client with a fourth-degree laceration? Select all that apply. 1. Pain management with oral analgesics 2. Continuous application of a warm pack 3. Assessment of the site every 15 minutes 4. Gentle cleansing with antibacterial cleanser 5. Application of an ice pack for 20-minute intervals 6. Instructing the client in how to promote normal bowel function

1. Pain management with oral analgesics 3. Assessment of the site every 15 minutes 5. Application of an ice pack for 20-minute intervals Providing pain management will prevent the client's pain from reaching an unmanageable level. Assessment of the site will identify any abnormal changes. Application of ice will decrease pain and edema. Warmth applied to newly traumatized tissue will increase pain and edema. Antibacterial cleanser would be caustic and painful to the laceration. Teaching regarding bowel function would be more appropriately presented after the client has completed the fourth stage and resumed normal intake.

A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? 1. Preventing Falls 2. Monitoring electrolytes 3. Administering antiemetics 4. Adjusting the diuretic therapy

1. Preventing falls A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls; therefore, to prevent injury, the priority nursing care is to prevent falls. Monitoring electrolytes daily until they return to normal is not the priority nursing care. Antiemetics are prescribed for vomiting and are given low priority. Once the client is protected from the risk of injury, diuretic therapy is adjusted.

A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect? 1. Primary prevention 2. Tertiary prevention 3. Secondary prevention 4. Therapeutic prevention

1. Primary prevention Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? Select all that apply. 1. Projection 2. Suppression 3. Sublimation 4. Identification 5. Rationalization

1. Projection 5. Rationalization Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. This defense mechanism commonly is used by clients with alcoholism because it helps make reality more acceptable. Rationalization is making acceptable excuses for behavior; this defense is used by people with alcoholism because it makes reality more acceptable. Suppression keeps uncomfortable thoughts, feelings, and wishes in the subconscious; suppression is used rarely by people with alcoholism. Sublimation (the rechanneling of anxiety into constructive activities) is rarely used by these clients. Identification is the unconscious wish to be like another person; it is not commonly used by clients with an alcohol problem.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. 1. Providing oxygen immediately 2. Notifying the rapid response team 3. Considering it a normal observation 4. Initiating an intravenous (IV) line and beginning fluid replacement 5. Obtaining an electrocardiogram (ECG) of the client

1. Providing oxygen immediately 2. Notifying the rapid response team Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. What should the nurse do? 1. Refer the mother to the psychiatrist 2. Explain to the mother the results of the tests 3. Suggest that the mother call the psychologist 4. Teach the mother about the tests that were administered

1. Refer the mother to the psychiatrist It is the responsibility of the psychiatrist, who is the primary care provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered.

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? Select all that apply. 1. Reflex irritability: cry 2. Respiratory rate: good cry 3. Heart rate: 110 beats/min 4. Color: body pink, extremities blue 5. Muscle tone: some flexion of extremities

1. Reflex irritability: cry 2. Respiratory rate: good cry 3. Heart rate: 110 beats/min A cry for reflex irritability rates a score of 2. A good cry for respiratory rate scores a 2. A heart rate of 100 beats/min or more rates a 2. A pink body with blue extremities rates a 1. Some flexion of extremities rates a 1 for muscle tone.

A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline what? 1. Renal studies 2. Liver enzyme studies 3. Adrenal function studies 4. Pulmonary function studies

1. Renal studies Because of the severity of side effects and the stress lithium places on the renal and cardiovascular systems, its administration is contraindicated in clients with renal or cardiovascular disease. Baseline renal studies can be used for comparison in the future. Liver enzyme studies are not necessary; lithium does not alter liver function. Adrenal function studies are not necessary; lithium does not alter adrenal gland functions. Pulmonary function studies are not necessary; lithium does not cause alterations in pulmonary function.

A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor? 1. Scheduling pain medication at regular intervals 2. Administering the medication only when the pain is severe 3. Avoiding the administration of medication unless it is requested 4. Recognizing that less pain medication will be needed by this client compared with other women in labor

1. Scheduling pain medication at regular intervals This client will have a lower tolerance for pain and a greater need for pain relief. Larger doses may be needed if pain medication is administered only when the pain is severe. Delays increase anxiety and discomfort, and larger doses will be necessary. Individuals who abuse drugs require more medication than do others because of tolerance to the addictive drug.

A pregnant client who has a history of cardiac disease asks how she can relieve her occasional heartburn. The nurse should instruct the client to avoid antacids containing what? 1. Sodium 2. Calcium 3. Aluminum 4. Magnesium

1. Sodium If the client consumes more than the usual daily sodium intake, excess fluid retention results; this will increase the cardiac workload. Antacids that contain calcium, magnesium, or aluminum do not cause fluid retention; however, it is still best for this client to seek medical advice before taking an antacid.

The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority? Select all that apply. 1. Stroke 2. Skin rash 3. Active hemorrhage 4. Respiratory distress 5. Chest pain with diaphoresis 6. Displaced or multiple fractures

1. Stroke 3. Active hemorrhage 4. Respiratory distress Clients presenting with signs of a stroke, active hemorrhage, or respiratory distress should be triaged under the emergent tier level because the conditions are life threatening. Clients with a skin rash are categorized as nonurgent because treatment can be delayed. Clients presenting with chest pain with diaphoresis and displaced or multiple fractures are triaged as urgent, which needs quick treatment but is not immediately life threatening.

A client has received instructions to take 650 mg aspirin every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply. 1. Take the aspirin with meals or a snack. 2. Make an appointment with a dentist if bleeding gums develop. 3. Do not chew enteric-coated tablets. 4. Switch to acetaminophen if tinnitus occurs. 5. Report persistent abdominal pain.

1. Take the aspirin with meals or a snack 3. Do not chew enteric-coated tablets 5. Report persistent abdominal pain Acetylsalicylic acid (aspirin) is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Enteric-coated tablets must not be crushed or chewed. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner. Aspirin therapy may lead to GI bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately.

A nurse is preparing a teaching plan for a client with syphilis. The nurse includes that syphilis is not considered contagious in which stage? 1. Tertiary stage 2. Primary stage 3. Secondary stage 4. Incubation stage

1. Tertiary stage The tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponemes. The primary stage lasts 8 to 12 weeks; the chancre is teeming with spirochetes, and the individual is contagious. The duration of the secondary stage is variable (about five years); skin and mucosal lesions contain spirochetes, and the individual is highly contagious. The incubation stage lasts two to six weeks; spirochetes proliferate at the entry site, and the individual is contagious.

A nurse observes regular patterns that look like they were made by a belt buckle, wire hanger, and chain on a child's skin. What behavioral change might the nurse also expect from the child? 1. The child expresses fear of going home 2. The child shows self-stimulatory behavior 3. The child's intellectual development is lagging 4. The child displays age-inappropriate sexual play

1. The child expresses fear of going home A child suffering from physical abuse is likely to express a fear of going home. Self-stimulatory behavior is most likely to be observed in a child suffering physical neglect. A child who is a victim of emotional maltreatment may have low intellectual development. Age-inappropriate sexual play is observed in the child who is a victim of sexual maltreatment

While caring for clients with anorexia nervosa and bulimia nervosa, a nurse plans to include a behavior-management program. What is the rationale for this nursing intervention? 1. To help these clients maintain control over their eating 2. To help clients express themselves with the use of toys 3. To bring any maladaptive eating behaviors to the surface 4. To correct the clients' perceptions of distorted body image

1. To help these clients maintain control over their eating Anorexia nervosa and bulimia nervosa are psychological eating disorders that can be treated with behavior-management programs. These programs allow clients to maintain control over their eating and over the amount of exercise they are engaged in. Play therapy helps children to express their feelings with the use of toys such as puppets. Psychoanalysis, developed by Sigmund Freud, enables clients to express formerly unconscious thoughts such as maladaptive eating behaviors. Cognitive therapy helps clients correct feelings of distorted body image.

What potentially dangerous adverse effect of an intravenous titrated drip of lidocaine should the nurse immediately report to the healthcare provider? 1. Tremors 2. Anorexia 3. Tachycardia 4. Hypertension

1. Tremors Tremors are a precursor to the major adverse effect of seizures. Although anorexia may occur, it is not a dangerous side effect. Bradycardia, which may lead to heart block, may occur, not tachycardia. Hypotension, not hypertension, may occur.

A client at 24 weeks gestation is admitted to the high-risk unit with a diagnosis of preeclampsia. She has a seizure. What is the nurse's priority action? 1. Turning the client's head to the side 2. Checking the client for an imminent birth 3. Inserting an airway into the client's mouth 4. Checking for bleeding from the client's vagina

1. Turning the client's head to the side Turning the client's head to the side will allow saliva to drain from the mouth by gravity, which will help maintain a patent airway. Although birth may be imminent, the priority is maintaining a patent airway. Placing an airway in the client's mouth is contraindicated because it may cause injury. Inspecting the client's vagina is not the priority, and bleeding is not an expected response to a seizure.

A client's hands are raw and bloody from a ritual involving frequent handwashing. Which defense mechanism does the nurse identify? 1. Undoing 2. Projection 3. Introjection 4. Suppression

1. Undoing Undoing is an act that partially negates a previous one; the client is using this primitive defense mechanism to reduce anxiety. Clients who wash their hands compulsively may be having thoughts that they consider "dirty." Projection is the attribution of one's thoughts or impulses to another. Introjection is treating something outside the self as if it is actually inside the self. Suppression is a process that is often listed as a defense mechanism, but it is actually a conscious, intentional exclusion of material from one's awareness.

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? Select all that apply. 1. Urinary urgency 2. Loss of skin elasticity 3. Increased body warmth 4. Swallowing difficulties 5. Elevated blood pressure

1. Urinary urgency 2. Loss of skin elasticity 4. Swallowing difficulties 5. Elevated blood pressure Weakened muscles supporting the bladder in women and enlargement of the prostate gland in men commonly cause urinary urgency and frequency in older adults. Skin elasticity decreases in older adults because of a decline in subcutaneous fat and collagen fibers, as well as thinning of the epidermis. Swallowing difficulties result from a decrease in salivary gland secretions. With aging, an increase in systolic blood pressure and a slight increase in diastolic blood pressure occur. A decrease in subcutaneous fat results in a decreased body warmth.

A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in which substance? 1. Vitamin C 2. Fat content 3. Water content 4. Vitamin B complex

1. Vitamin C Vitamin C aids the absorption of iron. Fat content, water content, and vitamin B complex are all unrelated to the absorption of iron.

A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's blood chloride level is decreased. What is the most efficient way this can be corrected? 1. Low-residue diet 2. Intravenous therapy 3. Oral electrolyte solution 4. Total parenteral nutrition (TPN)

2. Intravenous therapy Intravenous therapy ensures a rapid, well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed. Oral electrolyte solution is not a rapid or well-controlled method for correcting electrolyte deficiencies. TPN is not necessary at this time, although it may be used eventually.

A client reports sleeping longer with fewer interruptions and awakening later than usual. Which question should the nurse ask to determine the cause of the change? 1. "Have you lost weight recently?" 2. "Have you gained weight recently?" 3. "Do you have a respiratory disease?" 4. "Do you have restless legs syndrome?"

2. "Have you gained weight recently?" Longer periods of sleep with fewer interruptions and later awakening may be caused by weight gain. Therefore the nurse should ask the client whether he or she has gained weight recently. Weight loss may cause a reduction in the total time spent asleep, as well as broken sleep and earlier awakening. Restless legs syndrome and respiratory disease may disrupt a client's sleep, and they do not cause a client to sleep longer than usual.

The nurse is counseling an a woman who is HIV positive on precautions to be followed. Which statement by the client indicates the need for further counseling? 1. "I will avoid smoking and have nutritious food." 2. "I will get a pelvic examination every 12 months." 3. "I will undergo regular screening for syphilis, gonorrhea, and other vaginal infections." 4. "I will use female condoms if my partner refuses to use condoms.

2. "I will get a pelvic examination every 12 months." The routine gynecological care for clients who are HIV positive includes pelvic examination every 6 months. General prevention strategies such as smoking cessation and sound nutrition are an important part of care in clients who are HIV positive. Clients who are HIV positive are at increased risk for opportunistic infections. Therefore, they should be regularly screened for syphilis, gonorrhea, and other vaginal infections. In order to prevent the transmission of HIV to partners, women should use female condoms or abstinence if the partner is not willing to use condoms.

When teaching an African American patient about heart failure, which statement should the nurse include in the educational session? 1. "If you develop heart failure it will be at an older age than a Caucasian patient ." 2. "You will have a higher risk of death and disability if you develop heart failure." 3. "You have a lower risk for developing heart failure than a Caucasian patient." 4. "If you develop heart failure and are prescribed an ACE-inhibitor you are likely to develop a cough."

