EAQ Nursing Process - Implementation

A client is scheduled for amniocentesis. What should the nurse do before the procedure?

Remind the client to empty her bladder

Which side effect may be experienced by a client taking an antianxiety agent?

Ataxia

What does a nurse understand about the secondary level of prevention?

Secondary prevention is focused on individuals who are in the early stage of their illnesses.

A 16-year-old girl has been admitted to the pediatric eating disorders unit with a diagnosis of anorexia and is undergoing behavioral therapy. Unit privileges are based on weight gain and have been explained to the client. What is the mostappropriate intervention for the nurse to use when taking the lunch tray to the client's room?

Setting the tray down and say nothing

The parents of a 2-year-old child are watching the nurse administer the Denver II Developmental Screening Test to their child. They ask, "Why did you make our child draw on paper? We don't let our child draw at home." What is the best response by the nurse?

"It lets us test the child's ability to perform tasks requiring the hands."

A client with tuberculosis is to begin a medication that combines isoniazid, rifampin, and pyrazinamide, and streptomycin sulfate therapy. The client says, "I've never had to take so much medication for an infection before." What should the nurse explain?

"This type of organism is difficult to destroy."

A nurse on a mental health unit has developed a therapeutic relationship with a manipulative, acting-out client. One day as the nurse is leaving, the client says, "Please stay. I'm afraid that the evening staff doesn't like me. They're always punishing me." What is the nurse's most therapeutic response?

"You know I leave at this time. We'll talk about this in the morning.

Which interventions are appropriate for measuring tympanic temperature in a three-year-old client with an electronic thermometer? Select all that apply.

*Fitting an ear probe snugly into canal *Pointing the digital readout toward the nurse *Sliding a disposable plastic speculum cover over the otoscope-like tip

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ______ gtts/min.

21

A client in preterm labor does not respond to therapy, and birth seems imminent. The client begins to cry and says, "I'm so worried about my baby." What is the nurse's best response?

"All of this must leave you very confused and frightened."

A young client who has just lost her first job comes to the mental health clinic very upset and says, "I just start crying without any reason and without any warning." How should the nurse respond initially?

"Crying unexpectedly can be very upsetting."

A terminally ill client appears happy and tells a nurse a joke about the situation despite becoming sicker and weaker. What is the nurse's most therapeutic response?

"Does it help to joke about your illness?"

Which medication is used in the treatment of obsessive-compulsive disorder (OCD)?

Clomipramine

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. In response to the clinical manifestations, what should the nurse do?

Assess the client's pulse and respirations

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action?

Changing the maternal position

A client is scheduled to begin chemotherapy 2 weeks after surgery for colon cancer. What explanation does the nurse give to explain the delay following surgery?

Chemotherapy interferes with cell growth and delays wound healing.

A low-residue diet is recommended for a client. Which food should the nurse encourage the client to select from a menu?

Creamed potatoes

A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. What does the nurse instruct them to do?

Encourage the client to speak while being patient with each attempt

A 12-year-old child with cystic fibrosis is to receive four pancrelipase (Pancrease) capsules five times a day. The nurse explains that the medication should be taken with meals and snacks because this will do what?

Facilitate nutrient utilization

A client with type 2 diabetes has been receiving insulin in the hospital while being treated for sepsis. The client's infection is resolving, and the health care provider writes a prescription to discontinue the 7 AM dose of insulin and administer glyburide 5 mg twice daily (8 AM and 8 PM). The nurse on the day shift administers the Micronase at 8:30 AM. When recording its administration in the client's record, the nurse sees that the insulin had already been administered at 7 AM. What is the prioritynursing action?

Monitor for signs of hypoglycemia.

What is the priority nursing care immediately after an amniocentesis?

Monitoring for signs of uterine contractions

After a subtotal gastrectomy a client is returned to the surgical unit. Which is the best nursing action to prevent pulmonary complications?

Promoting frequent turning and deep breathing to mobilize secretions

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

Remove secretions from the pharynx

A shy, withdrawn adolescent boy, newly admitted to the psychiatric unit, asks one of the female psychiatric nurses for a date. What is the best initial response by the nurse?

Restating the purpose of the nurse-client relationship

A client who has participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the infant's discharge comes to the unit on the last hospital day with an alcohol odor on her breath and slurred speech. What is the most appropriate action for the nurse to take at this juncture?

Speak with the mother about her condition and assess her willingness to participate in an alternate discharge plan.