LS II E #2
The nurse is teaching the parents of a very young client newly diagnosed with attention-deficit/hyperactivity disorder (ADHD) about the newly prescribed medication methylphenidate (Ritalin). Which instruction should the nurse include? Give the medication prior to going to bed at night. Give the medication first thing in the morning. Restrict the amount of calories that the client eats each day. Observe the child for excessive sleepiness.
Give the medication first thing in the morning.
An woman planning to get pregnant inquires how best to reduce the risk of her child having CP. What advice is most accurate? Have prenatal care from a qualified obstetrician Have prenatal care and avoid having any vaccinations Have prenatal care and take precautions to avoid preterm labor Have prenatal care and take folic acid
Have prenatal care and take precautions to avoid preterm labor
During an assessment, the nurse suspects that an 18-month-old client is demonstrating manifestations of cerebral palsy (CP). Which assessment finding should the nurse use to validate this conclusion? (Select all that apply.) Thumb sucking Good trunk control Head lag Asymmetric crawling Arched back
Head lag Asymmetric crawling Arched back
The nurse is teaching the parents of a child recently diagnosed with autism spectrum disorder (ASD). Which etiologies should the nurse include? (Select all that apply.) Breast feeding Mercury-containing vaccinations Immunologic factors Environmental factors Genetics
Immunologic factors Environmental factors Genetics
The nurse notes a high level of stress between the parents of a child with cerebral palsy (CP). Which action should the nurse take to support the parents? Listen to concerns and encourage expression of feelings Make a referral for marriage counseling Refer all medical questions to the healthcare provider Explain that most children with CP are eventually placed in long-term care facilities
Listen to concerns and encourage expression of feelings
The nurse is preparing discharge instructions for an older adult client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. Which topics should the nurse include in the discharge teaching for this client? Select all that apply. Obtain annual influenza immunization. Restrict fluids. Engage in frequent hand washing. Cover the nose and mouth when coughing. Avoid crowds.
Obtain annual influenza immunization. Engage in frequent hand washing. Cover the nose and mouth when coughing. Avoid crowds.
Which of the following patients is at highest risk for developing metabolic alkalosis? Pt with hyperemesis gravidarum Pt with pneumonia Pt with a stroke Pt with diabetes
Pt with hyperemesis gravidarum
After performing a physical assessment, the nurse suspects that a client is experiencing manifestations of osteoarthritis (OA). Which finding supports the nurse's suspicion? (Select all that apply.) Reduced joint flexibility Joint tenderness Leg tremors Crepitation Joint stiffness
Reduced joint flexibility Joint tenderness Crepitation Joint stiffness
A client with CHF has an order for furosemide (Lasix) IVP. What will the nurse assess first to evaluate the effectiveness of the medication? Leg circumference Serum electrolytes Lung sounds Urine output
Urine output
An adult client seeks care for attention-deficit/hyperactivity disorder (ADHD). Which items in the collected history would support this diagnosis. high level of contentment, positive work relations, and mild temperment forgetfulness, anxiety, and trouble multitasking excessive planning, poor sleep, and high stress passive attitude, low energy, and strong relationships
forgetfulness, anxiety, and trouble multitasking
Serum potassium of 3.25 mEq/L indicates hypokalemia hyperkalemia hypernatremia hypocalcemia
hypokalemia
When considering acid-base balance, health promotion should focus on conducting yearly health screenings. obtaining immunizations. beginning an exercise regimen. maintaining fluid balance.
maintaining fluid balance.
The nurse is assessing a client suspected of having multiple sclerosis. Which manifestation should the nurse place as the top priority? tingling sensations stress incontinence vertigo sexual dysfunction
vertigo
The nurse is assessing an older adult client in a long-term care facility after a fall. Which finding requires priority action? The client is repeatedly flexing the injured leg at the hip. Pain is relieved by moving the affected extremity. The injured leg is shortened and externally rotated. Redness and severe swelling are found at the hip joint.