2. "You will have a higher risk of death and disability if you develop heart failure." African American patients have a higher mortality rate when developing heart failure; therefore, the nurse should include this statement in the education session. The African American patient is likely to develop heart failure at a younger, not older, age. The African American patient has a higher risk for developing heart failure when compared to a Caucasian patient. The Asian, not African American, patient has a greater risk for developing a cough when prescribed an ACE-inhibitor to treat heart failure.

A nurse is assessing clients who are to be given the smallpox vaccination. Which client should the nurse remove from the immunization line for medical counseling? 1. 20-year-old healthy woman 2. 45-year-old woman with breast cancer 3. 50-year-old man with diabetes mellitus 4. 75-year-old man who has Parkinson disease

2. 45-year-old woman with breast cancer The smallpox vaccine should not be given to individuals who may be immunocompromised as a result of therapy for cancer. There is no contraindication to giving the smallpox vaccination to a healthy woman, a client with diabetes mellitus, or a client with Parkinson disease.

The child with leukemia has been placed in reverse isolation. Which person should not enter the room? 1. A 5-month-old sibling who was born prematurely 2. A 3-year-old sibling who is coughing and sneezing 3. A nursing student who is 5 months pregnant 4. A parent who works at a waste management plant

2. A 3-year-old sibling who is coughing and sneezing Any person with an active infection should not enter the room. Also, the 3-year-old who has symptoms of a cold is likely to touch, crawl, climb, and desire to play with his/her sibling. Pregnancy is not a contraindication. Parents should routinely shower and change clothes before coming to the hospital to visit. The 5-month-old is not infectious; however he/she is likely to have a weaker immune system and parents should reconsider exposing him/her to the hospital environment

A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse provides the client with which information? 1. A rubella vaccine must be administered immediately 2. A rubella vaccine must be administered after childbirth 3. She will not contract rubella if she is exposed to the disease 4. She does not need to be concerned about being exposed to rubella

2. A rubella vaccine must be administered after childbirth A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist.

A client with diabetes is self-administering insulin. Which action performed by the client indicates a need for correction? 1. Inspecting the vial for crystals 2. Washing the hands with hot water 3. Inspecting the barrel for air bubbles 4. Bringing the insulin to room temperature

2. Washing the hands with hot water The client should perform hand-washing with warm water before the administration of insulin to reduce the risk of contamination. The insulin may have crystals in it if stored for a long duration, so the vials should be inspected for crystals. The client should inspect the barrel for air bubbles. A cold insulin injection would be painful; the insulin should be brought to room temperature to minimize pain during injection.

The nurse knows that when a magnesium sulfate infusion is given to a client with preeclampsia, it can build to a toxic level. Which assessment finding should prompt the nurse to withhold the medication and notify the primary healthcare provider? 1. Respirations of 14 breaths/min 2. Absence of deep tendon reflexes 3. Urine output of 30 mL/hr 4. Blood pressure of 140/100 mmHg

2. Absence of deep tendon reflexes A side effect of magnesium sulfate is depressed reflex responses; this may indicate toxicity, and intervention is necessary. Respirations of 14 breaths/min is a positive sign that toxicity has not occurred. A respiratory rate of 12 breaths/min or slower is a concern that requires nursing intervention. The amount of urine output is important, because oliguria may signify magnesium toxicity, but 30 mL/hr is within the acceptable range. The blood pressure is expected to increase; this medication is administered to prevent a seizure, not to lower blood pressure.

A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to take which action? 1. Avoid the use of shampoo on the infant's scalp 2. Apply oil to the affected area on the infant's scalp 3. Wash the infant's scalp daily, using only tepid water 4. Shampoo the infant's scalp, avoiding the anterior fontanel area

2. Apply oil to the affected area on the infant's scalp Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation.

A client with cancer is receiving a multiple chemotherapy protocol. Included in the protocol is leucovorin. The nurse concludes that this drug is administered for what purpose? 1. To potentiate the effect of alkylating agents 2. Because it diminishes toxicity of folic acid antagonists 3. To limit the occurrence of vomiting associated with chemotherapy 4. Interference with cell division at a different stage of cell division than the other drugs

2. Because it diminishes toxicity of folic acid antagonists Leucovorin limits toxicity of folic acid antagonists, such as methotrexate sodium, by competing for transport into cells. Leucovorin does not potentiate the effect of alkylating agents; however, leucovorin promotes binding of fluorouracil (5-FU) to target tumor cells. Antiemetics such as prochlorperazine maleate and ondansetron minimize nausea and vomiting associated with chemotherapeutic agents. Leucovorin does not interfere with cell division; this is the purpose of a multiple-drug protocol.

A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1. Cardiac arrest 2. Carbonic acid deficit 3. Reduction in serum pH 4. Excess oxygen saturation

2. Carbonic acid deficit Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis; the pH is increased. Excess oxygen saturation cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%.

During the postpartum period a client tells a nurse that he has been having leg cramps. Which foods should the nurse encourage the client to eat? 1. Liver and raisins 2. Cheese and broccoli 3. Eggs and lean meats 4. Whole-wheat breads and cereals

2. Cheese and broccoli The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content. Although liver and raisins, eggs and lean meats, and whole-wheat breads and cereals are recommended as part of a high-quality nutritional intake, they are inadequate sources of calcium.

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is what? 1. Early ambulation 2. Coughing and deep breathing 3. Wearing anti-embolic elastic stockings 4. Maintenance of a nasogastric tube

2. Coughing and deep breathing The client who has a cholecystectomy will have difficulty taking deep breaths and coughing because of the location of the surgical incision. Therefore, it is important to instruct the client preoperatively to improve compliance with the procedure in the early "postoperative period. Although ambulation, antiembolism stockings, and maintaining a nasogastric tube, if ordered, are important postoperative procedures, maintaining the airway and preventing further pulmonary problems is the priority.

While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum alpha-fetoprotein level is lower than is typical. What does the nurse recognize that this may be associated with? 1. Fetal demise 2. Down syndrome 3. Neural tube defects 4. Esophageal obstruction

2. Down syndrome Chromosomal trisomies such as Down syndrome may be marked by a lower-than-typical level of alpha-fetoprotein. The other options listed typically cause alpha-fetoprotein increases.

Which drug may cause malformations of the male external genitalia? 1. Etretinate 2. Dutasteride 3. Methimazole 4. Propylthiouracil

2. Dutasteride Dutasteride is a 5-alpha-reductase inhibitor that causes malformations of external genitalia in males. Etretinate is a vitamin A derivative that may cause multiple central nervous system defects. Methimazole and propylthiouracil are antithyroid drugs that may cause goiters and hypothyroidism

During which period of pregnancy may drug exposure cause meromelia, cleft lip, and enamel hypoplasia? 1. Fetal period 2. Embryonic period 3. Presomite period 4. Preimplantation period

2. Embryonic period Gross malformations may occur during the embryonic period when the basic shape of the fetus starts to develop. Teratogenic exposure during the fetal period may cause a disruption in the functional ability of the fetus. Teratogenic exposure during the presomite period or preimplantation period may result in fetal death.

What step should a nurse take when preparing to administer Rho(D) immune globulin to a postpartum client? 1. Start a primary intravenous (IV) line so that the drug may be administered via IV piggyback 2. Ensure that the client is Rh negative and the neonate is Rh positive 3. Obtain a syringe and needle appropriate for the subcutaneous injection 4. Determine that the client has not eaten since midnight of the previous night

2. Ensure that the client is Rh negative and the neonate is Rh positive Rho(D) immune globulin is given to Rh-negative mothers not previously sensitized who have Rh-positive neonates; it prevents Rh incompatibility in the next pregnancy. Rho(D) immune globulin is administered intramuscularly, not intravenously or subcutaneously. There is no need for the client to fast; the client may eat and drink before receiving this medication.

During their initial visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? 1. Recent history of drug abuse 2. Family history of genetic abnormalities 3. A client history of more than three prior spontaneous abortions 4. Maternal age older than 30 years at the time of the first pregnancy

2. Family history of genetic abnormalities One of the specific reasons for performing amniocentesis is the diagnosis of genetic problems. A recent history of drug abuse is not a reason to perform this invasive procedure. A history of more than three prior spontaneous abortions is not a reason to perform this invasive procedure. Amniocentesis is no longer performed routinely if the client is an older primigravida; a sonogram is performed first.

A client at 32 weeks gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone 12 mg is prescribed. What should the nurse tell the client about why the medication is being given? 1. Cervical dilation is increased. 2. Fetal lung maturity is accelerated. 3. The risk of a precipitous birth is reduced. 4. The potential for maternal hypertension is minimized.

2. Fetal lung maturity is accelerated A steroid such as betamethasone or dexamethasone administered to the mother crosses the placenta and promotes lung maturity in the fetus. Steroids do not cause an increase in cervical dilation, reduce the risk of precipitous birth, or minimize the potential for maternal hypertension.

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 1. Skin condition 2. Fluid and electrolyte balance 3. Food intake 4. Fluid intake and output

2. Fluid and electrolyte balance Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea leads to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and therefore not the nursing priority. Even though absorption of nutrients is decreased with diarrhea, malnutrition is not a life-threatening condition and therefore not the priority nursing intervention. Fluid intake and output provide information about fluid balance, only without taking into consideration the loss of electrolytes that accompanies diarrhea.

The primary healthcare team is caring for four different groups of clients who were affected by a mass casualty burn event. Which group of clients is considered the lowest priority for care? 1. Group A: Extreme respiratory distress 2. Group B: Third degree/ 90 percent burns 3. Group C: Moderate shortness of breath 4. Group D: Bruises with bleeding

2. Group B: Third degree/ 90 percent burns Black tags are given to the clients who are dead or about to die. In a mass casualty scene, the healthcare team tries to save the lives of as many people as they can instead of caring for clients who are almost dead. In group B, clients with 90 percent third degree burns have the need for immediate surgical intervention, which may not be possible in a mass casualty event. First priority of care is given to clients with life-threatening conditions. They receive a red tag and are provided immediate attention. Clients with moderate shortness of breath may receive a green tag and can be treated even after few hours. Clients with bleeding bruises may receive yellow tags and should be treated after the treatment of red tagged clients.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1. Hypernatremia 2. Hyponatremia 3. Hyperkalemia 4. Hypokalemia

2. Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L, and for serum potassium it is 3.5 to 5 mEq/L. Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurological symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L; hyperkalemia results when serum potassium is greater than 5.0 mEq/L; hypokalemia results when serum potassium is less than 3.5 mEq/L.

A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery? 1. Decreased appetite 2. Impaired swallowing 3. Change in bowel habits 4. Slight edema of the neck

2. Impaired swallowing Impaired swallowing may occur as a result of cranial nerve damage during surgery. Slight edema of the neck is expected from the trauma of surgery; it is not a complication. Decreased appetite, change in bowel habits, and slight edema of the neck are not complications of a carotid endarterectomy.

A client tells a nurse that she does not want an episiotomy and would rather tear naturally. What information should be offered to the client regarding each of these birthing methods? 1. Lacerations are more painful than an episiotomy. 2. Lacerations are easier to repair than an episiotomy. 3. An episiotomy causes less posterior trauma than lacerations. 4. An episiotomy is preferred over lacerations, according to evidence-based practice.

2. Lacerations are easier to repair than an episiotomy Lacerations require less suture time and cause less perineal trauma, which can have lifelong implications such as rectal-vaginal fistulas. Lacerations are less painful than an episiotomy and tend to heal more quickly. An episiotomy causes more posterior trauma than lacerations. Evidence indicates that a policy of routine episiotomy results in more perineal trauma, more suturing time, and more complications than lacerations.

The nurse determines that the fetus of a client in labor is in the left sacrum anterior position. Where should the nurse place the fetal heart transducer on the client's abdomen? 1. Left lower quadrant 2. Left upper quadrant 3. Right upper quadrant 4. Midline lower quadrant

2. Left upper quadrant The left sacrum anterior position indicates that the fetus is in a breech presentation and the head is in the fundus; fetal heart sounds are best heard in the left upper quadrant. Fetal heart sounds will be in the left lower quadrant if the fetus is in the left occiput anterior position. Fetal heart sounds will be in the right upper quadrant if the fetus is in the right sacrum anterior position. The fetal heart sounds will not be heard in the midline part of a lower quadrant in a single-fetus pregnancy.

A client with newly diagnosed hyperthyroidism is treated with propylthiouracil, an antithyroid drug, along with potassium iodide. What should the nurse take into consideration when caring for the client? 1. Iodide solutions must be diluted in water and taken on an empty stomach. 2. Monitoring for signs of infection or bleeding is necessary. 3. Postoperative hemorrhage is a common complication if these drugs are used before a thyroidectomy. 4. These drugs will be discontinued as soon as the temperature and pulse rate return to the expected range.

