HESI EAQ ticket Health Assessmment

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.

Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? 1 Accept the client's behavior. 2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions.

Accept the client's behavior. At this time the client is using this behavior as a defense mechanism. Acceptance can be an effective interpersonal technique because it is nonjudgmental. Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies non-acceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse. 1. Don a pair of clean gloves. 2. Run the transfusion slowly. 3. Determine the client's vital signs. 4. Ensure that the client signed a consent for the transfusion. 5. Compare the number on the blood product and laboratory record.

Compare the number on the blood product and laboratory record. Incorrect 3. Determine the client's vital signs. A client must sign a consent for the transfusion before the procedure; clients have the right to refuse. Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected. Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize risk of transfusion reactions. Clean gloves must be worn before inserting the spike of the blood administration set. The transfusion is run slowly for the first 15 to 20 minutes, but only after other steps have been completed.

A nurse is working as a triage nurse in the emergency department. Place the following clients in the order in which they should receive care. 1. Man with acute pancreatitis 2. Infant having a seizure 3. Woman with acute chest pain 4. Adolescent with a blood glucose level of 190 5. Child with a non-life threatening cut that needs stitches

Correct 1. Infant having a seizure Correct 2. Woman with acute chest pain Correct 3. Man with acute pancreatitis Incorrect 5. Child with a non-life threatening cut that needs stitches 4. Adolescent with a blood glucose level of 190 Incorrect An infant having a seizure should receive care first because the infant is in acute distress. A person having a seizure should never be left alone. The primary responsibilities include maintaining client safety and observing the characteristics of the seizure. A woman having acute chest pain should receive care second because chest pain can indicate a myocardial infarction or other potential fatal cardiac event. Acute pancreatitis is extremely painful and therefore this client should be medicated as soon as possible after clients with life-threatening problems are stabilized. A child with a non-life-threatening cut and needing stitches can wait until the more acute clients are attended to and stabilized. Although a blood glucose level of 190 is elevated it is not life threatening; therefore, meeting the needs of clients with more acute problems first is appropriate.

A client is receiving therapy that includes a radioactive sealed implant. What nursing intervention should be implemented to protect against exposure to radiation? 1 Wearing a dosimeter film badge at all times 2 Limiting exposure to the client to one hour daily 3 Using long-handled forceps to retrieve a dislodged implant 4 Ensuring that visitors maintain a minimum distance of 3 feet from the client

Correct3 Using long-handled forceps to retrieve a dislodged implant sing long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily.

1. A nurse is caring for a female client who is receiving rifampin (Rifadin) for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply. 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." 2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." 3 "I cannot take an antacid within two hours before taking my medicine." 4 "My health care provider must be called immediately if my eyes and skin become yellow." 5 "If I can't swallow the pill, I can't open the capsule and mix the powder with applesauce." 00:00:43 Question Answer Confidence Buttons

Correct 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." Correct2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." Correct 4 "My health care provider must be called immediately if my eyes and skin become yellow." Alcohol may increase the risk of hepatotoxicity. Rifampin has teratogenic properties and also may reduce the effectiveness of oral contraceptives. Yellowing of the eyes and skin are signs of hepatitis and should be reported immediately. An antacid may be taken one hour before taking the medication. The capsule may be opened and the powder mixed with applesauce. 1 "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." Correct2 "This drug may reduce the effectiveness of the oral contraceptive I am taking." Incorrect 3 "I cannot take an antacid within two hours before taking my medicine." Correct 4 "My health care provider must be called immediately if my eyes and skin become yellow." 5 "If I can't swallow the pill, I can't open the capsule and mix the powder with applesauce." Alcohol may increase the risk of hepatotoxicity. Rifampin has teratogenic properties and also may reduce the effectiveness of oral contraceptives. Yellowing of the eyes and skin are signs of hepatitis and should be reported immediately. An antacid may be taken one hour before taking the medication. The capsule may be opened and the powder mixed with applesauce.

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. 2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. 3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.

Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

A spouse of a client, while visiting at the hospital, slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take? 1 Initiate an agency incident report. 2 Report the fall to the state health department. 3 Write a brief description of the incident to be kept by the nurse manager. 4 Determine that no documentation is needed because the visitor is not a client in the hospital.

Initiate an agency incident report. Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.

The nurse identifies silvery scales on a client's elbows and knees. To help identify the origin of this rash, the nurse should assess the client's history of: 1 Using a harsh, irritating soap Correct2 Stress in recent months 3 Excursions into uncultivated, weedy areas 4 Infection with the human immunodeficiency virus (HIV)

Stress in recent months The client is exhibiting the clinical manifestations of psoriasis. Psoriasis is characterized by white scaly plaques on the scalp, knees, or elbows. The etiology is not known but it is thought to be a multifaceted disease that is related to stress and an immune response. Harsh soaps may cause dry, itchy, cracked skin, not silvery scales. However, too frequent washing may be irritating; tar-based soaps may be recommended. The client is exhibiting the signs of psoriasis, not Lyme disease. The lesions described are not associated with HIV.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall.

Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention.

A client is treated with lorazepam (Ativan) for status epilepticus. What effect of lorazepam does the nurse consider therapeutic? 1 Slows cardiac contractions. 2 Dilates tracheobronchial structures. Correct3 Depresses the central nervous system (CNS). 4 Provides amnesia for the convulsive episode.

Depresses the central nervous system (CNS). Lorazepam an anxiolytic and sedative, is used to treat status epilepticus because it depresses the CNS. Slower cardiac contractions are not an effect of lorazepam. Dilating tracheobronchial structures is not an effect of lorazepam. Providing amnesia for the convulsive episode is not an effect of lorazepam.

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin

Globulin The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen. The 3 major plasma proteins are? albumin, globulins, fibrinogen What is the function of albumin? to maintain osmotic pressure which prevents plasma from leaking into tissues What is the function of globulins? to transport substances such as antibodies which protects the body against infection What is the function of fibrinogen? to be converted to fibrin What is the function of fibrin? to assemble together to form structures (threads) that are important in blood clotting

A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when recording on the client's progress report? Incorrect1 Spastic 2 Steppage Correct3 Shuffling 4 Scissoring

Shuffling Steps are short and dragging; this is seen with defects of the basal ganglia. Spastic gait is associated with unilateral upper motor neuron disease. Steppage gait is when the foot is lifted high to clear the toes; there is no heel strike, and the ground is hit first with the toes. It is associated with advanced diabetic neuropathy and peripheral neuritis. Scissoring gait is associated with bilateral spastic paresis of the legs.

A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply. 1 Corn 2 Cheese 3 Oatmeal 4 Rye bread 5 Fruit juice

Oatmeal

A client had a cerebrovascular accident (also known as a "brain attack") and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client? 1 Splints 2 Blocks 3 Cradles 4 Sandbags Splints

Splints Various types of splints or boots are available to keep the foot in a position of functional alignment. Blocks elevate the frame of the bed and have no effect on the position of the feet. Although a cradle will keep the pressure of the linen off the client's feet, which otherwise may promote footdrop, the cradle does not maintain functional alignment of the ankle. Sandbags help prevent rotation of an extremity or the head; they are not used to prevent footdrop.

A nurse manager uses a participative leadership approach to change. List the steps in order of priority that the manager should follow to create effective change processes. 1. Provide opportunities for ventilation. 2. Be supportive. 3. Offer feedback. 4. Introduce new information.

The nurse manager first should create a supportive environment that will enable the personnel to be receptive to new information. Allowing time to ventilate about the new information received enhances the learning process. Feedback provides an opportunity for the nurse manager to evaluate the effectiveness of the learning experience.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress

An unconscious means of reducing stress When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply. 1 Carrots 2 Oranges 3 Tomatoes 4 Skim milk 5 Leafy greens

Carrots Leafy greens Yellow/orange vegetables contain large quantities of the pigments alpha-, beta-, and gamma-carotene; beta-carotene is the major chemical precursor of vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots also are high in vitamin A. Dark green leafy vegetables contain large quantities of the pigments alpha-, beta-, and gamma-carotene; beta-carotene is the major chemical precursor of vitamin A in human nutrition. Broccoli, cabbage, spinach, and collards also are high in vitamin A. Oranges are considered a good source of both vitamin C and potassium. Tomatoes are a good source of vitamin C. Levels of vitamin A are higher in whole milk than in skim milk. Study Tip: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list? Select all that apply. 1 Eggs 2 Liver 3 Cheese 4 Squash 5 Chicken