The injured leg is shortened and externally rotated.
Case Study: Fluid and Electrolyte and Acid-Base Imbalances As a nurse on a medical-surgical unit, you frequently care for postsurgical patients, including Earl Robinson, a 54-year-old mail carrier. Mr. Robinson was admitted to your unit postoperatively after his left knee repair with vomiting and a Wound Vac on his left knee. As IV fluids are infusing on the vast majority of your post-op admissions, understanding fluid balance and electrolyte function is primary to your nursing practice—and vital to your patients' well-being. What conditions, in the above patient, might lead to the development of hypovolemia?
The patient is experiencing vomiting and has a wound vac on his Left Knee. The patient is being depleated of fluids he also is being depleated of his blood as the wound-vac sucks his infection out. The patient would be at a bigger risk of hypovolemia due to the blood loss and losing fluids.
Case Study: Fluid and Electrolyte and Acid-Base Imbalances As a nurse on a medical-surgical unit, you frequently care for postsurgical patients, including Earl Robinson, a 54-year-old mail carrier. Mr. Robinson was admitted to your unit postoperatively after his left knee repair with vomiting and a Wound Vac on his left knee. As IV fluids are infusing on the vast majority of your post-op admissions, understanding fluid balance and electrolyte function is primary to your nursing practice—and vital to your patients' well-being. Describe how hypovolemia and third-space fluid shift correlate.
The third space fluid shift is when the fluid moves to a space where it is unusable by the body. The fluid moves out of the intravascular space and the body will not be able to use the fluid. The third space shift will cause low blood volume which is hypovolemia.
A Pt with Parkinson's is reporting that his gait is more unsteady; there is an increased risk for falls. Which suggestion could the nurse offer to diminish this risk? Walk leaning forward using a cane with a base Walk by stepping over imaginary lines on the floor Use a wheelchair Walk standing erect with a walker with wheels
Walk by stepping over imaginary lines on the floor
The order is for D5W 1 liter at 160 mL/hour. The tubing drop factor is 15 gtts/mL. How many gtts/min?
40
A nurse conducted a class on fall prevention for a group of older adult clients in the community. Which observation during a client home visit indicates that teaching on fall prevention was effective? A shower seat was placed in the shower. All meat is placed in the freezer. Throw rugs are placed in the kitchen. The locks were changed on the doors
A shower seat was placed in the shower A shower seat in the shower can prevent falls. The client who installed the seat has understood the nurse's teaching. Changing the locks may promote safety if there have been frequent break-ins, but there is no evidence of that. Throw rugs in any area of the home are a safety hazard. Placing meat in the freezer does not help prevent falls.
The first day after surgery to repair a fractured hip sustained from a fall, an older adult client refuses to ambulate but states, "I will consider it tomorrow." In this situation, which is the priority action by the nurse? Assess why the client is refusing to ambulate Document the client's refusal Coordinate personnel to assist with ambulation Notify the healthcare provider
Assess why the client is refusing to ambulate The first thing the nurse should do is assess why the client is refusing to ambulate. The client might be fearful of falling, given that a prior fall resulted in a fractured hip. Following this assessment, the nurse could plan interventions that would facilitate ambulation, such as controlling pain and reducing the fear of falling. It is premature to notify the healthcare provider. The nurse should not force the client to get out of bed. Documenting the client's refusal is appropriate, but after determining the reason for the refusal.
The quick and easiest way to help correct respiratory alkalosis in a hyperventilating patient is Assist them to slow their breathing Have the the patient do some exercise Have them drink an acidic drink like fruit juice Use IV interventions
Assist them to slow their breathing
The nurse assesses an older adult woman and determines the client is at high risk for osteoporosis and hip fractures. Based on these findings, which test should the nurse request from the healthcare provider? Computerized tomography (CT) scan Magnetic resonance imaging (MRI) scan Bone density testing Hormone levels
Bone density testing
The wife of a client with Parkinson disease (PD) expresses frustration about trying to communicate with her husband. What can the nurse do to facilitate communication between the client and spouse? Suggest the client and spouse communicating by writing. Suggest that the spouse obtain a hearing aid. Consult with speech therapy for exercises to aid the client with speech and language. Recommend that the client and spouse learn sign language.
Consult with speech therapy for exercises to aid the client with speech and language. The spouse is frustrated with the client's impaired verbal communication. The best intervention would be to consult with speech therapy for exercises to aid the client with speech and language. The spouse does not need a hearing aid. The spouse and client do not need to learn sign language in order to communicate. The client may or may not be able to write because of hand tremors, so it may not be appropriate for the nurse to suggest that the client and spouse communicate via writing.
The nurse is caring for a client admitted with an exacerbation of multiple sclerosis (MS). The client is demonstrating frustration with eating because he is experiencing hand and arm spasms that prevent the proper use of utensils. Which intervention should the nurse implement to best assist this client? "Symptoms will develop slowly, but continuously with no periods of remission." "Symptoms will become progressively worse with periods of flare-ups." "Symptoms will not develop for at least several years after diagnosis." "Symptoms will flare up at times, with periods of partial or complete remission."
Consult with the occupational therapist regarding assistive devices for meals.
________ is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to one of lower pressure. Filtration Diffusion Osmosis Active transport
Filtration
The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment? Eye pain and redness Hyphema Subconjunctival hemorrhage Floaters in the visual field
Floaters in the visual field
The nurse is assessing a toddler client for an upper respiratory infection. The nurse suspects the child may have autism spectrum disorder (ASD). Which behavior caused the nurse's suspicion? Speaking to the nurse in sentences Having a tantrum when touched by the nurse Crying after the administration of immunizations Playing with the other children and toys while awaiting the nurse
Having a tantrum when touched by the nurse
A client with chronic hip pain is diagnosed with osteoarthritis. Which instruction regarding home safety is most appropriate for the nurse to provide to this client? Rest in a recliner. Walk up and down the steps at home as much as possible. Place scatter rugs in high-traffic areas. Install grab bars in the bathroom near the commode and in the shower.
Install grab bars in the bathroom near the commode and in the shower. The client should be encouraged to install grab bars in the bathroom near the commode and in the shower. The client should be instructed not to overuse the affected joints with excessive stair climbing. Scatter rugs are a hazard to mobility and should be avoided. The client should also be instructed to sit in a straight-back chair, avoid slumping, and avoid use of a recliner.
The nurse is providing teaching about home care for a client with osteoarthritis of the knees. Which information should the nurse include? (Select all that apply.) Installing handrails in the bathroom Continuing activity with repetitive movement Using assistive devices to minimize stress placed on affected joint Taking pain medications as ordered Encouraging heavy lifting to maintain muscle strength
Installing handrails in the bathroom Using assistive devices to minimize stress placed on affected joint Taking pain medications as ordered
Extra Credit: The nurse is assessing a 4-month-old infant. Which developmental milestone should the nurse expect the infant to have mastered by this time?
Looks at and plays with own fingers
A client with Parkinson disease (PD) is prescribed an anticholinergic agent to treat tremors and rigidity. The nurse should teach the client about which adverse effect they may experience from this medication? (Select all that apply.) Rigidity Loss of perspiration Tremors Drooling Dry mouth
Loss of perspiration Dry mouth
The nurse is planning care for a client with osteoarthritis (OA). Which nursing diagnosis is a priority for the nurse to address? Family Processes, Interrupted Lifestyle, Sedentary Skin Integrity, Impaired Pain, Chronic
Pain, Chronic
Using the provided ABG values, what is the acid base imbalance shown? pH = 7.26 HCO3 = 12 PCO2 = 28 Compensated Metabolic Acidosis Partially Compensated Metabolic Acidosis Compensated Respiratory Acidosis Partially Compensated Respiratory Acidosis
Partially Compensated Metabolic Acidosis
The nurse is caring for a client who has cerebral palsy (CP). Which intervention should the nurse use to promote flexibility and prevent contractures? Administer mood stabilizers Offer the use of assistive devices Provide muscle relaxants Perform range-of-motion (ROM) exercises
Perform range-of-motion (ROM) exercises
The parents of a young client newly diagnosed with attention-deficit/hyperactivity disorder (ADHD) are concerned about the school environment and the child's grades. Which suggestion should the nurse encourage the parents to discuss with the child's teacher? (Select all that apply.) Place the child in the back of the classroom. Place the child in the front of the classroom close to the teacher. Allow the child to have snacks in class. Don't allow the child to do special tasks or run errands without supervision. Provide a quiet area for examinations and extra time if necessary.
Place the child in the front of the classroom close to the teacher. Don't allow the child to do special tasks or run errands without supervision. Provide a quiet area for examinations and extra time if necessary.
The nurse caring for a child recently diagnosed with cerebral palsy (CP) is discussing the plan of care with the parents. Which should the nurse identify as a major goal of therapy for this child? Promoting optimal global development Reversing the degenerative processes that have occurred Curing the underlying defect Increasing the child's IQ level
Promoting optimal global development Promoting optimal development in all areas is the goal of therapy with children with CP. CP is caused by a probable brain insult and cannot be cured. Most children with CP have normal IQs, but they might have behavior or perceptual problems. CP is caused by an irreversible brain insult.
The nurse is caring for a child diagnosed with autism spectrum disorder (ASD) who is being admitted to the hospital with dehydration. Which action by the nurse is appropriate when the child arrives to the care area? Take the child to the playroom for arts and crafts. Quietly orient the child to a single-bed hospital room. Orient the child to a four-bed patient room Take the child on a tour of the pediatric unit.
Quietly orient the child to a single-bed hospital room.
The nurse is assessing a 3-year-old child with autism spectrum disorder (ASD). In which area should the nurse expect to find impairments? (Select all that apply.) Social adaptability Communication Knowing their own name Ability to organize responses to situations Ability to engage in complex thought process
Social adaptability Communication Ability to organize responses to situations
A mother of a toddler questions what can be done to assist her child's development. All of the following are ways to help except. read simple short stories with the child provide age appropriate toys such as blocks Speak with child using single step directions limit introduction of solid foods
limit introduction of solid foods
A client is admitted to the hospital with sudden, severe abdominal pain. The client is diagnosed with respiratory alkalosis. Which arterial blood gas value does the nurse document to support this diagnosis? pH is 7.51 and HCO3 is 30. pH is 7.47 and PaCO2 is 25. pH is 7.35 and PaO2 is 88. pH is 7.33 and PaCO2 is 36.
pH is 7.47 and PaCO2 is 25. Acute pain usually causes hyperventilation, which causes the PaCO2 to drop and the client to experience respiratory alkalosis. The pH would denote alkalosis and would be higher than 7.45. HCO3 would trend downward as the kidneys begin to compensate for the alkalosis by excreting HCO3. The PaO2 is likely to be normal unless the client has been hyperventilating for a long time and is beginning to tire.
The nurse is caring for an 8-year-old child who sustained a hip fracture from a motor vehicle crash. The parents ask if the child will be scheduled for a hip replacement. How should the nurse respond? "We will place the child in traction for a few days, then do the hip replacement." "Hip replacements are not done in children because they need to be revised with growth." "Treatment for hip fractures in children often involves casting for 4 to 6 weeks." "A hip replacement will be performed once the child is medically stable."
"Treatment for hip fractures in children often involves casting for 4 to 6 weeks."
Extra Credit: In the video segment featuring Ryan teaching about CP, what is he studying in college?
Business
The nurse is teaching older adults with osteoarthritis (OA) actions to effectively manage chronic pain. Which recommendation should the nurse include? (Select all that apply.) Using firm support in chairs and mattresses to properly align the body Teaching proper posture and good body mechanics for activities of mobility Encouraging resting painful joints Limiting isometric exercises to reduce strain on the joints Applying cool compresses to painful joints to reduce inflammation
Teaching proper posture and good body mechanics for activities of mobility Encouraging resting painful joints Using firm support in chairs and mattresses to properly align the body
A middle-aged female client states to the nurse, "I have noticed a slight tremor in my left hand when it's at rest. I think I might have Parkinson disease because my mother had it." Which response by the nurse is the most appropriate? "You shouldn't worry too much, because Parkinson disease has a higher prevalence in males." "Having a close relative with Parkinson disease can increase your chance of developing it as well." "You probably don't have Parkinson disease. Your mother was probably exposed to a toxin that caused her illness." "It is unlikely that you have the same illness as your mother."
"Having a close relative with Parkinson disease can increase your chance of developing it as well." In some individuals, Parkinson disease (PD) is inherited; approximately 15% to 25% of individuals with PD have a relative with PD. The nurse should not tell the client it is unlikely she has the same illness as her mother. Exposure to toxins is one theory for the development of the illness; however, the nurse has no way of knowing whether the client's mother was exposed to toxins or if that was the cause for her disease. Men are at higher risk for PD, with 50% more men than women developing the disease, but this does not eliminate the client's risk of having the disease, especially given her mother's diagnosis.
Why do clients with Parkinson disease (PD) nearly always take carbidopa in combination with levodopa? Carbidopa enhances levodopa's conversion to dopamine throughout the body, thus intensifying levodopa's effectiveness. Carbidopa prevents levodopa's conversion to dopamine in the brain, thus intensifying levodopa's effectiveness. Carbidopa minimizes the conversion of levodopa to dopamine within the brain, thus minimizing levodopa's unwanted side effects. Carbidopa prevents levodopa from converting to dopamine until it reaches the brain, thus minimizing levodopa's unwanted side effects.
Carbidopa prevents levodopa from converting to dopamine until it reaches the brain, thus minimizing levodopa's unwanted side effects. Levodopa is a natural chemical that can cross the blood—brain barrier and be converted directly to dopamine in the brain. Levodopa can also be converted to dopamine outside the brain, which leads to the most common side effects of nausea and orthostatic hypotension. Therefore, levodopa is almost always given in combination with carbidopa, which prevents levodopa from converting to dopamine until it reaches the brain.
While assessing a client with eye pain, the nurse finds red, cloudy conjunctiva and swollen eyelids. The nurse should suspect which eye injury? Corneal abrasion Chemical burn of the eye Penetrating trauma injury to the eye Detached retina
Chemical burn of the eye
Which intervention is most appropriate for the nurse to include in the plan of care for a child with autism spectrum disorder (ASD)? Encouraging the client's family to bring in familiar objects from home Scheduling procedures for different times each day Putting the television on loud to provide stimulation for the client Rearranging the hospital room until a comfortable arrangement is found
Encouraging the client's family to bring in familiar objects from home
The nurse is caring for a client admitted with an exacerbation of multiple sclerosis (MS). The client is demonstrating frustration with eating because he is experiencing hand and arm spasms that prevent the proper use of utensils. Which intervention should the nurse implement to best assist this client? Counsel the client to select finger foods for meals. Consult with the occupational therapist regarding assistive devices for meals. Plan time and staff to feed the client. Consult with the physical therapist regarding hand and arm exercises.
Consult with the occupational therapist regarding assistive devices for meals. Because the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse should consult with the occupational therapist regarding devices the client can use to maintain independence at mealtimes. The nurse should not counsel the client to select finger foods for meals, nor should the nurse feed the client. Neither of these actions would support the client's self-concept and self-esteem needs. The nurse might consult the physical therapist regarding hand splints, but hand and arm exercises might not be beneficial for this client.
In clients with Parkinson disease, increasing doses of and long-term exposure to levodopa can cause which of the following conditions? Hypertension Insomnia Compulsive behavior Dyskinesia
Dyskinesia With increasing doses and long-term exposure, levodopa usually causes dyskinesia, which may become less tolerable for the client than the symptoms of PD. Insomnia and hypertension are not side effects of levodopa. Compulsive behavior is a side effect of dopamine antagonists, not levodopa.
A client with a history of relapsing-remitting multiple sclerosis (MS) is expecting her first child. Which of the following nursing interventions would be indicated for this client? Tell the client to expect a period of remission after delivery. Suggest the client seek reproductive counseling. Discuss the client's options for pain control during labor, as her contractions will be especially severe. Instruct the client to expect an exacerbation of symptoms while pregnant.
Suggest the client seek reproductive counseling A definite genetic cause of MS has not been established; however, studies suggest that genetic factors make some individuals more susceptible to the disorder than others. Also, some medications used in the treatment of MS can be harmful to a fetus. Thus, reproductive counseling would be recommended for this client. Pregnancy often brings about remission (not exacerbation) of MS, and there is a slightly increased relapse rate postpartum. The strength of uterine contractions in a client with MS is not severe, and because clients often have lessened sensation, labor may be almost painless.
The school nurse is helping to create an individualized education plan (IEP) for a young client with attention-deficit/hyperactivity disorder (ADHD). Which behavioral goal should the nurse include in the plan of care? The client will achieve school performance to minimum competency. The client will respect the boundaries of others. The client will demonstrate a decrease in attentiveness. The client will accurately manage medication administration.
The client will respect the boundaries of others
The nurse performs a focused assessment on a client diagnosed with multiple sclerosis (MS). Which assessment should the nurse perform as a part of the physical examination specific to MS? (Select all that apply.) The client's breathing sounds The client's balance The client's speech The client's visual acuity The client's affect
The client's balance The client's speech The client's visual acuity The client's affect
The nurse is assessing an older adult client. Which finding should cause the nurse to suspect the client has Parkinson disease (PD)? (Select all that apply.) The client's facial expression shows no emotion. The client does not remember what he ate for breakfast. The client's blood pressure increases when the client stands up. The client has hand tremors at rest. The client has slurred speech.
The client's facial expression shows no emotion. The client does not remember what he ate for breakfast. The client has hand tremors at rest. The client has slurred speech.
What is an example of an objective family burden? amount of unsecured financial debt criticism by extended family member as to care management options child requiring monitoring for self-harm limited access to specialized care
amount of unsecured financial debt
The most common disorder that increases a client's risk for respiratory alkalosis is: a chronic respiratory infection disorder a cardiovascular disorder. an anxiety disorder. a congenital disorder.
an anxiety disorder.
The nurse is caring for a client with third spacing. Which information should the nurse use to explain this health problem to the client's family? "Fluid leaves the body through increased urination." "Fluid moves into the fatty tissue under the skin." "Fluid in the blood vessels is unavailable for the body to use." "Fluid moves into an area where it is not available to support normal physiological functioning."
"Fluid moves into an area where it is not available to support normal physiological functioning." Rationale: In third spacing, fluid moves from the vascular space into an area where it is not available to support normal physiological functioning. The fluid may move into the peritoneal space or pleura, where it is trapped. The unavailable fluid in third spacing may be located in the bowel or peritoneal cavity. The fluid loss that can be attributed to third spacing may be difficult to detect because the client's weight may remain stable and intake and output records may not indicate a fluid loss. Fluid does not leave the body or enter the intracellular space or subcutaneous tissue.
A client diagnosed with localized idiopathic osteoarthritis (OA) asks the nurse what this means. Which response by the nurse provides the most accurate information? "Idiopathic describes OA overall while localized indicates that it affects more than 3 body joints." "Idiopathic describes OA overall while localized indicates that it affects one to two body joints only." "Idiopathic OA, as compared with secondary OA, is caused by some kind of underlying condition." "Idiopathic refers to the fact that the OA has already progressed significantly in one or two joints."
"Idiopathic describes OA overall while localized indicates that it affects one to two body joints only."