2. Monitoring for signs of infection or bleeding is necessary Propylthiouracil can cause depression of leukocytes and platelets. Propylthiouracil and potassium iodide should be given with milk, juice, or food to prevent gastric irritation. Drug therapy decreases the risk of postoperative hemorrhage because this drug regimen decreases the size and vascularity of the thyroid gland. Drug therapy is continued for at least 6 to 8 weeks, even if the client's temperature and pulse return to the expected range.

What nursing care should be included for a client who is receiving doxorubicin for acute myelogenous leukemia? 1. Serving hot liquids with each meal 2. Providing frequent oral hygiene and increasing oral fluids 3. Emphasizing that the disease will be cured with this treatment 4. Administering medications intramuscularly and encouraging activity

2. Providing frequent oral hygiene and increasing oral fluids Stomatitis and hyperuricemia are possible complications of therapy; therefore, oral care and hydration are important. Food and fluids with extremes in temperature should be avoided because of the common occurrence of stomatitis. Emphasizing that the disease will be cured with this treatment may provide false reassurance. Abnormal bleeding is a common problem, and thus injections are contraindicated; rest is important for increased fatigability.

During a vaccination drive at a well-child clinic, a nurse notes that a recently hired nurse is not wearing gloves while vaccinating an infant. What should the nurse advise the newly hired nurse to do? 1. Speak with the nurse manager regarding techniques 2. Put on gloves because standard precautions are required 3. Continue with the immunizations because gloves are not needed 4. Evaluate the child's appearance to determine whether gloves are needed

2. Put on gloves because standard precautions are required The protocol of the Centers for Disease Control and Prevention (CDC) (Canada: Public Health Agency of Canada [PHAC]) for administering parenteral medications requires standard precautions, which include the use of gloves. It is the nurse's responsibility to maintain standard precautions within the clinic environment. Gloves are needed and must be worn when children are given parenteral medications. The child's appearance is not a factor; the CDC (Canada: PHAC) protocol for administering parenteral medications requires standard precautions.

A 54-year-old client has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After being found walking down a street, disoriented and semi-naked, the client is admitted to the hospital, and a diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety. What is the best approach for the nurse to take? 1. Exploring the reasons for the client's concerns 2. Reassuring the client with the frequent presence of staff 3. Initiating the program of planned interaction and activity 4. Explaining the purpose of the unit and why admission was necessary

2. Reassuring the client with the frequent presence of staff The client needs constant reassurance because forgetfulness blocks previous explanations; frequent presence of staff serves as a continual reminder. This client will be unable to explain the reasons for concerns. Too many varied activities will increase anxiety in a confused client. Clients with dementia need simple, structured, routine environments and activities. This client will not remember the explanation from one moment to the next.

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do? 1. Put the unopened sterile glove package carefully on the sterile field 2. Remove the sterile drape from its package by lifting it by the corners 3. Don sterile gloves before opening the package containing the field drape 4. Pour irrigation liquid from a height of at least three inches above the sterile container

2. Remove the sterile drape from its package by lifting it by the corners The outer one inch of the sterile field is considered contaminated and can be touched without wearing sterile gloves. The outside of an unopened sterile glove package is not sterile. The field will become contaminated if the unopened package is placed on the sterile field. The outer package, which contains a sterile field drape, is not sterile; if it is touched with sterile gloves, the sterile gloves will become contaminated. Liquids should be poured from a height of 4 to 6 inches; this ensures that the solution bottle does not contaminate the sterile container.

During the admission procedure a client appears to be responding to voices. The client cries out at intervals, "No, no! I didn't kill him! You know the truth, tell that police officer! Please help me!" What is the most appropriate response by the nurse? 1. Listening attentively and assuming an expression of disbelief 2. Saying, "I want to help you. I realize that you must be very frightened." 3. Sitting quietly and refraining from responding to the client's statements 4. Saying, "Don't be so upset. No one is talking to you; those voices are part of your illness."

2. Saying, "I want to help you. I realize that you must be very frightened." Telling the client that help is available demonstrates an understanding of the client's feelings and encourages the client to share feelings, which is an immediate need. Assuming an expression of disbelief is judgmental and demeaning to the client. Sitting quietly and not responding to the client's statements will probably intensify the client's fears. Although telling the client not to be upset because no one is talking points out reality, it also gives a command that is unrealistic and closes the communication process.

A nurse is caring for a client who has abruptly stopped taking a barbiturate. What should the nurse anticipate that the client may experience? 1. Ataxia 2. Seizures 3. Diarrhea 4. Urticaria

2. Seizures Seizures are a serious side effect that may occur with abrupt withdrawal from barbiturates. The other options are not associated with barbiturate withdrawal.

What are the signs associated with serotonin syndrome? Select all that apply. 1. Fatigue 2. Shivering 3. Mydriasis 4. Weakness 5. Diaphoresis

2. Shivering 3. Mydriasis 5. Diaphoresis The autonomic dysfunctions of serotonin syndrome are shivering, diaphoresis, marked pupil dilation (mydriasis), tachycardia, and hyperthermia. Fatigue and weakness are the signs of bulimia nervosa, commonly known as binge-eating.

A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? 1. The client is obese and attempting to lose weight. 2. The client behaves appropriately and looks normal. 3. The client has a distorted body image and sees the body as fat. 4. The client is struggling with a conflict of dependence versus independence.

2. The client behaves appropriately and looks normal Bulimic clients hide much of their bingeing and purging behaviors and, unlike clients with anorexia, may have near-ideal body weights. Clients with bulimia nervosa are usually not obese. Distorted body image and conflict of dependence versus independence are associated with both anorexic and bulimic clients.

A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using? 1. Regression 2. Transference 3. Reaction formation 4. Cognitive distortion

2. Transference In transference a client assigns to someone the feelings and attitudes originally associated with an important significant other. In regression a client reverts to past levels of coping to reduce anxiety. In reaction formation a client displays the exact opposite behavior, attitude, or feeling to that which is demonstrated in a given situation. Cognitive distortions are thought patterns that exaggerate reality or are irrational, such as black-and-white thinking or overgeneralization.

After several months of chemotherapy treatment, a client with the diagnosis of multiple myeloma comes to the emergency department because of confusion, muscle weakness, and diarrhea. The nurse reviews the client's electronic medical record. Which complication associated with chemotherapy does the nurse suspect that the client is experiencing? 1. Septic shock 2. Tumor lysis syndrome 3. Superior vena cava syndrome 4. Disseminated intravascular coagulation

2. Tumor lysis syndrome Hyperkalemia occurs when large quantities of tumor cells are destroyed, releasing potassium and purines more rapidly than the body can manage them (tumor lysis syndrome). A serum potassium of 5.8 mEq/L (5.8 mmol/L) is more than the expected range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L), resulting in the abnormal ECG results. Hyperkalemia can cause a pulse in the lower range of that expected for an adult, numbness in the extremities, flaccid paresis, hyperactive bowel sounds, and diarrhea. There are no adaptations indicating septic shock. The white blood cell count (WBC) and vital signs are all within the expected range. A rapid, weak pulse, rapid respirations, increased temperature, hypotension, and warm flushed skin are associated with septic shock. Superior vena cava syndrome occurs when a tumor obstructs or compresses the superior vena cava, resulting in blockage of blood flow to the venous system of the head, neck, and upper trunk and in edema of the face (especially periorbital edema) and distention of veins of the head, neck, and chest. With disseminated intravascular coagulation (DIC) there is abnormal coagulation, resulting in bleeding from many sites, clot formation, and decreasing blood flow to major organs. Decreased circulation to organs causes pain, dyspnea, tachycardia, oliguria, bowel necrosis, and multiple organ failure.

A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vaginal and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain? 1. Full bladder 2. Vaginal hematoma 3. Infected episiotomy 4. Enlarged hemorrhoid

2. Vaginal hematoma A vaginal hematoma caused by fetal head pressure during the birthing process can result in severe pain. Bladder distention causes abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should not be excruciating; it is too early for an infection to have developed. Although hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel full and heavy.

A nurse is planning care for a client with cancer who is receiving the plant alkaloid vincristine. In contrast to the side effects of most chemotherapeutic agents, what is a common side effect of vincristine that the nurse must address in the client's care plan? 1. Nausea 2. Alopecia 3. Constipation 4. Hyperuricemia

3. Constipation Although most chemotherapy causes diarrhea, vincristine can cause severe constipation, impaction, or paralytic ileus. Nausea, alopecia, and hyperuricemia are side effects shared with most other chemotherapeutic agents.

An intravenous infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dosage is twice the usual adult dosage. When a nurse questions the dosage, the primary healthcare provider insists that it is the desired dosage and directs the nurse to administer the medication. How should the nurse respond to this directive? 1. Administer the dose and monitor the client 2. Withhold the dose and notify the nurse manager 3. Administer the dose and document it on the client's record 4. Withhold the dose and notify the director of the obstetric department

2. Withhold the dose and notify the nurse manager To administer the incorrect dose would be an act of negligence that could endanger the client, and the nurse would be liable. If the dosage is not changed after the primary healthcare provider is questioned, the nurse should contact the nurse manager. The medication should be withheld, because it could cause respiratory depression and endanger both the client and fetus. The nurse should follow hospital protocol and notify the nurse manager, not the director of the obstetrics department, first.

A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the nurse, "Which of the medications will be the most helpful against the psychotic signs and symptoms?" What response should the nurse give? 1. Citalopram (Celexa) 2. Ziprasidone (Geodon) 3. Benztropine (Cogentin) 4. Acetaminophen with Hydrocodone (Lortab)

2. Ziprasidone (Geodon) Ziprasidone (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin. Citalopram (Celexa) is a selective serotonin reuptake inhibitor antidepressant. Benztropine (Cogentin) is an anticholinergic. Acetaminophen with hydrocodone (Lortab) is an analgesic/opioid.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1. "Moderate amount of drainage." 2. "No change in drainage since yesterday." 3. "A 10-mm-diameter area of drainage at 1900 hours." 4. "Drainage is doubled in size since last dressing change."

3. "A 10-mm-diameter area of drainage at 1900 hours." A 10-mm-diameter area of drainage at 1900 hours is an objective fact and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage" "No change in drainage since yesterday" and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.

Isoniazid is prescribed as a prophylactic measure for a client whose spouse has active tuberculosis (TB). What statements by the client indicate that there is a need for further teaching? Select all that apply. 1. "I plan to start taking vitamin B 6 with breakfast." 2. "I'll still be taking this drug six months from now." 3. "I sometimes allow our children to sleep in our bed at night." 4. "I know I also have tuberculosis because the skin test was positive." 5. "I'll be skipping the wine but enjoying the cheese at my neighbor's party."

3. "I sometime allow our children to sleep in our bed at night." 4. "I know I also have tuberculosis because the skin test was positive." 5. "I'll be skipping the wine but enjoying the cheese at my neighbor's party." The children are at an increased risk because the client's spouse has TB; the children should be screened as members of the household. The positive skin test indicates that the client has been exposed to the bacilli and developed antibodies, not necessarily the disease itself; further diagnostic studies are indicated. Both wine and aged cheese contain tyramine and histamine, which when taken concurrently with isoniazid can cause headache, flushing, and a drop in blood pressure; these should be avoided when taking isoniazid. Pyridoxine should be taken to prevent neuritis, which is associated with isoniazid. The prophylactic drug therapy will be continued for 6 to 12 months.

A client with asthma and depression is admitted to the hospital. Which tasks delegated by the delegator would indicate the task is applicable for the registered nurse? 1. "Administer oral antidepressants." 2. "Administer a pain killer intramuscularly." 3. "Teach the client how to use a meter dose inhaler." 4. "Reinforce tips for stress management with the client."

3. "Teach the client how to use a meter dose inhaler." The registered nurse is delegated to teach the client about using a meter dose inhaler for asthma. Oral administration of drugs is under the scope of practice of a licensed practical nurse (LPN) and a licensed vocational nurse (LVN). Administration of intramuscular medications will also be tasks delegated to an LPN or LVN. Reinforcing teachings is the task of an LPN, LVN, or unlicensed assistive personnel (UAP).

A practical nurse discusses with a group of nursing students about teaching to be given to a client being admitted to the health care facility. Which statements by the nursing students indicate a need for further teaching? Select all that apply. 1. "Instructions are provided when the client is attentive." 2. "Teaching should begin early in the client's admission to a facility." 3. "Teaching should be provided to every client who stays for short time." 4. "A formal teaching plan should begin with the assessment and care plan." 5. "Instructions about the medications are provided on the day of discharge."

3. "Teaching should be provided to every client who stays for short time." 4. "A formal teaching plan should begin with the assessment and care plan." Clients who have a short stay in a health care facility may not receive teaching until the day of discharge. A formal teaching should not begin until the assessment is complete and care plan has been developed. The nurse should provide instruction when the client is attentive. The nurse should being teaching early when the client is admitted to the facility. The nurse should instruct the client about medications on the day of discharge

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" What is the most appropriate response by the nurse? 1. "Let me ask your primary healthcare provider for you." 2. "I can understand why you are worried." 3. "Tell me about your concerns right now." 4. "It depends on whether the tumor has spread."

3. "Tell me about your concerns right now." The response "Tell me about your concerns right now" encourages the client to review facts and provides an opportunity to talk about feelings. The response "Let me ask your primary healthcare provider for you" suggests the nurse does not want to discuss the subject; it abdicates the nurse's responsibility to explore the issue with the client. Although it is an empathic answer, the response "I can understand why you are worried" does not encourage the client to explore feelings; it may increase anxiety. Although the statement "It depends on whether the tumor has spread" is true, the response does not encourage the client to examine feelings.

A client with schizophrenia is going to occupational therapy for the first time. The client doesn't want to go and tells the nurse so. What is the most therapeutic initial response by the nurse? 1. "It's only for an hour, and then you'll be back." 2. "Try it once. If you don't like it, you don't have to go back." 3. "Tell me what concerns you about going to occupational therapy." 4. "Your primary healthcare provider prescribed it as part of your treatment. You should go."

3. "Tell me what concerns you about going to occupational therapy." "Tell me what concerns you about going to occupational therapy" is an open-ended statement that allows the nurse to explore the patient's concerns. If the patient would feel more comfortable having the nurse go with the patient to the first session, this idea may be explored next. The statement "It's only for an hour, and then you'll be back" will do nothing to allay the client's anxiety about facing a new situation. Telling the client to try it once and that the client won't have to go back is not true; even if the client does not like the therapy, the client should be encouraged to go as part of the overall therapy program. Telling the client that the primary healthcare provider has prescribed the therapy as part of the treatment and that the client should go will do nothing to allay the client's anxiety about facing a new situation.

Which anomaly may be observed when a fetus is exposed to a teratogen during the embryonic development? 1. Death of the fetus 2. Normal growth of the fetus 3. Improper functioning of the fetus 4. Improper development of the organs

3. Improper functioning of the fetus Exposure to a teratogen during embryonic development may result in improper development of internal organs. Death of the fetus may occur when the exposure to a teratogen is during the presomite stage. Normal growth of the baby may occur if the exposed teratogen dose is very low. Defect in the functioning of the fetus may occur if the exposure to the teratogen is during the fetal stage.

A client asks the nurse how psychotropic medications work. How should the nurse reply? 1. "These medications decrease the metabolic needs of your brain." 2. "These medications increase the production of healthy nervous tissue." 3. "These medications affect the chemicals used in communication between nerve cells." 4. "These medications regulate the sensory input received from the external environment."

3. "These medications affect the chemicals used in communication between nerve cells." Most psychotropic medications affect neurotransmitters such as dopamine and norepinephrine, which enter the synapses between neurons, allowing them to signal each other. Psychotropic medications do not work by changing the metabolic needs of the brain. Psychotropic medications do not increase the production of nervous tissue. Although there may be some effect on sensory input, this is because of the change in neurotransmitters.

A client who had a panic attack yesterday says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? 1. "It's best that you try to talk about it." 2. "Why don't you want to talk about it now?" 3. "What were you doing yesterday when you first noticed the feeling?" 4. "I understand that you're upset, but don't be concerned because that feeling probably won't come back."

3. "What were you doing yesterday when you first noticed the feeling?" The response "What were you doing yesterday when you first noticed the feeling?" helps the client focus on the situation that precipitated the frightening feelings but not the attack itself. The response "It's best that you try to talk about it" will not help the client focus on feelings. Asking, "Why don't you want to talk about it now?" will not help the client focus on feelings; also, "wh?" questions often make people feel defensive. The response "I understand that you're upset, but don't be concerned because that feeling probably won't come back" is false reassurance; the nurse cannot guarantee that the feeling will not come back.

Which statement about addiction needs correction? 1. Alcoholism is an example of addiction. 2. Addiction is excessive use or abuse of a substance. 3. A person can have only a single addiction at one time. 4. Addiction can be characterized by a display of psychological disturbance.

3. A person can have only a single addiction at one time A person can have more than one addiction at the same time. The other statements are correct: Alcoholism is an example of addiction. Addiction is excessive use or abuse of a substance, and it can be characterized by a display of psychological disturbance.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1. Place the client in a left side-lying position. 2. Apply oxygen via non-rebreather mask. 3. Apply a petroleum gauze dressing over the site. 4. Prepare to reinsert a new chest tube.

3. Apply a petroleum gauze dressing over the site A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress. Preparing to reinsert a new chest tube is not a priority of the nurse at this moment. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress.

A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first take which action? 1. Locate the fetal heart tone 2. Position the woman supine 3. Ask the client to empty her bladder 4. Count the fetal heart rate for 1 minute

3. Ask the client to empty her bladder In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman's comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones. Counting the fetal heart rate is not associated with Leopold maneuvers.

Which nursing action is useful when a telephone order is confusing and unclear? 1. Making notes of the doubts to be clarified 2. Calling the health-care provider immediately 3. Asking a peer nurse to listen to the conversation 4. Checking previous medication administration record (MAR)

3. Asking a peer nurse to listen to the conversation Whenever there is any confusion during a telephone order, the nurse should have another nurse listen to the conversation for clarification. The nurse should make notes of the telephone order and make sure to clear the doubts and confusions immediately before processing to prevent medication administration errors. The primary health-care provider may or may not be available around the clock. Checking the previous medication administration recored (MAR) may not help the nurse to clear the confusion

As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what? 1. Setting of care 2. Anxiety disorder 3. Attitudes and beliefs 4. Cultural and ethnic disparities

3. Attitudes and beliefs Some attitudes and beliefs include reluctance by older people to seek help because of pride in their independence, stoic acceptance of difficulty, unawareness of resources, and fear of being "put away." Although the client mentions "being put away", that is an attitude. He is not talking about all the resources that might be available to him. Anxiety is defined as an unpleasant and unwarranted feeling of apprehension. The client does not mention any cultural or ethnic issues, just his own feelings.

A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of which medication? 1. Vitamin K 2. Protamine sulfate 3. Calcium gluconate 4. Naloxone hydrochloride

3. Calcium gluconate Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium. Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid-induced respiratory depression.

A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1. Sprinkle the powder from the capsule into a cup of water. 2. Insert a rectal suppository containing 100 mg of phenytoin. 3. Contact the prescriber to determine if a change to a suspension form would be possible. 4. Obtain a change in the administration route to allow an intramuscular (IM) injection.

3. Contact the prescriber to determine if a change to suspension form would be possible When an oral medication is available in a suspension form, the nurse can discuss this with the prescriber for clients who cannot swallow capsules. Because a palatable suspension is available, it is a better alternative than opening the capsule. The route of administration cannot be altered without the health care provider's approval. Intramuscular injections should be avoided because of risks for tissue injury and infection.

The nurse is caring for a client with dementia whose expression of emotions is altered. Which behavior is unexpected with this client? 1. Lability 2. Passivity 3. Curiosity 4. Withdrawal

3. Curiosity Intellectual deterioration associated with dementia decreases interest in the environment. Diffuse impairment of brain tissue function results in fluctuations in the extremes of emotions; lability of mood is common with dementia. Clients with dementia usually fluctuate between aggressive acting out and passive acceptance. In clients with dementia, intellectual deterioration can result in behavior that mimics withdrawal.

A client with type 1 diabetes is found to have a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination? 1. Depressed respiration 2. Intensified action of both drugs 3. Decreased control of the diabetes 4. Increased danger of extrapyramidal side effects

3. Decreased control of the diabetes Haloperidol (Haldol) alters the effectiveness of exogenous insulin, and the combination of haloperidol and insulin must be used with caution. The occurrence of respiratory depression is more likely with a combination of antipsychotics and barbiturates. Intensified action of both drugs would be more likely to occur if the antipsychotic were Fluoxetine (Prozac). There are no data to support a claim of increased danger of extrapyramidal side effects.

The nurse is caring for a client in preterm labor who reports that she fell down the stairs. Bruises are apparent on the left part of the client's lower abdomen, the back of each shoulder, and on both wrists. After instituting electronic fetal monitoring, starting tocolytic therapy, and examining the monitor strips, what action should the nurse take next? 1. Ambulating the client to promote circulation 2. Inserting two small-bore intravenous catheters 3. Determining whether the client feels safe at home 4. Ensuring that the client has her glasses to ambulate

3. Determining whether the client feels safe at home Bruising on the backs of both shoulders and both wrists indicates potential abuse; asking the client whether she feels safe at home will open a dialogue to discuss the possible physical abuse. Whether or not the client admits abuse, the nurse is required to report the finding. A client in preterm labor should have a large-bore intravenous catheter. Ambulation is not appropriate for a client in preterm labor, and bed rest should be maintained. Reporting should not be delayed.

A home care nurse is instructing a client with hyperemesis gravidarum about measure to ease the nausea and vomiting. The nurse tells the client to take which action? 1. Eat foods high in calories and fat 2. Lie down for at least 20 minutes after meals 3. Eat carbohydrates such as cereals, rice, and pasta 4. Consume primarily soups and liquids at mealtimes

3. Eat carbohydrates such as cereals, rice, and pasta Low-fat foods and easily digested carbohydrates, such as fruit, breads, cereals, rice, and pasta, provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small, and foods with strong odors should be eliminated from the diet because food smells often incite nausea.

Which teratogenic effect is seen due to lithium? 1. Stillbirth 2. Shortened limbs 3. Ebstein anomaly 4. Neural tube defects

3. Ebstein anomaly Ebstein anomaly (cardiac defects) in the newborn occurs due to taking lithium during pregnancy. Stillbirth may occur due to alcohol use. Shortened limbs may occur due to thalidomide. Neural tube defects can be due to antiseizure drugs.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1. Increase fluid intake 2. Restrict fluids 3. Encourage early mobility 4. Elevate the knee gatch of the bed

3. Encourage early mobility In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore, restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and also increase the risk for thrombophlebitis.

A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38°C (100.4°F). Which is the most appropriate nursing action? 1. Notify the registered nurse 2. Recheck the temperature in 1 hour 3. Encourage the intake of oral fluids 4. Tell the client that antibiotics will be prescribed

3. Encourage the intake of oral fluids A temperature of 38°C (100.4°F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38°C, infection is a possibility, and the fever is reported to the registered nurse. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids.

The registered nurse teaches the student nurse regarding the priority of care provided to clients with eye injuries due to chemical exposure. Which activity performed by the student nurse indicates effective learning? 1. Assessing visual acuity 2. Administering analgesics 3. Performing ocular irrigation 4. Covering the eyes with sterile patches

3. Performing ocular irrigation Ocular irrigation with saline solution should be performed immediately in the client with eye injuries due to chemical exposure. Visual acuity tests can be performed after the client's condition is stabilized. Analgesics should be administered after assessing the client's medical records. The client's eyes should be covered with sterile patches after performing ocular irrigation.

A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received 10 mg of nalbuphine intravenously 30 minutes ago. Because the client is too sedated to sign the consent form, what should the nurse do? 1. Call the client's mother and request a verbal consent. 2. Proceed with the preparation and forgo written consent. 3. Ensure the surgeon and attending primary healthcare provider sign the consent form. 4. Sign the consent form and have the nurse manager countersign the form.

3. Ensure the surgeon and attending primary healthcare provider sign the consent form The data indicate a life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There is not enough time to obtain verbal consent. It is illegal to perform the surgery without a signed consent. Legally a nurse is not allowed to countersign an informed consent unless the client has signed it first.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1. Discharge in am 2. Blood glucose monitoring ac and bedtime 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW 4. Dalteparin (Fragmin) 5000 international units Sub-Q BID

3. Erythropoietin "TIW", indicating three times a week is an unacceptable abbreviation. It may be mistaken for "three times a day" or "twice weekly." The abbreviation "AM" for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of "ac" (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of just "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation "Sub-Q", indicating the subcutaneous route is an acceptable abbreviation. "BID," indicating twice a day, is an acceptable abbreviation. "International units" must be completely spelled out instead of just "IU" because it may be mistaken as a four.

Which patient should the nurse screen for Tay-Sachs when conducting a health history assessment? 1. African American male patient 2. Native American female patient 3. Female patient of Jewish descent 4. Male patient of Scandinavian descent

3. Female patient of Jewish descent The nurse should assess the female patient of Jewish descent for Tay-Sachs disease, as this is a hematologic problem associated with Jewish patients. African American patients should be screened for sickle cell, not Tay-Sachs, disease. Native American patients do not have an increased risk for any hematological diseases. Patients of Scandinavian descent have an increased risk for pernicious anemia, not Tay-Sachs disease.

A nurse reinforces instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to proceed in which way? 1. Take a cool shower just before breastfeeding 2. Avoid breastfeeding during the night time hours to ensure adequate rest 3. Gently massage the breasts during breastfeeding to help empty the breasts 4. Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling

3. Gently massage the breasts during breastfeeding to help empty the breasts Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown

A client is started on tetracycline antibiotic therapy. What should the nurse do when administering this drug? 1. Administer the medication with meals or a snack. 2. Provide orange or other citrus fruit juice with the medication. 3. Give the medication an hour before milk products are ingested. 4. Offer antacids 30 minutes after administration if gastrointestinal side effects occur.

3. Give the medication an hour before milk products are ingested

A licensed practical nurse cares for a very sick client. The client's family brings in a religious leader to anoint the client in preparation for death. The client's daughter confides in the nurse, "Maybe we'll see a miracle; maybe this will bring him back from the brink of death. " Which statements best describe the client's health belief system? Select all that apply. 1. Illnesses and diseases may be natural or unnatural 2. Diseases have a specific cause, onset, course, and treatment 3. Health powers may be ascribed to animate or inanimate objects 4. Religion dictates the practices designed to assist an individual in maintaining a healthy balance 5. Certain events interrupt the plan intended by God and are beyond the control of ordinary mortals

3. Health powers may be ascribed to animate or inanimate objects 4. Religion dictates the practices designed to assist an individual in maintaining a healthy balance The client's daughter is expressing her belief in a holistic health belief system, in which religious experiences are based on cultural beliefs. In this system, healing powers may be ascribed to animate or inanimate objects. Also, religion dictates social, moral, and dietary practices designed to assist an individual in maintaining a healthy balance and plays a vital role in illness prevention. Under the folk health belief system, illnesses or diseases are classified as natural or unnatural. Natural events have to do with the world as God made it and intended it to be, and unnatural events imply the exact opposite. Adherents of the biomedical health belief system believe that diseases have a specific cause, onset, course, and treatment. In the fold health belief system, unnatural events are believed to interrupt the plan intended by God; these events are beyond the control of ordinary mortal

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? 1. Bruising 2. Tachycardia 3. Hyperkalemia 4. Hypoglycemia

3. Hyperkalemia Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.

A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first takes which action? 1. Notifies the registered nurse 2. Documents the findings 3. Instructs the client to take several deep breaths 4. Administers 100% oxygen by way of face mask

3. Instructs the client to take several deep breaths If the client has been given an epidural opioid, the nurse should monitor the client's respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the registered nurse. If the deep breaths fail to increase the oxygen saturation level, the registered nurse is notified and may prescribe oxygen.

Screenings are being conducted on children for blood disorders. The nurse is aware that the most prevalent blood disorder is: 1. Hemophilia 2. Sickle cell anemia 3. Iron deficiency anemia 4. Idiopathic thrombocytopenic purpura

3. Iron deficiency anemia Iron deficiency anemia is the most common

A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse review with this client? 1. It is easily cured. 2. It occurs very rarely. 3. It can produce sterility. 4. It is limited to the external genitalia.

3. It can produce sterility Inflammation associated with gonorrhea may lead to destruction of the epididymis in males and tubal mucosal destruction in females, causing sterility. Many gonococci have become penicillin resistant and difficult to treat. Gonorrhea is a common sexually transmitted infection. Neisseria gonorrhoeae will invade internal structures, particularly the epididymis in males and the fallopian tubes in females. Topics

An older client who has had multiple hospital admissions for recurring heart failure is returned to the hospital by an adult child. The client is admitted for observation to the coronary care unit and calmly states, "I know I'm sick, but I can really take care of myself at home." What should the nurse conclude that the client most likely is attempting to do? 1. Suppress fears 2. Deny the illness 3. Maintain independence 4. Reassure the adult child

3. Maintain independence The client's statement is really saying, "I can manage this myself. I am capable." None of the information given leads to the conclusion that the patient is suppressing fears. Nothing in the statement can be interpreted as denial; the client has stated, "I know I'm sick." Telling the adult child that self-care is possible will not be reassuring to a family member who brought the client to the hospital and who probably is more reassured by having the client hospitalized.

What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia? 1. Limiting IV fluid intake 2. Preparing for a possible precipitous birth 3. Maintaining a quiet, darkened environment 4. Obtaining magnesium gluconate as an antagonist

3. Maintaining a quiet, darkened environment A quiet, darkened room reduces stimuli, which is essential for limiting or preventing seizures. IV infusions are not limited. Infusions are monitored closely and usually maintained at a volume of 125 mL/hr. Precipitous birth is not a usual side effect of magnesium therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be kept on hand in case signs of toxicity appear.

The nurse prepares an intravenous solution of lactated Ringer solution to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. Which condition will improve if the administration of lactated Ringer solution is effective? 1. Urinary stasis 2. Paralytic ileus 3. Metabolic acidosis 4. Increased potassium level

3. Metabolic acidosis Lactated Ringer solution is an alkaline solution that replaces bicarbonate ions lost from T-tube bile drainage, thus preventing or treating acidosis. Urinary stasis is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. Paralytic ileus is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution. An increased potassium level is unrelated to the effectiveness of the administration of intravenous lactated Ringer solution.

A nonstress test is performed, and the health care provider documents "accelerations lasting less than 15 seconds throughout fetal movement." The nurse interprets these findings in which way? 1. Normal 2. Reactive 3. Nonreactive 4. Inconclusive

3. Nonreactive A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording.

A health care provider determines that a fetus is in a breech presentation. For which complication should the nurse monitor the client? 1. Rapid dilation of the cervix, indicating precipitate labor 2. Stronger contractions, indicating progression of the labor 3. Nonreassuring fetal signs, indicating prolapse of the cord 4. Cessation of contractions, indicating primary uterine inertia

3. Nonreassuring fetal signs, indicating prolapse of the cord The feet or buttocks are not effective in blocking the cervical opening, and the cord may slip through and become compressed. Rapid dilation and precipitate labor are more likely to occur if the fetus is in a cephalic presentation. Stronger contractions, indicating progression of labor, is an expected occurrence. Uterine inertia may result from fatigue or cephalopelvic disproportion and is not related directly to fetal presentation.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents? 1. Colitis 2. Stomatitis 3. Paralytic ileus 4. Gastrocolic reflux

3. Paralytic ileus After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis , and gastrocolic reflux are not postoperative complications related to anesthetic agents.

A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client. What should the plan include? 1. Eliminating travel plans to combat anemia-related fatigue 2. Reinforcing a positive mental attitude to improve prognosis 3. Preventing infection; the client is at risk for leukopenia 4. Restricting fluid intake; the client is at risk for congestive heart failure

3. Preventing infection; the client is at risk for leukopenia The bone marrow is impaired with multiple myeloma; the effectiveness of white blood cells and immunoglobulin is reduced, which increases susceptibility to bacterial infections. Travel can be accomplished with careful planning and adequate rest periods. Although a positive mental attitude can contribute to quality of life and may even extend life, generally it does not change the prognosis. The client is encouraged to drink plenty of fluids to help dilute the Bence Jones protein fragments in the urine, which may help prevent kidney damage.

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client? 1. Vaginal bleeding 2. Urinary tract infection 3. Prolapse of the umbilical cord 4. Meconium in the amniotic fluid

3. Prolapse of the umbilical cord A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise. Unless there are other complications, vaginal bleeding is not expected. A urinary tract infection is not related to a breech presentation. As the fetal sacrum is compressed during labor, meconium may be expelled; this is not a fetal life-threatening concern with a breech presentation.

What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others? 1. Express disbelief about the client's delusion 2. Divert the client's attention to unit activities 3. React to the feeling tone of the client's delusion 4. Respond to the verbal content of the client's delusion

3. React to the feeling tone of the client's delusion Reacting to the feeling tone of the client's delusion helps the client explore underlying feelings and allows the client to see the message that the verbalizations are communicating. Expressing disbelief about the client's delusion denies the client's feelings rather than accepting and working with them. Attempting to divert the client rather than accepting and working with the client denies the client's feelings. Responding to the verbal content of the client's delusion focuses on the delusion itself rather than on the feeling that is causing the delusion.

A nurse is assessing the therapeutic action of drugs classified as tumor necrosis factor (TNF) inhibitors. What client response indicates to the nurse that a drug with this classification is effective? 1. Continued remission in a client with ovarian cancer 2. Increased insulin production in a client with diabetes mellitus 3. Reduction of inflammatory joint pain in a client with rheumatoid arthritis 4. Vasodilation of coronary arteries in a client with ischemic heart disease

3. Reduction of inflammatory joint pain in a client with rheumatoid arthritis TNF is produced mainly by macrophages in synovium; over time, through various mechanisms, the presence of TNF causes inflammation of synovium, destruction of bone and cartilage, joint stiffness, and pain. TNF inhibitors or blockers neutralize TNF, thereby interrupting the inflammatory cascade; this inhibits the inflammatory response and other mechanisms, thereby slowing tissue damage. TNF inhibitors are not prescribed for clients with ovarian cancer, diabetes mellitus, or ischemic heart disease.

What is the priority goal in the planning of care for a client in crisis? 1. Referring the client for occupational therapy 2. Arranging follow-up counseling for the client 3. Restoring the client's psychological equilibrium 4. Having the client work to gain insight into the problem

3. Restoring the client's psychological equilibrium Crisis intervention is short-term therapy with the major goal of restoring the client to the precrisis state. Referring the client for occupational therapy is not a goal but an action to help achieve a goal; it is not part of crisis intervention. Scheduling the client for follow-up counseling is not a goal but rather an intervention that may be necessary if psychological equilibrium cannot be restored. Having the client gain insight into the problem is not always necessary for a client to be able to function effectively.

A young woman with sickle cell disease wants to take a vacation with friends. Which trip would be the best choice to avoid the precipitating factors of a sickle cell crisis? 1. Cross-country ski trip 2. Hiking in the mountains 3. Road trip to the beach 4. Flying to Europe

3. Road trip to the beach The trip to the beach is less likely to include the usual precipitating factors: infection, fever, hypoxemia, dehydration, high altitudes, cold, or emotional stress

A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse takes which action? 1. Has the client void before the uterine assessment 2. Tells the woman to bear down during fundal massage 3. Simultaneously provides pressure over the lower uterine segment 4. Asks the client to take slow, deep breaths during fundal assessment

3. Simultaneously provides pressure over the lower uterine segment After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion.

Which stage of non-rapid eye movement (NREM) sleep is characterized by completely relaxed muscles? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

3. Stage 3 Stage 3 of non-rapid eye movement (NREM) sleep is characterized by completely relaxed muscles. Stage 1 of NREM sleep is characterized by decreased physiologic activity. Stage 2 of NREM sleep is characterized by the progression of relaxation. Stage 4 of NREM sleep is characterized by significant slowing of vital signs.

A licensed practical nurse (LPN) is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the LPN to contact the registered nurse? 1. Maternal fatigue 2. Clear amniotic fluid 3. Strong-smelling amniotic fluid 4. A fetal heart rate of 140 beats/min

3. Strong-smelling amniotic fluid Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38°C or 100.4°F or higher), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor.

The nurse is talking to a mother of a 10-year-old boy who has hemophilia. Which toy would be the best to recommend for this child? 1. Skateboard 2. Football 3. Swim fins 4. Bicycle

3. Swim fins The nurse recommends to the mother the best toy would be swim fins. The other toys offer a bigger risk for falls and injuries that could cause bleeding

Which hematological problems should the nurse screen for when providing care to an African American patient? Select all that apply. 1. Leukemia 2. Tay-Sachs 3. Thalassemia 4. Sickle cell disease 5. Pernicious anemia

3. Thalassemia 4. Sickle cell disease 5. Pernicious anemia The African American patient has an increased risk for Thalassemia, sickle cell disease, and pernicious anemia; therefore, the nurse should screen for these hematological problems when providing care. The African American patient is not at an increased risk for leukemia. Tay-Sachs is more prevalent in patients of Jewish descent.

A child is scheduled to receive the diphtheria, tetanus, and pertussis vaccine. After an assessment, the nurse concludes that the child cannot receive the vaccine safely. Which assessment finding supports the nurse's conclusion? 1. Fever has developed within 48 hours of previous vaccinations 2. The child exhibited a shock-like state after a previous vaccination 3. The child has a history of anaphylactic reactions after vaccinations 4. The child has an upper respiratory tract infection and mild febrile illness

3. The child has a history of anaphylactic reactions after vaccinations Vaccines are contraindicated in children who exhibit anaphylactic reactions because these reactions may be life-threatening. If a fever develops after a child's first vaccination, subsequent vaccines should be administered with caution. If a shock-like state has previously developed after a vaccination, subsequent vaccines should be administered with caution. When a child has an upper respiratory tract infection, vaccinations may be postponed until the infection is resolved

A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior? 1. It is an expected response. 2. Most people cry when their mother dies. 3. The co-worker may need help with grieving. 4. The co-worker was extremely attached to the mother

3. The co-worker may need help with grieving Crying is a release, but the individual should have developed effective coping mechanisms by this time. The co-worker may need help with the grieving process. Excessive crying 16 months after the death of a loved one is not an expected response. People express grief in a variety of ways, not necessarily by crying. Concluding that the co-worker was extremely attached to the mother is an assumption and is not a valid conclusion.

A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? 1. The client does not have an infection. 2. The donor blood is free of bloodborne pathogens. 3. The nurse should have worn gloves for self-protection. 4. The nurse was skilled enough to prevent exposure to the blood.

3. The nurse should have worn gloves for self-protection The Centers for Disease Control and Prevention (CDC) recommends that gloves be worn when there is the potential for contact with blood or other body fluids. Even if the client does not have an infection, gloves are always worn when exposure to blood or other body fluids is a possibility. All blood is considered potentially infectious. Nurses are required to take precautions that limit exposure; gloves must be worn.

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine or trihexyphenidyl in conjunction with the phenothiazine-derivative neuroleptic medications? 1. They reduce postural hypotension. 2. They potentiate the effects of the neuroleptic drug. 3. They combat the extrapyramidal side effects of the neuroleptic drug. 4. They ameliorate the depression that may accompany schizophrenia.

3. They combat the extrapyramidal side effects of the neuroleptic drug Benztropine and trihexyphenidyl control the extrapyramidal (parkinsonian) manifestations associated with the neuroleptics and are classified as antiparkinsonian drugs. These drugs do not reduce postural hypotension, nor do they potentiate phenothiazine derivatives or have an effect on depression.

Which modifiable risk factors for coronary artery disease (CAD) should the nurse include in a teaching session for a Native American patient? Select all that apply. 1. Age 2. Gender 3. Tobacco 4. Hypertension 5. Diabetes mellitus (DM)

3. Tobacco 4. Hypertension 5. Diabetes mellitus (DM) Modifiable risk factors for CAD that the nurse should include in a teaching session for a Native American patient include use of tobacco, hypertension, and DM. Age and gender are nonmodifiable risk factors for CAD.

A nurse is providing care to a client 8 hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? 1. Incisional pain 2. Absent bowel sounds 3. Urine output of 20 mL/hr 4. Serosanguineous drainage on the dressing

3. Urine output of 20 mL/hr A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings because this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.

When during the normal postpartum bourse would the nurse expect to note the fundal location shown in the figure? 1. Four days after delivery 2. The day after delivery 3. Immediately after delivery 4. When the client's bladder is full

3. immediately after delivery Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day.

The condition of a child dying of leukemia deteriorates, and the child becomes comatose. The parents state that a relative told them that they should not allow the child to be resuscitated, but they are unsure. Which response by the nurse best demonstrates recognition of the ethical issues involved? 1. "Let me tell you about the implications of a DNR order, and then you can decide." 2. "Maybe you should talk with your doctor first; I'll be happy to make the call for you." 3. "You should discuss this thoroughly with your doctor and with your religious adviser before coming to final decision." 4. "I can't imagine how difficult a decision this for you. Ultimately the final decision is made by you and your doctor."

4. "I can't imagine how difficult a decision this for you. Ultimately the final decision is made by you and your doctor." Telling the parents that they and the healthcare provider must make the final call but that it's important to discuss the issue is an ethically sound response that clearly defines who is involved in the decision making and allows parental expression of ideas and thoughts. Discussion of the implication of a do-not-resuscitate order should not take place until after the family has spoken with the practitioner. Although telling the parents to discuss the issue with the healthcare provider and offering to make the call promotes the practitioner-client relationship, it stops nurse-client interaction. Telling the parents to discuss the issue with the healthcare provider and religious adviser abdicates nursing responsibility, and the parents may have no desire to involve a religious adviser in the decision making process.

A registered nurse is teaching a licensed practical nurse (LPN) about collecting subjective data from a client who has a substance abuse disorder. Which statement made by the LPN will not provide subjective data? 1. "I'll document the quantity of drug the client uses." 2. "I'll document the date and time of the last drink or drug use." 3. "I'll document the client's normal drug usage or drinking pattern." 4. "I'll document the presence of tremors and the client's skin condition, especially on the forearms."

4. "I'll document the presence of tremors and the client's skin condition, especially on the forearms." While assessing a client who has a substance abuse disorder, the nurse should collect both subjective and objective data about the client. The presence of tremors and the condition of the client's skin are objective data, not subjective data. Subjective data include the quantity of drug the client uses, the date and time of the last drink or drug use, and the client's normal usage or drinking pattern.

Placenta previa is diagnosed when a client at 24 weeks gestation presents with painless vaginal bleeding. The client is concerned that she has done something to cause the bleeding. How should the nurse respond? 1. "It's not your fault; these things happen." 2. "Don't worry; it's just a sign that labor is beginning." 3. "Your uterus may be weak, that's what causes the vaginal bleeding." 4. "You have a low-lying placenta that separates when the cervix dilates."

4. "You have a low-lying placenta that separates when the cervix dilates." Presenting facts helps reduce feelings of guilt. Stating that the bleeding is not the client's fault is an inadequate explanation that does not offer any information. Labor may not be starting at this time. Placenta previa can occur in a woman with a healthy uterus.

The nurse is counseling a client with diabetes. Which statements made by the nurse are based on the second level of health promotion as per the U.S. Department of Public Health? Select all that apply. 1. "You should undergo a colonoscopy twice in a year" 2. "You should perform self glucose screening every day" 3. "You should have your hemoglobin test done every two months" 4. "You should follow your diet as prescribed by the dietitian" 5. "You should perform regular exercise to maintain a normal health status"

4. "You should follow your diet as prescribed by the dietitian" 5. "You should perform regular exercise to maintain a normal health status" According to the U.S. Department of Public Health, there are three levels of health promotion. Preventing further progression of disease severity is considered secondary prevention, which is the second level of health promotion. Counseling the client regarding diet and regular physical activity falls under secondary prevention. Suggesting the client undergo regular colonoscopies, regular screenings of blood glucose, and regular blood tests are considered primary prevention.

The primary healthcare provider plans to perform a vaginal examination of a client with a partial placenta previa. What should the nurse have available when this examination is performed? 1. 1 unit of freeze-dried plasma 2. Vitamin K and a syringe for injection 3. Heparin sodium for intravenous infusion 4. 2 units of typed and crossmatched blood

4. 2 unites of typed and crossmatched blood Vaginal examination in a patient with placenta previa may result in sudden, severe hemorrhage because of the location of the placenta near the cervical os; whole blood should be ready for administration to prevent shock. Because of this possible complication, a sonogram is preferred to vaginal examination. Fresh, not freeze-dried, plasma is used to restore coagulation factors after severe blood loss. Adults manufacture their own vitamin K, and an injection will not help prevent bleeding from the placenta. Administration of heparin sodium is contraindicated in the presence of hemorrhage.

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1. 6 hours 2. 12 hours 3. 18 hours 4. 24 hours

4. 24 hours After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.

A client being admitted for alcoholism reports having had alcoholic blackouts. The nurse knows that an alcoholic blackout is best described how? 1. A fugue state resembling absence seizures 2. Fainting spells followed by loss of memory 3. Loss of consciousness lasting less than 10 minutes 4. Absence of memory in relation to drinking episodes

4. Absence of memory in relation to drinking episodes Although the exact cause is unclear, alcoholic blackouts appear to result from responses of central nervous system cells to the substance. The individual does not have any type of seizure during the blackout. Fainting is not associated with the blackout. The individual loses memory but not consciousness.

The nurse at the mental health clinic is counseling a client with obsessive-compulsive disorder who spends a lot of time each day engaged in handwashing and has trouble keeping appointments on time as a result. What is the most therapeutic initial intervention by the nurse? 1. Discouraging the frequent handwashing to prevent skin breakdown 2. Encouraging the client to hasten the ritual so appointments can be kept on time 3. Telling the client how angry others become when activities are delayed for handwashing 4. Accepting the ritualistic behavior with a matter-of-fact attitude without displaying criticism

4. Accepting the ritualistic behavior with a matter-of-fact attitude without displaying criticism Responding to the ritualistic behavior in a matter-of-fact way prevents reinforcing the behavior; allowing time for rituals helps prevent an increase in the anxiety level. Attempts to discourage ritualistic behavior often increase the anxiety level and intensify the performance of the ritual. Attempts to hasten ritualistic behavior will increase the level of anxiety. Disparaging the client will decrease self-esteem, will increase anxiety and guilt, and may worsen the client's symptoms.

A client with a diagnosis of bipolar I disorder, manic episode, is started on a regimen of an antipsychotic agent and lithium carbonate. The nurse explains to the client that the rationale behind this regimen is that the antipsychotic has which action? 1. Potentiates the action of lithium for more effective results 2. Interacts with lithium to prevent progression to the depressive phase 3. Helps decrease the risk of lithium toxicity in the first week of therapy 4. Acts to quiet the client while allowing time for the lithium to reach a therapeutic level

4. Acts to quiet the client while allowing time for the lithium to reach a therapeutic level Antipsychotics usually are prescribed to calm agitated clients during the 3-week period it takes for the lithium to become effective. Antipsychotic drugs have a different, not a potentiating, mechanism of action. The drugs are used to control symptoms of mania, not to prevent depression. The neuroleptic drug has no effect on lithium toxicity.

A primary healthcare provider tells a client about the diagnosis of inoperable cancer and that the client does not have long to live. After the primary healthcare provider leaves, the client says to the nurse, "I feel fine. I probably only have the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the client's emotional needs? 1. Reassure the client that everything will be alright. 2. Leave the client alone to confront feelings of impending loss. 3. Encourage the denial until the client is able to accept reality. 4. Allow the denial and be available to discuss the situation with the client.

4. Allow the denial and be available to discuss the situation with the client Allowing the denial and being available to discuss the situation with the client does not remove the client's only way of coping, and it permits future movement through the grieving process when the client is ready. Reassuring the client that everything will be alright is false reassurance. The client must not be abandoned; the nurse's presence is a form of emotional support. The client's denial should be neither encouraged nor removed; encouraging denial is a form of false reassurance.

A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? 1. Water and pretzels 2. Low-fat cheese omelet 3. Nachos and fried chicken 4. Apple and whole-grain toast

4. Apple and whole-grain toast The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition.

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? 1. Apply pressure to the site. 2. Obtain vital signs. 3. Change the client's gown and bed linens. 4. Assess the catheterization site.

4. Assess the catheterization site Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client's gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.

A nurse is counseling a pregnant client with iron-deficiency anemia about when and how to take supplemental iron. What time of day is iron absorption most efficient? 1. Dinnertime 2. Bedtime 3. After lunch 4. Before breakfast

4. Before breakfast Iron should be taken before breakfast, on an empty stomach, to permit maximal absorption. Iron should not be taken with or after meals or at bedtime.

A client in the high-risk postpartum unit has had a precipitous labor and birth. Which maternal complication should the nurse anticipate? 1. Hypertension 2. Hypoglycemia 3. Chilling and shivering 4. Bleeding and infection

4. Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate, because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? 1. Dialysis 2. Osmosis 3. Diffusion 4. Capillarity

4. Capillarity When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low concentration.

Which is a lifestyle factor that can affect sleep? 1. Weight gain 2. Unfamiliar noises 3. Presence of a bed partner 4. Changing evening mealtime

4. Changing evening mealtime A change in evening mealtime is a lifestyle factor that can affect sleep. Weight gain is a nutritional, rather than lifestyle, factor that can affect sleep. Unfamiliar noises and the presence of a bed partner are environmental, not lifestyle, factors that can affect sleep.

A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight? 1. Lithium 2. Sertraline 3. Methylphenidate 4. Chlorpromazine

4. Chlorpromazine Clients taking chlorpromazine should be instructed to stay out of the sun. Photosensitivity makes the skin more susceptible to burning. Photosensitivity is not a side effect of lithium, sertraline, or methylphenidate.

A nurse is monitoring the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time? 1. Lochia alba 2. Lochial clots 3. Lochia serosa 4. Dark-red lochia rubra

4. Dark-red lochia rubra When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14.

During the initial prenatal visit of a woman at 23 weeks gestation, the nurse discovers that she has a history of pica. What is the most appropriate nursing action? 1. Seeking a psychology referral 2. Explaining the danger this poses to the fetus 3. Obtaining a prescription for an iron supplement 4. Determining whether the diet is nutritionally adequate

4. Determining whether the diet is nutritionally adequate The primary concern for a pregnant women who practices pica is that her diet is nutritionally inadequate. Nutritional guidance may be necessary, depending on the findings of this assessment. Pica does not indicate a psychologic/emotional disturbance; frequently it is influenced by the client's culture. If a substance is not toxic to the mother, it is generally not fetotoxic. Iron is routinely prescribed during pregnancy; this does not specifically address the practice of pica.

A nurse concludes that a client is using displacement. Which behavior has the nurse identified? 1. Ignoring unpleasant aspects of reality 2. Resisting any demands made by others 3. Using imaginative activity to escape reality 4. Directing pent-up emotions at someone other than the primary source

4. Directing pent-up emotions at someone other than the primary source When acting out against the primary source of anxiety creates even further anxiety or danger, the individual may use displacement to express feelings toward a "safer" person or object. Ignoring unpleasant aspects of reality is an example of denial. Resisting any demands made by others reflects an inability to mature and accept responsibility. Using imaginative activity to escape reality is fantasy.

A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What objective clinical finding indicates an impending seizure? 1. Persistent headache with blurred vision 2. Epigastric pain with nausea and vomiting 3. Spots and flashes of light before the eyes 4. Rolling of the eyes to one side with a fixed stare

4. Rolling of the eyes to one side with a fixed stare Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure. Persistent headache with blurred vision, epigastric pain with nausea and vomiting, and spots and flashes of light before the eyes are all clinical manifestations of severe preeclampsia, not eclampsia.

A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do? 1. Stay in bed, drink fluids, take a dose of aspirin, and ask the health care provider to reduce the dosage of clozapine 2. Discontinue the medication immediately and see the health care provider as soon as an appointment becomes available 3. Continue the medication, drink fluids, take aspirin, and see the health care provider in a few days if the symptoms do not improve 4. Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation

4. Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation Symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and can cause death. Remaining in bed, drinking fluids, taking aspirin, and asking the health care provider to decrease the dose of clozapine is unsafe because agranulocytosis may be developing, and this life-threatening side effect requires immediate treatment. Also, prescribing medications is outside the legal role of the nurse. Only a certified nurse practitioner can prescribe medications. Although discontinuing the medication is acceptable advice, delaying a health care provider's evaluation is unsafe. Continuing the medication, drinking fluids, taking aspirin, and seeing the health care provider in a few days if the condition does not improve is unsafe because agranulocytosis may be developing.

After the nurse provides education about hydrochlorothiazide, the client will agree to notify the healthcare provider regarding the development of which symptom? 1. Insomnia 2. Nasal congestion 3. Increased thirst 4. Generalized weakness

4. Generalized weakness Generalized weakness is a symptom of significant hypokalemia, which may be a sequela of diuretic therapy. Insomnia is not known to be related to hypokalemia or hydrochlorothiazide therapy. Although a stuffy nose is unrelated to hydrochlorothiazide therapy, it can occur with other antihypertensive drugs. Increased thirst is associated with hypernatremia. Because this drug increases excretion of water and sodium in addition to potassium and chloride, hyponatremia, not hypernatremia, may occur.

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered? 1. Telling the client that barbiturates and steroids will not be prescribed 2. Warning the client not to eat cheese, fermented products, and chicken liver 3. Monitoring the client for increased tolerance and reporting when the dosage is no longer effective 4. Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma

4. Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma Glaucoma is one of the side effects of imipramine (Tofranil), and the client should be taught the symptoms. Tolerance is not an issue with tricyclic antidepressants such as imipramine. The other actions are true of monoamine oxidase inhibitors (MAOIs); imipramine is not an MAOI.

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life-threatening response of thrombocytopenia? Select all that apply. 1. Fever 2. Diarrhea 3. Headache 4. Hematuria 5. Ecchymosis

4. Hematuria 5. Ecchymosis Hematuria is blood in the urine. Thrombocytes are involved in the clotting mechanism; thrombocytopenia is a reduced number of thrombocytes in the blood. Ecchymosis is a superficial bruise caused by bleeding under the skin or mucous membrane. With thrombocytopenia, bleeding occurs because there are insufficient platelets. Fever is unrelated to thrombocytopenia. Fever is a sign of infection; infection results when the white blood cells are reduced (leukopenia). Diarrhea is unrelated to thrombocytopenia; diarrhea may result from the effects of chemotherapy on the rapidly dividing cells of the gastrointestinal system. Headache is unrelated to thrombocytopenia; headache may be caused by the effects of chemotherapy on central nervous system cells or may indicate that the leukemia has invaded the central nervous system.

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given in one session to prevent the occurrence of what? 1. Hypercalcemia 2. Hypocalcemia 3. Hyperkalemia 4. Hypokalemia

4. Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells and extracellular fluid, which does not result in hyperkalemia.

While a client is being given intravenous magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. What reason does the nurse give to the client to explain why this is done? 1. Reveals her level of consciousness 2. Reveals the mobility of the extremities 3. Reveals the response to painful stimuli 4. Identifies the potential for respiratory depression

4. Identifies the potential for respiratory depression Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dL. Deep tendon reflexes disappear when the serum level is 10 to 12 mg/dL. The medication is withheld in the absence of deep tendon reflexes. The therapeutic serum level of magnesium sulfate is 5 to 8 mg/dL. Deep tendon reflexes do not reveal a client's level of consciousness, mobility of the extremities, or the response to painful stimuli. Deep tendon reflexes can be associated with muscle strengthening.

A client is receiving dexamethasone to treat acute exacerbation of asthma. For what side effect should the nurse monitor the client? 1. Hyperkalemia 2. Liver dysfunction 3. Orthostatic hypotension 4. Increased blood glucose

4. Increased blood glucose Dexamethasone increases gluconeogenesis, which may cause hyperglycemia. Hypokalemia, not hyperkalemia, is a side effect. Liver dysfunction is not a side effect. Hypertension, not hypotension, is a side effect.

A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client in which way? 1. Prone 2. In a semi-Fowler position 3. In the Trendelenburg position 4. Supine with a wedge under the right hip

4. Supine with a wedge under the right hip The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery.

The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse? 1. Encouraging him to express his feelings about the situation 2. Telling him to schedule an appointment with the gynecologist 3. Asking whether he can afford a home health aide for several weeks 4. Informing him that he should seek emergency intervention for his wife

4. Informing him that he should seek emergency intervention for his wife The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time. The wife has an emotional, not physiological, problem at this time. Asking whether the family can afford a home health aide for several weeks is not the priority at this time; the wife's emotional condition is the priority.

The nurse determines that the plan for bolstering an overweight adolescent's self-esteem has been effective when, 3 months later, the adolescent's mother reports that the adolescent is doing what? 1. Seems to be doing average work in school 2. Has asked her how to bake bread and cookies 3. Imitates a sibling's manner of speech and dress 4. Joined a dirt bike group that meets at the school

4. Joined a dirt bike group that meets at the school Joining a dirt bike group demonstrates a movement toward peer group activity and interests; exercise demonstrates an interest in an improved physical condition. There are no data to indicate that school is a problem. Average work in school and an interest in baking do not demonstrate an increase in self-esteem.

The nurse is caring for a high-risk pregnant client who has had a positive contraction stress test (CST). What would the nurse interpret the result to mean? 1. A nonstress test is needed. 2. An immediate cesarean birth is needed. 3. The fetal heart is within the expected limits for the average fetus. 4. Late decelerations of the fetal heart rate are occurring with each contraction.

4. Late decelerations of the fetal heart rate are occurring with each contraction Late decelerations of the fetal heart rate with each contraction constitute a positive CST result, which indicates fetal compromise. A CST performed after a nonstress test, not before, is nonreactive or equivocal. A positive CST result does not dictate a cesarean birth; an expeditious vaginal birth may be attempted. These variations in the fetal heart rate are expected in a healthy fetus.

The registered nurse is caring for an older client who is admitted with gastric ulcer and joint pains and is unable to perform activities of daily life (ADL). The legal authority has stated, "Provide the treatment according to the client's care sheet." Which delegatee should take up the task? 1. Orderlies 2. Certified nursing aide 3. Patient care associate 4 Licensed practical nurse

4. Licensed practical nurse The registered nurse will delegate the task of providing medication to the client to the licensed practical nurse (LPN). The LPN's scope of practice is to administer oral medications and to provide the treatment that is prescribed in the client's case sheet. Orderlies are unlicensed assistive personnel who are delegated with tasks such as providing basic care, hygiene care, and assisting the clients in ADLs. Certified nursing aides are also unlicensed assistive personnel whose scope of practice does not allow them to perform tasks such as administering medications. A patient care associate is an unlicensed assistive personnel who can care for the client with basic needs such as ADLs.

A 4-year-old child develops thrombocytopenia after vaccination. Which vaccination may be responsible? 1. Rotavirus vaccine 2. Varicella virus vaccine 3. Human papillomavirus vaccine 4. Measles, mumps, and rubella virus vaccine (MMR)

4. Measles, mumps, and rubella virus vaccine (MMR) Measles, mumps, and rubella virus vaccine (MMR) may cause transient thrombocytopenia. It is generally benign and occurs only rarely. Rotavirus vaccine carries a small risk for intussusception. Varicella virus vaccine and human papillomavirus vaccine may cause mild effects such as fever and fainting.

A postpartum woman treated with methylergonovine complained of dizziness, has low blood pressure, and has passed out. Which initial nursing action would help this client? 1. Document the findings 2. Encourage excess increased fluid intake 3. Advise to stop taking methylergonovine 4. Notify the primary healthcare provider

4. Notify the primary healthcare provider Methylergonovine may cause a sudden drop in blood pressure. Notifying the primary healthcare provider should be the priority action of the nurse in this condition in order to get proper treatment at the right time. Documentation of findings is also important, but it is not the initial step of the nurse. Excess fluid intake is necessary in this client, but it is not an initial step of the nurse. A nurse cannot advise stopping medication prescribed by primary healthcare provider unless instructed.

During the postpartum period a nurse determines that a client's rubella titer is negative. Which action should the nurse plan to take next? 1. Checking for allergies to penicillin 2. Alerting the staff in the newborn nursery 3. Assuring the client that he has active immunity 4. Obtaining a prescription for immunization at discharge

4. Obtaining a prescription for immunization at discharge A negative rubella titer indicates no immunity. Immunizations can be given safely during the immediate postpartum period but are teratogenic when given during pregnancy. Penicillin allergy is not a contraindication to the vaccine; only egg allergy is. The mother's negative rubella titer does not affect the infant. A client with a negative titer has no immunity to rubella.

A client with type 2 diabetes mellitus and hypothyroidism is admitted to a long-term care facility. Which system would provide a safe environment for the client? 1. Omnibus Budget Reconciliation Act (OBRA) 2. Health Care Financing Administration (HCFA) 3. Patient Protection and Affordable Care Act (PPACT) 4. Occupational Safety and Health Administration (OSHA)

4. Occupational Safety and Health Administration (OSHA) The Occupational Safety and Health Administration (OSHA) provides a safe environment for the elderly by increasing the cost of the care because personnel safety is mandatory. The Omnibus Budget Reconciliation Act (OBRA) defines the requirements needed to provide quality care to the residents of a long-term care facility, and it covers services such as nutrition, staffing, qualifications required of personnel, and many others. The Health Care Financing Administration (HCFA) monitors OBRA guidelines through institutional surveys. The Patient Protection and Affordable Care Act (PPACT) provides quality and affordable health care to older adults.

How should the nurse help a disturbed, acting-out child develop a trusting relationship? 1. Inquire about the child's feelings regarding the parents 2. Implement a half-hour one-on-one interaction every day 3. Initiate limit-setting and explain the rules to be followed 4. Offer periodic support and emphasize safety in play activities

4. Offer periodic support and emphasize safety in play activities Offering periodic support and emphasizing safety in play activities sets a foundation for trust because it allows the child to see that the nurse cares. Inquiring about the child's feelings regarding the parents would be threatening at this stage of the relationship. Implementing a half-hour one-on-one interaction daily is too infrequent for the development of trust. Although initiating limit-setting and explaining the rules to be followed are necessary, limit-setting does not support the development of a trusting relationship as much as providing support and emphasizing safety do.

