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Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? a) Force fluids for an adult client who has a urine output of less that 30 mL per hour. b) If the dressing was clean but now has a large amount of fresh blood, remove the dressing and reapply it. c) If client is febrile within 12 hours of surgery, notify the physician immediately. d) If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding.

Nurses teach patients to restrict food and fluids before surgery. What condition does this measure attempt to avoid? a) Infection b) Aspiration c) Bowel alterations d) Respiratory distress

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? a."I will need to check with your health care provider about that." b."Yes—you should be off all of your medications for 24 hours before surgery." c."You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery." d."No—you should stay on your normal medication schedule before the surgery."

A The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.

A client states he has a latex allergy. What action should the nurse take? a) Place an allergy identification band on the client. b) Inform the client to tell the anesthesiologist. c) Send the client to the OR with epinephrine. d) Have the client take a Benadryl before surgery.

Which of the following nursing action provides the greatest assistance in healing? a) Maintaining a restful environment b) Allowing family members to visit often c) Keeping the client recumbent d) Providing solid food in the first day

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort? A.Maintaining a calm environment B.Providing solid food during postoperative day 1 C.Allowing family members to visit often D.Keeping the client recumbent

A The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated.

What information must be provided to a client to obtain informed consent? Select all that apply. A.The underlying disease process and its natural course B.A description of the procedure or treatment, along with potential alternative therapies C.Customary insurance coverage for the procedure D.Explanation of the risks involved and how often they occur E.Explanation that a signed consent form is binding and cannot be withdrawn F.The name and qualifications of the nurse providing perioperative care

A, C, D The informed consent provides a description of the procedure or treatment (its name, site, and side effects if applicable), along with potential alternative therapies; the underlying disease process and its natural course; the name and qualifications of the person performing the procedure or treatment; explanation of the common risks involved, including risk for damage, disfigurement, or death, and how often they occur; explanation that the client has the right to refuse treatment and that consent can be withdrawn; and explanation of expected outcome, recovery, and rehabilitation plan and course.

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in a) Potassium b) Protein c) Calcium d) Bicarbonate

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care? A.Apply hairpins and clips. B.Avoid replacing dentures in the mouth. C.Cleanse drainage from the skin. D.Place a rolled towel under the head.

A nurse is teaching an older adult client to use an incentive spirometer following hip replacement surgery when the client asks why using this machine is necessary. How will the nurse respond? A.This exercise prevents deep vein thrombosis. B.The exercise keeps you from getting asthma. C.The exercise helps prevent pneumonia. D.This exercise keeps you from getting bronchitis.

C In the older adult client, postoperative pneumonia can be a very serious complication resulting in death. Therefore, it is especially important to encourage and assist the client in using the incentive spirometer and with deep-breathing exercises. These exercises do not address the client's risk for deep vein thrombosis, bronchitis, or asthma.

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? A."If possible, lie flat on your back while you're doing your breathing exercises." B."Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." C."Try to do your exercises every 1 to 2 hours." D."It's best to do your exercises before a meal rather than after eating and drinking."

C Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery.

The nurse recognizes that palliative surgery is performed for what purpose? A.to restore function to tissue that is traumatized B.to make or confirm a diagnosis C.to lessen the intensity of an illness D.to remove a part of the body that is diseased

C Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.

The nurse monitors the urine output of a postoperative patient. What condition does urine output indicate? a) Kidney failure b) Clot formation c) Tissue perfusion d) Lung capacity

C Tissue perfusion Explanation: Urine output is a good indicator of tissue perfusion. Patient may need more fluid or may need medication to increase blood pressure if it is low. 840

Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? a) Lower doses of anesthetic agents and lower doses of postoperative analgesics b) Larger doses of anesthetic agents and lower doses of postoperative analgesics c) Lower doses of anesthetic agents and larger doses of postoperative analgesics d) Larger doses of anesthetic agents and larger doses of postoperative analgesics

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing? A.acceptance B.anger C.bargaining D.denial

A nurse asks a preoperative patient what medications he is currently taking. Which of the following is an accurate guideline for patient teaching regarding these medications? a) Aspirin is generally stopped 1 month before surgery. b) Cardiac drugs must be stopped for 1 week before surgery .c) If the patient is diabetic and takes insulin, the dose may be increased before surgery. d) Certain respiratory drugs may be taken the day of surgery per physician's order.

A nurse is dressing the wound of a client who is admitted to the outpatient surgical unit. Which of the following is a major advantage of outpatient surgery? a) It allows less opportunity for family contact and support .b) It requires intensive pre-operative teaching in a short time. c) It reduces the time for establishing a nurse-client rapport. d) It interferes less with the client's daily routine.

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to: A.give permission for organ donation. B.make legal provisions for active euthanasia. C.dictate how the client wants his estate handled after his death, and by whom. D.specify the treatment measures that the client wants and does not want.

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? a) Call the house officer to obtain the signature .b) Inform the physician that the nurse manager will need to obtain the signature .c) Obtain the signature and ask another nurse to cosign the signature. d) Inform the physician that it is his or her responsibility to obtain the signature.

The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects a) Myocardial infarction b) Mitral valve prolapse c) Major blood loss d) Malignant hyperthermia

a The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated.

The nurse is performing a preoperative screening of laboratory work prior to a client's surgery in the morning. What test results should be immediately discussed with the surgeon and anesthesia care provider? Select all that apply. a.a hemoglobin of 7.2 gm/dL b.a potassium level of 4.2 mEq/L c.a BUN of 9 mg/dL d.a sodium level of 128 mEq/L e.increased hemoglobin level, indicating infection f.a white blood cell count of 18,000

a, d, f

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response? a."An advance directive is a living will. Some people already have one when they come to the hospital." b."An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." c."We are not sure if you will wake up after surgery, so the advance directive will let us know your wishes just in case." d."When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand."

Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? a) "When I can eat again, the best meal would be steak and orange juice." b) "I can have a hamburger and French fries as soon as I wake up." c) "I might be sick to my stomach and throw up after surgery." d) "The better I eat before surgery, the more likely I will heal."

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? a.Bowel alterations b.Respiratory distress c.Infection d.Aspiration

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? a.operative site marking b.informed consent c.preoperative checklist d.procedural pause (time-out)

A newly married client is attempting to fulfill the role of wife, professional, and lover. She tells the nurse that she does not feel that she is fulfilling any of the roles well. The nurse will document this as: a.role transition. b.role ambiguity. c.role strain. d.role conflict.

Role strain occurs when the person perceives himself as inadequate or unsuited for a role. This can occur in any role or because of numerous roles. People make multiple role transitions in a lifetime. Role ambiguity occurs when the person lacks knowledge of role expectations, which fosters anxiety and confusion. Role conflict is related to expectations concerning the role. Role conflict can be described as intrapersonal, interpersonal, or interrole. c

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? a.Guarding of the chest area b.High blood pressure c.Increased respiratory rate d.Decreased heart rate

a A person's behavioral response to pain can be demonstrated by protecting or guarding the painful area, grimacing, crying, or moaning. Increased blood pressure and respiratory rate are typical physiologic (sympathetic) responses to moderate pain. Decreased heart rate is a typical physiologic (parasympathetic) response to severe pain.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? a.Apply pressure to the surgical site to decrease bleeding. b.Assess the client's vital signs. c.Determine the possible cause of the client's bleeding. d.Notify the health care provider.

A It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client? 1 3 4 2

3 The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:1 = awake and alert; no action necessary2 = occasionally drowsy but easy to arouse; requires no action3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.

Which nursing action will best promote pain management for a client in the postoperative phase? A.Performing relaxation techniques B.Dimming the lights C.Breathing into a paper bag D.Providing food and medication

A Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.

The nurse determines that a client understands instruction regarding progressive relaxation when the client states that the technique requires: A.tensing and relaxing various muscle groups. B.focusing on pleasant images. C.using a mantra in a relaxed position. D.using a biofeedback machine.

A Progressive relaxation consists of systematically tensing and relaxing various muscle groups from head to toe. Progressive relaxation provides a method of identifying particular muscle groups and distinguishing between sensations of tension and tranquility.

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse? A."I will contact the health care provider to extend services since your family member meets the criteria." B."We can discontinue the service for a period of time and then when your family member gets worse, readmit them." C."Unfortunately, we are unable to continue services past the 6 month period of time." D."We can admit your family member to the hospital for treatment and they can reinstate the hospice benefits."

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? a) Conduct a nursing assessment. b) Obtain a signature on the consent form. c) Reduce the dosage of toxic drugs. d) Review the surgical checklist.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery? a.Inability to ambulate b.Voiding on a regular basis c.Inability to see from left eye d.Alert and oriented ×4

A nurse is caring for an older adult following hip surgery. Which of the following serious complications would the nurse attempt to avoid by encouraging use of the incentive spirometer? a) Pneumonia b) Asthma attack c) Hypertension d) DVT

A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective? A.The client repeats the explanation and instructions in one's own words to demonstrate understanding. B.The client explains the procedure should be completed first thing in the morning before rising from the bed. C.After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position. D.The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed

In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? a) Paralytic ileus b) Normal response c) Hernia development d) Abdominal infection

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis? A."I feel like I have absolutely no idea what to do next." B."I haven't let my children out of my sight. I am afraid something will happen to them." C."A lot of the time I'm terrified that I'm going to die the same way." D."I had a good time at my class reunion. It was nice to be out with other people again."

Which of the following nursing interventions is most likely to prevent respiratory complications such as pneumonia and atelectasis in a postsurgical client? a) Use of incentive spirometry b) Adequate nutrition and fluids c) Control of anxiety and agitation d) Adequate pain control

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for which of the following? a) Cardiac problems b) Infection c) Fluid imbalances d) Bleeding and anemia

A Cardiac problems Explanation : Hyperkalemia or hypokalemia increases the client's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated white blood cell count occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.829

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse? A."Have you been experiencing any strange tastes or aftertastes lately?" B."Close your eyes and tell me when you feel something." C."Repeat the words that I will softly speak close to each ear." D."Please read my name tag."

A Clients receiving chemotherapy may have altered gustatory or olfactory sensations. Asking about taste would be an assessment for this condition. Repeating softly spoken words assesses auditory disturbances, feeling assesses tactile disturbances, and reading assesses visual disturbances.

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as: A.delirium. B.somnolence. C.dementia. D.locked-in syndrome.

A Delirium involves disorientation, restlessness, confusion, hallucinations, agitation, and alternating with other conscious states, whereas dementia is associated with difficulties with spatial orientation, memory, language and changes in personality. Somnolence refers to a state of extreme drowsiness, but the client will respond normally to stimuli. Locked-in syndrome refers to a state of full consciousness where sleep-wake cycles are present, and where quadriplegic, auditory and visual function, and emotion are preserved.

An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? A.Delirium B.Boredom C.Dementia D.Opioid overuse

A Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.

Which client is handling stress by using the defense mechanism termed displacement? A.A mother who is angry at her husband shouts at the kids to "keep quiet." B.An athlete who doesn't make the team concentrates on body-building instead. C.A man with symptoms of prostate cancer refuses to see a doctor. D.A man who forgets his medication blames his wife for putting it awa

A Displacement is described as transferring (displacing) an emotional reaction from one object or person to another object or person, as with the mother who is angry at her husband and shouts at the kids to "keep quiet." The athlete who doesn't make a team and instead concentrates on body-building represents the defense mechanism of compensation. A man with symptoms of prostate cancer refusing to see a doctor is displaying the defense mechanism of denial. A man who forgets his medication and blames his wife for putting it way is demonstrating the defense mechanism of projection.

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? A.preoperative B.intraoperative C.postoperative D.postanesthesia care unit (PACU)

A Exercises and physical activities occurring in the preoperative phase include deep breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings. The intraoperative phase is when the client is in the operating room. In the postoperative area and postanesthesia care unit areas, clients are monitored and deep breathing exercises begin.

The circulating nurse calls for a time-out prior to the surgical procedure and the surgeon states, "I don't have time for this. I have another case to follow and need to get busy." What is the best response by the circulator? A."We all have the same goal and that is the safety of the client, so let's do the time-out." B."Whether you have time to do it or not, we will do it without you." C."I understand you are very busy, so we can move on without the time-out." D."These time-outs are ridiculous anyway; we all know what the client is having done."

A Final verification just prior to beginning the procedure is referred to as the time-out. The time-out occurs immediately before starting the surgical procedure and is initiated by a designated member of the team. The surgeon, the anesthesia provider, the circulating nurse, the operating room technician, and any other active participants conduct the time-out assessment and ensure that there are no questions or concerns. During the time-out, all members of the surgical team must agree on the identity of the client, the correct surgical site, and the procedure that will be performed. The completion of the time-out is documented appropriately.

The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptom associated with stress does the nurse recognize? A.impaired concentration B.difficulty falling asleep C.angry outbursts D.lack of interest in sex

A Impaired concentration is consistent with a cognitive symptom associated with stress. Difficulty falling asleep and lack of interest in sex are physical symptoms associated with stress, and angry outbursts are emotional symptoms associated with stress.

The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period? A.Food and liquids will be held in the immediate postoperative period. B.You will receive a diet high in vitamin B. C.You may eat anything you want following surgery. D.In the immediate postoperative period, you will receive a soft diet high in carbohydrates.

A Intestinal manipulation, pain medications, and anesthetic agents may result in a decrease in intestinal motility. The client may experience nausea and vomiting. Therefore, after surgery, fluids and food are often withheld until gastric motility returns. A diet with sufficient amounts of protein and vitamins A and C (not vitamin B) helps to rebuild tissues and promotes wound healing. A soft diet with adequate (not high) carbohydrates for energy is started after the client has demonstrated tolerance to liquids well. Clients are not able to eat anything they want following surgery; the diet is usually progressed from NPO, to clear then full liquids, a soft diet, and finally a regular diet.

A nurse is caring for a client with a chest incision. Which action should the nurse ask the client to perform to induce forced coughing? a) Pull the abdomen inward b) Lean slightly backward c) Inhale slowly through mouth d) Exhale through the nose

A Pull the abdomen inward Explanation: To induce forced coughing, the nurse should ask the client to pull the abdomen inward and lean slightly forward, not backward. The nurse could also tell the client to take a slow deep breath through the nose and exhale through the mouth and cough three times in a row while exhaling.834

A nurse is caring for a female client who will undergo a curative surgery for cholecystectomy. Which of the following precautions should the nurse take before surgery to prevent venous stasis? a) Recommend that the client wear antiembolism stockings b) Ask the client to wiggle the toes at regular intervals c) Ask the client to remove her dentures d) Enclose the client's leg in a pneumatic splint

A Recommend that the client wear antiembolism stockings Explanation: The client should wear antiembolism stockings or the client's legs should be wrapped in an elastic roller bandage before surgery to prevent venous stasis. Asking the client to wiggle the toes at regular intervals is a secondary precaution. However, enclosing the client's leg in a pneumatic splint is not correct because pneumatic splints are used to control swelling and bleeding of an injury. If the client wears dentures, some health care agencies remove them to prevent airway obstruction.849-850

When a person selects, organizes, and interprets sensory stimuli, the process is termed: A.perception. B.preoccupation. C.adaptation. D.stimulation.

A Sensory perception is a conscious process of selecting, organizing, and interpreting sensory stimuli that requires intact and functioning sense organs, neuronal pathways, and the brain.

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation? A.providing a backrub with morning and evening care B.delivering meticulous oral care C.orienting the client to his environment D.placing a calendar and clock on the client's bedside table

A Tactile stimulation includes backrubs, foot soaks, turning and repositioning, passive range-of-motion exercises, hugs, and touching. Orienting a client to his environment is cognitive input. Placing a calendar and clock on the client's bedside table is visual stimulation. Oral care is gustatory and olfactory stimulation.

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his: A.reticular activating system (RAS). B.limbic system. C.prefrontal cortex. D.cerebellum.

A The RAS is the network that mediates arousal. The limbic system is a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Cerebellum is the part of the brain that coordinates and regulates muscular activity. The prefrontal cortex is a part of the brain located at the front of the frontal lobe and is involved in a variety of complex behaviors and personality development.

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as: A.adaptation. B.cortical arousal. C.sensoristasis. D.sensory overload.

A The body quickly adapts to constant stimuli. The repeated stimulus of a continuing noise, such as a low-level cardiac alarm, eventually goes unnoticed. A stimulus must be variable or irregular to evoke a response. This phenomenon is termed adaptation. Sensoristasis is the optimal arousal state of the reticular activating system. Cortical arousal refers to the different states of arousal or awareness. Sensory overload is the condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement? A."What makes you think the food is poisoned?" B."It is okay to eat. The food is not poisoned." C."Would you like another meal?" D."I will get you another meal."

A The client is exhibiting delusional behavior. Delusions are beliefs not based on reality that reflect an unconscious need or fear. By asking an open-ended question the nurse can determine why the client is making the statement and create a strategy to change the client's perspective. Asking the client if he or she wants another meal or bringing the client another meal does not address the underlying issue. Telling the client it is okay to eat the meal is not recognizing the client's fear and could damage the nurse-client relationship.

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? A.exhaustion stage B.secondary stage C.resistance stage D.alarm stage

A The client is in the exhaustion stage, when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system, and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-or-flight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders, or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? A.an older adult man with a fractured hip B.a woman experiencing a cesarean birth C.an adolescent having arthroscopic surgery D.a young adult with a fractured leg

A The risk of hypothermia increases in the very young and the very old.

The nurse is caring for a client who has had unrelieved back pain for 3 years. How will the nurse document this type of pain? Select all that apply. a.chronic b.somatic c.acute d.visceral e.neuropathic

A , c Chronic pain is discomfort that lasts longer than 6 months. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Therefore, the nurse appropriately documents this client's pain as somatic and chronic. Cutaneous, visceral, referred, neuropathic, and acute pain are not being depicted in this scenario.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply. A.Depression B.Decreased interest in activities C.Sleeplessness D.Increased interest in interactions with others E.Increased appetite

A, B, C Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.

A client with chronic sinusitis reports loss of appetite. Which action(s) will the nurse recommend to the client to help overcome this issue? Select all that apply. A.Enhance the flavor of the food you eat. B.Research smell training C.Imagine the smell of the food while eating D.Carefully review expiration dates on food. EContact your health care provider

A, B, C, D, E Clients who are unable to smell may also develop nutritional deficits from the resulting loss of appetite. Tumors, cranial nerve damage, atherosclerosis, intranasal cocaine use, and sinusitis are all potential causes of impaired sense of smell. Contacting the heath care provider will allow the client to learn if there are any appropriate medical treatments. The client must be cautious about the accidental ingestion of food that has gone bad and will need to watch expiration dates. Adding extra flavor, for example chicken broth to chicken, can enhance the flavor to allow for taste to override smell. The client can imagine what the food smelled like before to increase appetite. A number of studies have been done in recent years which suggest that 'smell training'—repeated short-term exposure to odors—can potentially be of benefit to people who have been affected by olfactory loss, particularly those who have lost their sense of smell as the result of a virus such as the common cold.

The nurse is making preparations for a group of clients who have been experiencing some stressful events in their lives. Which nursing strategies should the nurse use to assist these clients? Select all that apply. A.implementing stress management techniques B.assisting in maintaining a network of social support C.preventing additional stressors D.ignoring the stressors E.assessing the client's response to stress

A, B, C, E Preventing additional stressors will eliminate the cumulative effects of other stressors. Assessing the client's response to stress will help indicate how well the client is adapting to the stressors. Implementing stress management techniques will provide strategies to assist the clients in mitigating further stressors. Maintaining a network of social support will provide the clients with other individuals to share their concerns with. Ignoring the stressors will just add to the cumulative effect or other stressful life events; it will not remove the stress.

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform? Select all that apply. A.Obtain vital signs, especially heart rate and blood pressure B.Give sublingual nitroglycerin as prescribed C.Give pain medication as prescribed D.Review prior medical history E.Ask the client to rate pain on a scale from zero to ten

A, B, E A client having chest pain and palpitations needs to have vital signs (particularly blood pressure and heart rate) checked to ensure that the client is hemodynamically stable. These symptoms may indicate cardiac problems, so the client must be examined closely for any complications such as a myocardial infarction. Sublingual nitroglycerin, not pain medication, is used to treat episodes of chest pain by relaxing the blood vessels, which increases the supply of blood and oxygen to the heart. Having the client rate the pain on a pain scale is useful to evaluate and assess the pain to determine plan of care and evaluate the effectiveness of treatment.

A nurse is caring for a client who is admitted to the health care facility for surgery. Which of the following activities take place before inpatient surgery? Select all that apply. a) Diagnostic tests b) Meet anesthesiologist c) Meet family members d) Home care note E) Prior laboratory tests

A, B, E, Explanation: Many people who have inpatient surgery undergo prior laboratory and diagnostic tests. Some clients meet the anesthesiologist or anesthetist, a nurse specialist who administers anesthesia under the direction of a physician. Most clients will have received preoperative instructions from either the surgeon's office nurse or a hospital nurse. Meeting family members is not part of inpatient surgery; neither is a home care note. A home care note is given to a client when he or she is discharged from the health care facility as part of the outpatient surgery routine. 825

The nurse is performing a preoperative assessment for a client prior to surgery in the morning. What statement made by the client alerts the nurse that there is a potential for latex allergy? Select all that apply. a."I had a rash after using a condom." b."I had whelps and itching when I took an aspirin." c."I broke out in hives after eating sliced avocado" d."I am allergic to banana's" e."I have bloating and gas after drinking milk or eating cheese."

A, C, D Clients that have an allergy to latex may have an associated allergy to banana's and avocado's. Client's developing a rash to a condom should be considered allergic to latex since the condom is latex. Bloating and gas after drinking milk or eating cheese may be attributed to a lactose intolerance. Aspirin allergy does not predispose a client to a latex allergy.

The nurse is working on a neurological unit and must perform an assessment on a client for disturbed sensory perceptions. The nurse thinks about the human senses and knows that they must assess for which of the following? Select all that apply. A.any recent changes in sensory stimulation B.history of recent immunizations C.medications that may alter sensations D.anything interfering with sensory reception E.use of assistive devices for senses

A, C, D, E

A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply. A.Have someone available for transportation home after recovery from anesthesia. B.Continue with all medications routinely taken. C.Wear clothing without buttons or zippers. D.Notify the surgeon's office if a cold or infection develops before surgery. E.List allergies and be sure the operating staff is aware of these.

A, D, E The nurse should list medications routinely taken and ask the physician which should be taken or omitted the morning of surgery. The nurse should also have the client notify the surgeon's office if a cold or infection develops before surgery. The nurse should list allergies and be sure the operating staff is aware of these. The nurse should tell the client to wear clothing that buttons in front. The nurse should tell the client to have someone available for transportation home after recovery from anesthesia. The nurse should also inform the client of limitations on eating or drinking before surgery, with a specific time to begin the limitations

Select all answer choices that apply.A nurse is assessing a client with asthma for latex allergy at the healthcare facility. Which of the following symptoms does a person manifest during an allergic reaction due to latex products? Select all that apply .a) Pruritus b) Headache c) Cough d) Redness e) Local inflammation

A,D,E

A patient has presented to a clinic for a presurgical consult, during which the patient has expressed concern about having to fast before surgery. Current recommendations for preoperative fasting include which of the following? a) Preoperative fasting is still often recommended, even though it is medically unnecessary. b) Patients can usually eat or drink up to 2 hours prior to surgery. c) New recommendations allow eating and drinking until just prior to anesthetic being administered .d) Patients generally must eat or drink nothing after midnight the night before surgery.

A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? a) Client's consciousness level can be monitored by equipment. b) Client is relaxed, emotionally comfortable, and conscious. c) Client can tolerate long therapeutic surgical procedures. d) Client can respond verbally despite physical immobility.

Following a successful coronary artery bypass graft (CABG), a 71-year-old male patient has been transferred to the postanesthetic care unit (PACU). What is the priority for the patient's nursing care during this stage of his recovery? a) Positioning the patient to prevent skin breakdown b) Protecting and maintaining the patient's airway c) Treating the patient's pain d) Preventing incisional infection and monitoring for signs and symptoms of infection

In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client's following statements indicates a sound understanding of leg exercises? a) "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time." b) "I'll practice these now and try to start them as soon as I can after my surgery." c) "I'll try to do these lying on my stomach so that I can bend my knees more fully." d) "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bed rest after my operation."

Palliative care is a structured system for care delivery. What is its aim? A.to give traditional medical care B.to prevent and relieve suffering C.to bridge between curative care and hospice care D.to provide care while there is still hope

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death? A."Each stage of dying must be completed prior to moving to the next stage." B."Sometimes a person returns to a previous stage." C."The process is the same from person to person." D."The duration of all stages is a few hours."

The nurse is preparing a patient for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia is commonly used for this procedure? a) Nerve block b) Conscious sedation c) Spinal anesthesia d) Epidural anesthesia

he nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states: A."I just want to see my son have a family of his own." B."Why did this have to happen to me?" C."I don't care about anything. I have no energy." D."I do not believe I have this disease."

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration? A.using numerous handouts and detailed education plan B.allowing more time for the processing of the information C.demonstrating a wide variety of syringes and techniques D.requesting hearing aids to help the client receive information

B As a person approaches 60 to 70 years of age, marked decrements in sensory/perceptual behaviors begin. This reduction in efficiency means that older people cannot process sensory input as rapidly as they did when they were young.

Family conflict around the care of a recently hospitalized woman has escalated to the point that crisis intervention may be required. This process should begin with: A.presentation of clear, achievable, and evidence-based solutions. B.clear identification of the relevant problem. C.careful and objective analysis of different proposed options. D.comparison of the family's situation to other similar situations.

B Crisis intervention is a problem-solving technique that begins with the identification of the problem. This precedes the identification of options and assessment of proposed solutions. Once the problem is identified by the client and the crisis team is way, interventions should be then be developed by the team members. The crisis intervention is very individualized and should not be compared to other families. Analysis is the last step of the process.

In what phase of the surgical experience would advance directives be discussed with the patient? a) Intraoperative b) Postoperative c) Preoperative d) Recovery

A patient had an open cholecystectomy (gall bladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the patient has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? a) Administer a cleansing enema. b) Monitor the patient closely and promote fluid intake. c) Contact the physician to come assess the patient. d) Increase the rate of the patient's intravenous infusion.

B Explanation: Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the patient and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage and an enema would likely be premature. The nurse may not independently increase the patient's IV infusion, and doing so would not necessarily promote a bowel movement. 845

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which of the following characteristics applies to this type of surgery? a) The client must be previously healthy with low surgical risks. b) The client will be admitted the day of surgery and return home the same day .c) The surgery will be conducted using moderate sedation rather than general anesthesia. d) The surgery is classified as urgent rather than elective.

B Explanation: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible, and common. This approach is more common for elective surgeries than urgent surgeries. 823

A nurse is caring for an older adult client who has been prescribed fluid restriction before surgery. Which of the following should the nurse check to assess the risks of fluid restriction in elderly clients? a) Anxiety level b) Vital signs c) Cardiac status d) Self-therapy

B Explanation: The nurse should assess the client's vital signs, weight, and sternal skin turgor prior to fluid restriction to serve as a baseline for comparison. The period of fluid restriction before surgery may be shortened for older adults to reduce their risk of dehydration and hypotension. Nurses check a client's self-therapy practices and cardiac status to avoid any complications of bleeding and elimination of intravenous fluids given at a standard rate. 826

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes: A.cleaning the clients' ears daily with a cotton-tipped applicator. B.demonstrating or pantomiming ideas to clients with hearing impairments. C.encouraging clients to use earphones adjusted to a loud volume for hearing. D.speaking loudly and directly to clients with hearing impairments.

B For hearing-impaired clients, demonstrating or pantomiming may assist in communication. Clients should be instructed to avoid cleaning the ear with cotton-tipped applicators or sharp objects as this can cause damage to the inner ear. While speaking directly may enhance communication, speaking loudly will not benefit the client. Clients should be discouraged from using earphones that concentrate loud noise in the ear canal causing acoustic damage.

The older adult client, who lives alone, has been admitted to the intensive care unit (ICU) following a stroke. She is now agitated and complaining about the noise. What will the nurse add to her care plan? A.Provide pet therapy. B.Provide a consistent, predictable pattern of stimulation. C.Instruct the client in self-stimulation methods such as singing. D.Offer frequent back rubs.

B In some clients, especially those coming from a quiet environment with unvarying stimuli, the experience of being hospitalized quickly results in sensory overload. One nursing action to decrease excessive stimulation is to provide a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment. The other options are nursing interventions used for sensory deprivation, as they increase stimulation.

The nurse is caring for a client in the postanesthesia care unit (PACU). Which assessment is the priority for this client? A.Obtain temperature. B.Assess respiratory status. C.Check the neurologic status. D.Auscultate bowel sounds.

B In the immediate postoperative period, the client is most at risk of respiratory compromise due to the effects of anesthesia; thus, a respiratory assessment takes priority. The client could have constipation postoperatively, but this is not a priority over respiratory status. Obtaining a temperature and neurologic status are important in the immediate postoperative period, but airway is priority

A nurse teaches deep-breathing exercises to a preoperative patient. Which of the following accurately describes a step in this exercise? a) Instruct the patient to place the palms of both hands along the upper posterior rib cage. b) Instruct the patient to exhale gently and completely before breathing in c) Instruct the patient to breathe in through the nose as deeply as possible and hold the breath for 10 seconds. d) Assist or place the patient in a supine position for the exercises.

B Instruct the patient to exhale gently and completely before breathing in.Explanation: The nurse should assist the patient to sit up and place the palms of both hands along the lower anterior rib cage. The patient should then exhale gently and completely and breathe in through the nose as deeply as possible, holding the breath for 3 seconds. 833

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation? A.Ask the client what one was doing in 1949 and what hotel the client is in. B.Reorient the client to place and time. C.Thank the client for the responses and document the cognitive status. D.Provide hints during conversation as to the correct year and place.

B It is appropriate to reorient clients with dementia who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient the client. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed by reorientation.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: A.the type of surgery. B.a partial airway obstruction. C.the effects of anesthesia. D.the normal return of reflexes.

B Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.

A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? a) Prepare a room for the client's return. b) Monitor the client for complications. C) Ensure the safe recovery of surgical clients .d) Assess the client's health constantly.

B Monitor the client for complications .Explanation: The immediate post-operative period refers to the first 24 hours after surgery. During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized. 839-840

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? A.Assist the client to ambulate every 2 to 3 hours. B.Place the client in semi-Fowler's position. C.Instruct the client to perform Valsalva maneuver. D.Attempt to overhydrate the client with fluids.

B Nursing interventions include notifying the physician immediately, calling the medical intervention team, maintaining the client on bed rest in the semi-Fowler's position, assessing vital signs frequently, administering oxygen, administering medications (e.g., anticoagulants, analgesics), and instructing the client to avoid Valsalva maneuver (this prevents increased intrathoracic pressure and, possibly, increased emboli).

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? A.Place the client in the prone position. B.Place the client in a flat position with legs elevated 45 degrees. C.Remove extra coverings on the client to keep temperature down. D.Do not administer any further medication.

B Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.

A nurse caring for a patient postoperatively notes that the patient's wound dressing was clean before but now has a large amount of fresh blood. What intervention should be taken by the nurse in this situation along with notifying the primary care provider? a) Change dressing b) Reinforce dressing c) Remove dressing d) Leave dressing as is

B Reinforce dressing Explanation: The nurse should not remove the dressing, but instead should reinforce the dressing with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. 840

An intensive care unit (ICU) nurse does not notice the noise within the environment. However, a client's family member states, "How can you stand it here? The lights, sounds, and activity would drive me crazy and I could not take it." How might noise in the ICU affect the client's well-being? A.Sensory overload can cause anxiety and irritability. B.Sensory adaptation occurs in the intensive care unit. C.Clients would be put in a state of sensoristasis. D.Increased noise levels depress the reticular activating system.

B Sensory stimulation in the environment affects sensory perception. The lights, sounds, and action in the ICU may put the client in a state of sensory overload, which results in irritability, anxiety, and difficulty concentrating. Sensoristasis is the state of optimal arousal. Sensory adaptation occurs when the brain stops perceiving constant stimuli. The RAS, or reticular activating system, brings together information from the brain with information from the sense organs.

The PACU nurse has received a semiconscious client from the operating room and reviews the chart for orders related to positioning of the client. There are no specific orders on the chart related to the client's position. In this situation, in what position will the nurse place the patient? a) Trendelenburg position 'b) Side-lying position c) Supine position d) Prone position

B Side-lying positionExplanation: If the client is not fully conscious, place the client in the side-lying position, unless there is an ordered position on the client's chart. 841

An adolescent describes a dysfunctional home life to the nurse and reports smoking marijuana to help cope with the situation. How will the nurse identify this form of coping? A.beneficial B.maladaptive C.cultural D.generational

B Substance use, beginning or increasing smoking, oversleeping, overeating, undereating, oversleeping, overexercising, excessive daydreaming, and fantasizing are various ways that individuals with the inability to cope with stress successfully deal with stress.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? A.Notify the health care provider. B.Apply warm blankets to the client. C.Apply an oxygen saturation monitor. D.Check the client's blood pressure.

B The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediatel

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. .What is the nurse's mostappropriate response? A.Explain the rationale for preoperative fasting to the client. B.Inform the anesthesiologist or surgeon of this fact. C.Assess the client's abdomen by inspection and auscultation. D.Have the OR postpone the surgery due to the risk of aspiration

B The surgeon or anesthesiologist must be informed if a client has not adhered to preoperative fasting instructions, since this constitutes a risk for aspiration. There is no benefit to assessing the client's abdomen. Unilaterally postponing the surgery would be beyond the nurse's scope.

A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms? A.obstructive sleep apnea B.moderate anxiety C.type 2 diabetes D.herniated lumbar disc

B This client may have increased anxiety from adjusting to retirement, a significant life stressor. There are not enough data to identify any of the other disorders as being present.

What is the rationale for having the client void before surgery? a) To assess for pregnancy in women b) To prevent bladder distention c) To prevent electrolyte imbalance d) To assess for urinary tract infection

B To prevent bladder distentionExplanation: Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure. 834

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, ."I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? A.Assess the client's rationale and affirm that she has made a good decision. B.Explore the client's feelings and inform the surgeon. C.Remind the client that she has signed the informed consent documents. D.Ask the client about her understanding of the potential benefits of the surgery.

B he nurse should discuss this and notify the care provider. Clients should not undergo surgery until they are sure that surgery is what they want. Informed consent documents do not bind the client to an earlier decision. It would be inappropriate to try to convince the client to go through with the surgery if she is questioning her decision.

Select all answer choices that apply.A nurse is caring for an inpatient client scheduled to undergo a surgery for the removal of a malignant tumor. Which of the following are risk factors that increase the likelihood of perioperative complications? Select all that apply. a) Raised temperature b) Obesity c) Low hemoglobin d) Bleeding tendencies e) Anxiety

B, C, D • Obesity• Bleeding tendencies• Low hemoglobin Explanation: Certain surgical risk factors, such as obesity, bleeding tendencies, low hemoglobin, smoking, diabetes, cardiopulmonary disease, drug and alcohol abuse, and diabetes, increase the likelihood of perioperative complications. Raised temperature and anxiety are causes for postponing or cancelling the surgery. 825

The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse identifies that the education has been effective when the family says they will know that death is imminent when they see which related symptoms? Select all that apply. A.Increased body temperature B.Restlessness C.Cyanosis of dependent areas D.Bowel incontinence E.Irregular respiratory rate

B, C, D, E,

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. a.administering inhalation anesthetics b.positioning the client on the operating table c.monitoring the client's vital signs d.administering regional nerve blocks e.counting sponges before and after surgery

B, C, E

Sensory function begins with the reception of stimuli by the senses. Which are special senses? Select all that apply. A.Kinesthetic B.Auditory C.Visual D.Visceral E.Gustatory

B, C, E Visual (sight), gustatory (taste), auditory (hearing), olfactory (smell), and tactile (touch) sensations are special senses. Their respective receptor organs are the eyes, taste buds of the tongue, the ears, the nose, and nerve endings in the skin. Kinesthetic and visceral sensations are somatic senses. Their receptors are nerve endings in the skin and body tissues.

A client experienced a fight-or-flight response immediately following a car accident. What clinical symptoms would the nurse expect to assess? Select all that apply. A.pupil constriction B.decreased digestion C.pallor D.relaxed muscle tone E.increased heart rate F.heightened awareness

B, C, E, F, When a situation occurs that the mind perceives as dangerous, the sympathetic nervous system prepares the body for a fight-or-flight response. Increased heart rate, decreased digestion, heightened awareness, and pallor are all clinical presentations of the sympathetic nervous system. Pupil constriction and relaxed muscle tone are associated with the parasympathetic nervous system, which restores equilibrium when danger is no longer present.

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply. A.Strong, bounding pulse B.Decreased urine output C.Regular deep respirations D.Pale, cool skin E.Irregular heart rate

B,D,E

While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of which of the following? a) Bowel functioning ceases due to becoming permanently paralyzed b) Bowel shrinks and appears deflated c) Bowel makes loud sounds constantly d) Bowel functioning is significantly decreased

Bowel functioning is significantly decreased Explanation : The nurse knows that when a client has paralytic ileus, the bowel functioning decreases significantly. In some cases, intestinal peristalsis may temporarily cease altogether, but it does not become permanently paralyzed. The bowel does not become deflated, but it does become distended and partially paralyzed. Bowel sounds are usually absent. 845

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model? A.denial B.acceptance C.bargaining D.depression

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing? a) Ask the client to drink plenty of water before coughing. b) Ask the client to lie in a lateral position when coughing. c) Administer prescribed pain medication 30 minutes before deliberately attempting to cough .d) Administer prescribed pain medication just before coughing.

A nurse asks a client to remove the dentures before administering anesthesia. What is the main reason the dentures must be removed prior to the administration of anesthesia? a) To retain oral fluids b) To avoid blood contamination c) To prevent airway obstruction d) To preserve facial contours

A nurse finds that a patient's temperature is increasing more than 1°C per hour when using a forced-air warming device to treat his postsurgery hypothermia. What condition might occur if this patient's temperature increases too rapidly?a) Hypertension b) Cardiac arrest c) Hypotension d) Respiratory distress

A nurse is assisting a physician in an emergency surgery for a client with intestinal perforation. Which of the following descriptions is most suitable to the type of surgery performed? a) Surgery performed at the client's request b) Surgery required within one or two days c) Surgery required immediately for survival d) Surgery planned as per client's convenience

The nurse is caring for a client with terminal illness who is refusing food and fluids. The family is concerned and suggests that a feeding tube be used. Which is the best response by the nurse? A."Stop feeding the patient by mouth! You will make him choke!" B."I will get some liquids and pureed foods for you to feed your loved one." C."When clients are in this stage, food and fluid are unnecessary." D."Do you feel that if you force your loved one to eat, he will get better?"

The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? a) After the pain becomes severe and relaxation techniques have failed b) When there is no pain, but it is time for the medication to be administered c) Before the pain becomes severe d) When the client experiences a pain rating of "10" on a 1-to-10 pain scale

When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of a) Effects of anesthesia b) Normal return of reflexes c) Partial airway obstruction d) Type of surgery

Which client is at greatest risk of sensory overload? A.an 8-year-old in isolation in a private room in a hospital B.a 17-year-old on bed rest after a surgical procedure C.an 88-year-old on a ventilator in an intensive care unit D.a 55-year-old, newly diagnosed with diabetes in a private room in a hospital

Which way can the nurse decrease the sensory deprivation that the client in isolation experiences? A.Remove clocks from the room so the client does not focus on time. B.Allow family and friends to visit during most difficult times of the day. C.Visit the client often to develop trust. D.Discourage self-care activities that overstimulate the client's sensory perception too suddenly.

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation? A - "Palliative care is the gradual withdrawal of mechanical ventilation from a client with terminal illness and poor prognosis. "B - "In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops." C - "The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." D - "The client will have to go to an inpatient hospice unit in order to receive palliative care."

C (Explanation:Palliative care involves taking care of the body, mind, spirit, heart, and soul. It views dying as something natural and personal. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. A do-not-resuscitate order means that no attempts are to be made to resuscitate a client whose breathing or heart stops. Gradual withdrawal of mechanical ventilation from a client with a terminal illness and poor prognosis is called terminal weaning. Clients do not have to be in an inpatient hospice unit to receive palliative care.)

A client in the immediate postoperative period begins to report nausea and begins vomiting. Which is the priority nursing action? A.Document the characteristics of emesis B.Provide an emesis basin at the bedside C.Make client NPO and auscultate bowel sounds D.Administer an antiemetic medication

C A concern regarding nausea and vomiting in the immediate postoperative period is paralytic ileus. As such, the nurse should immediately make the client NPO, auscultate bowel sounds, and notify the health care provider. Absent bowel sounds can indicate a paralytic ileus. Placing an emesis basin at the bedside is not the priority but is helpful. Administering the antiemetic is not the priority, as assessment should be done first. Documenting characteristics of the emesis should be done, but assessment of the abdomen takes priority.

A nurse is assessing a client with stress-related problems. Which factor influences responses to stressors? A.economic status B.eating habits C.social support D.personal hygiene

C A person's response to stressors depends on social support, intensity of the stressor, number of stressors, duration of the stressor, physical health status, life experiences, coping strategies, personal beliefs, attitudes, and values. A person's response to stressors is independent of education, eating habits, economic status, or personal hygiene.

Which of the following clients most likely requires special pre-operative assessment and treatment as a result of his or her existing medication regimen? a) A man who regularly treats his rheumatoid arthritis with over-the-counter nonsteriodal anti-inflammatory drugs (NSAIDs) b) A man who takes an angiotensin-converting enzyme (ACE) inhibitor because he has hypertension c) A woman who takes daily anticoagulants to treat atrial fibrillation d) A woman who takes daily thyroid supplements to treat her longstanding hypothyroidism

C A woman who takes daily anticoagulants to treat atrial fibrillationExplanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. 826

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client? A.Inform the client to tell the anesthesiologist. B.Obtain latex-free gloves for the client's room. C.Note the allergy on the client's record. D.Place a sign on the client's bed.

C Assessing the client for allergies to medications, food, and latex when in a health care facility is an important task of the nurse. Clearly marking the client's allergies on the client's record will communicate to all health care personnel who interact with the client. It is not the client's responsibility to notify the anesthesiologist; the allergy should be clearly noted on the medical record. Obtaining latex-free gloves for the client's room is an appropriate intervention, but it will not communicate to all hospital staff the client's allergy. Placing a sign on the client's bed will inform bedside caregivers of the allergy, but clearly marking the medical record will inform all health care staff of the client's allergy.

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family? A.Disturbed Thought Processes related to sensory overload B.Impaired Skin Integrity related to absent tactile sensation C.Impaired Parenting associated with failure to provide stimuli for growth D.Deficient Diversional Activity related to impaired senses

C Based upon lack of stimuli (sensory deprivation), an appropriate nursing diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There is no information that states the child has impaired senses, sensory overload, or impaired skin integrity.

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, A."My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? B.Insert a catheter into the bladder. C.Inform the operating room staff and assist the client to the bathroom. D.Remind the client that bladder fullness is a common preoperative sensation. Inform the client that anesthesia will prevent the bladder from emptying du

C Clients should empty the bowel and bladder before surgery. A urinary catheter is not indicated. The remaining statements are untrue.

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? A."I will splint my incision while I cough." B."Every 2 hours while I am awake, I will take deep breaths and cough." C."While my pneumatic compression device is on, I don't need to do leg exercises." D."I will sit up in bed before using my incentive spirometer."

C Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia.

A nurse is meeting with a young woman who has recently lost her mother, lost her job, and moved with her husband to a new city. She is reporting acute anxiety and depression. What does the nurse know about stress that would be helpful with this client's situation? A.Adaptation often fails during stressful events and results in homeostasis. B.Acute anxiety and depression are seldom associated with stress. C.Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease. D.Stress is a part of our lives and eventually this young woman will adapt.

C Four concepts—constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Homeostasis is maintained through emotional, neurologic, and hormonal measures; stressors create pressure for adaptation. Sometimes too many stressors disrupt homeostasis, and if adaptation fails, the result is disease. If a person is overwhelmed by stress, that person may never adapt. Acute anxiety and depression are frequently associated with stress.

A nurse admitting an unconscious person to the unit considers which guideline when performing care for this client? A.Hearing is the first sense lost in an unconscious client; therefore, verbal communication is unnecessary. B.Keep the environmental noise level high in the client's room to help stimulate the client. C.Assume the client can hear you, and talk with him or her in a normal tone of voice. DDo not touch the unconscious client unnecessarily because it may confuse him or her.

C Hearing is usually the last sense lost, making it important to converse with all clients, including unconscious ones, in a normal tone of voice. Touching the unconsciousness client shows care and concern, and provides tactile stimuli. A high environmental noise level may overstimulate an unconscious client.

A nurse is assessing the pre-operative checklist of a client. Which of the following observations listed in the pre-operative checklist should the nurse verify? a) If the client has worn a fresh set of clothes b) If the client has worn his or her dentures c) If the client has urinated properly d) If the client is responding to reversal drugs

C If the client has urinated properly Explanation: In a pre-operative checklist, the nurse verifies that the client has urinated, is wearing an identification bracelet, has removed his dentures, and is wearing only a hospital gown and hair cover. Nurses assess a client's response to reversal drugs not when checking the pre-operative checklist but rather when the client is recovering from anesthesia. Reversal drugs are given to clients in case they become overly sedated. 837

Which of the following clients will see the greatest permanent changes in lifestyle following surgery? a) Left mastectomy b) Right total knee replacement c) Ileostomy d) Appendectomy

C Ileostomy Explanation: Permanent changes in the client's activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.845

A client who is blind is said to be experiencing: A.sensory deprivation. B.sensory overstimulation. C.sensory deficit. D.sensory overload.

C Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit. Sensory overload is excessive stimulation of one or more of the senses. Sensory deprivation is insufficient stimulation of one or more of the senses. Sensory overstimulation is not a common term used in health care.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls? A.Educate the client on the risk for falls. B.Require a family member to be in the room at all times. C.Monitor the client frequently. D.Secure a restraint order from the health care provider.

C Individualized nurse-client interaction promotes sensory health function. Clients at risk for sensory deprivation may need frequent interaction initiated by the nurse, whereas others may not. In any case, provide appropriate stimuli, such as addressing the client by name, introducing and reintroducing yourself as necessary, explaining all activities, and when leaving, acknowledging when you will return. Family may not be available to assist with client at all times. With a sensory deprivation, the client may not understand the nurse's teaching about fall prevention. Restraints should be used if other less restrictive measures have been exhausted.

A client has just been told that he has lung cancer. The health care provider then describes several potential courses of treatment to the client. When the health care provider leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing: A.sensory perception. B.sensoristasis. C.sensory overload. D.sensory deprivation.

C Sensory overload occurs when a person is unable to process or manage the intensity or quantity of incoming sensory stimuli. Imparting information to a client may lead to sensory overload. Some examples include educating a client on a procedure, informing a client about a diagnosis, making requests of a client, or helping the client solve a problem.

The young adult client is awaiting diagnostic test results for cancer. The client will not sit in the chair and is pacing in the room. The client's heart rate is 112 bpm and respirations are 32 breaths/min. The client's speech is rapid and makes little sense. The nurse assesses the client level of anxiety as: A.moderate. B.panic. C.severe. D.mild.

C Severe anxiety is manifested by difficulty communicating verbally, increased motor activity, tachycardia, and hyperventilating. Mild anxiety is present in everyday living and is manifested by restlessness and increased questioning. Moderate anxiety is manifested by a quavering voice, tremors, increased muscle tension, and slight increases in heart and respiration rates. Panic is manifested by difficulty with verbal communication, agitation, poor motor control, tachycardia, hyperventilation, palpitations, choking sensation, and chest pain or pressure.

A nurse is working with a preceptor after transferring to a unit where many of the clients are confused or unconscious. The preceptor determines that teaching is necessary when this nurse interacts with an unconscious client in which manner? A.Turns off the radio playing at the bedside while starting an intravenous line. B.Calls the client by name. C.Approaches the bed, takes the client's hand, and introduces herself. D.Explains the steps of the procedure about to be performed.

C The nurse should speak before touching the client. It is unknown if unconscious clients can hear and understand, but the nurse should assume they can. Explaining the steps of a procedure and calling the client by name are appropriate as is turning off background noise while speaking to the client.

9. A patient has a chloride level of 63 mEq/L. The patient is experiencing lethargy, confusion, spasms of muscles, and has a blood pressure of 90/54. What other lab finding below correlates with these findings?(Required) A. Potassium 4 mEq/L B. Potassium 8 mEq/L C. Sodium 115 mEq/L D. Sodium 190 mEq/L

C. A normal chloride level is 95-105 mEq/L. The patient is experiencing hypochloremia. Remember sodium and chloride mirror each other (when one is low the other is as well and vice versa). The patient is exhibiting signs and symptoms of hyponatremia. Therefore, a sodium level of 115 mEq/L would correlate with these findings.

During an interview of the client at the community clinic, the nurse finds that the client is providing care for a parent, who is terminally ill. Which statement by the client indicates anticipatory grieving? A"There is no way I can stay in the hospital because my parent is sick." B."I do not think my parent really has cancer. I think my parent needs to get a third opinion." C"It is fine if my parent dies. We have not been close for years." D"My parent is suffering with cancer and death will be a relief of the pain."

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response? A.Hospice provides physical and psychological support; palliative care provides social and spiritual support. B.Hospice care focuses on quality of life while palliative care focuses on length of life. C.Hospice care differs from palliative care in its foundational philosophy. D.Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness.

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? A."You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis." B."You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis." C."You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis." D."You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis."

D A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or opioids. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration.

A client is discussing stressors with the nurse and is describing how she feels better when she takes a brisk walk. The client's action is an example of: A.buffering. B.appraisal. C.secondary appraisal. D.adaptation.

D Adaptation is the process of adjusting to, or accommodating, a stressor. Appraisals involve the subjective evaluation of a potential stressor. Buffering is something that reduces the intensity of stress.

Upon admission for an appendectomy, the client provides the nurse with a document that specifies instructions his health care team should follow in the event he is unable to communicate these wishes postoperatively. What is the document best known as? a) An informed consent b) An insurance card c) A Patient's Bill of Rights d) An advance directive

D An advance directive Explanation: An advance directive, a legal document, allows the client to specify instructions for his or her health care treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the client to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for health care.823

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask? A."Do you live by yourself?" B."Are you receiving chemotherapy?" C."Do you have diabetes?" D."Do you work around loud noises at work?"

D Clients may be at risk for sensory disturbances for different reasons. Lifestyle factors include work or leisure activities that are potentially harmful to the eyes and ears, such as loud noises. Physiologic factors, such as diabetes and use of medications (chemotherapy), place clients at risk for sensory disturbances as well. Social and environmental factors include human and environmental stimulation (living by oneself).

The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? A.Have the client's family member sign the consent form. B.Immediately have the client sign the consent form. C.Ask the client if he still wants to proceed with the procedure. D.Notify the physician of the oversight.

D Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as opioids or barbiturates, can alter cognitive abilities and invalidate informed consent.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? a) Palliative surgery b) Elective surgery c) Diagnostic surgery d) Emergency surgery

D Explanation: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness, and diagnostic surgery is done to make or confirm a diagnosis. 821

A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to: A.sensory reaction. B.sensory transmission. C.sensory perception. D.sensory reception.

D Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli. In this case, sound is unable to stimulate the organs of hearing and the client does not have a deficit in the perception, transmission, or reaction to sound. Sensory perception of pain would come from temperature, mechanical, electrical or chemical stimuli. Sensory transmission occurs by a nerve that passes impulses from receptors toward or to the central nervous system through the afferent nerve and the dorsal root that passes dorsally to the spinal cord and that consists of sensory fibers. A sensory reaction is the reaction time during which the subject's attention is directed to the stimulus rather than the response.

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem? A.Disturbed sensory perception B.Acute confusion C.Chronic confusion D.Impaired memory

D Impaired memory is a state in which an individual experiences the inability to remember or recall bits of information or behavioral skills. Disturbed sensory perception is a state in which the individual experiences a change in the amount, pattern, or interpretation of incoming stimuli. Acute confusion is the abrupt onset of a cluster of global, transient changes, and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep-wake cycle. Chronic confusion is an irreversible, long-standing, or progressive deterioration of intellect and personality, characterized by decreased ability to interpret environmental stimuli or decreased capacity for intellectual thought.

An occupational health nurse at an oil refinery on the Gulf Coast of Texas performs client education with an adult client. The client is being seen after having suffering a chemical burn in an accident at the refinery. Which type of stressor has this client been exposed to? A.psychosocial B.socioeconomic C.maturational D.physiologic

D Physiologic stressors include chemical agents (drugs, poisons), physical agents (heat, cold, trauma), infectious agents (viruses, bacteria), nutritional imbalances, hypoxia, and genetic or immune disorders. Psychosocial stressors include both real and perceived threats. Environmental stressors are items found in our surroundings, such as noise and crowds. Socioeconomic stressors relate to income and home life (such as low household income and low occupational status of the householder).

A nurse has been caring for a client who experienced a physical assault a year ago. The client now describes being "totally recovered from it." Which stage of stress is the client currently experiencing? A.primary stage B.alarm stage C.exhaustion stage D.resistance stage

D The client is in the resistance stage, where the body has returned to the homeostasis state. The mind or brain is normal again, so the incident does not affect the client anymore. In the alarm stage, the stimulating neurotransmitters and neurohormones prepare the client for a fight-or-flight response. When one or more adaptive/resistive mechanisms can no longer protect the client experiencing a stressor, exhaustion occurs. The body loses its capability to fight stress. The primary stage is not related to stages of stress and is applicable for stress prevention.

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? A."We needed to be sure you didn't have any skin breakdown before surgery." B."We wanted to be sure we didn't leave any sponges or syringes underneath you." C."The covers underneath you need to be straightened out. They look messy." D."The operating table is a firm surface; we need to be sure your skin looks okay."

D The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown.

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? A.Have the client perform leg exercises every 30 minutes. B.Administer analgesia (pain medications). C.Encourage the client to create an advance directive. D.Assess the client's allergy status.

D The nurse should assess or confirm the client's allergy status prior to surgery. An advance directive may be in place, but one would not be created on the day of surgery if it were not already established. Analgesia is not normally given preoperatively. Leg exercises should be taught and modeled preoperatively, but they do not need to be performed during this phase.

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider? A."My hip pain has prevented me from doing the things I enjoy." B."I have not had anything to eat or drink for 8 hours." C."My other hip will probably need to be done eventually." D."I've been taking ibuprofen for my hip pain twice a day."

D The nurse should immediately report the use of ibuprofen twice daily for the hip pain since this medication can cause the complication of postoperative bleeding. The history of hip pain and the inability to perform activities that were previously enjoyed are not relevant in determining complications. The intake of food or fluids is relevant, but the amount of time the client has been NPO is acceptable and reduces the risk of complications from anesthesia.

A freshman college student comes to the health clinic reporting insomnia and difficulty concentrating in class. The student has three red, scaly patches of skin on his arms and chest. The nurse believes the primary nursing diagnosis for this client is: A.Impaired Skin Integrity related to psoriasis. B.Sleep Deprivation related to change in living arrangements. C.Disturbed Thought Processes related to increased scholastic workload. D.Anxiety related to stress of achievement in school.

D This student, new to college, is demonstrating classic anxiety symptoms stemming from high stress levels. The best nursing diagnosis would be Anxiety. Sleep deprivation, impaired skin integrity, and disturbances of thought are applicable, but these diagnoses do not address the primary problem.

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? a) Verbalize absence of pain b) Exhibit no bleeding c) Eat without nausea d) Void normally

D Void normally Explanation: Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.845

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? A.Use vocabulary and concepts that are as simple and unambiguous as possible. B.Use written communication whenever possible in order to minimize the client's frustration. C.Repeat each direction or question in different terms in order to maximize understanding. D.Minimize background noises and ensure that lighting is adequate to see the nurse's face.

D When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading. It would be unnecessary and inappropriate to exclusively use written communication with a client who has moderate hearing loss, or to repeat all questions and instructions in different terms. A hearing deficit is not synonymous with a cognitive deficit; consequently, it is not usually necessary to simplify concepts or vocabulary.

Which response to stressors results from the activation of the local adaptation syndrome (LAS)? A.A man is experiencing moderate anxiety before meeting with an important client. B.A woman's impending job interview has prompted the activation of her fight-or-flight response. C.A man has a sudden urge for a bowel movement before undergoing thoracentesis. D.A girl quickly withdraws her hand from a stream of hot tap wat

D he local adaptation syndrome (LAS) is a localized response of the body to stress. It involves only a specific body part (such as a tissue or organ) instead of the whole body. The reflex pain response is a response to physiologic stress that is a component of the local adaptation syndrome (LAS). Psychological anxiety and the activation of the fight-or-flight response are not considered to be manifestations of the local adaptation syndrome. The sudden urge for a bowel movement involves the entire gastrointestinal system and not a tissue or organ.

A nurse is assessing clients in a burn unit for sensory alterations. Which factors contribute to severe sensory alterations? Select all that apply. A.Cultural overload B.Sensory saturation C.Sensory overload D.Sensory discrepancies E.Sensory deprivation F.Sleep deprivation

E, F, B Severe sensory alterations can occur, especially in certain areas, such as the critical care or intensive care units (termed intensive care unit [ICU] psychosis). Factors contributing to severe sensory alteration include sensory overload, sensory deprivation, sleep deprivation, and cultural care deprivation. Sensory saturation and sensory discrepancies are not terms typically used.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? a.Cerebral cortex b.Midbrain c.Medulla d.Hypothalamus

The hypothalamus has control centers for several involuntary activities of the body, one of which concerns sleeping and waking. Injury to the hypothalamus may cause a person to sleep for abnormally long periods. The medulla and midbrain are part of the reticular activating system (RAS), which plays a part in the cyclic nature of sleep. The cerebral cortex does not have any role in the sleep process. d

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? a.tell the family they are causing too much stress b.limit the family visits to once daily c.do not intervene and allow the client to work out the family issue d.explain that family visits and support are important

When a person is experiencing a stressor, it is important for the nurse to reduce or eliminate the stress. In this case, it is appropriate to limit the family visiting time to allow the client to recover without experiencing a stress response. Telling the family they are causing the stress is not therapeutic. Telling the client that the family should be there invalidates the client's feelings. Doing nothing is not an appropriate response to decrease or remove the stressor. b

A 15-year-old student is on the high school soccer team. She tells a nurse how she has really started to take a leadership role on the team. When the nurse talks with the client's mother, the mother tells the nurse that her daughter's best friend is a natural leader and may be voted team captain next year. The client's behavior is an example of what defense mechanism? a.Introjection b.Lying c.Denial d.Projection

A client who was brought to the emergency room for gunshot wounds dies in intensive care 15 hours later. Which statement concerning the need for an autopsy would apply to this client? A - The coroner must be notified to determine the need for an autopsy. B - The closest surviving family member should be consulted to determine whether an autopsy should be performed. C - The physician should be present to prepare the client for an autopsy. D - An autopsy should not be performed because the nature of death has been established.

A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that: A - hospitals are mandated to notify transplantation programs of potential donors. B - nursing focus should be directed at organ donation once it is decided to withdraw life support. C - clients must have an organ donor card to donate organs. D - non-heart-beating cadavers are not potential organ donors.

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action? A - Call a code and begin resuscitating the client. B - Consult with the charge nurse or nurse manager before calling the code. C - Initiate a slow-code until the physician arrives. D - Respect the client's wishes and avoid calling a code.

A patient has a phosphate level of 1.0. Which condition below is NOT a cause of this phosphate level? a*Hypoparathyroidism bOncogenic Osteomalacia cThermal Burns dRefeeding Syndrome

The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain? a."Can you describe the type of pain you are having?" b."How long have you experienced this pain?" c."Could you please rate your pain on a 1-10 scale?" d."When did your pain begin?"

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? a) Sodium b) Magnesium c) Potassium d) Calcium

Which client would the nurse expect to have negative coping skills? a.a 19-year-old diagnosed with schizophrenia who is heading off to college b.a 37-year-old factory worker who is laid off for the summer c.a 13-year-old diabetic who joins a softball league d.a 72-year-old retiree who needs to take an expensive new chemotherapeutic agent

a All of these clients will be facing stressors and need to develop adaptation skills. The client with schizophrenia, a chronic but manageable psychiatric illness, is most at risk for reacting negatively to the new life stressor. Clients with mental illness may have decreased physiologic reserve with which to effectively cope and adapt.

A nurse is providing care to a client who has undergone skin grafting to her face due to a burn injury. The client states, "I know it could have been worse, but my face will never be the same as it was. I haven't been able to look at myself in the mirror because of what I might see." The nurse interprets this statement as most likely reflecting which pattern? a.Body image b.Personal identity c.Role performance d.Self-esteem

a Although self-esteem, role performance, and personal identity are components of self-concept, the client's statements reflect her feelings about her physical appearance, or body image.

A new mother of twins is struggling with role performance issues related to balancing the demands of motherhood with working outside the home. What question would be most appropriate to help the client move forward with a positive self-concept? a."What new behaviors might be necessary to help modify your current roles?" b."Would it be an option for you to quit your job and stay home?" c."What do you think makes this struggle that you feel?" d."Why do you think it is so hard to raise two babies?"

a Asking "What new behaviors might be necessary to help modify your current roles?" allows the client to think through what she could do to regain a sense of balance in the performance of her role. The other options are judgmental or impose solutions versus allowing the client to think through the options related to the role struggle.

An older adult client with a diagnosis of early-stage Alzheimer's disease has recently moved to a long-term care facility, largely as a result of the spouses caregiver burnout. What question can the nurse ask to foster the client's sense of self? a."What line of work were you in?" b."Do you feel like you're adjusting to the routines around here?" c."How did you feel when you first got your diagnosis?" d."How are you feeling about being apart from your wife?"

a Asking a client about his life experiences and accomplishments can help individuals maintain a sense of self, especially later in life. Issues such as separation from a spouse focuses on the client and spouse's relationship are not relevant to a sense of self. Adjustment to a new setting is challenging and focuses on the needs of the client being meet but it does not enhance the client's sense of self. The feelings around a serious diagnosis are important but not relevant with a client with Alzheimer's as they may not recall or have difficulty expressing the feelings.

Which is not a lifespan consideration for sleep cycles? a.By middle age, the frequency of nocturnal awakenings decreases, and satisfaction with sleep quality increases. b.Newborns can sleep up to 16 to 18 hours per day. c.In adolescents, there is a shift to later evening bedtime. d.Getting the toddler and preschooler to fall asleep is a common problem

a By middle age, the frequency of nocturnal awakenings increases, and satisfaction with sleep quality decreases. Situational variables such as job-related stress, pregnancy, parenting, family caregiving responsibilities, and illness may explain these changes in sleep patterns.

The nurse recognizes which statement is true of chronic pain? a.It may cause depression in clients. b.It disappears with treatment. c.It is always present and intense. d.It can be easily described by the client.

a Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation.

The nurse involved in coordinating a support group for spinal cord injury clients learns that one of the participants in the support group was a college athlete prior to his diving accident. The client informs the group that he earned a scholarship based upon his athletic abilities and not his academic performance, and after the injury, he focused his energies on his studies. He has been on the dean's list for two semesters. What defense mechanism is illustrated in this scenario? a.compensation b.sublimation c.projection d.reaction formation

a Compensation is overcoming a perceived weakness by emphasizing a more desirable trait or achieving in a more comfortable area. Sublimation involves a person substituting a socially acceptable goal for one whose normal channel of expression is blocked. Projection is a person's thoughts or impulses attributed to someone else. Reaction formation is the development of conscious attitudes and behavior patterns that are opposite to what he would prefer to do.

The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take? a.Assess the client's vital signs and pulse oximetry. b.Ask a peer to come and observe the sleep pattern. c.Call a code blue, as the client is not breathing. d.Review the client's medical record for sleep disturbances.

a Considering the client's sleep pattern, including periods of apnea; obesity; and cardiovascular disease, the client is likely experiencing sleep apnea. Sleep apnea may result in periods of life-threatening apnea, hypoxia, and bradycardia. As such, the nurse should awaken the client, obtain and record vital signs, and notify the health care provider of the sleep pattern and vital sign results. Calling a code blue is inappropriate, as the client is experiencing periods of apnea that are consistent with a sleep disorder and there is no indication that the client does not have a pulse. Asking a peer to observe the sleep pattern is inappropriate, as the nurse should assess the client's well-being. Reviewing the medical record is inappropriate, as attention should be on the client's well-being.

Which medical client is most likely to be experiencing diffuse pain? a.A client with shingles affecting her entire torso b.A client who has been prescribed antibiotics for the treatment of strep throat c.A client who has presented to the emergency department with a stab wound d.A client who is undergoing diagnostic testing for appendicitis

a Diffuse pain is pain that covers a large area and, usually, the client is unable to point to a specific area without moving the hand over a large surface, such as the client's entire torso. Pain related to appendicitis, a stab wound, or strep throat is more likely to be localized and sharp.

The nurse should obtain a sleep history on which clients as a protocol? a.all clients admitted to a health care agency b.only clients who suffer from a sleep disorder or have been unconscious c.only clients who have been suffering from a sleep disorder d.clients who suffer from a sleep disorder or who are spending time in the CCU

a Interview questions help identify the client's sleep-wakefulness patterns, the effect of these patterns on everyday functioning, the client's use of sleep aids, and the presence of sleep disturbances and contributing factors. If the client's sleep is adequate and poses no problems, the sleep history may be brief but should still be conducted. As issues or concerns are identified in the general assessment, more detailed questions can be asked to gather more information.

A client who is diagnosed with renal failure has been informed about the need to start dialysis. Which assessment information supports the client is struggling with a change in life role? a.Client exhibits signs of posttraumatic stress disorder b.Client continues on with life as usual c.Client's lack of interest in sexual relations with the spouse d.Client's worry about the inability to continue work

a Life roles, such as one's occupation or profession, can constitute a major portion of a person's identity. The ability to successfully execute societal roles, as well as one's own expectations regarding role-specific behaviors (or role performance), is easily compromised by illness or injury. The inability to work temporarily is an example of this. A lack of interest in sex would be a normal response to illness. The client showing no changes and continuing on with life as usual would not signify struggle. Posttraumatic syndrome is a mental health condition that is triggered by a terrifying event—either experiencing it or witnessing it.

A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the bestresponse by the nurse? a."Light therapy can be beneficial and help ease the transition to a new time schedule or zone." b."Try to stay awake for the duration of the flight and sleep when you arrive." c."You should take sleeping pills when you board so that you will sleep until you arrive at your destination. d."If you have jet lag once, you shouldn't have any further problems on your next

a Light therapy helps ease the transition to a new schedule or time zone. It involves exposing the client's eyes to an artificial bright light that simulates sunlight for a specific and regular amount of time during the time the person should be awake. Sleeping pills may exacerbate the jet lag and cause difficulty regulating sleep patterns. The client should attempt to nap while on the plane and not try and stay awake to be able to adjust to the new time zone. Jet lag not only occurs once, it can be a repeated experience each time transition to a new time zone occurs.

How can nurses who provide care in long-term care settings best enhance the self-esteem of older adults who reside in these facilities? a.Maximize the autonomy of residents in organizing their routines. b.Provide opportunities for the residents to engage with children and adolescents. c.Encourage residents to talk openly about their opinions. d.Ensure that residents are not presented with tasks that carry a risk of failure.

a Maximizing autonomy and control is likely to enhance the self-esteem of older adults who may be very aware of their increasing dependence and loss of control. Encouraging frank discussion and interaction with other generations are also positive interventions, but these are less direct methods of fostering self-esteem. It is inappropriate to completely remove all risk of failure from older adults' activities as this encourages growth even in the older adult years.

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because: a.they may be disoriented on awakening. b.they are the age group least likely to use prescribed sleep medications. c.they nap in the afternoon, which lessens their hours of sleep at night. d.they are typically prone to sleep walking.

a Older adults sleep less soundly for less time, and have little or no Stage IV deep sleep. It is common for them to be confused upon awakening, which could lead to injury. Napping does not alter their safety. Somnambulism is commonly seen in children. Older adults commonly take prescribed or over-the-counter sleep aids.

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? a."I should only take medication when my pain is intense." b."I give myself the pain medication by pushing the button." c."The pump is programmed to limit the chance of overmedicating." d."This will allow me to control my own pain medication."

a PCA pumps allow the client to control the amount and timing of pain medication by pushing a button when the sensation of pain occurs versus waiting until the pain becomes intense. The pump is programmed with a lockout period that limits the chance of clients overmedicating themselves.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? a.The dose that is delivered when the client activates the machine is preset. b.An antidote is automatically delivered if the client exceeds the recommended dose. c.Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. d.Thorough client education is necessary to prevent overdoses.

a PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdose

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? a.referred pain b.limited pain c.chronic pain d.acute pain

a Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

4. A patient is admitted to the ER. The patient receives dialysis on Tuesdays and Thursdays of every week, and presents with a palpable AV shunt (thrill present) in the left upper arm. The patient is extremely lethargic and family members are present to help answer questions. While collecting the patient's medication history the daughter states her mother has been taking "a lot" of Maalox lately due to upset stomach. You note this to be a significant finding. Which of the following lab values correlates with this finding?* A. Magnesium level of 1.0 B. Magnesium level of 2.4 C. Magnesium level of 3.6 D. Magnesium level of 1.4

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to: a.anticipate sleeping overnight at a health care center. b.take a prescribed sedative before trying to sleep. c.apply a facial mask that will deliver positive air pressure. d.insert an oral appliance prior to attempting sleep.

a Polysomnography is a sleep study. The client will be scheduled for the study at a health care center and sleep overnight as part of the study. The client should avoid sedatives, as this will aggravate OSA. Interventions for OSA include inserting an oral appliance or applying a facial mask for continuous positive airway pressure.

A client is using prayer to assist in relieving stress. How would the nurse respond when entering the room to administer medication? a.Leave and allow the client to continue for as long as needed. b.Softly alert the client it is time for medication. c.Ask if there is anything the nurse can do to make this activity more comfortable. d.Place the medication on the hospital tray and return to ensure it has been taken.

a Prayer and meditation aid the client in physical relaxation, connection with the inner self, and accessing higher power. Because prayer and meditation are highly personal, some clients may wish for the nurse to participate with them, while others may not. The nurse should allow the client to complete this activity without interruption. The nurse should not leave medication in the room for the client to be responsible to take on one's own. After the client has completed the prayer, then the nurse may ask if there is anything that can be done to help make this practice more comfortable in the future.

A nurse is providing community education about the importance of getting enough sleep. Which information about REM sleep is most accurate? a.It plays a role in memory. b.The blood pressure decreases. c.Muscle tone is enhanced. d.The person is easily arousable.

a REM sleep is believed to play a role in learning, memory, and adaptation. It is more difficult to arouse a person during REM sleep than during NREM sleep. During REM sleep, the pulse, respiratory rate, blood pressure, metabolic rate, and body temperature increase, whereas general skeletal muscle tone and deep tendon reflexes are depressed.

nurse encourages a young female whose leg was amputated to continue to pursue her dream to become a dancer. How does the nurse identify this need to reach one's potential through full development of one's unique capability? a.Self-actualization b.Self-esteem c.Self-concept d.Ideal self

a Self-actualization refers to the need to reach one's potential through full development of one's unique capabilities. Self-concept includes personal identity, body image, self-esteem, and role performance. Self-esteem is the need to feel good about oneself and to believe that others hold one in high regard. Ideal self constitutes the self one wants to be.

During an interview, the client tells the nurse, "I know who I am and I know my strengths and weaknesses." How will the nurse interpret this statement? a.self-concept. b.social self. c.self-expectation. d.self-evaluation.

a Self-concept is the mental image a person has of oneself. It is the person's meaning when stated as "I" or "me." Self-concept is the frame of reference that influences how a person handles situations and relationships. Self-expectation involves the "ideal" self — the self a person wants to be. It is the setting of present and future goals. Social self is how a person sees himself in relation to social situations, including behavior and interaction with others. Self-evaluation is the conscious assessment of the self, leading to self-respect or self-worth. "Have I met my expectations? Do I like who I see in the mirror? Do I like how I behave?"

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns? a.sleep paralysis and automatic behavior b.hypnogogic hallucinations and sleep paralysis c.cataplexy and hypnogogic hallucinations d.sleep paralysis and hypnogogic hallucinations

a Sleep paralysis occurs when the person cannot move for a few minutes just before falling asleep or awakening. Cataplexy occurs with a sudden loss of muscle tone triggered by an emotional change such as laughing or anger. Hypnogogic hallucinations are dream-like auditory or visual experiences while dozing or falling asleep. Automatic behavior is the performance of routine tasks without full awareness, or later memory, of having done them. This client experiences sleep paralysis and automatic behavior

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? a.A client who has a sprained ankle b.A client who has appendicitis c.A client with chest pain who is having a myocardial infarction d.A client suspected to have a perforated peptic ulcer

a Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed such as with a ruptured peptic ulcer or appendicitis. A client having a myocardial infarction with chest pain is experiencing referred pain.

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: a.actively solicit information about the client's pain level. b.document the client's lack of medication. c.ask the client's family if he ever uses pain medicines. d.assume the client does not need medication.

a Some cultures see pain tolerance as a virtue; often men are expected to tolerate pain more stoically than women do. Health care providers need to recognize the client's cultural beliefs and not impose their own judgments

A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis? a.Provide an opportunity for the client to talk about concerns. b.Use tactile relaxation techniques, such as a back massage. c.Bring the client a warm glass of milk at bedtime. d.Help the client maintain normal bedtime routine and time for sleep.

a Stress and anxiety interfere with a person's ability to relax, rest, and sleep. The client is scheduled for a surgical procedure in the morning. The nursing diagnosis addresses this particular concern. Providing an opportunity for the client to talk about concerns and issues would be beneficial. The other options are incorrect because the options do not address the situation at hand, or the nursing diagnosis that is noted.

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse? a.Administration of 0.4 mg of naloxone b.Administer a lower dose of the analgesic for the next dose c.Place the client in the supine position d.Begin CPR

a The client is experiencing impending respiratory arrest due to the effect of the medication and this should be reversed immediately prior to arrest. This is the priority action and will correct the respiratory depression immediately. CPR is not indicated at this time, because the client is not in full arrest. Placing the client in the supine position may decrease respirations further.

A nurse is conducting discharge teaching for a postoperative client prescribed oral pain medication. The client states that pain medications always causes nausea. What is the appropriate response by the nurse? a."Do you take the medication on an empty stomach?" b."Do not take the pain medication." c."Take the pain medication with an antacid." d."Does the nausea go away after a while?"

a The nurse should ask the client whether the pain medication is taken on an empty stomach, as this can be the reason for the nausea. Clients should be taught to avoid taking pain medication on an empty stomach. The nurse should not encourage the client to not take the medication if it is helping with the pain. Taking the medication with an antacid is not warranted because the antacid will neutralize acid, not stop the overproduction of the acid. Asking the client if the nausea goes away is not the right question to determine the cause of the nausea.

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? a.reviewing and revising the pain management treatment plan b.beginning pain medications before the pain is too severe c.administering a placebo and performing a reassessment of the pain d.judging whether the client is in pain or is just depressed

a The nurse's focal point should be on reviewing and revising the pain management treatment plan presently in place. The client is status-post bowel resection, so administering a placebo is not the correction option, and could be ethically wrong. The nurse would possibly do a depression assessment, but if the client is reporting constant pain, the pain management plan must be reviewed and revised. The question does not address if the client is taking pain medications, so the option addressing beginning pain medications before the pain is too severe is not correct.

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention? a.Low-flow oxygen b.A hypnotic medication c.An opioid medication d.Warm milk

a The pattern of frequent arousals seen in people with chronic obstructive pulmonary disease may result from the body's adaptation to maintain adequate oxygenation. Usually, these clients require low doses of oxygen at night.

the nurse is performing an assessment for a client related to pain. To determine the need for pain medication, on what primary source will the nurse base the decision? a.nonverbal clues b.increased respiratory rate c.verbal report d.generalized increase in metabolism

a Verbal reports of pain, although subjective, are the most dependable indicators of pain in people who are able to communicate verbally. Therefore, the nurse should use them as the primary source of data, even if they vary from other objective information. The nurse also collects objective data. Pain often increases respiratory and heart rates, as well as blood pressure. Pain often sets off a generalized increase in metabolism, such as an increase in oxygen consumption, blood glucose, free fatty acids, blood lactate, and ketones. Nonverbal cues, such as grimacing and increased muscle tension, may also be used.

In which client would a back massage be contraindicated? a.Client who has a fractured rib b.Client who is experiencing anxiety c.Client who has diabetes mellitus d.Client who is ambulatory

a back massage would be contraindicated in a client who has a fractured rib as the massage could accidently dislodge the fracture and cause injury to nearby organs. Back massage is also contraindicated in clients with severe burns because of the risk of disturbing the wounds and in clients who have recently had open heart surgery because of the risk of injury to the new sternal incision. None of the other clients present a contraindication to back massage. Back massage does not present a risk for the client who is ambulatory, experiencing anxiety, or has diabetes mellitus. In fact, it could be quite beneficial, as massage helps the client to relax and helps relieve muscle tension, hopefully helping him or her to rest and sleep better while hospitalized.

Which signs assessed in a dying client would the nurse recognize as signs of death? Select all that apply. A - Nausea, flatus, abdominal distention B - Racing pulse C - Cheyne-Stokes respirations D - Increased body temperature E - Increased blood pressure F - Loss of movement, sensation, and reflexes

a c f

7. Which arrhythmia is a patient who has a Mg+ level of 0.8 most likely to experience?* A. Heart block B. Bradycardia C. Torsades de pointes D. Normal sinus rhythm

A rehabilitation nurse is caring for Steve Branson, a 23-year-old man, who has suffered a spinal cord injury and has tetraplegia. One of the rehabilitative goals for Steve is to attain adaptive patterns of behavior related to his injury. Which of the following would indicate that he is achieving this goal? Choose all that apply. a.makes decisions related to his care b.uses available resources c.refuses necessary help d.depends on others for care e.declines responsibility for his care

a, b Independence-dependence patterns include the following: (a) adaptive responses, in which a client assumes responsibility for care (makes decisions), develops new self-care behaviors, uses available resources, and interacts in a mutually supportive way with family; (b) maladaptive responses, in which a client assigns responsibility for his care to others, becomes increasingly dependent, or stubbornly refuses necessary help.

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. a.Distended neck veins b.Crackles in the lung fields cShortness of breath dDecreased blood pressure eBradycardia

a, b, c

A nurse is assessing a client who has experienced significant trauma affecting her body appearance. The nurse identifies a nursing diagnosis of Disturbed Body Image. When developing the plan of care, which information would be most important for the nurse to consider? Select all that apply. a.client's view of the importance of the alteration on the body part or function the medical treatment plan b.feelings associated with the change in body image c.client's perception of the alteration d.the conflict arising from a change in roles

a, b, c, The ability to retain an intact self-concept in the face of illness, trauma, and surgery varies among people. Although the medical treatment plan and any role conflicts that arise due to the trauma may play a role, the person's perception of the alteration and the importance that she places on the body part or function affected (as well as the feelings associated with disturbed body image) will influence body image dysfunction.

The nurse is working on the rehabilitation unit today caring for a client with a traumatic amputation of the left hand 6 days ago. The nurse is assessing the client for adaptive responses to physical deficits. Which statement by the client indicates an adaptive response? Select all that apply. a."I am okay with this now." b."I don't believe this has happened to me." c."I am not worth anything to anybody now." d."I am so angry that this has happened to me." e."I am not going to any of the rehab classes."

a, b, d The client exhibits signs of adaptive behavior by showing grief and mourning (shock, disbelief, denial, anger, guilt, acceptance). The client shows signs of maladaptive behavior by continuing to deny, and to avoid dealing with, the deformity or limitation, engaging in self-destructive behavior, and talking about feelings of worthlessness or insecurity.

A nurse is performing a comprehensive nursing assessment of a client who comes to the clinic for a first visit. When assessing the client's self-concept, which area would be an important focus for this assessment? Select all that apply. a.Self-esteem b.Role performance c.Personal limitations d.Body image e.Personal identity

a, b, d, e The nurse assessing a client's self-concept focuses on personal identity, personal strengths (not limitations), body image, self-esteem, and role performance.

The nurse is caring for a client who has come to the emergency department reporting chest pain rated at 9 on a scale of 1 to 10. The pain shoots down the left arm and started 45 minutes ago. How will the nurse document this pain in the electronic health record? Select all that apply. a.visceral b.chronic c.referred d.acute e.cutaneous

a, c, d Visceral pain (discomfort arising from internal organs) is associated with disease or injury. It is sometimes referred or poorly localized. Referred pain (discomfort perceived in a general area of the body, usually away from the site of stimulation) is not experienced in the exact site where an organ is located. Acute pain (discomfort that has a short duration) lasts for a few seconds to less than 6 months.

A middle-aged client reports to the nurse that the client has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. What should the nurse instruct the client to try? Select all that apply. a.Establish a set time to go to sleep each night. b.Eat a snack that contains a small amount of fat. c.Perform moderate exercise three or four times each week. d.Participate in an enjoyable activity each day. e.Drink one or two ounces of alcohol before bedtime.

a, c, d, Behaviors that will promote sleep include establishing a regular routine, such as time, for bedtime, exercising three to four times each week, and participating in an activity that is enjoyable each day. The client should avoid alcohol and eat a small carbohydrate snack prior to bedtime.

A nurse is reviewing a journal article about the physiology of sleep. The nurse demonstrates understanding of the information by identifying which neurotransmitter as being involved with excitation? Select all that apply. a.Acetylcholine b.GABA c.Serotonin d.Dopamine e.Norepinephrine

a, c, d, e Various neurotransmitters are involved with the sleeping process. Norepinephrine and acetylcholine—in addition to dopamine, serotonin, and histamine—are involved with excitation. Gamma-aminobutyric acid (GABA) appears to be necessary for inhibition.

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included? (Select all that apply.) a.Promote a restful environment. b.Encourage the use of a sitter. c.Play the client's favorite music. d.Encourage increased protein. e.Encourage deep breathing.

a, c, e Anxiety, lack of sleep, and muscle tension may all increase the client's perceived intensity of pain. Therefore, the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay with the client in the room at all times, is not indicated and may cause the client's anxiety level to increase. Encouraging increased protein does not aid in the client's perceived intensity of pain.

A client who works night shift is struggling with sleeping during the day after working all night. What actions can the nurse suggest to help promote sleep? Select all that apply. a.sleeping in a room with curtains that block the light b.reading and drinking coffee before going to bed c.sleeping in a different location for day sleeping d.eating breakfast before going to sleep e.having an alcoholic drink before trying to sleep f.leaving the television on while attempting sleep

a, d Sleeping in darkness or dim light as well as satiation helps to promote sleep. Hunger or thirst can suppress sleep. Varied sleep locations and drinking alcohol or stimulants like caffeine in coffee can also suppress sleep. Leaving the television on creates noise, and a quiet environment is a sleep-promoting factor.

The nurse is massaging an older adult client's back and notices a reddened area on the client's sacrum. What actions would the nurse perform in response? Select all that apply. a.Institute a turning schedule. b.Lightly massage the area. c.Do not massage the client's back; immediately report the area to the physician. d.Document the reddened area on the client's medical record. e.Following the massage, position the client on the sacral area. f.Report the finding to the primary care provider.

a, d, f The nurse would document the reddened area on the client's medical record, report the finding to the primary care provider, and institute a turning schedule. The nurse should not massage the area or position the client on the sacral area. The nurse would not immediately report the area to the physician until further assessment is completed.

. A patient has a Chloride level of 70 mEq/L. Which condition below can cause this type of level?(Required) A. None, this is a normal Chloride level. B. Cystic Fibrosis C. Metabolic acidosis D. Hypertonic fluids

4. You're assessing a patient's morning lab work. The patient has a chloride level of 98 mEq/L. The nurse interprets this finding as?(Required) A. Hypochloremia B. Normal C. Hyperchloremia

6. A patient's magnesium level is 0.9. The doctor orders Magnesium Sulfate IV. Which nursing intervention takes PRIORITY?* A. Assessing for hypertension B. Monitoring deep tendon reflexes C. Monitoring potassium levels D. Monitoring skin turgor

A client is informed of the diagnosis of leukemia based on recent testing results. The client states, "I do not have leukemia." Which additional statement indicates the client is experiencing denial? A - "If I start going to church again, God will heal me. "B - "Mistakes are made with laboratory tests all the time." C - "I do not want a bone marrow transplant!" D - "Leukemia does not have to be a death sentence."

The nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique? a.The nurse plays soft music in the client's room. b.The nurse gives the client a massage before bed. c.The nurse assists the client to focus on something pleasant rather than on pain. d.The nurse teaches the client deep-breathing techniques for relaxation.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief? A - spiritual distress B - coping strategies C - pain management D - self-care activities

Which assessment finding would best support a nursing diagnosis of Dysfunctional Grieving? A - A man blames himself for not doing more to make his wife's recent death more comfortable. B - A man is unable to return to work after his sister's death 18 months ago. C - A woman cries frequently and loudly in the weeks following her child's death in an accident. D - A woman has been experiencing chronic insomnia since her mother's death earlier this year.

Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? a.A PCA pump must be used and monitored in a health care facility. b.The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. c.The PCA pump is not effective for chronic pain. dThis approach can only be used with oral analgesics

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client: a.experiencing acute pain. b.experiencing chronic pain. c.in the postoperative stage with occasional pain. d.in the early postoperative period.

b A PRN (as needed) medication would be most appropriate for a client in the postoperative stage with occasional pain. A client in the early postoperative period would benefit from the dosage of pain medication with around the clock dosing. A client experiencing chronic pain would benefit from the dosage of pain medication with around the clock dosing. A client experiencing acute pain would benefit from the dosage of pain medication with around the clock dosing.

An adolescent client tells the nurse about asking oneself, "Do I like who I see in the mirror?" Which additional strategy can the nurse encourage the client to use to promote self-evaluation? a.Meeting friends b.Setting goals c.Allowing life to unfold d.Taking a self-improvement class

b A client who asks oneself, "Do I like who I see in the mirror?" is engaging in self-evaluation. Self-evaluation is the conscious assessment of the self, leading to self-respect or self-worth. Setting goals will provide a client with a structured set of actions to attain. Allowing life to unfold does not provide structure for the client. Improving one's knowledge can be useful but does not factor into one's self-evaluation. Being more social may be a goal but is not a strategy for self-evaluation.

A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep? a.it is best to avoid a snack prior to bedtime b.a snack containing carbohydrates and protein c.a snack containing carbohydrates and fat d.a snack containing protein and fat

b A small snack containing protein and carbohydrates may be effective in promoting calmness and relaxation prior to bedtime. Fat does not assist with digestion or rest.

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. a.What effect might this alcohol be having on the client's sleep? b.decreased REM sleep c.shorter sleep cycles d.increased amount of total sleep e.increased stage IV NREM sleep (delta sleep)

b Alcohol is known to decrease the amount of REM sleep. Alcohol does not typically shorten sleep cycles or increase the total amount of sleep. Delta sleep is decreased by alcohol consumption, not increased.

A client who has multiple sclerosis (MS) has been diagnosed with ineffective coping related to a diagnosis of chronic health alteration. What outcome is least appropriate to include in a plan of care? a.Communicates his feelings in a way that is comfortable. b.Communicates a sense of helplessness to his spouse. c.Reports feeling better about himself. d.Integrates positive self-knowledge into self-concept.

b All are appropriate outcomes except communicating a sense of helplessness. Some clients who are struggling with self-concept issues will communicate manipulative helplessness that encourages another (the spouse or nurse) to take charge. This does not promote coping or acceptance of self.

A client who responds to bad news concerning laboratory results by crying uncontrollably is handling stress by using: a.defense mechanism. b.coping mechanism. c.adaptation technique. d.withdrawal behavior.

b Anxiety often is managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. Coping mechanisms are immediate responses and are often involuntary. Crying is considered a coping mechanism. The change that takes place as a result of the response to a stressor is adaptation. Withdrawal is a type of coping mechanism. Defense mechanisms protect one's self-esteem and are useful in mild to moderate anxiety; if they used to an extreme, however, they distort reality and create problems with relationships.

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse? a.Assess the client for signs of opioid addiction. b.Assess for medication prescription for breakthrough pain. c.Tell the client he or she will have to wait for 1 hour. d.Administer the next dose of the pain medication.

b Breakthrough pain is a temporary flare-up of moderate to severe pain that occurs even when the client is taking pain medication around the clock. It can occur before the next dose of analgesic is due (end of dose pain). It is treated most effectively with supplemental doses of a short-acting opioid taken on an "as needed basis." Therefore, the nurse should check for a prescription for breakthrough pain medication. Telling the client that he or she has to wait is not a therapeutic action by the nurse. Administering the next dose of pain medication is a violation of nursing practice and does not follow the standard of care. The nurse needs to assess for the therapeutic effects of the pain medication and not opioid addiction.

A nurse introduces herself to a visually impaired client, addresses the client by name, speaks to the client respectfully, and explains all the nursing activities. The nurse is implementing health promotion with this client by which mechanism? a.helping in positive self-evaluation b.fostering a sense of self c.aiding goal formulation d.identifying strengths

b By treating the client respectfully and personally, the nurse is fostering a sense of self. The nurse pays special attention to the client's individuality and emotional needs by explaining all the nursing activities, which will promote the client's self-concept. To implement health promotion by identification of strengths, the nurse would assist the client in identifying and cultivating his personal strengths, such as a nice smile, hobbies, and strong health maintenance patterns. The nurse would assist the client in positive self-evaluation by focusing on positive attributes and pointing out accomplishments that deserve positive feedback. The nurse assists the client in goal formulation by identifying the desired outcome.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure? a.Patient-controlled analgesia (PCA) b.Cutaneous stimulation c.Biofeedback mechanism d.Guided imagery

b Cutaneous stimulation techniques include acupressure, massage, application of heat and cold, and transcutaneous electrical nerve stimulation (TENS).

The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What intervention by the nurse will assist with the client's report of fatigue? a.Encourage the client to drink or eat more foods with caffeine during the day b.Have the client further evaluated for depression c.Encourage the client to increase the amount of fluids during the evening hours d.Inform the client that taking frequent naps during the day will help

b Depression often goes undiagnosed in the older adult client and one of the symptoms is polysomnia. The nurse should make a referral for further investigation into this possibility. Decreasing the intake of caffeine can be beneficial for restful sleep. The client should avoid taking naps during the day so that sleep will be easier to achieve in the evening. Decreasing fluid intake and not increasing will help the client sleep so that rising to go to the bathroom is not as often.

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia? a."Do you want me to call the hospital chaplain before you have anesthesia?" b."When was the last time you had anything to eat or drink?" c."Which medications do you take daily?" d."Can you tell me why you are here this morning?"

b Determining when the last time the client had anything by mouth is important when undergoing anesthesia. The client ideally should be NPO, nothing by mouth, at least 8 hours prior to a general anesthesia to avoid aspiration during intubation. Assessing daily medications is done before surgery, not in the holding area. Asking the client to verify orientation should have been completed prior to arriving in the holding area. Asking the client if a chaplain should be called is not an appropriate action to take in the holding area.

In Stage 4 sleep, the: a.temperature increases b.pulse rate is slow c.respirations are irregular d.blood pressure is elevated

b During slow-wave sleep, the muscles are relaxed, but muscle tone is maintained; respirations are even; and blood pressure, pulse, temperature, urine formation, and oxygen consumption by muscle all decrease.

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary? a."I will keep track of my sleep information for 2 months." b."I will record the time I go to bed and how long it takes me to fall asleep." c."I will write down all my morning activities." d."I will only keep track of my sleep habits at home, not when I am traveling out of town."

b Keeping notes of times of sleep and waking are important details to record in a sleep diary. The notes are usually maintained for 14 days and include specifics such as all wakeful activities and sleep patterns in strange environments.

The nurse is preparing to educate a client with restless legs syndrome who reports sleeplessness and prefers to use nonpharmacologic methods to promote sleep. Which recommendation will the nurse include in the teaching? a.Have a glass of wine before bed. b.Massage the legs before bed. c.Go to bed whenever you feel tired. d.Sleep in a warm environment.

b Massaging the legs is a recommended technique for improving discomfort from restless legs syndrome. It is recommended to avoid alcohol, sleep in a cool environment, and set a regular sleep routine.

A client asks the nurse if hot chocolate at bedtime will improve the client's sleep. Which is the best response by the nurse? a."Hot chocolate relaxes you and can help you sleep." b."Milk is a better option to help you sleep." c."You should try cola to promote sleep." d."Tea is the best option for promoting sleep."

b Milk contains L-tryptophan, a chemical that is known to facilitate sleep. Although hot chocolate may contain milk, most hot chocolate, tea and cola drinks contain caffeine. Caffeine is a stimulant and will not help to facilitate sleep

Which of the following is objective data related to self-concept? a.The person admits that she always wears baggy clothes in order to hide her body. b.The person refuses to make eye contact. c.The person states, "I am worthless." d.The person's mom tells a nurse that her child is never happy.

b Objective data constitutes what the nurse can observe with her own eyes. Other objective data that may be collected include a missing body part, a concealment of a body part, or weeping.

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy? a.A walking aid b.A chronic opioid therapy plan c.Acupuncture d.Physical therapy referral

b Opioids are not contraindicated in older adults but are rarely used in chronic pain prior to nonpharmacologic measures.

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse? a.Reassess the client's pain in 30 minutes. b.Administer the pain medication. c.Hold the pain medication. d.Contact the client's health care provider.

b Pain is considered to be present whenever the client states it is. Therefore, the nurse should administer the client's pain medication. It is important that the nurse understand that clients have different ways to manage their pain. It would be inappropriate to delay administration or to hold the medication. There is no indication that the client's health care provider needs to be notified at this time.

Which client is experiencing the panic level of anxiety? a.A client displays a narrow perception field. b.A client loses control and expresses irrational thinking. c.A client focuses narrowly on specific detail. d.A client experiences increased alertness and motivated learning.

b Panic causes the person to lose control and experience dread and terror. The resulting disorganized state is characterized by increased physical activity, distorted perception of events, and loss of rational thought. Increased alertness and motivated learning describes mild anxiety. Narrowing the focus on a specific detail describes moderate anxiety. A client displaying a narrow perception field shows characteristics of severe anxiety.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? a.The client requires less nursing care. b.The client is actively involved in pain management. c.The client is able to have long hours of rest. d.The client obtains pain relief slowly and steadily.

b Patient-controlled analgesia (PCA) gives the client the advantage of playing an active role in pain management, as the client is allowed to self-administer medication. Pain relief is rapid, not slow and steady, because the drug is delivered intravenously. PCA does not replace nursing care or reduce the amount of care that the client requires.

When a nurse asks a client to describe her personal characteristics and traits, the nurse is most likely assessing the client for what self-concept factors? a.Role performance b.Personal identity c.Self-esteem d.Body image

b Personal identity describes a person's conscious sense of who he or she is. Asking the client to describe her personal characteristics and traits assesses a person's personal identity. Body image is the person's subjective view of one's physical appearance. Role performance is one's ability to successfully live up to societal as well one's own expectations regarding role-specific behaviors. Self-esteem can be described as the need to feel good about oneself and to believe that others hold one in high regard.

A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs? a.Administer an antianxiety medication and report to the health care provider b.Attempt to calm the client and administer oxygen c.Offer a distraction by asking about the client's family or interests and d.continue to monitor vitals Place the client in the semi-Fowler position and have the client explain what happened to cause this reaction

b The alarm reaction is initiated when a person perceives a specific stressor and the person experiences an increase in energy level, oxygen intake, cardiac output, blood pressure, and mental alertness. The best way to address this is to attempt to calm the client and administer oxygen as needed to maintain oxygen levels and optimal breathing and cardiovascular function. Semi-Fowler position may help with breathing as well as taking deep breaths but is not the immediate need.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? a.The nurse should expect slight resistance during the removal of the epidural catheter. b.The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. c.If the client develops a headache, an opioid analgesic may be administered along with the epidural analgesia. d.If a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted.

b The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min or has unmanaged pain, leakage at the insertion site, fever, inability to void, paresthesia, itching, or headache. No other medications should be administered; a peripheral IV line should already be in place. Resistance should not be felt when removing an epidural catheter.

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to: a.ingest a small amount of alcohol prior to bedtime. b.use caution when driving an automobile. c.drink at least 1 cup of coffee with the evening meal. d.change bedtime to later in the evening.

b The client is describing hypersomnia and is at increased risk for a motor vehicle accident when drowsy while driving an automobile. The client is to avoid alcohol, caffeine, and late-night activities.

A 73-year-old man has been the primary caregiver for his wife, who has multiple sclerosis (MS). After 30 years with the disease she died and he has become increasingly withdrawn and refuses to leave the house. Which nursing diagnosis is most appropriate? a.Disturbed body image related to death of spouse and loss of the role of caregiver b.Disturbed personal identity related to the unresolved crisis of his wife's death c.Low self-esteem related to feeling unloved now that his spouse has passed away d.Risk for altered self-esteem related to the recent death of his spouse

b The client is experiencing disturbed personal identity as he is no longer a spouse or a caregiver. This is related to the recent death of his chronically ill spouse. Without her to care for he is unable to define who he is or what his role is without her. He does not have low self-esteem or disturbed body image.

A nurse is caring for a client with cancer who is experiencing pain. What would be the mostappropriate assessment of the client's pain? the nurse's impression of the client's pain the client's pain based on a pain rating the client's recent responses to pain and to pain medication nonverbal cues of the client

b The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.

A client calls a sleep clinic helpline and describes the spouse's sleep patterns of snoring loudly then becoming startled and waking up five or six times a night. The client is asking how to improve the spouse's sleep patterns. Which Information will the nurse include in teaching about healthy sleep patterns? a.Limit food intake before bed. b.Discuss the sleep pattern with the health care provider. c.The spouse's sleeping pattern seems normal. d.Sleep in another room to limit your disruption of the spouse's sleep.

b The description of the client's snoring is suggestive of sleep apnea. The treatment plan should be to attempt detection of this disorder rather than disguising it by lowering the spouse's sensitivity to it. The client's spouse should discuss the symptoms with the health care provider. Advising the spouse that partners often sleep in separate rooms is not therapeutic and is masking potential sleep apnea. Snacks do not affect sleep apnea.

The nurse takes the health history of a soldier who lost the right leg in a roadside bomb. Which question will the nurse ask the client while performing the health history? a."Will you show me how you ambulate?" b."How has the loss of your leg affected your body image?" c."Do you attend a support group of people who lost limbs?" d."Has your family been a good support for you?"

b The human body is the self's physical manifestation. How a person pictures and feels about the body describes body image. Any deviation from the ideal body, such as the loss of a limb, might affect a person's body image. Asking how the client feels about family and friends would be part of the social history assessment. Watching the client ambulate is not part of the health history and may be performed during the physical assessment. A support group would be helpful for a client who lost a limb but would not be included in the health history.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse? A - "Does your family agree with this decision? "B - "Once you've started treatment, it's important to continue. "C - "Can you tell me about why you've made this decision?" D - "Have you discussed this with your health care provider?

A patient is experiencing hypercalcemia and has developed renal calculi. What is the affect on the phosphate level in hypercalcemia?* a.Phosphate level normalizes b.Phosphate level remain the same c,Phosphate level decreases d.Phosphate level increases

A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep? a."The CPAP prevents you from snoring so your spouse can sleep." b."The CPAP assures you get enough oxygen throughout the night." c."Using the CPAP will increase your energy during the day by allowing you to sleep at night." d."By maintaining the oxygen in your body during sleep other health problems can be avoided."

b The nurse can explain that during the apneic or hypopneic periods, ventilation decreases and blood oxygenation drops. The accumulation of carbon dioxide and the fall in oxygen cause brief periods of awakening throughout the night. Sleep apnea occurs in conjunction with snoring which can be difficult for a spouse but less urgent than a lack of oxygen in the body. By getting more oxygen during sleep the client may have more daytime energy, and associated health problems can be avoided when the body has proper oxygen balance. These outcomes, however, are not guaranteed and should be considered less urgent than the lack of oxygen.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? a.Compare the client's current assessment with previous admission assessment b.Examine the effectiveness of the current pain regimen c.Assess the client's serum albumin level d.Educate the client/caregiver about signs of impending death

b When a client has a painful diagnosis and is nearing the end of life, pain management is the priority. Education is important along with assessment and comparison, however, these are not the priority.

A female client with a long and complex history of chronic pain has begun a program of biofeedback with an advanced practice nurse. Together, the nurse and the client would identify what goal of this program? a.The client will learn to cope more effectively and constructively with her pain. b.The client will learn to alter her physiological responses to her pain. c.The client will learn to identify the signs of impending pain more clearly. d.The client will be able to lessen her pain through the use of massage.

b With biofeedback, a client learns to control or alter a physiologic phenomenon (e.g., pain, blood pressure, headache, heart rate and rhythm, seizures) as an adjunct to traditional pain management. Biofeedback does not involve massage or specific coping techniques.

A nurse is explaining the use of sleep hygiene to a client experiencing insomnia. Which statement accurately describes recommended guidelines for the use of this technique? Select all that apply. a.Take frequent naps during the day. b.Eat a light meal before bedtime. c.Take a warm bath before bedtime. d.Sleep in a dark room that is as warm as possible. e.Drink an alcoholic beverage before bedtime.

b, c Sleep hygiene involves the following: restricting the intake of caffeine, nicotine, and alcohol, especially later in the day; avoiding activities after 5 p.m. that are stimulating; avoiding naps; eating a light meal before bedtime; sleeping in a cool, dark room; eliminating use of a bedroom clock; taking a warm bath before bedtime; and trying to keep the sleep environment as quiet as possible (Gevirtz, 2007

An adolescent client is brought to the clinic by the parents, who inform the nurse that they are concerned that the adolescent is using maladaptive coping mechanisms to deal with a bullying issue at school. Which statement(s) by the parents should the nurse report to the health care provider as correlating with the use of maladaptive coping mechanisms? Select all that apply. a."Friends come over frequently to watch television or play video games." b."Our adolescent is sleeping a lot more than usual." c."We have found evidence of drug use, which is very unlike our adolescent." d."We have tried to discuss the issues so we can find a solution but are met with anger and hostility." e."The school counselor is seeing our adolescent once a week to check in and see how things are going in school."

b, c, d ndications that the adolescent is using maladaptive coping mechanisms to deal with the bullying situation at school would be: excessive sleeping which prevents facing the conflict, not wanting to discuss the issue or using hostility and aggression when confronted, the use of drugs or mind and mood-altering substances to prevent having to face reality and create a solution. The negative coping mechanisms may provide a brief relief from the stressor, but eventually create problems when used for an extended period. When interacting with friends in social situations or seeing the school counselor, the adolescent is using positive coping strategies to deal with the present issues.

Which of the following are specific components of self-concept? Select all that apply. a.Personal wealth b.Body image c.Personal identity d.Self-esteem e.Role performance

b, c, d, e All of the feelings, beliefs, and values associated with "I" or "me" compose self-concept. Specific components of self-concept include personal identity, body image, self-esteem, and role performance. Crucial to each component are the dimensions of self-concept, which include self-knowledge, self-expectations, and self-evaluation.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply. AThe stages of grief occur linearly and are static. b.People vary widely in their responses to loss. c.Some people actually skip some stages of grief altogether. d.The stages are relatively discrete and identifiable. e.Stages occur at varying rates among people

b, c, e

Which outcome(s) will the nurse include in the plan of care for a client experiencing caregiver role strain? Select all that apply. a.Client will eliminate all stress in a period of 6 months. b.Client will demonstrate appropriate coping strategies. c.Client will identify support mechanisms to help with stress. d.Client will confront those responsible for additional stress. e.Client will identify one or two stressors to eliminate.

b, c, e

10. A patient's magnesium level is 3.0. The cater associate brings the patient a dinner tray. Which item on the tray would you remove to ensure the patient does not eat?* A. Macaroni B. Tomatoes C. Kale D. Onions

A patient's blood tests show they have a critically low parathyroid hormone (PTH). What effect would this have on phosphate and calcium levels in the blood? a*Phosphate levels low, calcium levels high bPhosphate and calcium levels low cPhosphate levels high, calcium levels low dPhosphate and calcium levels high

After the physician has discussed euthanasia with a terminal client and family, the nurse assesses their understanding of the topic. Which statement by the family indicates that learning has occurred? a."The doctor will administer a lethal dose of barbiturates." b."Passive euthanasia is taking specific steps to cause a client's death." c."It is all right to stop dialysis." d."Allowing the client to stop eating is a form of active euthanasia."

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing? A - Normal grief B - Anticipatory grief C - Unresolved grief D - Inhibited grief

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death? A - "Each stage of dying must be completed prior to moving to the next stage." B - "The process is the same from person to person." C - "Sometimes a person returns to a previous stage." D - "The duration of all stages is a few hours."

The nurse is caring for several clients in the home care setting. Which client, when found deceased, will the nurse report as a case for the medical examiner? A - a client treated for end-stage kidney failure who is on home hemodialysis B - a client with lung cancer who refused hospice and is living with a spouse C - a client found with an empty bottle for a newly-prescribed opioid by the bedside D - a client who was recently discharged from the hospital after a myocardial infarction

The nurse is making sure that all factors are in place for a client's death certificate. What potential error that may occur does the nurse identify? A - The client lived with numerous comorbidities prior to death. B - The client was in good health prior to an accident or medical incident that caused death. C - The client had a condition that has the potential to temporarily suspend life process. D - The client was younger than 12 years of age or older than 75.

What of the following is NOT an expected treatment for a phosphate level of 2.2? a*Encouraging the patient to eat fish, beef, chicken, and organ meats bEnsuring patient safety due to risk of bone fractures cAdministering Phoslo by mouth with meals dAdministering Vitamin-D supplements

Which patient is likely to present with a phosphate level of 6.0? a*A patient taking an aluminum hydroxide-based antacid four times a day. bA patient on total parenteral nutrition therapy (TPN). cA patient in end-stage renal failure who is scheduled for dialysis tomorrow. dA patient who reports drinking a 12 pack of beer daily.

During a health history, a client states, "Whatever happens, happens because of luck." The nurse interprets this statement as indicating: a.internal locus of control. b.expectancy for success. c.external locus of control. d..self-efficacy.

c A person with external locus of control perceives that outcomes happen because of luck, chance, or the influence of powerful others. A person with internal locus of control believes that personal behavior influences outcome and that he can achieve desired results. Self-efficacy is the degree of confidence a person has about the ability to perform specific activities. Expectancy for success means the person has a belief that personal behavior will lead to something desired.

Which data is most appropriate for the nurse to include when assessing an older adult client's capacity to adapt to current stressors? a.advanced age, number of children, and network of social factors b.expectations of life, attitudes, and advanced age c.social losses, network of social factors, and advanced age d.level of education, religious belief, and social losses

c Advanced age, loss of social network, and social losses is correct, because these can diminish older adults' ability to cope and may provoke the onset of physical or emotional disorders. Religious belief and one's attitude is incorrect, because these vary as to how older adults adapt to stress. Numbers of children, level of education, and life expectations do not determine how older adults adapt to stress.

A client is refusing to get out of bed the day after hip surgery. The nurse knows that for the intervention to be safe, therapeutic, and nonthreatening, she will need to not only enlist the client's cooperation, but also her willing participation. Which stress reduction technique does the nurse acknowledge as the best choice in this situation? a.Guided imagery b.Meditation c.Anticipatory guidance d.Biofeedback

c Anticipatory guidance is the technique wherein the nurse uses teaching about a procedure to prepare the client for what is to come. This can help foster trust, diminish fear of the unknown, and lessen the chance of a negative response to necessary treatments. Guided imagery, biofeedback, and meditation would take time to learn and would not be effective in this current situation.

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: a.Therapeutic Touch (TT). b.hypnosis. c.biofeedback. d.transcutaneous electrical nerve stimulation (TENS).

c Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? a.Discontinue the client's pain medication until his or her level of consciousness improves. b.Administer a dose of naloxone and report this finding to the primary care provider. c.Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours. d.Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case? A - Pharmacologic interventions should not be initiated .B - The client should be resuscitated if he experiences respiratory arrest. C - The client should be treated with antibiotics for pneumonia. D - The wishes of his family should be followed.

c C(Explanation:The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.)

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education? A - "Palliative care affirms life and regards dying as a normal process." B - "Hospice care programs focus on quality rather than length of life." C - "In hospice care, the nurses make most of the care decisions for the clients." D - "Palliative care provides relief from pain and other distressing symptoms."

c C(Explanation:The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life.)

A female client, prominent in the local media, has had surgery for a colostomy. The client avoids looking at the colostomy and refuses visitors. Identify the most appropriate nursing diagnosis. a.Altered Self-Esteem related to colostomy and poor self-image b.Fear of Rejection by Others related to colostomy and altered self-image c.Disturbed Body Image related to colostomy as evidenced by avoidance of colostomy d.Altered Role Performance related to inability to cope with visitors

c Disturbed Body Image possesses the clinical cues of behaviors of avoidance, monitoring, or acknowledgement of one's body.

The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from 1 hour ago. The nurse assesses the stage of nonrapid eye movement (NREM) sleep, which the client exhibits as Stage: a.II. b.IV. c.I. d.III.

c Easy arousal from sleep and involuntary muscle jerking that may awaken the client are signs of Stage I NREM. In the other stages, the client becomes increasingly more difficult to arouse and does not exhibit involuntary muscle jerking. In Stage IV NREM, the client's pulse, respirations, and blood pressure decrease, and muscles are relaxed.

An older adult client with mild hypothermia has been admitted to the health care facility. Which intervention will the nurse use to promote comfort and sleep for the older adult client? a.Keep an attendant with the client. b.Raise the side rails of the bed. c.Ensure that the environment is warmer. d.Use a bright light at night for safety.

c Ensuring that the environment is warmer than normal is the most appropriate activity to deal with hypothermia. Older adult clients tend to prefer warmer room temperatures because of decreased subcutaneous fat deposits. Raising the side rails may become a safety hazard if the older adult client becomes confused at night. Keeping an attendant with the client may not be feasible at all times and may not benefit the sleep quality of this client. Using a bright light at night provides safety but interferes with the client's sleep.

Which question would the nurse ask to assess a client's self-identity during a focused self-concept assessment? a.Do you like being a teacher? b.What do you like most about your body? c.What are your personal strengths? d.Who would you like to be?

c Identifying one's own personal strengths describes a person's self-identity. Self-esteem is assessed by asking the client who he or she would like to be. Asking the client what he or she likes most about his or her body assesses body image. Role performance is assessed by asking the client about their satisfaction in his or her job.

A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action? a.Contact the health care provider b.Call a code blue c.Administer naloxone d.Notify the family

c Naloxone is an opioid antagonist that reverses the respiratory depressant effects of opioids. If stimulation is ineffective in arousing a client using opioids, naloxone can be used. When the client is alert and the respiratory rate is greater than 9 breaths/min, the opioids may be resumed. A code blue is not appropriate, as there is no indication that the client is without pulse or respiration. However, being prepared for this action is necessary. The nurse will contact the health care provider but first needs to take action to prevent further deterioration of the client's condition. The family must be notified but the most pressing matter is the care of the client

During a counseling session a client states, "I just try to forget about my spouse hitting me." Which coping mechanism should the nurse document on the basis of this client's statement? a.rationalization b.regression c.repression d.reaction formation

c Repression is the coping mechanism that this client is using, in which the client has removed the experience of being abused from conscious memory. Reaction formation is a coping mechanism that sees an individual acting just the opposite of one's feelings. Rationalization is relieving oneself of personal accountability by attributing responsibility to someone or something else. Regression is behaving in a manner that is characteristic of a much younger age.

uring an interview, the client tells the nurse, "I know who I am and I know my strengths and weaknesses." How will the nurse interpret this statement? a.self-evaluation. b.self-expectation. c.self-concept. d.social self.

c Self-concept is the mental image a person has of oneself. It is the person's meaning when stated as "I" or "me." Self-concept is the frame of reference that influences how a person handles situations and relationships. Self-expectation involves the "ideal" self — the self a person wants to be. It is the setting of present and future goals. Social self is how a person sees himself in relation to social situations, including behavior and interaction with others. Self-evaluation is the conscious assessment of the self, leading to self-respect or self-worth. "Have I met my expectations? Do I like who I see in the mirror? Do I like how I behave?"

Which does not coincide with Kübler-Ross's stages related to a dying client? A - The client may be in several stages at once. B - Clients don't always follow the stages in order .C - Some client regress, then move forward again .D - The dying client usually exhibits anger first.

The emergency department nurse is triaging a 15-year-old adolescent who is brought in by a family member after finding the client with a bottle filled with a variety of pills. The family member shares that the client's parents recently divorced and the client's mother moved out-of-state, leaving the client and two younger siblings with the father. The father travels frequently for work, leaving the client alone to take care of the younger siblings. Which factor should the nurse prioritize? a.Lack of confidence b.Low self-esteem c.Inadequate coping d.Stress tolerance

c Stressful events can lead to inadequate coping. The stress of the divorce, mother leaving without the client and siblings, going to school, and taking care of the siblings without assistance can be extremely stressful and result in low self-esteem and depression and progress to suicidal ideation, which in this case should be assessed due to the bottle of pills. This could be a sign the individual is planning suicide. The other choices can all contribute to inadequate coping.

Question 7 of 10 The nurse is caring for a client newly diagnosed with chronic pain. When preparing to educate the client regarding chronic pain and management they ask who should be involved in the teaching. Which response is best? a."Your best friend." b."Your spouse or caregiver." c."Anyone you think needs to know." d."One of your neighbors will do."

c Teaching about pain should include anyone the client identifies as needing the information so that they understand the concept of pain and are able to help the person in pain. Designated people can be family members, caregivers, friends, or neighbors; therefore, the correct answer is whomever the client identifies as needing the information.

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern? a.What do you usually do to help yourself fall asleep? b.How much sleep do you think you need to feel rested? c.Do you usually go to bed and wake up about the same time each day? d.In what way does the sleep you get each day affect your everyday living?

c The best interview question for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern would be to ask if the client usually goes to bed and wakes up about the same time each day. The other questions are possible to ask the client, but are not related to recent changes in the client's sleep-wakefulness pattern.

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: a.cutaneous pain. b.neuropathic pain. c.visceral pain. d.somatic pain.

c The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? a.resistance stage b.alarm stage c.exhaustion stage d.secondary stage

c The client is in the exhaustion stage, when one or more adaptive/resistive mechanisms can no longer protect the person experiencing a stressor; this results in exhaustion. The effects of stress-related neurohormones suppress the immune system, and the body is open to various ailments. In the alarm stage, the person is prepared for a fight-or-flight response. In the resistance stage, the client's body is returned to the homeostasis state. Consequently, one or more organs or physiologic processes may eventually lead to increased vulnerability to stress-related disorders, or progression to the stage of exhaustion. The secondary stage is not a stage related to stress.

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care? a.Assessing for impaired urinary elimination b.Observing for bowel incontinence c.Preventing constipation d.Observing for diarrhea

c The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use. Urinary elimination and bowel incontinence are not affected by opioid use.

The nurse is caring for a client with an amputated limb. The client reports a severe burning sensation in the amputated limb and is asking for medication to help. Which medication, if prescribed, should the nurse administer? a.methocarbamol b.ibuprofen c.pregabalin d.acetaminophen

c The nurse should recognize the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. Pregabalin is a gabapentinoid used to treat neuropathic pain. Acetaminophen, ibuprofen, and methocarbamol are used to treat other forms of pain and are not specifically for neuropathic pain.

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client? a."I'll have the unit's care aide come check on you every few minutes after I set up the system." b."We'll be monitoring your use of the system closely, to ensure you don't develop an addiction to your pain medication." c."The pump is programmed with safeguards to limit the possibility overmedication." d."If you feel severe pain, either push the button yourself or ask one of your family members to push the button."

c The parameters programmed into the PCA pump prevent accidental overdose. Addiction is not a realistic risk for most clients. Care related to a PCA is not delegated to unlicensed care providers. The button should be pushed only by the client.

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so? a.At several points throughout your history-taking b.Before the client is discharged c.The first question you ask the client d.When obtaining client vital signs

Which nursing action helps to maintain a sense of self for clients? a.Maintaining the privacy of the client's room number b.Assessing weight and overall nutritional status c.Offering a simple explanation before initiating any procedure d.Asking the client to refrain from negative expressions

c The way nurses care for clients has a direct impact on the client's sense of self. By offering a simple explanation prior to any procedure, the nurse is respecting the client and shows that the client is a person first and foremost. Negative expressions should be encouraged and allowed. Privacy related to condition and keeping the body covered is important. The client's weight assessment does not help or hinder the client's sense of self. Reference:

The nurse is creating a plan of care for a client that is reporting an inability to sleep and rest. What outcome criterion will the nurse address for a goal that the client will demonstrate physical signs of being rested? a.The client reports drinking only one cup of coffee a day. b.The client reports a decrease in sleep latency to 10-15 minutes. c.The client has decreases both in under-eye circles and in excessive yawning by 1 week. d.The client reports less anxiety regarding falling asleep.

c This outcome criterion addresses the goal by stating physical, objective signs that the person is better rested. It also mentions a time frame, which makes it measurable and easier to evaluate.

A hospitalized client informs the evening shift nurse about not being able to sleep without a shot of whiskey each night before bed and asks if the spouse can bring in a bottle. Which is the best response by the nurse? a.."Go ahead and ask your spouse to bring a bottle." b."Do you really think that is a good habit?" c."Let's discuss that with your health care provider." d."It will be difficult for you to continue that routine in the hospital."

c To promote relaxation and sleep, the nurse should be alert to the client's bedtime rituals and observe them as much as possible. To prevent interference with medical care, the nurse and client should consult with the health care provider before adding alcohol to the bedtime routine. Questioning the client about the habit may cause the client to become defensive.

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is mostaccurate? a.They occupy cell receptors for neurotransmitters. b.They react with acetylcholine and serotonin. c.They bind to opioid receptor sites throughout the CNS. d.They block glutamate receptors and peptides.

c When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (CNS), blocking the release or production of pain-transmitting substances.

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? a.one-time order b.stat order c.PRN order d.standing order

c as needed basis

Which client could be diagnosed with insomnia? a.A 40-year-old obese man who is reporting fatigue. He states that he goes to bed around 9 p.m. every night and wakes up between 5 and 6 in the morning. He feels like he gets a good night's sleep, but his wife says that she constantly has to poke him throughout the night because he "stops breathing." b.A 20-year-old man who is reporting excessive drowsiness at work to the point that he falls asleep while at his computer. He goes to bed at 11 p.m. and wakes up at 7 a.m. without difficulty. Twice in the last year he passed out after getting extremely angry. c.A 50-year-old woman who is reporting increased irritability for the past 2 months. She states that she goes to bed at 10 p.m. every night and tries to sleep in but, no matter what she does, she always wakes up around 4 a.m. d.A 45-year-old woman who has been reporting fatigue for the last year. When asked about her sleep schedule, she states that she usually goes to bed around 1 a.m. and gets up at 7 a.m. when her 5-year-old daughter gets up. She describes herself as a night owl.

c he 50-year-old woman appears to be suffering from early awakening insomnia. Because it has been longer than 1 month, it is considered a chronic insomnia. The 45-year-old woman appears to be suffering from insufficient sleep syndrome. She does not have an adequate amount of time for sleep each night, as seen with insomnia, but it is a self-imposed restriction of sleep. The 40-year-old man is not getting enough sleep because he has some form of sleep-disordered breathing (SDB). Although he might think he is allowing enough time for sleep, his quality of sleep is disrupted by these periods of apnea. The 20-year-old man appears to be suffering from narcolepsy. Along with the two episodes of cataplexy, he is excessively sleepy throughout the day and falls asleep at inappropriate times.

The spouse of a client with cancer asks why the client's breakthrough doses of morphine have recently needed to be higher and more frequent for the client to achieve pain relief? Which response by the nurse is appropriate? a.The morphine is having more drug interactions with the client's other medications, requiring a higher dose. b.The higher dose is due to the client's physical dependence on the morphine. c.Higher doses are needed because the client has developed a tolerance to the morphine. d.The client is now addicted to the morphine and requires higher doses

c his client is likely developing drug tolerance, which occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief. This is not a pathologic finding and does not necessarily indicate physical dependence. Addiction is the fact or condition of being addicted to a particular substance, thing, or activity. Tolerance does not indicate addiction or a heightened risk for addiction. A drug interaction is a reaction between two (or more) drugs or between a drug and a food or beverage.

8. A patient has a Chloride level of 190 mEq/L. Which foods below should the patient avoid? Select all that apply:(Required) A. Carrots B. Canned beans C. Table Salt D. Tomato juice E. Olives F. Chicken

c, d, e

The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply .A - Systolic blood pressure which rose from 100 to 110 mm Hg B - A regular apical pulse of 90 beats/minute C - Distended abdomen with last bowel movement documented 7 days ago D - Cyanotic nail beds in hands and feet bilaterally E - Gurgling sounds emanating from the client's throat with each breath

c, d, e

A nurse is assessing a client and suspects that the client is experiencing a dysfunction in self-concept based on which behavioral findings? Select all that apply. a.taking on of additional responsibility b.intensive eye contact c.difficulty making decisions d.social withdrawal e.inability to discuss a change in body function

c, d, e, Behavioral changes indicating self-concept dysfunction include lack of interest in activities, inability to make decisions, withdrawal from social situations, isolation, refusal to look in the mirror, refusal to look at an affected body part or discuss a limitation, avoidance of responsibility, show of hostility toward others, refusal to make eye contact, and negative statements about self.

A perimenopausal woman reports insomnia. Which intervention(s) will the nurse suggest to the client? Select all that apply. a.Nap frequently during the day to make up for the lost sleep at night. b.Exercise vigorously before bedtime to promote drowsiness. c.Eat a small snack of protein and carbohydrate before bedtime. d.Discuss the use of a sleep aid with the health care provider. e.Eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle.

c, d, e, For many people, beverages containing caffeine or alcohol interfere with the ability to fall asleep. Thus, the nurse would advise the client to avoid both substances in the evening. The client should avoid eating a large amount of food before bedtime, but a snack with protein and carbohydrates before bedtime could be beneficial for promoting sleep. The client may wish to discuss use of a sleep aid with the health care provider. Sleep aids, however, should only be used if other nonpharmacologic options are not effective, because long-term use can cause dependence. The nurse would not encourage the client with insomnia to nap frequently during the day, because this interferes with the sleep cycle at night. Vigorous exercise before bedtime should be avoided. Vigorous exercise does not promote drowsiness.

1. A patient with a magnesium level of 3.6 would exhibit which of the signs and symptoms EXCEPT?* A. Hypotension B. Profound Lethargy C. Respiratory failure D. Hyperreflexia of the deep tendons

1. Which of the following does Chloride NOT play a role in?(Required) A. Digestion B. Acid-base balance C. Fluid balance D. Bone health

3. Which of the following patients is MOST at risk for hypermagnesemia?* A. A patient with alcoholism B. A patient taking a proton-pump inhibitor called Protonix C. A patient suffering from Crohn's Disease D. A patient with a magnesium level of 0.6 receiving IV magnesium sulfate

5. Which patient below is at risk for developing hyperchloremia?(Required) A. A 25-year-old with cystic fibrosis. B. A 55-year-old post-op from abdominal surgery that has a nasogastric tube with continuous suctioning. C. A 62-year-old prescribed IV loop diuretics for the treatment of heart failure. D. A 53-year-old who received several large fluid boluses of Normal Saline.

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important? a.a quiet environment b.an open attitude c.a focus of attention d.soft music

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death? a.The frequency of urination decreases. b.The client is calm and peaceful. c.The arms and legs are warm to touch. d.The client's breathing becomes noisy.

A nurse is reviewing the medication administration record. Which order does the nurse question? a.a diuretic administered every other day at noon b.a diuretic administered once daily at 9 a.m. c.a diuretic administered twice daily at 9 a.m. and 5 p.m. d.a diuretic administered twice daily at 9 a.m. and 9 p.m.

d A diuretic should not be administered after 6 p.m. This will promote sleep if a full bladder does not awaken the client. Once daily dosing and every-other-day dosing is not cause for question

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first? a.Administer naloxone. b.Increase the primary IV rate. c.Notify the physician. d.Stop the PCA pump.

d A side effect of morphine is respiratory depression. In this situation, the nurse should first stop the PCA pump and then notify the physician. Naloxone is used to reverse the sedative effects of opioids, but this is not the first step.

A 56-year-old construction worker is in for his annual physical. As the nurse takes his vital signs, he tells her that his blood pressure may be a little off this morning. He tells the nurse that he is recently unemployed, is quite stressed, and is having a hard time coping. He feels like he needs to numb the pain. What is the nurse most concerned about regarding this client? a.cocaine use b.exercise c.projection d.alcohol use

d Alcohol use is a common altered coping pattern for individuals with poor coping skills. It is legal and easily accessible. Phrases such as "I just cannot cope" and "I need to numb the pain" are common among those who misuse alcohol.

The nurse is instructing a parent on how to promote restful sleep for a child. What food would be the best bedtime snack for the child? a.grapes with honey b.tuna salad c.chocolate bar d.cheese and crackers

d Combining foods that are high in tryptophan with healthy, complex carbohydrates improves sleep. A small protein- and carbohydrate-containing snack such as cheese and crackers about an hour before bed may be effective in promoting restful sleep for the child. A chocolate bar contains caffeine, which is central nervous system stimulant. Grapes with honey contain a high quantity of fructose, a form of processed sugar which can interfere with sleep if ingested too close to bedtime. Tuna salad contains protein but also contain high amount of fat, which can disrupt the sleep cycle.

A withdrawn and isolated client is most likely suffering from what type of stressors on basic human needs? a.Safety and security needs b.Self-esteem needs c.Physiologic needs d.Love and belonging needs

d Effects of stress on basic human needs varies with each individual, but there are certain characteristics that are commonly seen with stressors on the basic human needs. Withdrawal and isolation from others is commonly seen when stressors are placed on love and belonging needs. Stressors on physiologic, safety/security, and self-esteem needs have other common characteristics.

An older adult client reports insomnia. Which interventions can the nurse implement to promote quality sleep for the client? a.Suggest that the client listen to music at bedtime to promote sleep. b.Keep lights on in the room to help prevent falls at night. c.Advise the client to briskly ambulate in the hall for 60 minutes before bed. d.Encourage the client to empty the bladder at bedtime.

d Encouraging the client to empty the bladder at bedtime and dimming the lights may help to promote relaxation and sleep. Keeping the lights on in the room is not appropriate, as lights are stimulants. Suggesting music at bedtime is avoided, as the noise is a source of stimulation. Light exercise such as walking 10 minutes before bed may promote rest; however, strenuous exercise, such as walking for 60 minutes before bed, stimulates the client.

In contrast to anxiety, fear is characterized by: a.a real, rather than perceived, threat. b.the creation of an action plan to deal with a perceived threat. c.short-term resolution. d.a cognitive response to a known threat.

d Fear is a cognitive response to a known threat, while anxiety is the emotional response to that threat. Fear does not necessarily resolve in the short term, and an action plan may or may not be formulated by the individual. The fact that fear involves the identification of a known threat does not necessarily mean that the object of fear is objectively real.

A client with uncontrolled hypertension experienced a stroke a week ago, leading to significant motor losses. A successful and normal adaptive response to these new limitations is evident if the client: a.refuses to participate in physiotherapy. b.changes the subject when the nurse addresses activities of daily living (ADLs). c.repeatedly states, "It is what it is." d.exhibits signs of grief.

d Grief is a normal response to a recent deformity or limitation. Signs and symptoms of grief include crying, sleep issues, and a decreased appetite. Changing the subject and refusing participation in physiotherapy would be considered maladaptive responses. Stating that "it is what it is" may possibly signal resignation and defeat, neither of which is associated with an adaptive response.

Which activity would be appropriate to suggest to the client who states that she has difficulty falling asleep every evening? a.Exercise lightly for 30 minutes before sleep. b.Watch television for a few minutes to induce sleepiness. c.Take a cool shower before bedtime. d.Drink a glass of warm milk before bed.

d Ingestion of L-tryptophan, a precursor of serotonin found in foods such as milk, beef, eggs, wheat flour, turkey, and corn, has been found to decrease sleep latency and increase stage 4 sleep. The other listed activities would not make the client more drowsy at bedtime.

What factor has been hypothesized by researchers regarding current thoughts on sleep? a.The population is healthier due to sleep. b.More sleep is obtained through napping. c.The current population requires less sleep. d.Chronic sleep deprivation is present.

d Most recently, researchers have hypothesized that much of the population in industrialized nations may be chronically sleep deprived.

Which nursing intervention is inappropriate when developing a plan of care to modify a negative self-concept? a.Asking the client to describe what makes her feel successful b.Teaching the client how to repeat "I can do this" when she has negative feelings c.Teaching the client how to "red flag" negative self-talk d.Teaching the client that everything will work out better than she expects

d Replacing negative feelings with positive self-talk is appropriate. Asking clients to explore positive dimensions about themselves will help them to incorporate positive knowledge of themselves into their self-concept. Teaching clients to "red-flag" negative self-talk as soon as they are aware of it is important in the modification process. Teaching clients that everything will work out better than they expect is not true and situational success does not determine self-concept.

A client started a nursing program and is trying to balance going to school full-time, a part-time job, and spending time with family. The client states, "I am trying to do everything and doing nothing well." Which role problem is this client experiencing from this role transition? a.Role ambiguity b.Role agreement c.Role conflict d.Role strain

d Role strain occurs when the person perceives himself as inadequate or unsuited for a role and can occur when a person is forced to assume many roles. Role ambiguity occurs when a person lacks knowledge of role expectations. This lack of knowledge causes anxiety and confusion. Role conflict is related to expectations concerning the role.

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea? a.explain that the physical symptoms are all in their head b.contact the primary care provider c.Immediately administer an antiemetic. d.sit with the client and ask them about their feelings

d Somatization is manifesting an emotional stress through a physical disorder. Treating the nausea with an antiemetic will not get at the root cause of the emotional issue. Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic. Sitting with the client to explore what is really going on is most appropriate nursing response.

An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include: a.a change in the normal progression of the sleep cycle. b.an increase in stage II of the sleep cycle. c.a decrease in stage I of the sleep cycle. d.a decrease in the deep sleep stage of the sleep cycle.

d The changes to the sleep cycle that usually occur in the older adult are an increase in stage I and a decrease in deep sleep. These changes lead to a less restful sleep and more frequent awakenings during the night.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate? a.Apply a warm compress to the area. b.Stop the back massage immediately. c.Massage the area using lotion. d.Document the finding.

d The nurse should document this finding after completion of the back massage and client care and report it to the health care provider. The nurse would also position the client to remove any pressure from that area. The nurse should not apply a warm compress or massage the reddened area.

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? a."It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to prevent accidental dislodgement of the catheter." b."It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to increase the effectiveness of the spinal analgesia." c."It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to decrease the risk of severe migraine headaches." d."It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

d The rationale for keeping the head of the bed elevated 30 degrees is that this position helps to minimize the upward migration of the opioid in the spinal cord, thereby minimizing the risk of respiratory depression. The nurse does not keep the head of the bed elevated to decrease the risk of migraines as migraines are not a common problem with epidural analgesia. Positioning of the client does not increase the effectiveness of the medication. Positioning also does not prevent accidental dislodgement of the catheter; this is accomplished by a secure dressing and taping the tubing so that it is not pulled.

A client with cancer has recovered from tumor removal surgery and is now stable while undergoing a chemotherapy treatment schedule. She is not having any symptoms at this time and is continuing to work and enjoy social events. What stage of the general adaptation syndrome (GAS) would the nurse place her in? a.Reflex pain response b.Exhaustion c.Alarm reaction d.Resistance

d This client's situation is an example of the resistance stage of the GAS. Stress is continuing, but the client is maintaining homeostasis. Alarm is the initial stage when major stress is encountered. Exhaustion is when homeostasis can no longer be achieved. The reflex pain response is part of the local adaptation syndrome.

A child age 5 years wakes up at night and finds he has wet the bed. He feels embarrassed that he had this accident and sleeps in the wet bed all night, afraid to tell his parents. In the morning, he wakes up early, gets dressed, and hides his pajamas because he still feels shame for this accident. This child is experiencing which feeling of self-evaluation? a.Pride b.Anxiety c.Guilt d.Shame

d Three major self-evaluation feelings or affects found in individuals are: (1) pride, based on a positive self-evaluation; (2) guilt, based on behaviors incongruent with ideal self; and (3) shame, associated with low global self-worth. These affects are learned in early childhood within relationships with significant others and maintained through practice. Anxiety is discussed in the theories on self-concept, according to Sullivan.

The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep? a.Enjoy the peace and quiet of the country. b.Avoid eating right before bedtime. c.Ingest 1 ounce of liquor before going to sleep. d.Find a phone app that plays sounds of the city.

d lients tend to adapt to the unique sounds where they live, such as traffic, trains, and the hum of appliance motors or furnaces. Unfamiliar sounds tend to interfere with the ability to fall or stay asleep. The nurse will recommend that the client find an app that plays sounds of the city, which mimics the sounds with which the client is most familiar. Ignoring the problem by telling the client to adapt to the new environment does not address the problem. Avoiding eating before bedtime could cause the client to wake up hungry in the middle of the night. The nurse does not recommend alcohol, a depressive drug, to clients.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: sodium. potassium . magnesium. phosphorus.

phosphorus

Which of the following would you NOT expect to see with a phosphate level of 1.2? *Weakness Confusion Osteomalacia Positive Trousseau's Sign

positive trousseaus sign

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