Correct 1 Eggs Correct 2 Liver Correct 3 Cheese Vitamin K decreases clotting time. Egg yolks are high in vitamin K and should be avoided. Liver, an organ meat, is high in vitamin K, as are all organ meats, and should be avoided. Cheese, a dairy product, is high in vitamin K, as are all dairy products, and should be eaten sparingly. Squash is low in vitamin K and is not limited in the diet of clients who are taking anticoagulants. Chicken contains about half the vitamin K that green, leafy vegetables contain and is permitted in the diet.

A nurse is assessing a client eight hours after the creation of a colostomy. Which assessment finding should the nurse expect? 1 Presence of hyperactive bowel sounds 2 Absence of drainage from the colostomy 3 Dusky-colored, edematous-appearing stoma 4 Bright bloody drainage from the nasogastric tube

Absence of drainage from the colostomy A colostomy does not function for two to four days postoperatively because of the lack of peristalsis. Bowel sounds will be absent until peristaltic activity returns. A dusky-colored, edematous-appearing stoma indicates a problem with circulation to the stoma; it should be cherry red. Bright bloody drainage from the nasogastric tube indicates gastric bleeding, which is abnormal.

Before a femoral arteriogram is started, the nurse plans to teach the client that: 1 Radioactive dye will be injected into the femoral vein 2 Local anesthesia will be used to lessen pain at the site 3 Contrast media will be injected into a small vessel of the foot 4 Medication will be administered intravenously to induce sleep

Correct2 Local anesthesia will be used to lessen pain at the site Teaching the client that local anesthesia will be used to lessen any pain at the site reassures the client and allays fears of pain. The contrast medium used is not radioactive. The femoral artery is used for contrast media. The client will be awake during the procedure.

A nurse is teaching an adult health and wellness class about bladder cancer. The nurse informs the class participants that which activities put a person at risk for bladder cancer? Select all that apply. 1 Jogging three miles a day Incorrect 2 Drinking three cans of cola a day Correct 3 Smoking two packs of cigarettes a day Correct 4 Working with dyes and ink every day 5 Using a jackhammer and chainsaw every day

Drinking three cans of cola a day Correct 3 Smoking two packs of cigarettes a day Correct 4 Working with dyes and ink every da Using a jackhammer and chainsaw every day The occurrence of bladder cancer is related to smoking. Dyes and ink are environmental carcinogens; working with them daily increases an individual's risk of bladder cancer. Jogging is unrelated to the development of cancer of the bladder. Ingestion of cola has not been linked to cancer of the bladder. Vibrations may result in musculoskeletal or kidney problems but are unrelated to cancer of the bladder.

A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. To safely position this client the nurse takes into consideration that the feet and legs should be: Correct1 Placed dependent to the torso 2 Dependent by using a fully extended knee gatch Incorrect3 Raised to a two pillow height above the buttocks 4 Elevated by raising the foot of the bed on blocks

Placed dependent to the torso Gravity will assist the flow of blood to the dependent legs and feet. An extended knee gatch keeps extremities horizontal, not dependent, and does not facilitate blood flow to the feet. Elevation impedes flow of arterial blood to the extremities; it facilitates venous return.

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. Correct3 Start another IV line for the vancomycin and continue the heparin as prescribed. Incorrect4 Hold the vancomycin and tell the health care provider that the drug is incompatible with heparin.

Start another IV line for the vancomycin and continue the heparin as prescribed. The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the health care provider's, to administer them safely.

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next? 1 Turn the client to the unaffected side 2 Cleanse the client's ear with sterile gauze 3 Place sterile cotton loosely in the external canal of the left ear 4 Test the drainage from the client's ear with a glucose reagent strip

Test the drainage from the client's ear with a glucose reagent strip If a basilar skull fracture has occurred, the cerebrospinal fluid (CSF) may drain through the client's ears or nose. This clear fluid may be tested with a glucose reagent strip; if the result is positive for glucose, then the fluid might be CSF. However, this test is not always reliable. Turning the client to the unaffected side will allow fluid to collect in the ear, and more importantly, manipulation of the neck while turning the client may cause further injury. Placing sterile cotton loosely in the external ear will absorb the drainage without causing further trauma, but does not help in determining the source of the fluid.

A dehydrated older adult is admitted to the hospital from a nursing home. The transfer form documents a history of liquid fecal incontinence. Which diagnostic intervention by the health care provider promotes identification of the cause of this incontinence? 1 Abdominal percussion 2 Digital rectal examination 3 Urine culture and sensitivity test 4 Pelvic and abdominal ultrasound

Digital rectal examination Fecal impaction is the primary cause of liquid fecal incontinence. A digital rectal examination will determine the presence of a fecal impaction. Abdominal percussion will not assist in the diagnosis of impaction. Urine culture and sensitivity test will identify urinary tract infection; urinary, not fecal, incontinence is associated with urinary tract infection. Pelvic and abdominal ultrasound might be done if earlier assessments are inconclusive and additional evaluations are required.

A client who has been taking ibuprofen (Advil) for rheumatoid arthritis asks the nurse if acetaminophen (Tylenol) can be substituted instead. An appropriate nursing response is: 1 "Acetaminophen is the preferred treatment for rheumatoid arthritis." 2 "Acetaminophen irritates the stomach more than ibuprofen does." Correct3 "Ibuprofen is an antiinflammatory and acetaminophen is not." 4 "Both are antipyretics and have the same effect."

"Ibuprofen is an antiinflammatory and acetaminophen is not." Ibuprofen has an antiinflammatory action that relieves the inflammation and pain associated with arthritis. Acetaminophen is not an NSAID. NSAIDs are preferred for treatment of rheumatoid arthritis. Acetaminophen does not cause gastritis; this is an effect of aspirin. Ibuprofen is not an antipyretic.

A client is scheduled for arthroscopy of the knee in the morning and asks the nurse about the procedure. Which statement by the nurse best describes the procedure? 1 "The procedure will determine the types of treatments that will be prescribed." 2 "It is a direct visualization of the joint to diagnose the extent of your knee injury." 3 "You will not remember anything about the procedure because you will be anesthetized." 4 "It is a radiologic procedure that will aid in the diagnosis of the extent of your knee injury."

"It is a direct visualization of the joint to diagnose the extent of your knee injury." The response "It is a direct visualization of the joint to diagnose the extent of your knee injury" describes an arthroscopy; a health care provider uses a scope to visualize knee structures to determine the extent of injury. Although the response "The procedure will determine the types of treatments that will be prescribed" is true, it evades the client's concern and does not describe the procedure. Although the response "You will not remember anything about the procedure because you will be anesthetized" is true, it evades the client's concern and does not describe the procedure. Arthroscopy is not a radiologic procedure.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

Assessment of skin turgor Administration of antiemetic drugs Correct 5 Replacement of fluid and electrolytes When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

A client calls out to all nursing staff members who pass by the door and asks them to do or get something. How can the nurse best manage this problem while meeting this client's needs? 1 Assign one staff member to approach the client regularly and interact with the client. 2 Close the door to the room so that the client cannot see the staff members as they pass by. 3 Inform the client that one staff member will come in frequently and check whether the client has any requests. 4 Arrange for a variety of staff members to take turns going into the room to see whether the client has any requests.

Assign one staff member to approach the client regularly and interact with the client. Assigning one staff member to approach the client regularly and interact with the client provides continuity and demonstrates to the client that the nursing staff is concerned; frequent contact should reduce the client's need to call the staff for reassurance. Closing the door to the room so that the client cannot see the staff members as they pass by may increase the client's anxiety and the need for contact with staff. Telling the client is not the same as doing it; the client may not believe that staff will come in frequently. Arranging for a variety of staff members to take turns going into the room to see whether the client has any requests will not facilitate the development of a therapeutic relationship with a staff member.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? 1 Moro 2 Babinski 3 Stepping 4 Cremasteric

Babinski This is the description of how to elicit the Babinski reflex. If it is present in adults it may indicate a lesion of the pyramidal tract. The Babinski reflex is expected in newborns and disappears after one year. The Moro (startle) reflex is expected in newborns. It disappears between the third and fourth months; if present after four months, neurological disease is suspected. The stepping reflex is expected in newborns. It disappears at about three to four weeks after birth and is replaced by more deliberate action. The cremasteric is a superficial reflex that tests lumbar segments 1 and 2. Stimulation of this reflex is useful in initiating reflex emptying of the spastic bladder after a spinal cord disruption above the second, third, or fourth sacral segment.

1. A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen. 00:00:37

Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

Belonging Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1 Bradycardia 2 Hypotension 3 Spastic paralysis 4 Bladder dysfunction 5 Increased pulse pressure

Bradycardia 2 Hypotension Bladder dysfunction Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

A client is awaiting surgery for a ruptured lumbar nucleus pulposus. Which activities should the nurse inform the client will most likely increase pain? Select all that apply. 1 Lying on the side 2 Flexing the knees Correct 3 Coughing excessively 4 Sitting for long periods of time Correct 5 Bearing down when having a bowel movement

Coughing excessively Bearing down when having a bowel movement Coughing places strain on the lumbar area, increasing herniation of the disc. The Valsalva maneuver increases intervertebral pressure and may cause pain. Lying on the side does not increase intervertebral pressure that can result in pain. Flexing the knees will not increase pressure or cause pain; flexing the knees usually promotes comfort. Sitting for long periods of time will not increase intervertebral pressure causing pain.

The nurse frequently provides care for clients with hearing aids. The nurse recalls that the condition that best responds to hearing aids is: 1 Destruction of the auditory nerve Correct2 Diminished sensitivity of the cochlea 3 Perforation of the tympanic membrane Incorrect4 Immobilization of the auditory ossicles

Diminished sensitivity of the cochlea Because hearing aids use the person's own middle ear, they increase hearing acuity in cases of diminished sensitivity of the cochlea; the amplified signal from the hearing aid gives the cochlea greater stimulation and promotes hearing. Destruction of the auditory nerve results in deafness because impulses cannot be transmitted to the brain's auditory center. Perforation of the tympanic membrane prevents ossicular conduction, which involves transmission of resonant vibrations from the tympanic membrane to the ossicles to the cochlea. Hearing aids will not correct this type of hearing loss; surgery is preferred. Immobilization of the ossicles prevents conduction of resonant vibrations from the tympanic membrane to the cochlea. Hearing aids may help but will not correct this problem; surgery is preferred.

What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving

Directive The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

A client is admitted for the repair and revision of a residual limb after a traumatic amputation of the hand. A week after surgery the client complains of constant throbbing in the affected limb. Which is the most appropriate nursing intervention? 1 Apply cool compresses to the limb 2 Secure a prescription for pain medication 3 Elevate the extremity on two pillows 4 Loosen the bandage around the limb

Elevate the extremity on two pillows Elevation of the extremity promotes venous return, which limits edema and the related pressure on nerve endings that causes pain. Cool compresses limit venous return; vasoconstriction interferes with wound healing. A week after surgery the discomfort probably is caused by venous congestion related to the limb's dependent position rather than incisional pain. Loosening the bandage around the limb is contraindicated because the bandage prevents bleeding and edema and promotes shrinkage of the residual limb. Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.

The nurse notes that the client's rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. The nurse realizes that the client is in: Incorrect1 First degree atrioventricular (AV) block. 2 Second degree AV block Mobitz I (Wenckebach). Correct3 Second degree AV block Mobitz II. 4 Third degree AV block (complete heart block).

First degree atrioventricular (AV) block. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Also called Mobitz I or Wenckebach phenomenon, second degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? Select all that apply. 1 Ripe bananas 2 Milk products 3 Green vegetables 4 Creamed potatoes 5 Whole grain bread

Green vegetables 4 5 Whole grain bread Green vegetables contain fiber, which promotes defecation. Whole grain bread contains fiber, which promotes defecation. Bananas have a binding effect and promote constipation. Milk and milk products have a binding effect and promote constipation. Creamed potatoes have a binding effect and promote constipation

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. The nurse concludes that these signs are suggestive of: 1 Spinal shock 2 Hypovolemic shock 3 Brain herniation 4 Increased intracranial pressure

Increased intracranial pressure Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.

A client had surgery for a strangulated hernia. One hour after surgery the client's blood pressure drops from 134/80 to 114/76 mm Hg. Assessment reveals that the client does not have postoperative bleeding. What action should the nurse take? 1 Place the client in the left side-lying position. Correct2 Instruct the client to move both legs. Incorrect3 Notify the primary health care provider immediately. 4 Administer the prescribed pain medication.

Instruct the client to move both legs. The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return. Turning the client onto the left side will not increase the blood pressure; this intervention is used for pregnant women to move the gravid uterus off the vena cava, which increases placental perfusion. Calling the health care provider eventually may be done after performing the initial interventions and evaluating results. Opioid analgesics may decrease the blood pressure further.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has: 1 No spontaneous reflexes 2 Shallow and slow breathing Correct3 No cortical functioning with some reflex breathing Incorrect4 Deep tendon reflexes only and no independent breathing

No cortical functioning with some reflex breathing A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of brain dead.

An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply. 1 Increased high-density lipoprotein (HDL) 2 Taking an aspirin a day 3 Occasional cocaine use 4 Reduced hemoglobin level 5 African-American heritage

Occasional cocaine use African-American heritage Cocaine is a stimulant that causes tachycardia (up to 200 beats per minute) and hypertension. Hypertension is more prevalent in African Americans in the United States. Damage to target organs, such as kidneys and eyes, is more severe in African Americans than in whites or Hispanics; the reasons for this are unclear. Increased HDL reduces the risk for cardiovascular disease because it helps to remove excess cholesterol from the blood, thereby preventing atheromas. Aspirin decreases platelet aggregation, thus reducing the risk for cardiovascular disease. Lowered hemoglobin may increase the heart rate, not the blood pressure.

Bed rest is prescribed after a client's cerebrovascular accident (also known as "brain attack") results in hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? Correct1 Passive range-of-motion exercises 2 Active exercises of the extremities 3 Light weight-lifting exercises of the right side 4 Isotonic exercises that will capitalize on returning muscle function

Passive range-of-motion exercises Passive range-of-motion exercises prevent the development of deformities (e.g., contractures) and do not require any energy expenditure by the client. Instituting range-of-motion exercises is an independent nursing function. Bed rest is prescribed to decrease oxygen demands; active exercises markedly increase oxygen consumption.

A nurse is providing education to a community group about hospice. The nurse clarifies that the primary goal of hospice is help clients do what? 1 Have the option of assisted suicide 2 Remain comfortable until the end of life 3 Explore the newest treatments for their form of cancer 4 Release family members from participating in care

Remain comfortable until the end of life Hospice care attempts to break the cycle of fear and pain; care focuses on keeping the client as comfortable and high functioning as possible. Hospice care does not provide assisted suicide. Hospice care is provided after all treatments have failed; this care is provided during terminal stages of illness. Family members can be involved in the client's care; hospice services provide a supportive environment for both client and family.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? Incorrect1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. Correct4 Stay nearby without initiating conversation.

Stay nearby without initiating conversation The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy. Crying, part of depression, usually ceases when the individual reaches acceptance. During acceptance the client may decide not to have visitors, preferring time for reflection. Detached from the environment, the client may find that the details of various procedures lose significance.

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation Correct3 Surgical asepsis Incorrect4 Medical asepsis Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

Surgical asepsis

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurological assessment, the nurse applies a painful stimulus to the client's left lower leg. An expected response in a healthy adult is: Correct1 Withdrawing the leg 2 Making no movement 3 Plantar flexing the left foot 4 Flexing the upper extremities

Withdrawing the leg Withdrawing the leg is an appropriate response, a purposeful withdrawal from pain. Making no movement may indicate cortical or midbrain compression. Plantar flexion occurs with flexion posturing (decorticate posturing) or extension posturing (decerebrate posturing); these are associated with brain dysfunction. Flexing the upper extremities, with leg extension and plantar flexion, indicates flexion posturing (decorticate posturing); this indicates dysfunction of the cerebral cortex or lesions of the corticospinal tracts above the brainstem.