Lippincott Practice exam
A client is admitted to the psychiatric unit with acute onset of schizophrenia. The physician orders the phenothiazine chlorpromazine, 100 mg by mouth four times per day. Before administering the drug, a nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects?
-droperidol When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. Guanethidine, lithium carbonate, and alcohol do not increase the risk of extrapyramidal effects.
Which statement indicates that a family member of a client in cardiogenic shock understands the need for an intra-aortic balloon pump?
"This device decreases the heart's need for oxygen." An intra-aortic balloon pump increases coronary perfusion and cardiac output, and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock. A defibrillator is commonly used for termination of life-threatening ventricular rhythms.
A client weighing 68 kilograms received full-thickness burns to both legs, including feet. According to the Parkland formula, how much intravenous fluid should be administered to this client in the first 8 hours after burn injury? Record your answer using a whole number.
- 4896 Total burn surface area (TBSA) for this client is 36. The Parkland Formula is 4 mL x kg x TBSA = 4 x 68 x 36 = 9,792 mL; divide by 2 = 4,896 mL over the first 8 hours.
The nurse is caring for a pediatric client post tonsillectomy. Which nursing actions are important when caring for a client postoperatively? Select all that apply.
- setting up suction - keeping the client side lying The nurse will keep the client side lying and set up suction for a client postoperatively. Restraining the client, keeping the room dark, and padding the siderails are not necessary for care.
A client with obsessive-compulsive disorders is in treatment. Which behaviors would indicate an improvement in this client's condition? Select all that apply.
- the client refrains from performing rituals during stress - the client verbalizes using the "thought-stopping" strategy - the client identifies situations promoting anxiety and ritualistic behaviors Refraining from rituals demonstrates that the client manages stress appropriately. Using the "thought-stopping" strategy demonstrates the client's ability to employ appropriate interventions for obsessive thoughts. Identifying situations that promote anxiety and precipitate ritualistic behavior help the client cope with the anxiety as well as understand the disease process. Avoiding, rationalizing, and hiding behaviors demonstrate maladaptive methods for managing stress and anxiety.
A client has been prescribed a narcotic analgesic to be given around the clock for cancer-related pain. The client is competent and has been actively involved in decisions regarding care. What would the nurse do when the client refuses the next dose of pain medication?
Ask why the client is refusing the medication at this time. The client has the right to choose whether to take the medication, but the nurse needs to assess the reason for the refusal and determine next steps based on the response. The nurse should assess the client's pain on a regular basis and educate the client that taking the medication before the pain gets out of control provides the most effective pain management plan. Simply documenting the refusal without performing an interview is insufficient, because the nurse must make a note about the interaction. While education is important, platitudes such as "the medication helps you get better" are not helpful.
A client's blood pressure is 160/90 mm Hg. The health care provider prescribed "clonidine 1 mg by mouth now." The nurse sent the prescription to the pharmacy at 0710, but the medication still has not arrived at 0800. What should the nurse do next? Select all that apply.
Check all appropriate places on the unit to which the drug could have been delivered. Check the client's blood pressure. Call the pharmacy. The nurse should first check to see if the medication has been misplaced, check the client's blood pressure to determine the immediacy of administering the drug, and then call the pharmacy to check that the medication was delivered. Although the nurse needs to obtain and administer the medication as soon as possible, it is inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy. The nurse should not use another client's medication.
In an initial screening for lead poisoning, a toddler is found to have a minimally elevated lead level. What is the most important action the nurse should take?
Educate parents on ways to reduce lead in the environment. Treatment for children with minimally elevated lead levels should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach high levels, 45 mcg/dL (2.2 μmol/L). There is no such thing as a "normal" lead level because there is no beneficial action in the body.
CASE STUDY: Prioritize Hypotheses A 21-year-old female has given birth in the hospital. The nurse recognizes that care needs to be prioritized. Select the four (4) most important care tasks.
Episiotomy wound care with site culture. Notify the provider of abnormal findings. Administer pain medication as ordered. Draw labs
After the administration of t-PA, the assessment priority is to:
Observe the client for chest pain. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.
CASE STUDY: Recognize Cues A 21-year-old female has given birth in the hospital. Which vital(s) and assessment(s) does the nurse identify as concerning? Select all that apply.
Heart rate of 112 beats per minute Respiratory rate of 35 breaths per minute Temperature of 101.0°F (38.4°C) Edema, redness and yellow drainage present at the episiotomy site Explanation: Normal range for adult heart rate is 60-100 beats per minute. A heart rate of 112 beats per minute is abnormal and would require follow-up. Normal range for adult respirations is 12-20 breaths per minute. Respirations of 35 breaths per minute is abnormal. Normal range for adult temperature is 97.0°F (36.1°C) to 99°F (37.2°C). The client's elevated temperature requires follow-up. Edema, redness and yellow drainage at the episiotomy site is an abnormal finding. Normal range for adult blood pressure is 120/80 mmHg. This client is within the normal range. Lochia in a small amount with no odor is a normal finding post childbirth. The fundus should be firm below the umbilicus post childbirth.
CASE STUDY: Generate Solutions A 35-year-old male is admitted to a small hospital for chest pain. The nurse is preparing to transfer the client. Select five (5) potential actions the nurse should take to transfer the client.
Give report to the receiving facility. Secure the client's IV and oxygen tubing. Ensure the client has all personal belongings. Educate the client on reasons for the transfer and the process. Verify that a transfer order is in place.
A 20-year-old seeks treatment at a local emergency care center after spraining an ankle while playing ball with friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply.
Initially apply cold pack. Instruct the client to elevate the ankle for 48 to 72 hours. Provide crutch-gait training. If needed, apply an elastic bandage from the toes to midcalf. Pain caused by an injury is best treated initially with cold applications. Cold reduces localized swelling and decreases vasodilation. Decreasing vasodilation prevents pain-producing chemicals from entering the circulation. The client should be instructed to call the physician if pain worsens or persists. Additional radiographs may be necessary to detect a fracture that might have originally been missed. The client should also be instructed to elevate the joint for 48 to 72 hours after the injury. If an elastic bandage is needed, the nurse should wrap the bandage from toes to midcalf, forming a figure eight, and teach the client how to reapply it. The nurse should ensure that the client also receives crutch-gait training.
CASE STUDY: Generate Solutions A 45-year-old male is admitted to the mental health unit for risk for harm to others. The nurse is identifying potential interventions that may help the client. Which intervention(s) should the nurse expect to perform? Select all that apply.
Protect the client's airway. Place pads on the client's side rails. Administer IV fluids. Check the client's blood sugar. Initiate venous thromboembolism (VTE) prophylaxis. Administer lorazepam IV. Prevent aspiration.
CASE STUDY: A nurse is caring for a client on a medical-surgical unit. 0600 Returned to client's room to prepare for transport to surgery. Client reports feeling dizzy, faint, and has blurred vision.
Summary Explanation: A client is receiving care on a medical-surgical unit. Recognize cues that require attention: the client has had a drop in heart rate after their medications were administered. Analyze the cues to determine that the client may have systemically absorbed their ophthalmic medication, timolol. Prioritize hypotheses by evaluating the client for additional side effects of systemic absorption. Generate solutions by identifying the need to check the client's blood pressure to assess for hypotension (an additional side effect of systemic absorption) due to the administration of timolol.
A client with a bicuspid aortic valve has severe stenosis and is scheduled for valve replacement. The client expresses anxiety over the surgical procedure and future implications. As the nurse explains the normal blood flow through the heart, at which location would the nurse highlight the location of the faulty valve?
The aortic valve is located between the left ventricle and the aorta. A bicuspid aortic valve is an inherited form of heart disease. It is one of the semilunar valves, which only has two leaflets instead of three. A person with a bicuspid aortic valve is at risk for aortic stenosis and aortic regurgitation. This impaired blood flow through the valve leads to increased pumping pressure of the left ventricle.
CASE STUDY: Analyze Cues A 21-year-old female has given birth in the hospital. After analyzing the concerning assessment data, what conclusion can the nurse make regarding the client? Select the best answer.
The client is developing an infection at the episiotomy site.
CASE STUDY: Evaluate Outcomes A 35-year-old male is admitted to a small hospital for chest pain. The nurse has given report to the receiving facility. Select the three (3) statements by the receiving nurse that indicate a need for additional follow-up.
The client is being transferred because of a bad stomach infection." "The client has not received any medication while at your facility." "I will have a translator device ready when the client arrives." Summary Explanation: A 35-year-old male client is admitted for chest pain. Recognize the most serious cues that the nurse should be concerned about—chest pain, elevated troponin levels, abnormal EKG, family history, and diaphoresis. Analyze these cues to compare different diagnosis. In this case, myocardial infarction and gastroenteritis were compared. Identify and prioritize the most likely hypotheses and most essential client need to prevent further harm in the client and be able to establish a care plan. In this case, the client is at risk for myocardial infarction and needs to be transferred to an acute-care facility to receive a cardiac catheterization. Generate solutions by anticipating what items are needed for a proper transfer. In this case, giving report to the receiving facility, securing the client's IV and oxygen tubing, ensuring the client has all personal belongings, educating the client on transfer reasons and process, and verifying a transfer order is in place are all necessary for a successful transfer. Take action by knowing how to properly call report to the receiving facility. In this case, talking directly to the receiving nurse using an SBAR handoff technique is the appropriate action. Evaluate which statements by the receiving nurse indicate a need for additional follow-up. In this case, being transferred due to a stomach infection, not receiving any medication at the transferring facility, and needing a translator device all indicate ineffective communication.
CASE STUDY: Prioritize Hypotheses A 45-year-old male is admitted to the mental health unit for risk for harm to others. Complete the following sentence(s) by choosing from the lists of options.
The nurse knows that the client's priority problem is alcohol withdrawal syndrome as evidenced by auditory hallucinations and a history of 10-12 beers per day
CASE STUDY: Prioritize Hypotheses A 35-year-old male is admitted to a small hospital for chest pain. Complete the following sentence(s) by choosing from the lists of options.
The nurse knows the client is at greatest risk for myocardial infarction, and therefore, the priority need is a transfer to an acute-care facility to obtain cardiac catheterization
CASE STUDY: Generate Solutions A 21-year-old female has given birth in the hospital. Drag words from the choices below to fill in each blank in the following sentence.
The nurse knows to notify the provider and anticipate orders, in order to continue proper
CASE STUDY: Take Action A 21-year-old female has given birth in the hospital. Complete the following sentence(s) by choosing from the lists of options.
The nurse should first perform episiotomy wound care with site culture from the providers orders.
CASE STUDY: Take Action A 35-year-old male is admitted to a small hospital for chest pain. The nurse is deciding the best way to communicate with the receiving facility. Complete the following sentence(s) by choosing from the lists of options.
The nurse should speak directly with the receiving nurse and use the SBAR (situation, background, assessment, recommendation) communication technique
CASE STUDY: Take Action A 45-year-old male is admitted to the mental health unit for risk for harm to others. Complete the following sentence(s) by choosing from the lists of options.
The nurse's first priority is protect the client's airway in order to prevent aspiration
A nurse is preparing a plan of care for a postoperative client. What is the most appropriate nursing intervention to prevent the development of atelectasis?
Use of an incentive spirometer Using an incentive spirometer will require the client to take deep breaths that promote lung expansion. Chest physiotherapy would help mobilize secretions but won't prevent atelectasis. Reducing oxygen requirements, or placing someone on mechanical ventilation won't affect the development of atelectasis.
When the nurse administers intravenous midazolam hydrochloride, the client demonstrates signs of an overdose. What should the nurse do next?
Ventilate with an oxygenated bag valve mask. The nurse should have a bag valve mask in the client's room because midazolam hydrochloride can lead to respiratory arrest if it is administered too quickly. The client does not need to be shocked back into a normal rhythm or receive epinephrine unless cardiac compromise develops after the respiratory arrest. The client would receive titrated dosing of flumazenil to reverse the midazolam, but first, the nurse should ventilate the client.
CASE STUDY: Analyze Cues A 45-year-old male is admitted to the mental health unit for risk for harm to others. The nurse is analyzing the results of the assessment. For each finding, click to specify if it indicates withdrawal syndrome, myocardial infarction, or gastroenteritis. Each finding may support more than 1 condition.
Withdrawal syndrome - Confusion, Nausea, Diaphoresis, Diffuse abdominal pain, Agitation, Auditory hallucinations, Hand tremor, Myocardial infarction -Nausea, Diaphoresis, Agitation Gastroenteritis - Nausea, Diaphoresis, Diffuse abdominal pain
The health care team is developing a care plan for a client who has burns on 30% of their body. When should the team initiate rehabilitation plans for this client?
after the client's circulatory status has been stabilized Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to eliminate the client's pain; pain control is a major challenge in burn care.
A nurse provides care for clients who come to the emergency department of a local hospital. Which observation(s) should alert the nurse to a decrease in a client's condition as they sit in the waiting room before they are seen by a health care provider? Select all that apply.
decrease in the level of consciousness skin appearing more pale breathing appearing more rapid Visual cues can include a change in level of consciousness, change in skin color, change in respiratory rate, and work in breathing. Refusing to sit down and talking with others around them may not be an indication of a change if the client has been doing this from when they first walked in; further data would be needed to determine if this is a decrease in this client's condition.
A nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are
fine crackles Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
While the nurse is teaching a group of volunteers for a crisis hotline, a volunteer asks, "What if I'm not sure why someone is calling?" Which statement by the nurse is most helpful?
"Ask the caller to tell you why they are calling you today." The crisis worker needs to use active focusing techniques to determine the crisis-precipitating event or the immediate problem. Asking the caller, "Why are you calling today?" or "What is the immediate problem?" will assist the caller to focus on the specific need or event. Telling the client to make an appointment is inappropriate because the problem might be life-threatening. Telling the caller to go to the nearest emergency department is precipitous and may be unnecessary. Asking to speak to someone else in the home may be futile because the caller might be alone. This action also ignores the caller and their feelings.
In preparing a postoperative cardiac client for discharge to home, the nurse works with the case manager to insure coordination of rehabilitation services. What is the primary goal for this client post-discharge?
- Direct all the needed outpatient client health services. The primary goal for the nurse and the case manager, along with other members of the health care team, is to coordinate the outpatient care and community and home care services needed for a successful reintegration into the community. The activities related to education, monitoring client progress, and communicating with the insurance companies are additional goals to implement as the client's care necessitates.
A nurse administers indomethacin to a neonate. What should the nurse do to ensure that the nurse has identified the neonate correctly? Select all that apply.
- Verify the infant's full name with the parent. - Check the neonate's identification band against the medical record number. - Verify the date of birth from the medical record with the date of birth on the neonate's identification band. The nurse should use at least two sources of identification prior to administering medication to any client, such as the medical record number and the client's date of birth. Verifying the infant's full name with the parent provides an additional verification. It is not safe practice to ask another nurse to verify the correct neonate. It is also not safe to use the room number or crib number as a source of identification because neonates' locations in the hospital change frequently.
CASE STUDY: Recognize Cues A 35-year-old male is admitted to a small hospital for chest pain. Which finding(s) should the nurse be concerned about? Select all that apply.
Chest pain 9/10 Elevated troponin levels Family history of heart disease EKG results Clammy, diaphoretic skin Chest pain at 9/10 can indicate that the client is at risk for a cardiac event. This is a concerning finding. Elevated troponin levels support the likelihood of a cardiac event. This should be a concerning finding. A significant family history of heart disease, especially in the males of the family, increases the client's risk of a cardiac event. EKG results of sinus tachycardia with ST depression and T wave inversion are suspicious for a semi cardiac event. This should be a concerning finding. Clammy, diaphoretic skin is an abnormal finding and is supportive evidence of an impending cardiac event. Previous use of antacid tablets does not affect the nurse's care of the client. A history of celiac disease is not a concerning assessment at this time. The nurse should be more concerned about a potential cardiac event.
CASE STUDY: Analyze Cues A 35-year-old male is admitted to a small hospital for chest pain. The nurse is analyzing the client's symptoms. For each assessment finding, click to specify if it indicates myocardial infarction or gastroenteritis. Each finding may support more than one disease process.
Myocardial Infarction: -Acid reflux -Radiating chest pain -ST depression -Elevated troponin levels -Diaphoretic skin Gastroenteritis -Acid reflux -Diarrhea -Hyperactive bowel sounds -Diaphoretic skin
CASE STUDY: A nurse is caring for a client on a medical-surgical unit. 0600 Returned to client's room to prepare for transport to surgery. Client reports feeling dizzy, faint, and has blurred vision.
The nurse should plan to first check the client's blood pressure in order to assess for the presence of hypotension due to the administration of timolol Due to the drop in the client's heart rate, a side effect of the client's timolol medication, the nurse suspects that the timolol may have been absorbed systemically. Therefore, the nurse should check the client's blood pressure to assess for the presence of hypotension (an additional side effect of systemic absorption) due to the administration of timolol. The client may need a thyroid-stimulating hormone (TSH) test to assess for the presence of hyperthyroidism due to an inadequate levothyroxine dose; however, this is not consistent with the symptoms the client is currently experiencing and is not a priority action. The client may need their glucose level checked; however, this is not consistent with the symptoms the client is currently experiencing and is not a priority action. Additionally, metformin would more likely cause hypoglycemia as opposed to hyperglycemia. The client's symptoms are inconsistent with the development of angioedema. Therefore, assessing the client's tongue and lips for the presence of angioedema due to the administration of lisinopril is not currently indicated.
A client is diagnosed with a highly drug-resistant Klebsiella pneumonia. What priority information will the nurse include in the client's teaching plan?
Washing hands before and after eating and as frequently as possible Clients should wash hands before and after they eat and as frequently as possible while hospitalized to reduce infections. Klebsiella is spread by person to person contact. The house does not need to cleaned with a bleach solution. The course of antibiotics may continue with discharge. There are no special precautions with a mask for the client because the bacteria does not spread through airborne means.
When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of
fresh fruits. Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.
Which assessment finding would advise the nurse of a need to change from the prescribed intranasal route to an injection of desmopressin acetate for a child with diabetes insipidus?
mucous membrane irritation Mucous membrane irritation, caused by a cold or allergy, can render the intranasal route unreliable. Severe coughing, pneumonia, and nosebleeds shouldn't interfere with the intranasal route.
A 40-year-old client at 8 weeks' gestation has a 3-year-old child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling (CVS) as genetic screening methods for the expected baby. The nurse is confident that the teaching has been understood when the client makes which statement?
"CVS can be performed earlier in pregnancy." CVS can be performed from approximately 8 to 12 weeks' gestation, while amniocentesis cannot be performed until between 11 weeks' gestation and the end of the pregnancy. Eleven weeks' gestation is the earliest possible time within the pregnancy to obtain a sufficient amount of amniotic fluid to sample. Because CVS takes a piece of the membrane surrounding the infant, this procedure can be completed earlier in the pregnancy. Amniocentesis and chorionic villus sampling identify the genetic makeup of the fetus in its entirety, rather than a portion of it. Laboratory analysis of CVS takes less time to complete. Both procedures place the fetus at risk, and postprocedure teaching asks the client to report the same complicating events (bleeding, cramping, fever, and fluid leakage from the vagina).
A parent asks, "How should I bathe my baby now that they have had surgery for an inguinal hernia?" Which instruction should the nurse give the parent?
"Give them a sponge bath daily for 1 week." The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. The infant can have more than just the face and diaper area cleaned following surgery. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days. Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable. Because the incision must be kept clean and dry, full tub baths are inappropriate.
CASE STUDY: Evaluate Outcomes A 21-year-old female has given birth in the hospital. The nurse is giving the client self-care instructions. Which statement(s) indicate client understanding? Select all that apply
"I should use warm water in the peri bottle and make a sweeping motion from side to side." "I should pat the area with warm washcloths, front to back." "I should monitor for swelling and redness at the site of the sutures." "I should wash my hands before and after performing self care." Summary Explanation: A young adult has an episiotomy performed during delivery. Recognize that the assessment vitals and episiotomy site condition are of concern and need follow-up from the provider. Analyze the assessment findings together to understand that the client is showing signs of an infection. Prioritize hypothesis to contact the provider and to be able to anticipate orders. Generate solutions to prioritize orders received from the provider. Take action to resolve the client's needs before discharge can occur. Evaluate outcomes by having the client repeat knowledge is a good way to evaluate if they understand. Knowing what improvements are necessary for discharge readiness can help reduce length of stay.
A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor?
"My child's abdomen seems bigger, and his diapers are much tighter." The most common presenting sign of a Wilms' tumor is abdominal swelling or an abdominal mass. Therefore, the mother's observation that her child's abdomen seems bigger suggests a Wilms' tumor. A rapid increase in length (height) isn't associated with this type of tumor. Although lethargy may accompany a Wilms' tumor, abdominal swelling is a more specific sign. Children with a Wilms' tumor usually have a decreased, not increased, appetite.
A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts, and two episodes of hitting a coworker at the grocery store where they work. The client is very anxious and tells the nurse who admits them, "I didn't mean to hit them. They made me so mad that I just couldn't help it. I hope I don't hit anyone here." How should the nurse respond?
"When you start to feel angry here, talk to the staff about your feelings." Offering the client a method to help them cope with their feelings focuses on the client's problem and the need to handle it appropriately without becoming aggressive.Threatening statements do not elicit further information and are not therapeutic.Asking the client to explain what happened is a therapeutic statement likely to elicit assessment data, but it is less focused on the client's immediate need to cope with anger.Providing false reassurance is never therapeutic, may decrease the client's trust, and does nothing to help the client manage feelings.
A parent of a child with acute poststreptococcal glomerulonephritis (APSGN) asks how a strep infection caused the child to have a kidney problem. What is the nurse's best response?
- "By-products of immune complexes that fought the infection are depositing in the kidneys." APSGN is an immune complex disease. Large antigen-antibody complexes are formed that deposit in the glomerular capillary loops, leading to obstruction. APSGN is considered an autoimmune disorder, not an infection. Antibodies do not attack the kidneys in this disorder.
The nurse is teaching an older adult client who was assigned female at birth various steps to help reduce future urinary tract infections (UTIs). Which statement by the client will indicate the teaching session was successful?
- "Cranberry products will help me prevent future UTIs." Cranberry products provide prophylaxis to reduce the risk of future UTIs for clients assigned female at birth. Drinks containing citrus, however, should be avoided as they can irritate the bladder and increase the risk for infection. Older adults do not show the usual signs of a UTI. The only sign may be a change in mental status. Antibiotics are not usually given prophylactically as these medications increase the chances of developing a bacteria-resistant form of UTI.
Refraining from rituals demonstrates that the client manages stress appropriately. Using the "thought-stopping" strategy demonstrates the client's ability to employ appropriate interventions for obsessive thoughts. Identifying situations that promote anxiety and precipitate ritualistic behavior help the client cope with the anxiety as well as understand the disease process. Avoiding, rationalizing, and hiding behaviors demonstrate maladaptive methods for managing stress and anxiety.
- "Toilet training may be difficult." Toilet training is commonly more difficult for children who have undergone surgery for Hirschsprung disease than it is for other children. This is because of the trauma to the area and the associated psychological implications. Abdominal distention is an early sign of infection, and therefore the parents need to report it to the health care provider. Typically, dietary restrictions are not required, but fiber is encouraged. Usually, the infant is placed on an age-appropriate diet. Vitamin supplementation is not necessary if the infant's dietary intake is adequate.
The nurse is giving care to an infant in an oxygen hood (see figure). Which intervention(s) are indicated? Select all that apply.
- Assure that the oxygen is not blowing directly on the infant's face. - Place the butterfly mobile on the outside of the hood. - Encourage the parents to visit the child. When an oxygen hood is used, the nurse should be sure the oxygen source is not directed at the infant's face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the health care provider has written the prescription. There should be as little movement in and out of the hood as possible to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.
A RN is delegating client care responsibilities to a licensed practical/vocational nurse (LPN/VN). Which nursing responsibilities would be appropriate to delegate to the LPN/VN? Select all that apply.
- Changing the client's decubitus foot ulcer dressing. - Reinforcing the teaching of proper diabetic diet. - Obtain a bedside glucose specimen test at 1100. As per the ANA Code of Ethics for Nurses Provision 4, the nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum client care. An LPN/VN cannot administer IV push medications or blood, or assess the client's swallowing ability. The LPN/VN can change a simple dressing, reinforce education, or obtain a blood glucose level under the LPN's Nurse Practice Act.
A client has Raynaud phenomenon. What information should the nurse include in a teaching plan about managing an attack? Select all that apply.
- Go to a warm room. - Move the fingers and toes. - Massage the fingers and toes. - Place hands under the armpits. When the client with Raynaud disease is having a vasospastic attack, the nurse can teach the client to go to a warmer room, move the fingers and toes to improve circulation, massage the extremities to promote circulation, and put the hands under the armpits to take advantage of body heat. The client should not put the hands or fingers under hot water as there is a risk for burns. If necessary, the client can warm the hands and fingers under slightly warm water.
A client has a total right knee replacement. In preparing the client for the first day after surgery, the nurse should instruct the client to do which action?
- Sit in a chair with the leg elevated. Usual postoperative activity prescriptions for a client with a total knee replacement include transferring the client out of bed to a chair on the first postoperative day. The affected leg is protected with a knee immobilizer and elevated while the client is up in the chair. Bed rest is unnecessary and increases the risk of thrombophlebitis. Activity will progress to ambulating with a walker and assistance after the client is first up in a chair. Activity progresses to partial weight bearing with the use of assistive devices.
A bystander is administering cardiopulmonary resuscitation (CPR) to a person who has collapsed in an airport and is not breathing and does not have a pulse. Which criterion is acceptable for a bystander rescuer to use to discontinue CPR in an out-of-hospital cardiac arrest?
- The rescuer is exhausted. According to the American Heart Association and the Heart and Stroke Foundation of Canada, CPR, once initiated, may be discontinued only when the rescuer is exhausted or when a health care provider is present to determine the victim's status. A health care provider, not the rescuer, must determine the victim's status and ability to survive. There is not an established time limit for discontinuing CPR. Family members' requests to discontinue CPR cannot be honored. It is the health care provider's responsibility to determine when CPR can be discontinued.
CASE STUDY: Recognize Cues A 45-year-old male is admitted to the mental health unit for risk for harm to others. The nurse is reviewing the client's assessment. Click to highlight the findings that will require immediate follow up.
- agitated and diaphoretic - Oriented to person and place only - frequent heart palpitations - diffusely tender - severe nausea - grips weak and equal - Severe tremor - hearing a voice Rationale: Agitation and diaphoresis indicate an acute process is happening. Prompt follow-up and intervention is needed. Confusion is abnormal and requires prompt and thorough follow-up. Frequent heart palpitations require prompt follow-up. A diffusely tender abdomen could indicate many acute processes and should be promptly evaluated. Severe nausea could indicate an acute process and should be evaluated further. A severe tremor is abnormal and should be evaluated further. Auditory hallucinations are not normal and should be promptly evaluated. Tooth pain is abnormal, but is not a high priority in this circumstance. Considering the client's lack of medical care, the client has unlikely received dental care. Grips that are weak and equal could indicate several different disease processes, but given the client's current status and the ability to move all extremities equally, it is likely not due to an acute process. It can be evaluated at a later time.
A nurse is teaching a pregnant client about the role of the placenta. The nurse realizes further teaching is needed when the client states that the placenta:
- produces maternal antibodies. Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus, the placenta isn't responsible for the production of maternal antibodies. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.
A newborn is diagnosed with meconium ileus. Which diagnostic test should be performed on the client?
- sweat chloride test A meconium ileus should trigger the screening for cystic fibrosis, which would be diagnosed with a sweat chloride test. A rectal biopsy is used to diagnose Hirschsprung's disease, which is not related to cystic fibrosis. A heel stick would be appropriate to diagnose low blood sugar not related to cystic fibrosis in the infant. A chest X-ray would be used for pleural effusion not specific to cystic fibrosis.
The nurse is assessing the client's urinary stoma, which was created 4 days ago. Which sign indicates stomal edema?
- urine output below 30 mL/hr Urine output below 30 mL/hhr could indicate stomal edema, which obstructs urine output. An elevated temperature should be noted, but it is not related to stomal edema. Urine dribbling from the stoma is normal. Discomfort around the stoma is common postoperatively after construction of an ileal conduit.
CASE STUDY: Evaluate Outcomes A 45-year-old male is admitted to the mental health unit for risk for harm to others. The nurse is evaluating the client's progress. For each assessment, click to specify if the finding indicates improvement, decline, or no change.
Improved - AAOx4, No hallucinations Declined - Enlarged firm hepatic borders No change - Palpitations, Hand tremor Summary Explanation: A 45-year-old male is admitted to the mental health unit for risk for harm to others. Recognize the most serious cues that need immediate follow-up: agitation, diaphoresis, confusion, palpitations, nausea, abdominal pain, tremors, and hallucinations. Analyze these cues to compare different disease processes. In this case, withdrawal syndrome, gastroenteritis, and myocardial infarction were compared. Identify and prioritize the most likely hypotheses to prevent further harm in the client. In this case, alcohol withdrawal syndrome as evidenced by history of 10-12 beers per day and hallucinations. Generate solutions by anticipating that this client will need airway protection, seizure precautions, VTE prophylaxis, IV fluid replacement, blood sugar monitoring, and lorazepam administration. Take action by knowing what the priority intervention is. In this case, protection of the airway is the first priority. Evaluate whether the client has improved, declined, or had no changes. In this case, AAOx4 and resolution of hallucinations indicates an improvement, palpitations and a continued tremor indicate no change, and enlarged firm liver borders indicate a decline.