A health care provider prescribes famotidine and magnesium hydroxide/aluminum hydroxide for a client with a peptic ulcer. At what time should the nurse instruct the client to take the magnesium hydroxide/aluminum hydroxide? 1. Only at bedtime, when famotidine is not taken. 2. Only if famotidine is ineffective. 3. At the same time as famotidine, with a full glass or water. 4. One hour before or two hours after famotidine.

4. One hour before or two hours after famotidine Antacids interfere with complete absorption of famotidine; therefore, antacids should be administered at least one hour before or two hours after famotidine. Magnesium hydroxide/aluminum hydroxide usually is taken one hour after meals and at bedtime. Famotidine usually is prescribed once a day at bedtime. The client has received a prescription for both medications; the client should not be instructed to omit one of the medications without checking with the health care provider first.

A mother brings her 5-year-old daughter to the children's clinic after teachers report that the girl is disobedient and hostile. The child has a negative attitude and argues often with her teachers. At this time she has not violated the rights of other students. The mother reports that she has also noticed this behavior at home. The nurse suspects that the behavior described is associated with what disorder? 1. Anxiety disorder 2. Conduct disorder 3. Major depressive disorder 4. Oppositional defiant disorder

4. Oppositional defiant disorder Oppositional defiant disorder usually becomes evident before 8 years of age. Affected children do not violate the rights of others. They do not see themselves as defiant but feel that they are responding to unreasonable demands or situations. Children who are anxious or depressed may exhibit some disobedience during the school day but do not exhibit the argumentative and hostile behavior pattern seen with oppositional defiant disorder. Conduct disorder is characterized by a pattern of behavior in which the rights of others and social norms or rules are violated. There is a lack of guilt or remorse for inappropriate behavior, and blame is placed on others.

A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response? 1. Respirations are enhanced 2. Bladder tonicity is increased 3. Abdominal muscles are strengthened 4. Peripheral vasomotor activity is promoted

4. Peripheral vasomotor activity is promoted There is extensive activation of the blood-clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization, which can be limited through activity. Respirations are enhanced by encouraging the client to turn from side to side and deep-breathe and cough. Bladder tone is improved by regular voiding and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.

A client who is having a difficult labor is found to have cephalopelvic disproportion. Which medical order should the nurse question? 1. Maintain NPO status. 2. Start peripheral IV of 0.9% NS. 3. Record fetal heart tones every 15 minutes. 4. Piggyback another 10-unit bag of oxytocin (Pitocin).

4. Piggyback another 10-unit bag of oxytocin (Pitocin) When there is cephalopelvic disproportion, a cesarean birth is indicated; infusing oxytocin (Pitocin) at this time could result in fetal compromise and uterine rupture. The nothing-by-mouth (NPO) status is appropriate in anticipation of a cesarean birth. A peripheral IV is needed not only for hydration but also for venous access if IV medications become necessary. The client probably has an electronic monitor recording the fetal heart rate and uterine contractions; the findings of these assessments should be documented regularly in accordance with hospital protocol.

A client has been attending weekly outpatient psychotherapy sessions for several months. The nurse psychotherapist has been working with the client to help lessen obsessive-compulsive behaviors that have interfered with the client's work performance. What information about the client best validates the client's improvement? 1. States spending less time on ritualistic behaviors while at work 2. Discusses techniques used to provide distraction from obsessive thoughts 3. Reports spending an increased amount of time with friends in pleasurable activities 4. Receives a letter from a supervisor at work stating job performance has improved

4. Receives a letter from a supervisor at work stating job performance has improved The letter provides objective validation that the client's work performance has improved. Although spending less time at work on compulsive behavior, coming up with techniques to lessen the need for the behavior, and spending more time with friends in pleasurable activities are all acceptable outcomes of therapy, they all represent subjective information reported by the client.

A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client which information? 1. To perform a vaginal douche 2. To come to the clinic for a checkup 3. That this is an indication of an infection 4. That this is a normal postpartum occurrence

4. That this is a normal postpartum occurrence For the first 3 days after childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, at which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased, and the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect.

A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? 1. Clonus is present 2. Magnesium level is 10 mg/dL 3. Deep tendon reflexes are absent 4. The client experiences diuresis within 24 to 48 hours

4. The client experiences diuresis within 24 to 48 hours Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client's lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 2+ but should not be absent.

A client confides to the nurse, "I've been thinking about suicide lately." What conclusion should the nurse make about the client? 1. The client intends to frighten the nurse. 2. The client wants attention from the staff. 3. The client feels safe and can share feelings with the nurse. 4. The client is fearful of the impulses and is seeking protection from them.

4. The client is fearful of the impulses and is seeking protection from them Clients frequently report suicidal feelings so the staff will have the chance to stop them. They are really asking, "Do you care enough to stop me?" It may be true that the client feels safe and can share feelings with the nurse, but, more importantly, the client is seeking help and protection. It may be true that the client wants to frighten the nurse or wants attention from the staff, but these are unlikely motivations for the behavior.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider what about clients with OCD? 1. They are unaware that the ritual serves no purpose 2. They can alter the ritual depending on the situation 3. They should be prevented from performing the ritual 4. They do not want to repeat the ritual but feel compelled to do so

4. They do not want to repeat the ritual but feel compelled to do so The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

The nurse is advising a client with acquired immunodeficiency syndrome (AIDS) to avoid the consumption of undercooked meat. Which infection can be prevented in the client by following this measure? 1. Tuberculosis 2. Cryptococcosis 3. Cryptosporidiosis 4. Toxoplasmosis encephalitis

4. Toxoplasmosis encephalitis Toxoplasmosis encephalitis is caused by Toxoplasma gondii and may occur due to the ingestion of infected undercooked meat or by contact with contaminated cat feces. Tuberculosis is caused by Mycobacterium tuberculosis and is spread by airborne routes. Cryptococcosis is caused by Cryptococcus neoformans and is a debilitating meningitis that can be a widely spread infection in AIDS. Cryptosporidiosis is an intestinal infection caused by Cryptosporidium organisms.

A nurse is caring for a client who is being given intravenous magnesium sulfate to treat preeclampsia. Which effect alerts the nurse to notify the primary healthcare provider? 1. Respiratory rate of 18 breaths/min 2. 2+ patellar reflex response 3. Blood pressure of 112/76 mm Hg 4. Urine output of less than 100 mL in 4 hours

4. Urine output of less than 100 mL in 4 hours A decreased urine output of less than 25 mL/hr may be indicative of kidney damage, a result of the preeclampsia, and impending renal failure. Magnesium sulfate is excreted by the kidneys, and magnesium toxicity may occur. Respirations at this rate are within the expected range; a rate of at least 16 breaths/min should be present before each dose of magnesium sulfate. Loss of the patellar reflex is suggestive of magnesium sulfate toxicity; a 2+ reflex is within the expected range. A blood pressure of 112/76 mm Hg is within normal limits.

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for what? 1. High fat diet 2. Supplemental cod liver oil 3. Total parenteral nutrition (TPN) 4. Water-soluble forms of vitamins A and E

4. Water-soluble forms of vitamins A and E Vitamins A, D, E, and K are known as fat-soluble vitamins because bile salts and other fat-related compounds aid their absorption. A high fat diet will not achieve the uptake of fat-soluble vitamins in this client. Supplemental cod liver oil will not achieve the uptake of fat-soluble vitamins in this client. TPN is unnecessary; a well-balanced diet is preferred. Water-miscible forms of vitamins A and E can be absorbed with water-soluble nutrients.

A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a low of appetite and complains of feeling "too full to eat." What does the nurse encourage the client to do? Select all that apply. A. Avoid drinking fluids before and during meals B. Eat a variety of dark-green vegetables, such as broccoli C. Have snacks, such as crackers and cheese, between meals D. Select foods that are easy to chew and are not gas forming E. Consume high-calorie drinks, such as milkshakes, between meals

A. Avoid drinking fluids before and during meals d. Select foods that are easy to chew and are not gas forming COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and should also be avoided by the client. The nurse should also teach the client about foods that are easy to chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas-forming food, should be avoided.

A tuberculin test (Mantoux test) is administered to a client with a diagnosis of HIV infection. Forty-eight hours after administration, the nurse checks the test site. The nurse documents the result of the test as: A. Positive B. Negative C. Insignificant D. Indeterminate

A. Positive The tuberculin, or Mantoux, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is considered positive in a non-immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease.

The nurse is reinforcing instructions to a client with newly diagnosed diabetes mellitus who has been prescribed NPH insulin on how to recognize the signs of hypoglycemia. The client states that he must look for certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood the instructions. What are these signs and symptoms? Select all that apply. A. Shakiness B. Drowsiness C Blurred vision D. Increased thirst E. Feeling of hunger F. Nausea and vomiting

A. Shakiness C. Blurred vision E. Feelings of hunger The client taking NPH insulin experiences peak medication effects 6 to 12 hours after administration. When the medication's action peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse teaches the client to be alert for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse, shakiness, and hunger. The other options are signs and symptoms of hyperglycemia.

Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse reinforces information to the client about the medication. Which occurrences does the nurse tell the client to report to the health care provider? Select all that apply. A. Lethargy B. Chest pain C. Palpitations D. Weight gain E. Constipation F. Rapid heart rate

B. Chest pain C. Palpitations F. Rapid heart rate The client taking levothyroxine sodium may have manifestations of hypothyroidism if the dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is too high. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart, which may result in angina and cardiac dysrhythmias. The client should be instructed to report chest pain, palpitations, or a rapid heart rate immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy (e.g., levothyroxine sodium).

A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. A. Apple slices and skim milk B. Whole-milk shake and granola C. Baked potato topped with cheese D. Cheese and whole-wheat crackers E. Cauliflower with low-fat ranch dip

B. Whole-milk shake and granola C. Baked potato topped with cheese D. Cheese and whole-wheat crackers To facilitate healing and meet continued high metabolic needs, the client with a major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also keeps the client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and whole-wheat products are acceptable choices. Although fresh fruits and vegetables and skim milk are high in nutrients, higher-calorie foods, including versions of dairy products prepared with whole milk, are preferable in this situation.

A client arrives in the emergency department after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads at which level? A. 7.28 B. 7.30 C. 7.40 D. 7.50

C. 7.40 First aid after a chemical burn to the eye consists of irrigation of the eye with copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before, during, and after irrigations to determine the pH and to ascertain whether the substance was acid or alkaline. The normal body pH is 7.40.

A nurse is visiting a client who is receiving home health care, focusing on medication and dietary instructions and management of heart failure. The nurse should reinforce which instruction? A. If you feel tired and short of breath, lie down flat and prop up your feet B. Eating liver several times a week will help build up your strength C. Your daily dose of furosemide should be taken first thing in the morning D. The dose of enalapril will help prevent vasodilation from occuring

C. Your daily dose of furosemide should be taken first thing in the morning The client should be instructed to take the dose of furosemide early in the morning to minimize nighttime trips to the bathroom. Excessive activity tends to tire clients with heart failure. If the client feels tired and short of breath, the mid-high Fowler position is recommended. Liver is not recommended several times a week because of the cholesterol content of organ meats. Enalapril helps prevent vasoconstriction.

A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse tell the client to take on a daily basis, reinforcing teaching to the client about measures to manage the disorder? A. Vitamin C B. Phosphorus C. Beta-carotene D. Calcium carbonate with vitamin D

D. Calcium carbonate with vitamin D Hypoparathyroidism is an endocrine disorder in which parathyroid function is decreased. The client with hypoparathyroidism is likely to have low calcium and high phosphate levels and should consume a diet high in calcium but low in phosphorus. Additionally, the generally used treatment is calcium supplementation (either as calcium carbonate or calcium citrate) coupled with vitamin D supplementation. Vitamin C supplementation is not a treatment measure for this disorder. Beta-carotene is incorrect because a client with hypoparathyroidism typically has an increased phosphorus level.

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 190 mg/dL and a total cholesterol level of 210 mg/dL in an otherwise healthy client. What should the nurse tell the client to do next? A. Seek treatment for diabetes mellitus B. Ask the health care provider about starting insulin therapy C. Consult with a nutritionist about foods that are high in cholesterol D. Call his health care provider to have these values rechecked as soon as possible

D. Call his health care provider to have these values rechecked as soon as possible Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g., polydipsia, polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a random plasma glucose level greater than 200 mg/dL, and a fasting plasma glucose level greater than 140 mg/dL on two separate occasions are all diagnostic of diabetes mellitus. The total cholesterol should be less than 200 mg/dL. Confirmation of this client's results is needed to ensure appropriate diagnosis and therapy.

A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding? A. Asking the client whether the dressing feels wet B. Looking for moisture on the top of the dressing C. Removing and replacing the dry sterile dressing every 2 hours D. Checking for moisture on the back of the dressing over the client's neck and shoulders

D. Checking for moisture on the back of the dressing over the client's neck and shoulders Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection.