exam 1 transitions

A nurse is conducting an interview with a client who has come to the clinic after finding a lump in her right breast during breast self-examination. The client says, "I am so worried. I know that this must be breast cancer. What am I going to do?" Which response should the nurse give the client? "Tell me what worries you." "Most lumps found in the breast aren't cancer." "Let's talk again after the doctor examines you." "You shouldn't be so worried. After all, if it is cancer, you found it at an early stage."

"Tell me what worries you." The nurse should always focus on the client's feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. "Tell me what worries you" is the only option that gives the client this opportunity. The other options are nontherapeutic and place the client's feelings on hold.

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. Spaghetti with fresh tomatoes Boiled lobster with baked potato Grilled chicken with turnip greens Instant hot cereal with bacon Tomato soup with a ham sandwich

Spaghetti with fresh tomatoes Correct Grilled chicken with turnip greens Correct Rationale: Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods and luncheon meats are high in sodium unless they are specifically labeled "low sodium." Saltwater fish and shellfish are higher in sodium.

When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate which type of feeding? cereal-thickened formula full-strength formula half-strength formula oral electrolyte solution

oral electrolyte solution When a child is ready to take fluids by mouth postoperatively, clear liquids are given initially. If clear liquids are tolerated, the concentration and amount of oral feedings are gradually increased. This means advancing to half-strength formula and then to full-strength formula while increasing the amount given with each feeding.

The nurse is caring for a child with cystic fibrosis. What behavior exhibited by the parents of a child with a chronic illness may indicate feelings of guilt about the child's illness? anger sadness dejection overindulgence

overindulgence

A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. Plums Prunes Apples Broccoli Cabbage Cranberries

plums, prunes, cranberries Rationale: Meats, eggs, whole-grain breads, cranberries, plums, and prunes increase urine acidity. These foods are metabolized into acid end-products that eventually enter the urine. The incorrect options are not food items that will acidify the urine.

The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities and toys are appropriate for her child. What should the nurse suggest? picture books peek-a-boo rattle colored blocks

rattle Although chronologically the infant is 7 months old, because of being born 6 weeks early, the child is only 5½ months old developmentally. Appropriate activities for a 5- to 5½-month-old infant include placing a rattle or ball in the infant's hand. Picture books are an appropriate choice for an infant older than 9 months. Playing peek-a-boo is appropriate for a 9- to 12-month-old infant. Colored blocks are appropriate for a toddler approximately age 15 to 18 months.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: functional incontinence. reflex incontinence. stress incontinence. total incontinence.

stress incontinence. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned? salt water vinegar ammonia bleach

vinegar A distilled vinegar solution acts as a good deodorizing agent after an appliance has been cleaned well with soap and water. If the client prefers, a commercial deodorizer may be used. Salt solution does not deodorize. Ammonia and bleaching agents may damage the appliance.

Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? A client with a history of recurrent candidiasis A client who had her first pregnancy before the age of 20 A client infected with the human papillomavirus (HPV) A client who has used oral contraceptives for 27 years

A client infected with the human papillomavirus (HPV) HPV causes genital warts, which are associated with an increased incidence of cervical cancer.

The nurse is instructing the client with ulcerative colitis about the best diet to maintain nutrition for tissue healing while avoiding foods that will exacerbate ulceration. Which diet would be most appropriate? high-calorie, low-protein high-protein, low-residue low-fat, high-fiber low-sodium, high-carbohydrate

high-protein, low-residue Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? Data related to follow-up care A complete (total health) database Data related to the respiratory system Data related to the treatment for the cold

Data related to the respiratory system Rationale: An episodic database is compiled for a limited or short-term problem and is focused mainly on one problem or body system. The history and examination will be focused primarily on the respiratory system in this client. A complete database includes a complete health history and a full physical examination. It describes the client's current and past state of health and forms a baseline against which all future changes can be measured. A follow-up database is used to evaluate an identified problem at regular and appropriate intervals.

A nurse may use self-disclosure with a client if: the nurse has experienced the same situation as the client. the client asks directly about the nurse's experience. it helps the client to talk more easily. it achieves a specific therapeutic goal.

it achieves a specific therapeutic goal. Self-disclosure (making personal statements about oneself) can be a useful nursing tool. However, a nurse should use self-disclosure judiciously and with a specific therapeutic purpose in mind. The nurse should listen closely to the client and remember that the experiences of different people are sometimes similar but never identical. Using too many self-disclosures is unethical and can shift the focus from the client to the nurse. Self-disclosure that distracts the client from treatment issues doesn't benefit the client and may alienate the client from the nurse.

The nurse is obtaining a health history for a client with pancreatitis. The client does not drink alcohol because of religious convictions and becomes upset when the nurse asks about alcohol intake. What should the nurse tell the client about why this is an important question? "There is a strong link between alcohol use and acute pancreatitis." "Alcohol intake can interfere with the tests used to diagnose pancreatitis." "Alcoholism is a major health problem, and all clients are questioned about alcohol intake." "The health care provider (HCP) must obtain the pertinent facts, regardless of religious beliefs." TAKE ANOTHER QUIZ

"There is a strong link between alcohol use and acute pancreatitis." Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

The family caregiver of a client with Alzheimer disease tells the nurse that the client thinks someone is stealing their things. Which response by the nurse would be most helpful? "That behavior is typical of people with Alzheimer disease and will become worse." "The client has problems remembering where they put things." "We have checked their room and nothing was missing." "We asked the health care provider to evaluate the client for paranoid delusions, which are common in people with Alzheimer's disease."

"We asked the health care provider to evaluate the client for paranoid delusions, which are common in people with Alzheimer's disease." The best response addresses the caregiver's concern and explains that paranoia and delusions are common in Alzheimer disease.

A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet? Rice and fish Eggs and bacon Cereals and broccoli Meats and citrus fruits

Meats and citrus fruits increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Liver and other meats, from which 10% to 30% of available iron is absorbed, are good choices. Less than 10% of iron is absorbed from eggs and less than 5% from grains and vegetables.

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply. Eggs Yogurt Parsley Broccoli Cucumbers Cranberry juice

Yogurt Parsley Cranberry juice Rationale: Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods.

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods? Select all that apply. Milk Peanuts Chicken Broccoli Asparagus Whole-grain cereals

peanut, asparagus, whole-grain cereals Rationale: Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin, but other good sources are peanuts, asparagus, legumes, and whole-grain and enriched cereals. Milk is high in vitamins A and D, calcium, and magnesium. Chicken is high in protein. Broccoli is high in calcium and folic acid.

A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray? peas Scrambled eggs Cheese casserole Mashed potatoes

peas Rationale: In general, flavorful, warm, or well-chilled foods with texture stimulate the swallow reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables, chunky vegetables such as diced beets, stringy vegetables, and those with skin, such as corn and peas are foods commonly excluded from the diet of a client with dysphagia.

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? A. Identify any hereditary traits related to the epilepsy B. Make accurate nursing diagnoses C. Determine what the client believes has caused the epilepsy D. Confirm the medical diagnosis

C. Determine what the client believes has caused the epilepsy Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican-American culture, epilepsy is seen as a reflection of physical imbalance. Although the nurse may obtain data related to family history (hereditary) and formulate nursing diagnoses, these are not the primary reasons for including cultural information in the health assessment. A nurse gathers assessment data but does not confirm a medical diagnosis.

What dietary recommendations should the nurse provide for a client with intermittent claudication to assist in the prevention of disease? SATA reduce fat substitute saturated fats for unsaturated fats decrease cholesterol limit calorie intake to 1500 calories per day refrain from eating processed foods

reduce fat decrease cholesterol Intermittent claudication is a symptom of atherosclerosis. Association guidelines recommend a diet with decreased fat, decreased cholesterol, and unsaturated fats instead of saturated fats to prevent disease. Guidelines do not recommend limiting the number of calories to 1500, nor do they specifically recommend refraining from processed foods.

A nurse is assessing a client's spiritual needs when the client becomes angry and defensive about the questions being asked. What would the nurse say to make the client comfortable? We ask everyone these questions. It's nothing personal." "You appear upset about these questions. Is this true?" "We ask because having a spiritual connection can really help you during this time." "Many clients get uncomfortable when asked about their spiritual beliefs."

"You appear upset about these questions. Is this true?" The nurse should first clarify if the client's appearance as angry or defensive is actually related to the spirituality-related questions before making assumptions. Some clients are relieved to know that the spiritual aspect of their being is worthy of the nurse's concern. However, the nurse should not sound vague and judgmental by saying something like, "We ask because having a spiritual connection can really help you during this time." Saying something like, "Many clients get uncomfortable when asked about their spiritual beliefs" takes the focus away from this client. Just telling the client everyone is asked these questions does not explore the reaction.

A client is found to have post-traumatic stress disorder (PTSD) after witnessing a terrorist attack and seeing several people jump to their deaths from a burning building. The client, who is undergoing counseling, says to the nurse, "Those people who jumped were my friends and coworkers. The only reason I wasn't there is that it was my turn to get the coffee and doughnuts for everyone that morning. If I hadn't gone, I would have been with them. Maybe I could have helped." Which response should the nurse give to the client? "You just weren't meant to be there." "It was a horrible attack, and there wasn't anything anyone could do." "You need to think about the families of the victims and what they are dealing with." "You are not responsible for the attack but are responsible for learning how to cope with the trauma.

"You are not responsible for the attack but are responsible for learning how to cope with the trauma." PTSD is precipitated by a specific overwhelming and devastating event. A positive outcome for the client is that the client will cope effectively with thoughts and feelings associated with the traumatic event. To help reduce the client's feelings of powerlessness and guilt, the nurse should note that the client was not responsible for the event. Stating that it was a horrible attack or that the client wasn't meant to be there does not help the client interpret the event or develop coping skills. Thinking about the families of victims and how they are dealing avoids addressing the client's thoughts and feelings.

The nurse is participating in a planning session for public health services that promote primary prevention. The nurse should guide the group into selecting to focus on which aspects? Select all that apply. Immunizations Pollution control An exercise regimen Cardiac rehabilitation Self-examination practices Diabetes mellitus management

Immunizations Pollution control An exercise regimen Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management.

A client is beginning to participate in the alcohol treatment program. Which nursing approach would be most effective in decreasing their denial about their alcoholism? Give him reading materials about the disease of alcoholism. Point out concrete problems that are a direct consequence of his alcoholism. Explain the physiologic effects of alcohol on the body. Teach them assertiveness techniques.

Point out concrete problems that are a direct consequence of his alcoholism. The nurse should discuss concrete problems that are directly caused by the client's alcoholism in order to (a) confront them, (b) increase their awareness of how alcohol has gotten them into trouble, and (c) help break through their denial. Explaining the physiologic effects of alcohol will not help break through the client's denial.

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu? Chicken breast, broccoli, strawberries, milk Correct

Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin, jelly, tea, and ginger ale have no nutritional value. Pasta, rice, and bread deliver complex carbohydrates. Spare ribs may contain some protein but are high in fat.

A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. For a critically ill client, the nurse interprets this statement to reflect fluid loss occurring through which routes? wound drain and skin Skin and mechanical ventilator Nasogastric tube and wound drain Indwelling catheter and nasogastric tube

Skin and mechanical ventilator Rationale: Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis, without the client's awareness. Sensible losses are those that are measurable; they include wound drainage, gastrointestinal tract losses, and urine output.

A nurse is caring for a client who has just returned from a cardiac catheterization through the right femoral artery. The client tells the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which action should the nurse take to stimulate the client's micturition reflex? Helping the client stand Elevating the head of the bed 90 degrees Turning on the water in the sink in the client's room and allowing it to run Obtaining assistance to ambulate the client to the bathroom in the client's room

Turning on the water in the sink in the client's room and allowing it to run Rationale: To stimulate the micturition reflex, the nurse may provide sensory stimuli such as placing the client's hand in a pan of warm water, warming a bedpan if one is needed for use, running water from a faucet and encouraging the client to listen to it, pouring water over the client's perineum, and encouraging fluid intake. The incorrect options are all inappropriate because the client who has just returned from a cardiac catheterization should remain in bed and head elevation should be minimal to prevent the formation of a hematoma at the catheter insertion site.

The nurse is performing an assessment of a 1-week old infant. Which findings would correlate with a need to plan measures to prevent skin breakdown? Select all that apply. café-au-lait spots epicanthal folds reddened perineum sunken fontanelles Babinski response

reddened perineum sunken fontanelles The infant who is 1-week old has a risk for impaired skin integrity with the development of a reddened perineum, which may be an indication of developing diaper rash. The fontanelles should not be sunken; this indicates dehydration and is also a risk factor for developing impaired skin integrity due to a loss of moisture and elasticity in the skin. Epicanthal folds relate to excess skin from the nose to the inner canthus and can be a normal finding in infants of Asian descent or an indication of Down's syndrome. Infants have a Babinski response normally, and this is not pathological until discovered after the age of 2 years old. Café-au-lait spots can be an indication of a pathology if there are 6 or more, but do not affect skin integrity

A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance? Fats Vitamins Potassium Carbohydrates

Potassium Rationale: Most excretion of potassium and control of potassium balance is carried out by the kidneys. In the client with AKI, potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis. Vitamins, carbohydrates, and fats are not normally restricted in the client with AKI.

Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance? Administer sleep medication before bedtime. Ask the client to describe the quality of the previous night's sleep. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation to practice over the next 3 weeks. Promote a bedtime routine such as a warm bath, back rubs, and snacks.

Promote a bedtime routine such as a warm bath, back rubs, and snacks. The nurse should begin with the simplest interventions, such as a warm bath or snacks, before introducing interventions that require greater skill and time such as teaching relaxation techniques. Sleep medication should be avoided whenever possible. Asking the client about the quality of his sleep is appropriate if simpler interventions fail.

The nurse is caring for a client who reports that the common-law spouse sexually assaulted the client. Which statement by the nurse would hinder the therapeutic relationship between the nurse and this client? "You handled the attack as well as you could because you survived." "You may feel anger, guilt, fear, or embarrassment, but these are very normal reactions." "You didn't do anything to cause the attack, and it's not your fault that you were raped." "You may want to have an abortion if you find out you are pregnant."

"You may want to have an abortion if you find out you are pregnant." This statement hinders the therapeutic relationship because it advises the client to make a personal choice that may be against the client's values and beliefs. This statement would block further communication about the options that are available to the client. The other statements appropriately respond to feelings a victim may have following sexual assault or violent attack and provide reassurance that the victim acted as rationally and appropriately as anyone could in a life-threatening situation and let the client know that the nurse understands the emotions one commonly feels following a violent attack.

.ID: 26423979604 A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate? Telling the parents, "Medication noncompliance is the most frequent reason that people with this diagnosis relapse." Telling the parents, "Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication." Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?" Saying to the parents, "Your concerns are appropriate, but I wonder whether your s

Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?" Rationale: The therapeutic response is the one in which the nurse models speaking directly to the client. This facilitates further assessment of the situation and helps elicit the causes of and motivations for the client's behavior for both the nurse and the family. In the correct option, the nurse also seeks clarification of the degree of openness and mutuality felt by the client and his family toward each other. The nurse provides information to the family when stating that noncompliance is the most frequent reason for relapse in people with this diagnosis. However, the statement is nontherapeutic at this time because it does not facilitate the expression of feelings. The nurse uses a superego style of communication when stating, "Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication." The content of this statement may be true, but it is nontherapeutic in that it carries a threatening message and may prevent the family from trusting the nurse. By stating, "Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication," the nurse gives approval and prematurely analyzes the client's motivation without sufficient assessment.

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: A. Normal egophony B. Normal whispered pectoriloquy C. Abnormal bronchophony D. Abnormal vesicular breath sounds

C. Abnormal bronchophony Rationale: The quality of voice resonance can be performed by testing for the presence of bronchophony, egophony, and whispered pectoriloquy. In bronchophony, the nurse asks the client to repeat the word "ninety-nine" as the nurse listens to the client's chest with a stethoscope. Normal voice transmission is soft, muffled, and indistinct. The nurse normally hears sound through the stethoscope but cannot distinguish exactly what is being said. A pathologic condition that increases lung density enhances the transmission of voice sounds; in such a case, the nurse will hear "ninety-nine" clearly. Vesicular breath sounds are heard over peripheral lung fields where air flows through smaller bronchioles and alveoli. In egophony, the client's chest is auscultated while the client phonates a long "ee-ee-ee-ee" sound. Normally the nurse hears "eeeeee" through the stethoscope. In whispered pectoriloquy, the client is asked to whisper a phrase such as "one-two-three" as the nurse listens to the chest. The normal response is a muffled, almost inaudible sound.

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease.

Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.

A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? A. An external auditory canal that is longer than normal B. Redness and swelling of the tympanic membrane C. The presence of edema in the external auditory canal D. A yellowish or brownish waxy material in the external auditory canal

D. A yellowish or brownish waxy material in the external auditory canal Rationale: Cerumen (ear wax) is a yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal. It becomes impacted because of the narrow tortuous canal or as a result of poor cleaning methods. Cerumen may partially obscure the eardrum or totally occlude the ear canal. Even when the canal is 90% to 95% blocked, hearing is normal, but when the last 5% to 10% becomes occluded (e.g., when cerumen expands after the client swims or showers), the client experiences sudden hearing loss and a feeling of fullness in the ear. Redness and swelling of the tympanic membrane, edema in the external auditory canal, and an external auditory canal that is longer than normal are not descriptions of cerumen.

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply. Giving the client a device holder to wear around the waist Giving the client a diary in which to record activity and signs/symptoms Telling the client to rest as much as possible during the next 24 hours Instructing the client to enclose the monitor in plastic wrap before taking a bath Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless

Giving the client a device holder to wear around the waist Giving the client a diary in which to record activity and signs/symptoms Rationale: The nurse applies electrocardiogram (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor radio-sized monitor (walkie-talkie), which is worn around the chest or waist. Clients undergoing Holter monitoring are instructed to maintain a normal schedule and to keep a diary of all activity and signs/symptoms. The client is told to avoid activities — such as operating heavy machinery, electric shavers, or hairdryers; bathing; or showering — that could interfere with the ECG recording. The client does not feel any shocks from the device.

The nurse is developing a plan of care for a client in skeletal traction. Which interventions should the nurse include in the plan of care? SATA Expect to note some purulent drainage from the pin sites. Ensure that there are no knots in any of the traction ropes. Monitor color, motion, and sensation in the affected extremity. Lift the weights only when it is necessary to reposition the client. Ensure that the weights for the traction device hang freely and do not touch the floor.

Monitor color, motion, and sensation in the affected extremity. Ensure that the weights for the traction device hang freely and do not touch the floor. Traction is the exertion of a pulling force in two directions as a means of reducing and immobilizing a fracture. Nursing responsibilities for the client in traction include ensuring proper body alignment of the client, ensuring that weights hang freely and do not touch the floor, refraining from removing or lifting the weights without a health care provider's prescription, ensuring that pulleys are not obstructed and that the ropes in the pulleys move freely, and tying knots in the ropes to prevent slippage. The nurse should also monitor the color, motion, and sensation of the affected extremity frequently; changes could indicate circulatory compromise and could require health care provider notification. Purulent drainage, which is not an expected finding, is an indication of infection.

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure? Flexing the feet against a footboard Slightly elevating the foot of the bed Keeping the head of the bed elevated 45 degrees Placing the bed in reverse Trendelenburg position

Slightly elevating the foot of the bed Rationale: In Buck's extension traction, the counter traction is typically applied with the use of the client's body and may be augmented through elevation of the foot of the bed. Usually the foot of the bed is elevated on blocks or the bed is put in the Trendelenburg position. For counter traction to be maintained, it is essential that the client not slide down in the bed. Therefore the use of the high Fowler position is discouraged. A footboard is not used for the purpose of counter traction.

Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication? Select all that apply. Volume of urine output Strength of peripheral pulses Ability to move the extremities Frequency of bowel movements Color, motion, and sensation of extremities

Volume of urine output Correct Frequency of bowel movements Correct Rationale: Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client's urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements. Other side/adverse effects include hypotension and slowed respiration. The incorrect options are not specifically associated with this medication.

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food selected by the client indicates further instruction is required? Bran Pasta Boiled rice Low-fat cheese

bran Rationale: Ileostomy output is liquid. The addition or elimination of various foods can help thicken this liquid drainage. Bran is high in dietary fiber and will therefore increase the output of liquid stool by hastening its propulsion through the bowel. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese.

Calcitriol is prescribed for a client with hypocalcemia. The nurse has instructed the client in foods that may interfere with calcium absorption. The nurse realizes the teaching has been effective if the client verbalizes the importance of limiting which items? Select all that apply. Bran Milk Clams Spinach Orange juice

bran spinach Rationale: The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach, rhubarb, bran, and whole-grain cereals, all of which may limit calcium absorption. Good dietary sources of calcium include milk products, dark-green leafy vegetables, clams, oysters, sardines, and orange juice fortified with calcium.

A 12-year-old child is sent home for pediculosis after being at camp for 1 week. The parent thinks others at camp have it. The parent asks the nurse how their child could have gotten pediculosis. How should the nurse reply? "Children at camp usually get it from the animals here." "Children who sleep close to someone who has it get it more easily." "Your child probably got it at basketball practice." "Usually the kids get it at camp in the pool."

"Children who sleep close to someone who has it get it more easily." Pediculosis is spread from person to person or on other objects that are shared, such as helmets, combs, or other personal items used near the hair. Lice are not transmitted by animals or pets or during swimming.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. The nurse knows that the client understands the management of the disorder when the client says "I will eat five or six small, nutritious meals each day but with mostly carbohydrates for more energy." "I will eat three meals each day but will avoid all simple carbohydrates in my diet." "I will eat five or six small meals each day and have some protein with each meal." "I will eat my evening meal an hour before bedtime so that digestion can occur while I am resting."

"I will eat five or six small meals each day and have some protein with each meal." Digestion of a large meal shunts blood to the gastrointestinal tract, increasing fatigue levels. Clients with this disorder should ingest small, frequent, and nutritious meals five or six times per day. It is not necessary to completely avoid simple carbohydrates. Eating immediately before bedtime can disturb sleep patterns. A pregnant woman with cardiac issues benefits from sound sleep.

A client with physical deficits related to a recent cerebral vascular accident states tearfully, "I no longer can take care of myself." Which statement by the nurse is most therapeutic? "It is hard not to be able to care for yourself." "You will get back to normal after you have some physical therapy." "Let me help you dress, and then we can get some breakfast." "Let's focus on the positive things that you can still do."

"It is hard not to be able to care for yourself." Therapeutic communication is client centered, meaning that it is focused on supporting the client's physical and emotional well-being. The client is in control of the topic and supported in expressing feelings of concern. Responding with open-ended questions or validating statements allows the client an opportunity to explore the ideas and feelings they wish to discuss. The nurse would not offer the condescending or potentially untrue statement that the client will be back to normal. It is also not appropriate to deflect the client's feelings by changing the topic to breakfast or focusing on "positive things."

A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic? "The voices will disappear in a few weeks as your hormones stabilize." "This must be very distressing to you. Can you tell me more about the voices?" "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." "You will want to tell the health care provider about them when you visit him next week. He is very interested in these voices and will want to help you with them."

"It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." Correct immediate attentions is needed for safety of mother and baby.

A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? "I need to eat foods high in calcium." "How I eat can affect my baby's growth." "I need to take vitamins throughout my pregnancy." "My risk for malnourishment is much higher while I'm pregnant."

"My risk for malnourishment is much higher while I'm pregnant." Rationale: Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Calcium intake is critical during the third trimester, but calcium intake must be increased from the start of pregnancy. Adequate nutrition during pregnancy significantly and positively influences fetal growth and development. Intake of dietary iron and vitamins is insufficient for the majority of pregnant women, and the use of iron and vitamin supplements is routinely encouraged.

82.ID: 26423978363 The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic? "I can see that this isn't a good time to visit." "You seem to be having a very difficult time." "Do you think your wife would want you to behave like this?" "What are you doing? How much are you drinking, and how long has this been going on?"

"You seem to be having a very difficult time." Correct Rationale: The therapeutic statement is the one that helps the client explore his situation and express his feelings. The correct option involves the use of reflection and will help the client begin to express his feelings. In stating, "I can see this isn't a good time to visit," the nurse uses humor to avoid dealing with the client's behavior. In asking, "Do you think your wife would want you to behave like this?" the nurse uses admonishment and tries to shame the client, which is not therapeutic because it belittles the client, will elicit anger, and may cause the client to act out. In asking, "What are you doing? How much are you drinking, and how long has this gone on?" the nurse is belittling and uses social communication.

A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position? 2 inches (5 cm) to the front and side of the toes 8 inches (20 cm) to the front and side of the toes 15 inches (38 cm) to the front and side of the toes 22 inches (56 cm) to the front and side of the toes

8 inches (20 cm) to the front and side of the toes Rationale: The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed between 6 and 10 inches (15 to 25.5 cm) in front and to the side of the client, depending on the client's body size, providing a wide enough base of support and improving the client's balance. The remaining options are incorrect.

The nurse is teaching a health promotion class to new parents about sudden unexplained infant death syndrome (SUIDS). What information would be most important for the nurse to teach? "Prevention includes placing the infant supine on a firm sleeping surface."

All the statements are true, but the most important information for new parents would be related to steps they can take to reduce the risk for SUIDS, such as using a firm sleeping surface and placing the infant on the back. Statistics about the age at which SUIDS occurs or stating that the cause is not known may be included as basic background information, but this information does nothing to help parents prevent SUIDS. Similarly, although premature birth is a risk factor, this information is less important than guidance that equips parents to protect their infants.

A client is admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. After the clinical intake assessment, the nurse observes that the client is repetitively wiping the furniture in her room with a facecloth and warm water. Which action should the nurse take initially? Allow the client to perform the repetitive act Stop the client from performing the repetitive act Help the client wipe the furniture while talking to her about her repetitive act Tell the client that it is not necessary to repetitively wipe the furniture because it has been thoroughly disinfected by the housekeeping staff

Allow the client to perform the repetitive act Initially the nurse should not interfere with the repetitive act, as long as the act is not harmful, and the nurse should never ridicule the client's behavior. The client is performing the repetitive act to keep anxiety at a tolerable level. Also, the nurse should not attempt to argue with the client about the repetitive behavior, attempt to reason with the client and persuade him or her to stop the behavior, or reinforce the ritual by focusing attention on it and talking about it a great deal. With time, the nurse can begin to set limits on the client's behavior to modify the behavior.

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee? Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting Rationale: The nurse helps the client get out of bed after putting a knee immobilizer on the affected joint for stability. A compression dressing (a.k.a. elastic wrap or Ace bandage) is usually applied after the surgical procedure is complete. The surgeon prescribes weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in a chair to minimize edema. A CPM machine may be prescribed by some surgeons and is used while the client is in bed.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first? Reassure the client that the PCA system is working and will relieve pain. Request a prescription for a cough suppressant Assess the pain using a pain scale and compare to the previous assessment. Encourage the client to take deep breaths and expectorate the mucous that is stimulating the cough.

Assess the pain using a pain scale and compare to the previous assessment. Beginning immediately following surgery, the nurse should assess the client for pain frequently and note changes on the pain scale as a guide to pain management. Reassuring the client is not sufficient when the client is reporting pain. The nurse should encourage the client to cough and take deep breaths; cough suppression is contraindicated because the client must raise and expectorate retained secretions.

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding? A. Palpate the area for a mass B. Notify the healthcare provider C. Document the finding D. Percuss the abdomen to check for tympany

B. Notify the healthcare provider it could indicate a of an aneurysm and no not palpate or percuss because of risk for rupture

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply? 7 days after fertilization

Implantation occurs at the end of the first week after fertilization, when the blastocyst attaches to the endometrium. During the second week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop. During the third week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form. Early during the fourth week (28 days after implantation), cellular differentiation and organization occur.

A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. Carrots Tapioca Scallops Broccoli Chicken liver

Chicken liver correct Scallops Correct Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of which speech pattern? Echolalia Tangential speech Clang associations Loosened associations

Clang associations

The nurse is assessing a client whose history includes type 2 diabetes and atrial fibrillation, treated with warfarin. The client tells the nurse that the client began taking ginseng supplements several days ago in an effort to boost the immune system. After providing health education, what is the nurse's priority action? Collaborate with the care team to have the client's prothrombin time and international normalized ratio (INR) assessed. Assess the client's random glucose level, and administer antihyperglycemics as prescribed. Assess the client for signs and symptoms of hypokalemia, and collaborate with the care team to have cardiac telemetry ordered. Assess the client for Chvostek's sign or Trousseau's sign.

Collaborate with the care team to have the client's prothrombin time and international normalized ratio (INR) assessed. Ginseng is contraindicated with warfarin, which is commonly prescribed for the treatment of atrial fibrillation; an increased risk of hypercoagulation can occur. Chvostek's and Trousseau's signs are suggestive of hypocalcemia, which is unrelated to ginseng use. Similarly, blood glucose levels and potassium levels are not significantly affected.

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? Cranial nerve II Cranial nerve IX Cranial nerve VII Cranial nerve VIII

Cranial nerve VIII Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client's visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve).

A client who has undergone vascular surgery of the legs suddenly complains of dyspnea and sharp chest pain. The nurse quickly checks the client and notes the presence of tachycardia on the cardiac monitor. Which action should the nurse take immediately? Contact the surgeon Contact the respiratory therapist Check the client's apical heart rate Check the client's peripheral pulses

Contact the surgeon Any complaint of sudden sharp chest or upper abdominal pain must be reported immediately to the surgeon. Pulmonary embolism is a serious postoperative complication that can cause sudden death. A clot or part of a clot breaks away from a vessel and travels through the heart and into the pulmonary circulation and may occlude a pulmonary vessel, resulting in a pulmonary embolism. Common signs/symptoms include dyspnea, sudden sharp chest or upper abdominal pain, tachypnea and tachycardia, anxiety, and cyanosis. A respiratory therapist may be needed during treatment, but contacting the therapist would not be the immediate action. There is no useful reason for checking the client's apical heart rate, because the client is attached to a cardiac monitor, which displays the heart rate. Likewise, there is no useful reason for checking the peripheral pulses.

Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. Prunes Apples Peaches Avocados Nectarines Cranberries

Cranberries apples peaches Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectiveness of the tube feedings? Daily weight Serum protein level Calorie count sheets Daily intake and output records

Daily weight Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is the daily weight. The client should be weighed at the same time (preferably early morning) each day, wearing the same clothes, on the same scale. The incorrect options may be used to assess nutrition and hydration status, but the effectiveness of the diet is measured by whether the client's body weight is maintained.

The nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which should be the nurse's primary focus? Group therapy Recreational therapy Goals and objectives The client's medical diagnosis

Goals and objectives Rationale: Goals and objectives are a tool for both the client and the nurse, and the nurse should focus on them as the primary means of accomplishing work with this client

A nurse is conducting an assessment of a client who underwent partial gastrectomy 12 hours ago. On auscultating the abdomen, the nurse does not hear bowel sounds. What is the most appropriate action for the nurse to take? Contact the surgeon Document the findings Encourage the client to increase oral fluid intake Help the client walk and then check again for bowel sounds

Document the findings An absence of bowel sounds 12 hours after surgery is an expected finding; the nurse would document the finding and continue assessing the client. After abdominal surgery, motility of the gastrointestinal tract is diminished and normal bowel tone and peristalsis may be faint or absent in all four abdominal quadrants. Motility normally resumes within 24 hours of surgery in the small intestine and within 3 to 5 days in the large intestine. It would not be necessary to contact the surgeon at this time. After partial gastrectomy, the client would be prohibited from eating or drinking and would have a nasogastric tube attached to suction. Encouraging the client to increase oral fluid intake is therefore incorrect. Ambulation will aid the restoration of normal gastrointestinal function but will not restore it immediately.

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving pre-procedure instructions tell the client that is important to do before the procedure? Eat only a light breakfast Wear comfortable clothing and shoes Drink 6 to 8 glasses of water without voiding Stop eating or drinking at midnight before the test

Drink 6 to 8 glasses of water without voiding Rationale: Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth. A client undergoing abdominal (not pelvic) ultrasound may have to refrain from eating or drinking for several hours before the procedure.

During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms? eustachian tube vascularization

During pregnancy, increasing levels of estrogen — not progesterone — cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears. The client's symptoms don't suggest a serious neurologic disorder or an ear infection.

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction? Pork Beef Eggs Raisins

Eggs

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action? Apply a warm compress. Elevate the ankle. Assess range of motion. Administer I.V. morphine sulfate as needed.

Elevate the ankle. Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury. Morphine is not the drug of choice for pain due to inflammation.

The nurse is caring for an elderly nursing home client who is anxious and fearful after being admitted to the hospital. Which intervention is the nursing priority? Have the client contact the family to come down to visit. Ask what the fears are and why the client is becoming agitated. Check on the client frequently to see the adjustment. Explain procedures and unit routines to the client, as well as checking orientation.

Explain procedures and unit routines to the client, as well as checking orientation. Explaining procedures and routines decreases the client's anxiety about the unknown. This is especially important to an elderly client who has been transferred from a familiar environment to a new one. Checking orientation gives feedback as to how the client is coping with the changes. Since there is fear and anxiety, it would be a challenge for the client to contact the family. "Why" questions tend to be judgmental and do not address the main concerns. Checking on the client is not sufficient; explanations will help ease the anxiety.

A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. What instructions would be most appropriate to include in the plan of care? Start in a sitting position, lie back, and then return to a sitting position, repeating this five times. Assume a prone position, and then do push-ups by using the arms to lift the upper body. Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. Flex the knees while supine, bring the chin to the chest while exhaling, and then reach for the knees by lifting the head and shoulders while inhaling.

Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. after an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles

The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which information points in the teaching plan? Vegetables should be introduced before fruits when the infant is 6 months old. Solid foods should not be introduced until the infant is 10 months old. Iron-fortified cereals should not be introduced until the infant is 8 months old. Formula can be changed to whole milk when the infant is 12 months old

Formula can be changed to whole milk when the infant is 12 months old Infants should be kept on formula or breast milk until 1 year of age. The protein in cow's milk is harder to digest than the protein found in formula. It does not matter in what order fruits and vegetables are introduced as long as the foods are introduced slowly. Solids are introduced into the infant's diet around 4 to 6 months, after the extrusion reflex has diminished and when the child will accept new textures. Iron deficiency develops in term infants between 4 and 6 months when the prenatal iron stores are depleted. Fortified cereals can be added to the infant's diet at 4 to 6 months to prevent iron deficiency anemia

A client is in the emergency department with their partner. The client is just recovering from a temporary drug-induced psychosis from lysergic acid diethylamide (LSD). The client is still frightened and a little suspicious. Which nursing action is most appropriate? having an unlicensed assistive personnel (UAP) stay with the client to decrease the client's fear

Having a UAP stay with the client provides reassurance and safety. Being next to the nursing desk will increase stimuli and confusion. Being alone will increase the client's fears and anxiety. It is inappropriate to ask the partner to provide client supervision for the nurse.

The nurse is working with a new nurse employee who has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. The new nurse employee has developed a plan of care for the client. The nurse realizes the new nurse employee requires additional instruction if which aspect is included in the plan of care? Initiating confinement measures Acknowledging the client's behavior Assisting the client to an area that is quiet Maintaining a safe distance with the client

Initiating confinement measures escalation period >>behavior s moving toward loss of control. Nursing actions: taking control, maintaining a safe distance, acknowledging the behavior, moving the client to a quiet area, and medicating the client as appropriate. It is not appropriate during this period to initiate confinement measures; appropriate during the crisis period.

A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem? Skin breakdown Injury to the nerves An abnormal stance A fall and further injury

Injury to the nerves Rationale: When crutches are correctly fitted, the tops are three to four fingerbreadths, or 1 to 2 inches (2.5 to 5 cm), from the axillae. This ensures that the client's axillae are not resting on the crutches or bearing the weight of the crutches, which could result in injury to the nerves of the brachial plexus. The incorrect options are not the primary concerns in this situation.

A client returns from the PACU after abdominal surgery. Which position in the bed does the nurse initially select for the client after helping move the client from the stretcher to the bed? Prone Supine Low Fowler's High Fowler's

Low Fowler's Unless contraindicated, the client is placed in the low Fowler's position after surgery to maximize thorax size for lung expansion. The high Fowler's position would restrict thorax size. Occasionally the primary health care provider prescribes the side-lying position; however, this position is not presented as one of the options. Because of the risk of aspiration, the nurse should avoid using the supine position until pharyngeal reflexes have returned. In the prone position, the client lies on the stomach; this is not safe or comfortable for the client who has undergone abdominal surgery.

A nurse is monitoring the intake and output of a client with a Foley catheter who returned from surgery at 1 p.m. On the client's return, the nurse empties 100 mL of urine from the catheter drainage bag. At 4 p.m., the nurse checks the client's urine output and notes that the bag contains 40 mL. What is the most appropriate action for the nurse to take? Continue to monitor the client's urine output. Increase the rate of administration of IV fluids. Notify the surgeon of the decreased urine output. Document the urine output on the fluid balance form.

Notify the surgeon of the decreased urine output. Although the nurse would document the urine output, the most appropriate action would be to contact the surgeon. Urine output is closely monitored after surgery until normal urinary tract function has been reestablished. A urine output of at least 30 mL/hr is required to maintain adequate kidney function. Because the client has produced only 40 mL of urine in 3 hours, the surgeon should be notified. Continuing to monitor the client's urine output would delay necessary interventions. The nurse would not increase the rate of administration of IV fluids without a specific prescription to do so.

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? One low in protein One high in fluids One high in carbohydrates One with a moderate amount of fat

One low in protein Rationale: A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, resulting in the formation of ammonia. Therefore the client would benefit from a low-protein diet.

A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement? Placing the client in a private room and locking the client's closets and bathroom Placing the client in a private room and removing all knives and glass from the client's meal tray Allowing the client to go out on pass as long as the client is accompanied by a responsible adult Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times do not isolate in private room. SI patietn needs to be wateched even when showering or using RR.

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? To increase the intake of legumes That seafood should be included in the diet That organ meats should be included in the diet To have at least one serving each day of a citrus fruit

Rationale: Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease intake of purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application? An older client A client with renal calculi A client with osteoporosis A client with rheumatoid arthritis

Rationale: Older clients have diminished sensitivity to pain and are therefore at great risk for injury from heat or cold applications. Other clients at risk for injury are the very young; those with open wounds; those with spinal cord injuries or peripheral vascular disorders, such as the client with diabetes mellitus; and those who are confused or unconscious.

The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods, when selected by the client, indicate the need for further instruction? ? Sata Peas Broccoli Potatoes Red wine Avocados Cereal with raisins

Red wine Avocados Cereal with raisins Rationale: Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, beer, and certain fruits, including avocados, raisins, and figs. Vegetables, with the exception of broad-bean pods, are generally acceptable.Calcitriol is prescribed for a client with hypocalcemia. The nurse has instructed the client in foods that may interfere with calcium absorption. The nurse realizes the teaching has been effective if the client verbalizes the importance of limiting which items? Select all that apply.

A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication? Prunes Oranges Rhubarb Cranberries

Rhubarb Rationale: When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be instructed to consume an acid ash diet. Rhubarb reduces the acidity of the urine and should be avoided when acidic urine is required. Prunes, oranges, and cranberries are acceptable foods.

A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? Left heel Scapulae Right heel Back of the head

Right heel Rationale: Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the unaffected leg, which is used as a brace when the client pushes up from the bed). Other such pressure points include the ischial tuberosity, popliteal space, and Achilles tendon.

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? Roast turkey with a baked potato Fruit plate with fresh whipped cream Fried chicken with macaroni and cheese Barbecued spare ribs with buttered noodles

Roast turkey with a baked potato Rationale: The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. Therefore the correct answer is roast turkey with a baked potato, which is a meal low in fat.

A nurse notices a client's glaring eyes during a conversation with the client. The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be beneficial? Allowing the client to pace Escorting the client to a quiet room Changing the conversation to a less threatening subject Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

The nurse is observing a new nurse employee who is examining the peripheral vision of a client using the confrontation test. The nurse determines the new nurse is using correct technique if the nurse performs which action? Asks the client to discriminate numbers on a chart composed of colored dots Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field Rationale: The confrontation test is a gross measure of peripheral vision. It compares the client's peripheral vision with the examiner's vision under the assumption that the examiner's vision is normal. The examiner positions himself or herself at eye level with the client, about 2 feet (60 cm) away. The examiner directs the client to cover one eye with an opaque card and look straight at the examiner with the other. The examiner covers his or her own eye opposite the client's covered one. Next the examiner holds a pencil or flicking finger as a target midline between himself or herself and the client and slowly advances it from the periphery in several directions. The examiner asks the client to say "now" as the target is first seen. This sighting should occur just as the examiner sees the object for the first time. Asking the client to discriminate numbers on a chart composed of colored dots and darkening the room and asking the client to identify colored blocks and shapes that appear in the visual field are both components of testing for color vision.

The nurse is caring for a 5-year-old child who is cognitively challenged. The parents ask the nurse how best to teach the child skills in order to foster independence. Which of the following teaching points should the nurse emphasize? Select all that apply. "Teach your child with a group of other children." "Teach one step at a time to facilitate short-term memory." "Use generous praise as a reward for learning." "Limit principles and abstract concepts in the teaching." "Use repetition to reinforce learning."

Teach one step at a time to facilitate short-term memory." "Use generous praise as a reward for learning." "Limit principles and abstract concepts in the teaching." "Use repetition to reinforce learning." Pedagogy for a child who is cognitively challenged should incorporate teaching one step at a time, using praise, repeating information and practice, and limiting abstract concepts. These techniques provide a supportive learning environment for the child. Having a group of other children around may be distracting; children with cognitive challenges need to be in an environment with few extra stimuli so they can focus on learning.

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? Imposing nothing-by-mouth (NPO) status for 4 hours Asking the client to sign an informed consent form Asking the client about a history of allergy to iodine or shellfish Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

Telling the client that the procedure is painless and takes 30 to 60 minutes to complete Rationale: In echocardiography, ultrasound is used to evaluate the heart's structure and motion. It is a noninvasive, risk-free, pain-free test that involves no special preparation and is commonly performed at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. The other options are incorrect.

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? The client's vital signs The amount of drainage The client's lung sounds The chest tube connections

The chest tube connections Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires primary health care provider intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's signs/symptoms should resolve.

A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding? The client has normal, healthy lungs. The client may have a pneumothorax. The client most likely has a lung tumor. An excessive amount of air is present in the lungs.

The client has normal, healthy lungs. Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor.

A nurse performing a physical assessment of a client is checking the client's mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve XII. Which of the following best indicates adequate functioning of this nerve? The client is able to frown. The client is able to show the teeth. The client is able to stick out the tongue. The client is able to say "ah" as the tongue is depressed with a tongue blade.

The client is able to stick out the tongue.

A nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? SATA It is not safe to use someone else's crutches. Rubber crutch tips will not slip, even when wet. The client should use both crutches when navigating stairs. Lean into the crutches as needed to support the body's weight. Crutch tips are made of a material that will not wear down

The client should use both crutches when navigating stairs. It is not safe to use someone else's crutches. Rationale: The client should use only crutches that have been measured and set for that client. When ascending or descending stairs, the client generally uses a three-phase sequence involving both crutches. Crutch tips should be kept as dry as possible. Water could cause slippage by reducing the friction of the rubber tip against the floor. If the tips get wet, the client should dry them with a cloth or paper towel. The tips should be inspected for wear, and spare crutches and tips should be available. Leaning into the crutches to support the body's weight increases the risk of axillary nerve injury.

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client? She should avoid napping during the day The only thing that will help is a sleeping pill This is a normal occurrence as a person gets older She needs to stay up later at night to prevent these awakenings

This is a normal occurrence as a person gets older Correct Rationale: The total amount of sleep a person needs does not change with increasing age. However, the quality of sleep appears to deteriorate for many older adults, giving rise to complaints of feeling less rested. An older adult awakens more often during the night than a younger person does, and it may take an older adult longer to fall asleep. Therefore the other options are incorrect. Additionally, measures other than medication should be implemented to promote rest and sleep.

The campus health nurse is caring for a client after she was sexually assaulted. Which of the following intervention would be most beneficial for this client? Explore the client's strengths and resources with her.

The goal of crisis intervention is to support clients to resume pre-crisis levels of functioning. Variables in a client's recovery include support and access to resources. Suggesting courses in martial arts could be a strategy, but more important for the client's adjustment would be helping the client identify strengths and resources that could give her support. Assessing for coping should include all client activity, not only negative coping behaviors. Agreeing with the client that she should move on would be giving advice, a nontherapeutic technique.

A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse? The nurse should listen attentively and provide realistic verbal reassurance. The nurse should report the client statements to the physician. The nurse should proceed with the assessment and preparation for surgery. The nurse should request an anti-anxiety medication from the anesthesiologist.

The nurse should listen attentively and provide realistic verbal reassurance. Clients routinely experience preoperative anxiety. Nurses should use basic communication skills to reduce their apprehension. Other answers are incorrect because they don't address the client's immediate need.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on which client factor? Sources of support The object of the crisis The client's coping mechanisms The physical condition of the client

The physical condition of the client Rationale: The initial priority in the nursing assessment of a client in a crisis state is to assess physical condition, potential for self-harm, and potential for harm to others. Once these questions have been answered and the appropriate interventions have been initiated, the nurse may proceed in providing psychosocial care.

A mother expresses concern because her 3-year-old son frequently fondles his penis. The mother does not know the best approach for the child's behavior. What is the nurse's best response to the mother? This behavior is normal for a child of his age." "You should discourage this behavior now before it worsens as he gets older." "This is a strong sign that he is ready for toilet training." "We should obtain a urine sample to assess for an infection." TAKE ANOTHER QUIZ

This behavior is normal for a child of his age." Children ages 1 to 3 years enjoy fondling their genitals. Punishment for genital fondling may lead to guilt and shame regarding sexual behavior later in life.

The nurse has provided instructions to a client about the use of an incentive spirometer and is watching the client use the device. Which observation indicates that the client is using the spirometer correctly? The client holds the breath for 3-4 seconds on reaching maximal inspiration.

To use an incentive spirometry, the client assumes an upright position. After exhaling completely, the client uses the lips to form a seal around the mouthpiece; inhales slowly, maintaining a constant flow through the unit; holds the inspiration for 3-4 seconds; and then exhales slowly.

A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client's supper on the day of admission? Smoked ham, fresh carrots, boiled potato Hot dog in a bun, sauerkraut, baked beans Turkey, baked potato, salad with oil and vinegar Shrimp, baked potato, salad with blue cheese dressing

Turkey, baked potato, salad with oil and vinegar Rationale: Foods that are high in sodium should be limited in the diet of the client with hypertension and heart failure. Foods in the meat group that are higher in sodium include bacon, luncheon meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for clients with hypertension.

A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client? Urine output will be decreased Urine production will be increased Serum osmolality will be decreased Urine specific gravity will decreased

Urine output will be decreased Rationale: A febrile client would be expected to have some degree of dehydration resulting from increased metabolic demands. In response to dehydration, the body attempts to restore fluid balance by reducing urine production. The client who is diaphoretic also loses a large amount of fluid through insensible water loss, which worsens dehydration and further decreases urine production. Urine specific gravity is increased in the presence of dehydration; serum osmolality also increases, indicating hemoconcentration related to dehydration.

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor? a normal pattern in infants of this age the need for an apnea monitor a need for close monitoring by the parent the need for a chest radiograph

a normal pattern in infants of this age The infant is exhibiting periodic breathing, which is normal in infants of this age. The infant typically alternates short periods of rapid, louder respirations with periods of slower, quieter respirations. Since the finding is normal there is no need for a monitor, close parental monitoring, or a chest Xray.

Which meal would be appropriate for the child with osteomyelitis to choose? beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk beef hot dog, and an apple potato soup; jelly sandwich; and a peach tomato soup made with water, grilled cheese sandwich, and a banana

beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients.

A 42-year-old female who comes to the clinic frequently for symptoms of neck pain is upset because there is no medical cause for the discomfort. Select the intervention(s) the nurse would take to help meet the client's needs. Acknowledge the client's pain Ask what helps relieve the pain Provide teaching about phantom pain Review activities to use as a distraction Suggest the client ignore the discomfort Encourage participation in groups of interest Remind the client that there is no reason for the pain

acknowledge the client's pain Ask what helps relieve the pain Encourage participation in groups of interest Review activities to use as a distraction

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area? n the bridge of the client's nose below the client's eyebrows below the client's cheekbones over the client's temporal area

below the client's cheekbones To palpate the maxillary sinuses, the nurse would place hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. Kale Cherries Broccoli Cabbage Potatoes Spaghetti

cherries potatoes spaghetti Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as kale, broccoli, spinach, Brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are foods that are low in vitamin K.

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? at least every hour for the first 48 hours every 2 to 3 hours for the first 48 hours every 4 to 5 hours for the first 5 days after birth whenever the client desires, until weaning occurs

every 2 to 3 hours for the first 48 hours Soon after giving birth, the client should breastfeed every 2 to 3 hours until the milk supply is established. Feeding every hour is not necessary and will lead to maternal exhaustion. Feeding every 4 to 5 hours is not often enough to help establish the milk supply. Feeding whenever the client desires is inappropriate because the client may only feel like feeding less often, thus not providing enough stimulation for milk production while not supplying the neonate with the needed nutrition.

A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing a beating at gunpoint, the client is paralyzed. Which action should the nurse initially focus on when planning this client's care? helping the client identify and verbalize their feelings about the incident helping the client identify any stressors or psychological conflicts teaching the client to deal with any limitations of the paralysis exploring personal relationships that may be related to the paralysis

helping the client identify and verbalize their feelings about the incident In functional neurologic symptom disorder, the client represses and converts emotional conflicts into motor, sensory, or visceral symptoms that have no physiologic cause. All of these interventions are appropriate for this client. However, the client needs first to express feelings that can help to reduce anxiety and anger, and lead to understanding and insight into the situation.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? full-liquid high-protein 1,800-calorie ADA low-fat

high-protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption