NUR 211 Final pt. 2

The nurse is conducting preoperative teaching to parents and their child about an external fixation device. What should the nurse include in the teaching session? (Select all that apply.) a. Pin care b. Crutch walking c. Modifications in activity d. Observing pin sites for infection e. Full weight bearing will be allowed after 24 hours

A,B,C,D The device is attached surgically by securing a series of external full or half rings to the bone with wires. Children and parents should be instructed in pin care, including observation for infection and loosening of pins. Partial weight bearing is allowed, and the child needs to learn to walk with crutches. Alterations in activity include modifications at school and in physical education. Full weight bearing is not allowed until the distraction is completed and bone consolidation has occurred.

What factors should be considered as a possible trigger for a palliative care consult? (Select all that apply.) A. Multiple hospitalizations over a short period of time B. Cognitive impairment C. Multifaceted care needs Correct D. Metastatic cancer E. An established advanced care plan

A,B,C,D The triggers for a palliative care consult includes multiple hospitalization over a short period of time, presence of cognitive impairment, multiple care needs, metastatic cancer, and the lack of an advance care plan.

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

A,B,D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the clients patient-controlled analgesia button. d. Reposition the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

A,B,D Postoperative care for a client who has ORIF of the hip includes elevating the clients heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown. ***It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip.*** The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.

What situation is considered a barrier to palliative care? (Select all that apply.) A. Poor of understanding of the role and nature of the care B. Insufficient numbers of appropriately trained professionals C. The need to delivery care only in home settings D. How palliative care is paid for E. Ineffective communication with potential palliative care patients

A,B,D,E Barriers to the delivery of palliative care to those illegible include poor communication about the role and nature of the care and the information potential patients need to arrive at the decisions appropriate for themselves. The issue of payment for the care and the training of palliative care professionals are also barriers to the implementation of such care. The care can be delivered in a variety of setting and is not limited to only home care.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

A,B,D,E Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

The focus of quality health care should be on which of the following items? (Select all that apply.) a. Excellent services b. Comprehensive communication c. Private hospital rooms d. Health team collaboration e. Culturally competent care

A,B,D,E Excellent services, communication, collaboration, and culturally competent care brings quality to the health care delivered to the patient. Private hospital rooms may be a preference by some patients, but they do not add to the quality of care.

The nurse is assisting with application of a synthetic cast on a child with a fractured humerus. What are the advantages of a synthetic cast over a plaster of Paris cast? (Select all that apply.) a. Less bulky b. Drying time is faster c. Molds readily to body part d. Permits regular clothing to be worn e. Can be cleaned with small amount of soap and water

A,B,D,E The advantages of synthetic casts over plaster of Paris casts are that they are less bulky, dry faster, permit regular clothes to be worn, and can be cleaned. Plaster of Paris casts mold readily to a body part, but synthetic casts do not mold easily to body parts.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the clients vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the clients oral fluid intake. e. Assess the chest and back for skin breakdown.

A,B,E A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

What are the major attributes of healthcare quality? (Select all that apply.) a. Conforms to standards b. Sound decision making c. High acuity patients d. Low health care costs e. Identifies adverse events

A,B,E Major attributes of healthcare quality include confirmation to standards set by regulatory agencies, sound decision making regarding care, and identifying potential adverse events. High acuity of patients does not contribute to quality health care, because the care demand is increased, and low health care costs mean fewer services may be available.

In teaching a 16-year-old adolescent who was recently diagnosed with systemic lupus erythematosus (SLE), what statements should the nurse include? (Select all that apply.) a. You should use a moisturizer with a sun protection factor (SPF) of 30. b. You should avoid pregnancy because this can cause a flare-up. c. You should not receive any immunizations in the future. d. You may need to be on a low-protein, high-carbohydrate diet. e. You should expect to lose weight while taking steroids. f. You may need to modify your daily recreational activities.

A,B,F Teaching for an adolescent with SLE should foster adaptation and self-advocacy and include using a moisturizer with an SPF of 30, avoiding pregnancy because it can produce a flare-up, and modifying recreational activities but continuing with daily exercise as an essential part of the treatment plan. The adolescent should continue to receive immunizations as scheduled, should expect to gain weight while on steroid therapy, and would not have a specialized diet.

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

A,C,D,E Diagnosing disease is not a nursing action. Evaluating the effectiveness of medical treatments is not a nursing action either. Nurses are to use the nursing process to evaluate the effectiveness of nursing interventions, not medical treatments. Identifying patient needs, determining priorities of care, setting realistic goals, and implementing nursing interventions are all steps in the clinical decision-making process.

The nurse recognizes a potential health threat to an alcoholic patient who is using the drug disulfiram (Antabuse) when the nurse reads in the health record that the patient is also which of the following? (Select all that apply.) a. On blood thinners b. Taking diphenhydramine (Benadryl) tablets c. Ingesting alcohol d. On penicillin e. Using mouthwash

A,C,E Disulfiram increases the effect of anticoagulants such as warfarin (Coumadin). Ingesting alcohol may cause headache, nausea, vomiting, tachycardia, chest pain, or dizziness. Mouthwash can have alcohol as one of the main ingredients and should be checked prior to using.

After hip replacement surgery, a client receives two doses of enoxaparin (Lovenox) during the day shift. What orders does the nurse anticipate for the client? (Select all that apply.) a. Laboratory draw for platelet count b. Laboratory draw for prothrombin time (PTT) c. Laboratory draw for international normalized ratio (INR) d. Order for protamine sulfate e. Order for vitamin K

A,D Lovenox is a low molecular-weight heparin. Side effects can include thrombocytopenia. The antidote for all heparin products is protamine sulfate, although it will not be as effective for Lovenox as it is for unfractionated heparin.

The nurse is caring for a 14-year-old child with systemic lupus erythematous (SLE). What clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Arthralgia b. Weight gain c. Polycythemia d. Abdominal pain e. Glomerulonephritis

A,D,E Clinical manifestations of SLE include arthralgia, abdominal pain, and glomerulonephritis. Weight loss, not gain, and anemia, not polycythemia, are manifestations of SLE.

The nurse is caring for a child immobilized because of Russel traction. What interventions should the nurse implement to prevent renal calculi? (Select all that apply.) a. Monitor output. b. Encourage the patient to drink apple juice. c. Encourage milk intake. d. Ensure adequate fluids. e. Encourage the patient to drink cranberry juice.

A,D,E To prevent renal calculi in a child who is immobilized, a nurse should monitor output; ensure adequate fluids; and encourage cranberry juice, which acidifies urine. Apple juice and milk alkalize the urine, so they should not be encouraged.

The healthiest form of communication is the ________ style.

Assertive Assertive communicators are honest and direct while valuing and respecting other individuals' views and seeking a win-win solution without the use of manipulation or game-playing.

A child has had a short-arm synthetic cast applied. What should the nurse teach to the child and parents about cast care? (Select all that apply.) a. Relieve itching with heat. b. Elevate the arm when resting. c. Observe the fingers for any evidence of discoloration. d. Do not allow the child to put anything inside the cast. e. Examine the skin at the cast edges for any breakdown.

B,C,D,E Cast care involves elevating the arm, observing the fingers for evidence of discoloration, not allowing the child to put anything inside the cast, and examining the skin at the edges of the cast for any breakdown. Ice, not heat, should be applied to relieve itching.

A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

B,C,D,E The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.

A client is admitted for a cardiac catheterization. It is essential for the nurse to ask the client about which allergies? (Select all that apply.) a. Penicillin b. Latex c. Iodine d. Shellfish e. Keflex f. Dilantin g. Bananas

B,C,D,G It is important to check for all allergies, but for a cardiac catheterization, the nurse needs to question about shellfish, iodine, latex, and bananas specifically. The contrast used contains iodine, and the equipment in the laboratory frequently contains latex. Information concerning these allergies needs to be passed on to laboratory personnel before the client goes to the laboratory. This will prevent the client from having an anaphylactic reaction during the procedure.

Strategies that a nurse could use in a motivational interview to increase the chances of change include which of the following? (Select all that apply.) a. Educating the patient on the physical damage the substance is causing b. Encouraging the patient to think of ways to change environmental triggers to abuse substances c. Asking the patient how they think substance abuse affects their family life d. Explaining to the patient that substance abuse affects everyone in the family and give examples e. Asking the patient what methods they think would work and encouraging participating in self-help groups

B,C,E Empowering the patient by helping them see what effect the abuse has on their life is a key component of motivation. Educating the patient is too much like lecturing and may cause resistance. Explaining how the family responds to the problem may elicit guilt and resistance.

A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

B,C,E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used.

What interventions does the nurse recommend for a client who is to be discharged home following total hip replacement surgery? (Select all that apply.) a. Continuous passive motion machine b. Elevated toilet seat c. Walker d. Crutches e. TED hose f. Heating pad

B,C,E The client will be using a walker, crutches are used only by younger clients. TED hose should be worn until the client regains full mobility and Coumadin is discontinued. A walker will be needed until the client regains full strength and is able to walk with full weight bearing on the operative side. Crutches are not used because they do not provide enough support for the client during ambulation and pose a risk for falls. Heating pads increase blood flow to the area and may increase pain. Ice packs should be used instead, as needed. Continuous passive motion machines are not used after hip surgery.

The nurse is caring for a hospitalized client who has AIDS and is severely immunocompromised. Which interventions are used to help prevent infection in this client? (Select all that apply.) a. Use sterile gloves and gowns whenever the nursing staff is in contact with the client. b. Provide an incentive spirometer to encourage coughing and deep breathing by the client. c. Keep a blood pressure cuff, thermometer, stethoscope in the client's room for his or her use only. d. Use N95 respirators (all nursing staff) when in the client's room. e. Request that the family take home the fresh flowers that are at the client's bedside. f. Assist the client with meticulous oral care after meals and at bedtime.

B,C,E,F The nursing staff should encourage coughing and deep breathing to prevent pneumonia, and incentive spirometry will be helpful. Assessment equipment such as thermometers and blood pressure cuffs should be kept in the room only for the use of this client, rather than being used by other clients on the unit as well. Fresh flowers can harbor microorganisms and should be removed from the room. Meticulous oral care will help to prevent infection by Candida.

A patient has been taking disulfiram (Antabuse) as part of his rehabilitation therapy. However, this evening, he attended a party and drank half a beer. As a result, he became ill and his friends took him to the emergency department. The nurse will look for which adverse effects associated with acetaldehyde syndrome? (Select all that apply.) A. Euphoria B. Severe vomiting C. Diarrhea D. Pulsating headache E. Difficulty breathing F. Sweating

B,D,E,F Acetaldehyde syndrome results when alcohol is taken while on disulfiram (Antabuse) therapy. Adverse effects include CNS effects (pulsating headache, sweating, marked uneasiness, weakness, vertigo, others); GI effects (nausea, copious vomiting, thirst); and difficulty breathing. Cardiovascular effects also occur; see Table 17-2. Euphoria and diarrhea are not adverse effects associated with acetaldehyde syndrome.

A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence

B,D,E,F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.

A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read the labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.

B,E The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne; smelling alcohol-laden fumes; and eating foods prepared with wine, brandy, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

C,D,E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

When admitting a patient with a suspected diagnosis of chronic alcohol use, the nurse will keep in mind that chronic use of alcohol might result in which condition? A. Renal failure B. Cerebrovascular accident C. Korsakoff's psychosis D. Alzheimer's disease

C. Korsakoff's psychosis A variety of serious neurologic and mental disorders, such as Korsakoff's psychosis and Wernicke's encephalopathy, as well as cirrhosis of the liver, may occur with chronic use of alcohol. Renal failure, cerebrovascular accident, and Alzheimer's disease are not associated directly with chronic use of alcohol.

A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. I've gotta get out of here. What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. C. has symptoms of alcohol withdrawal delirium. D. is having a recurrence of an acute psychosis.

C. has symptoms of alcohol withdrawal delirium. Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. C. runny nose, yawning, insomnia, and chills. D. anxiety, agitation, and aggression.

C. runny nose, yawning, insomnia, and chills. Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flu like illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever

D,E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. C. hallucinations. D. anterograde amnesia.

D. anterograde amnesia. Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. C. healthy but underweight. D. microcephalic and cognitively impaired.

D. microcephalic and cognitively impaired. Fetal alcohol syndrome is the result of alcohol inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors.

Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) C. disulfiram (Antabuse) D. naltrexone (Revia)

D. naltrexone Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. C. coordinate emergency admission to a detoxification unit. D. tell the patient, We cannot see you today because you've been drinking.

D. tell the patient, We cannot see you today because you've been drinking. One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary.

***The nurse is caring for a young client who has acquired immune deficiency syndrome (AIDS) and a very low CD4+ cell count. The nurse is teaching the client how to avoid infection at home. Which statement by the client indicates that additional teaching is needed? a. I will let my sister clean my pet iguanas cage from now on. b. My brother will change the kitty litter box from now on. c. It will seem funny but I'll run my toothbrush through the dishwasher. d. I will not drink juice that has been sitting out for longer than an hour.

I will let my sister clean my pet iguanas cage from now on. Immunocompromised clients should avoid having reptiles or turtles as pets and should avoid changing cat litter to help prevent opportunistic infections. Drinking juice that has been at room temperature for longer than 1 hour can lead to opportunistic infection and should be avoided. Clients should clean their toothbrushes daily by running them in the dishwasher or rinsing them in liquid laundry bleach.

A client who has had total hip replacement surgery asks the nurse when she will be able to use a regular-height toilet seat again. What is the nurse's best response? a. As soon as you are able to walk without a limp. b. As soon as the staples are removed from the incision. c. When you are off pain medication and warfarin (Coumadin). d. When you can hold your leg 6 inches off the bed for 5 full minutes.

a. As soon as you are able to walk without a limp. When the client is able to walk without a limp, the artificial joint is seated sturdily enough in place that it will not be dislocated or dislodged by overflexing it. At that time, the client will no longer need assistive devices or ambulatory aids. With staples removed, holding the leg off the bed and taking Coumadin do not affect readiness to bend the hip enough to use a regular toilet seat.

Which instruction does the nurse include in the discharge teaching plan for a client who has osteoporosis? a. Avoid using scatter rugs. b. Avoid weight-bearing exercises. c. Use a cane when walking outside. d. Reduce the amount of protein in your diet.

a. Avoid using scatter rugs. To avoid falls, the client should keep a hazard-free environment, including avoiding scatter rugs, cluttered rooms, and wet floor areas. Weight-bearing exercises help prevent bone resorption. A cane is not needed unless the client has a physical disability. A protein deficiency should be avoided because it might cause a reduction in bone density.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructors needs? a. Concept mapping b. Reflective journaling c. Reading assignment with a written summary d. Lecture and discussion

a. Concept mapping Concept maps challenge the student to synthesize data and identify relationships between nursing diagnoses. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

Critical thinking characteristics include a. Considering what is important in a given situation. b. Accepting one, established way to provide patient care. c. Making decisions based on intuition. d. Being able to read and follow physician's orders.

a. Considering what is important in a given situation. Critical thinking involves being able to decipher what is relevant and important in a given situation and to make a clinical decision based on that importance. Patient care can be provided in many ways. Clinical decisions should be based on evidence and research. Following physicians orders is not considered a critical thinking skill.

The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Healthy individual, volunteers at church, works part time, takes care of family and house

a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

The nurse is caring for a client with HIV who has been prescribed didanosine (Videx EC). Which action by the nurse is most appropriate? a. Help the client plan specific meal and dosing times. b. Explain that the client will have frequent complete blood counts (CBCs) drawn. c. Advise the client to take Videx EC with milk or a small meal. d. Tell the client to take Tylenol (acetaminophen) for any abdominal pain.

a. Help the client plan specific meal and dosing times. Videx EC must be taken on an empty stomach 30 minutes before or 2 hours after a meal. The nurse should assist the client in planning a daily schedule that includes meals and drug doses. Videx does not affect bone marrow, so frequent CBCs are not needed. A client on this drug who reports abdominal pain should be assessed for pancreatitis, a common adverse effect.

A client had a total knee replacement this morning and has a continuous passive motion (CPM) machine. What activity related to the CPM does the RN delegate to the unlicensed assistive personnel? a. Placing controls out of the reach of confused clients b. Assessing the client's response to the CPM c. Teaching the clients family the rationale for the CPM d. Assessing neurovascular status of the leg in the CPM

a. Placing controls out of the reach of confused clients All activities are appropriate for the client with a CPM, but the nurse can delegate only the task of keeping controls out of reach of the confused client. All other activities would need to be performed by the RN.

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub the leg. c. Carefully pick material off the leg. d. Apply powder to absorb the material.

a. Soak in a bathtub.

A student athlete was injured during a basketball game. The nurse observes significant swelling. The player states he thought he heard a pop, that the pain is pretty bad, and that the ankle feels as if it is coming apart. Based on this description, the nurse suspects what injury? a. Sprain b. Fracture c. Dislocation d. Stress fracture

a. Sprain Sprains account for approximately 75% of all ankle injuries in children. A sprain results when the trauma is so severe that a ligament is either stretched or partially or completely torn by the force created as a joint is twisted or wrenched. Joint laxity is the most valid indicator of the severity of a sprain. A fracture involves the cross-section of the bone. Dislocations occur when the force of stress on the ligaments disrupts the normal positioning of the bone ends. Stress fractures result from repeated muscular contraction and are seen most often in sports involving repetitive weight bearing such as running, gymnastics, and basketball.

During a staff meeting, a nurse who is mentoring new BSN graduate states, "We are lucky to have a new nurse join our staff who is a BSN graduate from our local university." Another staff nurse is heard saying, "BSN. BSN is you don't have a BSN you aren't valued. You don't see anyone welcoming any nurses with associate degrees—we are not valued." The conversation places the mentor in a negative position when her intention was simply to welcome the new employee. The staff nurse's negative response represents which logical fallacy? a. Straw man b. Appeal to tradition c. Confusing Cause and Effect d. Appeal to Common Practice

a. Straw man Straw man occurs when a person's position on a topic is misrepresented.

During history-taking, a patient tells the nurse that he is addicted to alprazolam (Xanax) and that he takes six 1 mg tablets a day. He quit cold turkey yesterday and now presents with extreme agitation, increased heart rate, and panic. The nurse suspects which disorder? a. Stress reaction b. DTs c. Overdose d. Relapse

a. Stress reaction Stress reaction is a withdrawal symptom that can occur when detoxing too quickly. DTs are usually associated with alcohol withdrawal. Overdose of alprazolam would present with extreme drowsiness, confusion, muscle weakness, and loss of balance or coordination. The effects of alprazolam are dizziness, drowsiness, dry mouth, and lightheadedness.

A client who is receiving highly active antiretroviral therapy (HAART) tells the nurse, The doctor said that my viral load is reduced. What does this mean? What is the nurse's best response? a. The HAART medications are working well right now. b. You are not as contagious as you were anymore. c. Your HIV infection is becoming resistant to your medications. d. You are developing an opportunistic infection.

a. The HAART medications are working well right now. The fact that the amount of virus is reduced means that the HAART regimen is working well to suppress viral replication. The risk of becoming infected by an HIV-positive person is always present. The reduced viral load is not related to an opportunistic infection or resistance to medication.

A staff nurse reports a medication error, failure to administer a medication at the scheduled time. An appropriate response of the charge nurse would be a. We'll do a root cause analysis. b. That means you'll have to do continuing education. c. Why did you let that happen? d. You'll need to tell the patient and family.

a. We'll do a root cause analysis. In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system-wide. b. large tidal volumes and decreased lung capacity. c. decreased tumor growth and longevity. d. decreased carbohydrate, protein, and fat destruction.

a. prolonged stress response and a cascade of harmful effects system-wide. Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrates, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

a. Acetaminophen All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client's vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpÓ 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowler's position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

a. Administer oxygen via nasal cannula. The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowler's position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotics as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

a. Administer preoperative antibiotics as ordered. To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client's lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

a. Albuterol (Proventil) via nebulizer The nurse has auscultated wheezing in the client's lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. Allow the client to be as independent as possible with activities. b. Assist the client with frequent and meticulous oral care. c. Assess the client's ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon.

a. Allow the client to be as independent as possible with activities Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the client's ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

a. Arrange a home safety evaluation. This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client's condition at discharge.

The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat schizophrenia. d. Treat schizophrenia first, and then establish the goals for the treatment of substance abuse.

a. Consider each disorder primary and provide simultaneous treatment. Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with a health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

a. Consult with a health care provider about administering both drugs to the client. Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.

a. Consult with the provider about an x-ray. Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.

A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. Enabling denies the seriousness of the patients problem or support the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

When working with a patient beginning treatment for alcohol abuse, what is the nurses most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

a. Empathetic, supportive Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

What information does the nurse teach a women's group about osteoporosis? a. For 5 years after menopause you lose 2% of bone mass yearly. b. Men actually have higher rates of the disease but are underdiagnosed. c. There is no way to prevent or slow osteoporosis after menopause. d. Women and men have an equal chance of getting osteoporosis.

a. For 5 years after menopause you lose 2% of bone mass yearly. For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. Patients who have ingested LSD respond well to being talked down by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

a. Have adequate help to transfer the client. The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.

a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped.

A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. It is a self-help group with the goal of sobriety. b. It is a form of group therapy led by a psychiatrist. c. It is a group that learns about drinking from a group leader. d. It is a network that advocates strong punishment for drunk drivers.

a. It is a self-help group with the goal of sobriety. AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? a. Meperidine (Demerol) 50 mg IV every 4 hours b. Patient-controlled analgesia (PCA) with morphine sulfate c. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days

a. Meperidine 50 mg IV every 4 hours Meperidine should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients pain management.

Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

a. Monitor the airway and vital signs every 15 minutes. Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight.

a. Participate in an exercise program to strengthen muscles. Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.

a. Tolerance develops. Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change.

In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distractors are desired outcomes later in the plan of care.

A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Bucks traction and screams, Somebody tied me up with ropes. The patient is experiencing: a. an illusion. b. a delusion. C. hallucinations. D. hypnagogic phenomenon.

a. an illusion The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

A patient's spouse was just diagnosed with lung cancer although there was no history of tobacco use. The spouse states, "I am so mad. How can you get cancer without smoking?" Which statement by the nurse represents empathy? a. "Research is identifying many risk factors for cancer besides smoking." b. "I understand how you could feel angry about the diagnosis." c. "He is still a good husband." d. "Why do you think he got cancer?"

b. "I understand how you could feel angry about the diagnosis." The nurse is placing herself in the wife's position and sharing her emotions.

What dose of epinephrine does the nurse prepare for a client in anaphylaxis who is 6 feet 3 inches tall and weighs 250 lb? a. 0.2 mL of a 1:1000 solution b. 0.5 mL of a 1:1000 solution c. 0.3 mL of a 1:10,000 solution d. 0.5 mL of a 1:10,000 solution

b. 0.5 mL of a 1:1000 solution Adult doses of epinephrine for anaphylaxis range between 0.3 and 0.5 mL of a 1:1000 solution. Because this client is large, the nurse should be prepared to give the higher dose initially.

An adult client's susceptibility to osteoporosis is caused by which aspect of his or her history? a. Fractured arm at age 16 b. Active smoking c. Vitamin D supplements d. Weight lifting

b. Active smoking A history of smoking has been identified as a risk factor for osteoporosis. A history of low-trauma fracture after the age of 50 has been identified as a risk factor. Vitamin D and weight lifting are measures that can be used to prevent this disease.

A nurse gives Dilantin intravenously with lactated Ringer's solution containing multivitamins. The drug precipitates and obstructs the only existing line. When the team leader informs the nurse that these drugs cannot be mixed, the nurse states, "Everyone just pushes the medicine slowly. No one checks for compatibility. There isn't even a compatibility chart on the unit." Which type of logical fallacy has influenced the nurse? a. Ad hominem abusive b. Appeal to common practice c. Appeal to emotion d. Appeal to tradition

b. Appeal to common practice An appeal to common practice occurs when the argument is made that something is okay because most people do it.

Which of these patient scenarios is most indicative of critical thinking? a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

b. Asking a patient what pain relief methods, pharmacological and nonpharmacologica, have worked in the past Asking the patient what pain relief methods have worked in the past is an example of exploring many options for pain relief. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on his/her patient and intervene accordingly. Non Pharmacological pain relief methods are available, as are medications for pain. Pain is subjective. The nurse should offer pain relief methods based on the patients reports without being judgmental.

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by a. Refusing the assignment. b. Asking for an orientation to the unit. c. Assuming that patient care will be the same as on the other units. d. Admitting lack of knowledge and going home.

b. Asking for an orientation to the unit. Humility and responsibility are displayed when the nurse realizes that lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

What is an appropriate nursing intervention when caring for a child in traction? a. Removing adhesive traction straps daily to prevent skin breakdown b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles c. Providing active range of motion exercises to affected extremity three times a day d. Keeping child prone to maintain good alignment

b. Assessing for tightness, weakness, or contractures in uninvolved joints and muscles

The nurse assesses for which clinical manifestation in a client with multiple sclerosis (MS) of the relapsing type? a. Absence of periods of remission b. Attacks becoming increasingly frequent c. Absence of active disease manifestations d. Gradual neurologic symptoms without remission

b. Attacks becoming increasingly frequent The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks. The other manifestations do not correlate with a relapsing type of MS.

The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? a. Are you able to shop for yourself? b. Do you use a cane, walker, or wheelchair to ambulate? c. Do you know what today's date is? d. Were you sad or depressed more than once in the last 3 days?

b. Do you use a cane, walker, or wheelchair to ambulate? Do you use a cane, walker, or wheelchair to ambulate? will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions? a. No restrictions of activity are indicated. b. Elevate casted arm when both upright and resting. c. The shoulder should be kept as immobile as possible to avoid pain. d. Swelling of the fingers is to be expected. Notify a health professional if it persists more than 48 hours.

b. Elevate casted arm when both upright and resting.

A teenage patient is using earphones to listen to hard rock music and is making gestures in rhythm to the music. The nurse assesses the amount of urine output in the Foley catheter and leaves the room. What communication technique is demonstrated in both of these situations? a. Blocking b. Filtration c. Empathy d. False assurance

b. Filtration Filtration is the unconscious exclusion of extraneous stimuli in communication.

An adolescent comes to the school nurse after experiencing shin splints during a track meet. What reassurance should the nurse offer? a. Shin splints are expected in runners. b. Ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain. c. It is generally best to run around and work the pain out. d. Moist heat and acetaminophen are indicated for this type of injury.

b. Ice, rest, and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve pain. Shin splints result when the ligaments tear away from the tibial shaft and cause pain. Actions that have an antiinflammatory effect are indicated for shin splints. Ice, rest, and NSAIDs are the usual treatment. Shin splints are rarely serious, but they are not expected, and preventive measures are taken. Rest is important to heal the shin splints. Continuing to place stress on the tibia can lead to further damage.

A client is receiving warfarin (Coumadin) daily following total hip replacement surgery. Which laboratory value requires intervention by the nurse? a. Potassium (K+), 4.2 mEq/L b. International normalized ratio (INR), 5.1 c. Prothrombin time (PT), 13.4 seconds d. Hemoglobin (Hg), 16 g/dL

b. International normalized ratio (INR), 5.1 Blood levels of Coumadin will be monitored by checking daily PT and INR (in some places, only INR). The INR is critically high. The K+ is normal and is not monitored for Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy. Hemoglobin would be important to assess because a side effect of Coumadin is bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring. PT and hemoglobin are within the normal range.

Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services

b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mind-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the minds capacity to affect bodily function and symptoms.

A 4-year-old child is placed in Buck extension traction for Legg-Calv-Perthes disease. He is crying with pain as the nurse assesses the skin of his right foot and sees that it is pale with an absence of pulse. What should the nurse do first? a. Reposition the child and notify the practitioner. b. Notify the practitioner of the changes noted. c. Give the child medication to relieve the pain. d. Chart the observations and check the extremity again in 15 minutes.

b. Notify the practitioner of the changes noted.

What finding is characteristic of fractures in children? a. Fractures rarely occur at the growth plate site because it absorbs shock well. b. Rapidity of healing is inversely related to the childs age. c. Pliable bones of growing children are less porous than those of adults. d. The periosteum of a childs bone is thinner, is weaker, and has less osteogenic potential compared to that of an adult.

b. Rapidity of healing is inversely related to the childs age. Healing is more rapid in children. The younger the child, the more rapid the healing process. Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the weakest point of long bones and a frequent site of injury during trauma. Childrens bones are more pliable and porous than those of adults. This allows them to bend, buckle, and break. The greater porosity increases the flexibility of the bone and dissipates and absorbs a significant amount of the force on impact. The adult periosteum is thinner, is weaker, and has less osteogenic potential than that of a child.

The critical thinking skill of evaluation in nursing practice can be best described as a. Examining the meaning of data. b. Reviewing the effectiveness of nursing actions. c. Supporting findings and conclusions. d. Searching for links between data and the nurses assumptions.

b. Reviewing the effectiveness of nursing actions. Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurses assumptions describes analysis.

A child with a hip spica cast is being prepared for discharge. Recognizing that caring for a child at home is complex, the nurse should include what instructions for the parents discharge teaching? a. Turn every 8 hours. b. Specially designed car restraints are necessary. c. Diapers should be avoided to reduce soiling of the cast. d. Use an abduction bar between the legs to aid in turning.

b. Specially designed car restraints are necessary.

In today's world of fast, effective communication, what is the most commonly used means of societal communication? a. Facial expression b. Spoken word c. Written messages d. Electronic messaging

b. Spoken word Verbal communication, which involves talking and listening, is the most common form of interpersonal communication. An important clue to verbal communication is the tone or inflection with which words are spoken and the general attitude used when speaking.

Professional nurses are responsible for making clinical decisions to a. Prove traditional methods of providing nursing care to patients. b. Take immediate action when a patient's condition worsens. c. Apply clear textbook solutions to patients problems. d. Formulate standardized care plans for groups of patients.

b. Take immediate action when a patient's condition worsens. Professional nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Clear textbooks solutions to patient problems are not always available. Care plans should be individualized.

To prevent Wernicke's encephalopathy from heavy alcohol use, the nurse anticipates an order for which medications? a. Benzodiazepine b. Thiamine and B complex IV c. Vitamins C and D3 d. Klonopin

b. Thiamine and B complex IV The B vitamins will prevent or reverse Wernickes if given early enough. Benzodiazepines are often used to prevent and treat DTs and to decrease respiratory depression and hypertension. Vitamins C and D3 are not related to alcohol withdrawal. Klonopin is administered for hypertension and anxiety related to withdrawal.

A 70-year-old patient is newly admitted to a skilled nursing facility with a diagnosis of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril, hydrochlorothiazide, warfarin, low-dose aspirin, ginkgo biloba, and echinacea. The nurse contacts the patient's medical provider over which potential drug-drug interaction? a. Lisinopril and echinacea b. Warfarin and ginkgo biloba c. Echinacea and warfarin d. Lisinopril and hydrochlorothiazide

b. Warfarin and ginkgo biloba Warfarin and blood thinners interact with ginkgo biloba as designed to improve memory. All herbal supplements should be evaluated with current pharmacological medications. The other options do not have drug interactions with each other.

The nurse is caring for a client who has undergone a spinal fusion. Which specific postoperative instructions does the nurse give this client? a. You may lift items up to 10 pounds. b. Wear your brace when you are out of bed. c. You must remain on bedrest for 48 hours after surgery. d. You will need to take steroids to prevent rejection of the bone graft.

b. Wear your brace when you are out of bed. Clients who undergo spinal fusion are fitted with a brace that they need to wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client does not need to remain on bedrest for the first 48 hours, should not lift anything, and will not take steroids for rejection prevention.

During height and weight assessments at a school's health fair, a child admits to drinking a cup of coffee with his mother every morning, and another child reports enjoying a morning cup of coffee on the commute to school. These two children are both below average on the height chart, and the nurse states, "Drinking coffee stunts a child's growth." This logical fallacy is referred to as: a. appeal to common practice. b. confusing cause and effect. c. ad hominem abusive. d. red herring.

b. confusing cause and effect. Cause and effect are confused when one assumes that a particular event must cause another just because the two events often occur together.

A patient who was admitted 24 hours ago has become increasingly irritable and now says there are bugs on his bed. The nurse suspects a. alcohol-induced psychosis. b. delirium tremens (DTs). c. neurologic injury related to a fall. d. posttraumatic stress reaction.

b. delirium tremens (DTs). During the 6 to 96 hours after last alcohol use, patients may experience DTs, as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse rate, and blood pressure measurement and visual and auditory hallucinations.

A student nurse is talking with his instructor. The student asks how quality of care is evaluated. The best response by the instructor is Quality of care is evaluated a. by the patient getting well. b. on the basis of process and outcomes. c. by the physicians assessment. d. by the patients satisfaction.

b. on the basis of process and outcomes. Quality of care is evaluated by process and outcomes. If the outcomes are achieved, then the care has achieved what is was designed to do. The patient getting well may be an action of the body doing what it is supposed to do and not quality of care; the same can be said of the physician assessment. The patients satisfaction is subjective according to his or her perceptions and not the quality of care.

An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making the rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to a. call a Code Blue. b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. c. call the primary hospitalist in charge of patient. d. call the anesthesia provider on call.

b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. Stop opioid; consider administering naloxone; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; and monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. Calling a Code Blue solely for a somnolent patient is not indicated as a solitary response. Calling the hospitalist assigned to the patient is an option only after the immediate treatment plan is enacted to reverse the opioid. Calling anesthesia is appropriate after stopping the opioid first.

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, After discharge, I'm sure everything will be just fine. Which remark by the nurse will be most helpful to the spouse? a. It is good that you are supportive of your spouse's sobriety and want to help maintain it. b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. c. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection. d. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully.

b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching? a. Take warm baths to promote muscle relaxation. b. Avoid crowds and people with colds. c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur.

b. Avoid crowds and people with colds. The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

b. Disturbed thought processes Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. Are you taking a nonsteroidal anti-inflammatory drug? b. Do you have a mental health disorder? c. Are you able to swallow medications? d. Do you smoke cigarettes or any illegal drugs?

b. Do you have a mental health disorder? Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain? a. Meperidine (Demerol) injections every 4 hours around the clock b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain

b. Patient-controlled analgesia (PCA) pump with morphine The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.

A nurse working at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurses drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

b. Seeking to be assigned as a medication nurse. The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility.

A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, cravings, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug

b. Substance addiction Nicotine meets the criteria for a substance, the criterion for addiction (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. Only lift items that are 10 pounds or less. b. Wear your brace whenever you are out of bed. c. You must remain in bed for 3 weeks after surgery. d. You are prescribed medications to prevent rejection.

b. Wear your brace whenever you are out of bed. Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. C. has been treated with disulfiram (Antabuse). D. has recently ingested both alcohol and sedative drugs.

b. has a high tolerance to alcohol. A non tolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, I see the need for ongoing treatment. C. identify constructive outlets for expression of anger. D. develop a trusting relationship with one staff member.

b. state, I see the need for ongoing treatment. The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

What percentage of hip fractures are the result of falls? a. 50% b. 80% c. 90% d. 100%

c. 90% About 90% of falls end with a hip fracture.

The nurse is seeing clients at a drop-in primary health clinic. Which client does the nurse teach about the risks of acquiring HIV? a. Middle-aged woman with a new sexual partner b. Young male who has male sexual partners c. All clients who come to the clinic d. Young woman having her first gynecologic examination

c. All clients who come to the clinic All sexually active people should know their HIV status, and all people need to have education on their risk of acquiring HIV infection. Anyone who engages in sexual activity has some risk.

The nurse is assessing a patient using the CAGE Questionnaire. The patient answers yes to all of the questions. The nurse suspects alcoholism and feels the patient is in denial when the patient states which of the following? a. I go to meetings once a day and still drink. b. My family and friends have been avoiding me lately. c. I don't have a problem with alcohol. I can quit anytime I want to. d. I know it will be hard to quit, but I am willing to try.

c. I don't have a problem with alcohol. I can quit anytime I want to. The patient may need help admitting that there is a problem. The CAGE is designed to objectively assist in assessing problems related to alcohol use. A patient who states they are going to meetings is admitting they have a problem even if they still drink. Admitting that quitting is difficult is acceptance that there is a problem. Reality is setting in for a patient who can see that family and friends are avoiding them.

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making? a. Uses an objective approach in all situations b. Obtains data in an orderly fashion c. Improves a plan of care while thinking back on interventions performed d. Provides evidence-based explanations for all nursing interventions

c. Improves a plan of care while thinking back on interventions performed Self-reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. The other options are not the best examples of self-reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion does not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence-based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation.

The nurse is caring for an older adult client who has fallen and fractured her hip. The client will have hip replacement surgery followed by extensive rehabilitation. The client confides in the nurse, I feel like I don't have any control over anything anymore now that I am old. What is the nurse's best response? a. I'll make sure that the physical and occupational therapists see you after surgery to help get your strength back. b. Its normal to feel this way, but hopefully you will be back on your feet after a stay in rehab. c. It's important to control what you can right now, like making out your menu every day and working with the therapists. d. I sense that you are feeling depressed about the situation. I will ask the doctor to prescribe an antidepressant for you.

c. It's important to control what you can right now, like making out your menu every day and working with the therapists. The nurse should support the clients self-esteem and increase feelings of competency by encouraging activities that assist in maintaining some degree of control, such as participation in decision making and performance of tasks that he or she can manage. The nurse should provide immediate control options for the client, rather than waiting until after rehabilitation. The clients desire for control does not indicate depression, so an antidepressant is not indicated. Therapy referrals are appropriate but do not address the client's desire for control.

An unknown unconscious client with an elevated temperature is ordered IV penicillin. What is the best action for the nurse to take? a. Administer the medication. b. Check the chart for allergies. c. Look for medical alert identification. d. Notify the nursing supervisor.

c. Look for medical alert identification. Allergies need to be identified before medications are administered. This client cannot talk and is unknown, so a chart cannot be retrieved. Clients with allergies are taught to carry medical alert identification.

The nurse assesses the outcomes of a motivational interview on a patient with a dual diagnosis of alcoholism with DTs and determines that the communication was nontherapeutic. What should the nurses next priority be? a. Encourage the patient to think of ways to change environmental triggers to abuse substances. b. Ask the patient what methods they think would work and encourage participating in self-help groups. c. Notify provider to obtain order for oxazepam (Serax) and vitamin B infusion. d. Notify provider to obtain order for CT scan and psychologic consult.

c. Notify provider to obtain order for oxazepam (Serax) and vitamin B infusion. The patient will need to be treated for psychosis prior to conducting the motivational interview, because the patient can become violent and non receptive to the interventions. Oxazepam and vitamin B are the two therapies that work for DTs.

The home care nurse is making a follow-up visit to a client who had total hip replacement surgery 2 weeks ago. Which client statement indicates a need for clarification regarding postoperative routine? a. My daughter helps me put on my elastic TED (thromboembolic deterrent) hose every day. b. I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep. c. Now that my hip doesn't hurt, I can cross my legs like a lady again. d. Each day, I try to increase my walking time by at least 10 minutes.

c. Now that my hip doesn't hurt, I can cross my legs like a lady again. Crossing the legs beyond midline can dislocate the new hip joint and should be avoided at all times. The other statements demonstrate correct behavior and understanding.

The nurse is caring for a patient who is experiencing alcohol withdrawal. What is the main priority for this patient? a. Describe how the alcohol is causing the withdrawal effects. b. Leave the patient by him/herself so as not to cause agitation. c. Promote a safe, calm, and comfortable environment. d. Refer the patient to an alcohol-abuse counselor.

c. Promote a safe, calm, and comfortable environment. The main priority is the patients safety due to risk of harm from seizures, DTs, and anxiety. The nurse could provide referrals or discuss the relationship of alcohol to physical problems after the withdrawal period is over. Do not leave the patient alone, as many patients will need reassurance that they will survive the ordeal of withdrawal.

A patient describes practicing a complementary and alternative therapy involving concentrating and controlling his respiratory rate and pattern, recognizing that breath work is to yoga as a. The zone is to acupressure. b. Massage therapy is to Ayurveda. c. Reiki therapy is to therapeutic touch. d. Prayer is to tai chi.

c. Reiki therapy is to therapeutic touch. This is an analogy that compares different therapies within specific categories. Both yoga and breath work are mind-body therapies, whereas both Reiki and therapeutic touch therapies are energy field therapies. The other options have different design structures; thus, they do not fit the analogy.

Professional standards influence a nurses clinical decisions by a. Bypassing the patients feelings to promote ethical standards. b. Establishing minimal passing standards for testing. c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. d. Utilizing evidence-based practice based on nurses needs.

c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care. Bypassing the patients feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses needs.

A patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. The nurse's best response is which of the following? a. Walk at least 5 miles every day for exercise. b. Wear proper fitting shoes to prevent tripping. c. Talk with your physician about a calcium supplement. d. Stand up slowly so you don't feel faint.

c. Talk with your physician about a calcium supplement. Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

A nurse wants to apply open communication to obtain a thorough history and to determine cognitive function. Which question represents the use of open communication? a. Is today Wednesday? b. Do you know what day it is? c. Tell me what day of the week today is. d. Do you know what the first day of the week is?

c. Tell me what day of the week today is. The patient must be able to name the day of the week rather than use answer yes or no.

Which condition is a type II hypersensitivity reaction? a. Allergic rhinitis b. Positive purified protein derivative (PPD) test for tuberculosis c. Transfusion reaction to improper blood type d. Serum sickness after receiving immune globulin

c. Transfusion reaction to improper blood type Common clinical situations caused by type II hypersensitivities include hemolytic transfusion reactions. Type II hypersensitivity reactions are caused by antibodies directed against body tissues that have some form of non-self (foreign) protein attached to them. Allergic rhinitis is an example of a type I hypersensitivity. A positive PPD test is an example of a type IV reaction. Serum sickness is a type III reaction.

An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. guided imagery, relaxation breathing, and meditation. c. herbs, vitamins, and tai chi. d. alternating ice and heat to relieve pain and inflammation.

c. herbs, vitamins, and tai chi. Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

A student nurse and clinical instructor are discussing quality in health care. The instructor knows the student understands when the student says, Quality is a. apparent in all health care. b. an outcome of health care. c. seen and unseen in health care. d. achieved by collaboration in health care.

c. seen and unseen in health care. Quality in health care is tangible and intangible. Quality in health care is not apparent in all health care, as many areas of health care are lacking. Quality of care does not always affect the outcome of care; the patient may recover no matter what care is given. Quality is not always achieved by collaboration.

A group of nurses are meeting to decide how to staff the upcoming holidays. Each of the four members freely expresses thoughts about fair staffing but is willing to listen to others thoughts and reconsider their first recommendations. The nurses are avoiding conflict and supporting professional communication through: a. empathy. b. positiveness. c. supportiveness. d. accommodation.

c. supportiveness. Supportive communication occurs when each person's opinion/position is valued and each participant has the freedom to express a position but is willing to change that opinion/position.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

c. A 45-year-old male with osteoarthritis Osteoarthritis causes changes to support structures, increasing the client's risk for low back pain. The other clients are not at high risk.

A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, Often my friend drinks, along with taking more of the drug than is prescribed. What is the effect of the use of alcohol with this drug? a. The drugs metabolism is stimulated. b. The drugs effect is diminished. c. A synergistic effect occurs. d. There is no effect.

c. A synergistic effect occurs. Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

c. Apply a heating pad for 20 minutes at least four times daily. Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.

A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication would the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesics, such as morphine

c. Benzodiazepine, such as lorazepam (Ativan) This patient is experiencing alcohol withdrawal delirium. Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Antidepressant, antipsychotic, and opioid medications will not relieve the patient's symptoms.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

c. Bradycardia Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

c. Nausea, vomiting, diaphoresis, anxiety, tremors The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

c. Nystagmus Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

c. Post-microvascular bone transfer client whose distal leg is cool and pale This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific post procedure care.

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

c. Provide one-on-one supervision. This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patients feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, I feel terrible. Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

c. Symptoms of opiate withdrawal are present. The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flu like in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. Assess distal pulses for potential compartment syndrome. b. Turn the client every 3 to 4 hours to promote cast drying. c. Use a cloth-covered pillow to elevate the client's leg. d. Handle the cast with your fingertips to prevent indentations.

c. Use a cloth-covered pillow to elevate the client's leg. When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.

What is the first component of the critical thinking model for clinical decision making? a. Experience b. Nursing process c. Attitude d. A scientific knowledge base

d. A scientific knowledge base A scientific knowledge base is the first component for clinical decision making. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. A critical thinking attitude is a guideline for how to approach a problem and apply knowledge to make a clinical decision.

Which component of an e-mail shown below would be effective? a. Subject: A short concise subject line: Meeting b. Body: I would like you to answer these questions before the next meeting: Where would you like to meet? Do you want all the staff to attend? Can we serve refreshments? What is one goal for our unit? c. Body: Dear Staff, As you know, each department must reduce staff by 2%. We will need to discuss how to inform unlicensed staff about the downsizing efforts of the hospital. d. Body: The next staff meeting is scheduled for Tuesday, January 19, at 5:00PM in the first floor auditorium. Please send items for the agenda. Sally Smith, MSN, RN, [email protected] or ext. 5582

d. Body: The next staff meeting is scheduled for Tuesday, January 19, at 5:00PM in the first floor auditorium. Please send items for the agenda. Sally Smith, MSN, RN, [email protected] or ext. 5582 This provides a message that is concise and accurate with a clearly conveyed message for the reader and contact information from the sender, all of which are important components of effective email communication.

The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital? a. Pain at the incision site b. Decreased appetite c. Slight redness and itching at the incision site d. Clear drainage from the incision site

d. Clear drainage from the incision site The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal. The client should be encouraged to eat a healthy diet but does not need to return to the hospital for a decreased appetite.

The nurse is caring for an older adult client who will be discharged after being hospitalized for a total hip replacement. Which statement indicates that arrangements may have to be made to have the client's medications supervised at home? a. I will take my Coumadin pill every day just before the evening news. b. My wife takes iron too, so we will take our pills together every morning. c. I prepare all my pills for the week and will place them in a labeled medi-set. d. If my legs get swollen, I will take an extra Coumadin pill that day.

d. If my legs get swollen, I will take an extra Coumadin pill that day. Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous thromboembolism after joint replacement surgery. It is not used for edema. The other statements show that the client has an appropriate plan for self-administration of his medications.

A 45-year-old man is brought to the emergency department presenting with a respiratory rate of 6 breaths/min, and cardiac dysrhythmias. The most appropriate question the nurse should ask the patient's friend is a. Does he take amphetamines or uppers? b. Has he ever used LSD? c. Have you two been out of the country in the last 2 days? d. Is he using any opioids such as heroin?

d. Is he using any opioids such as heroin? The clinical manifestations of an opioid overdose include seizures, shock, respiratory depression, dysrhythmias, and altered level of consciousness. An opioid overdose is a medical emergency. Amphetamine overdose is ruled out because it causes hypertension and central nervous system disturbances such as paranoia, panic, and delusions. LSD overdose would also manifest with hypertension and tachypnea along with hallucinations and possible loss of contact with reality. Travel outside the country is unrelated.

The nurse needs a reminder of professional responsibility when performing which of these actions? a. Making an informed clinical decision b. Making an ethical clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

d. Making a clinical decision based on previous shift assessments The professional nurse is responsible for assessing patients each shift. Making informed, ethical decisions in the patient's best interest is practicing responsibly.

A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylprednisolone Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate.

During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. This best describes the skill of a. Mindfulness. b. Focusing. c. Passivity. d. Receptivity.

d. Receptivity. Receptivity is defined as the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical. Passivity is the ability to stop unnecessary goal-directed and analytical activity. Focusing is the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period. Mindfulness is not a cognitive skill needed in relaxation therapy.

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

d. Using the nursing process Using the nursing process along with applying components of the nursing critical thinking model will help the new graduate nurse make the most appropriate clinical decisions. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address the point of care exemplars such as a. care coordination. b. documentation. c. electronic records. d. fall prevention.

d. fall prevention. The most common safety issues at the sharp end include prevention of decubitus ulcers, medication administration, fall prevention, invasive procedures, diagnostic workup, recognition of/action on adverse events, and communication. These are the most common issues the staff nurse providing direct patient care encounters. Each of the other options are classified as systems level exemplars.

Mobility for the patient changes throughout the lifespan; this is known as the process of a. aging and illness. b. illness and disease. c. health and wellness. d. growth and development.

d. growth and development. Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don't always affect mobility.

A sentinel event refers to an event that a. could have harmed a patient, but serious harm did not occur because of chance. b. harms a patient as a result of underlying disease or condition. c. harms a patient by omission or commission, not an underlying disease or condition. d. signals the need for immediate investigation and response.

d. signals the need for immediate investigation and response. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof called sentinel because they signal the need for immediate investigation and response. A near-miss refers to an error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance. Harm that relates to an underlying disease or condition provides the rationale for the close monitoring and supervision provided in a health care setting. An adverse event is one that results in unintended harm because of the commission or omission of an act.

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

d. A 74-year-old man who smokes and has a fractured pelvis Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.

An adult in the emergency department states, I feel restless. Everything I look at wavers. Sometimes Im outside my body looking at myself. I hear colors. I think I'm losing my mind. Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. C. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.

d. D-lysergic acid diethylamide (LSD) ingestion. The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going crazy. Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

A patient admitted to an alcoholism rehabilitation program says, I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening. The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial

d. Denial Minimizing ones drinking is a form of denial of alcoholism. The patient's own description indicates that social drinking is not an accurate name for the behavior. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one's own system.

Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

d. Drowsiness, constricted pupils, slurred speech Heroin, opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine abuse.

A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

d. Establish a patent airway Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

After teaching the wife of a client who has Parkinson's disease, the nurse assesses the wifes understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease? a. His mask like face makes it difficult to communicate, so I will use a white board. b. He should not socialize outside of the house due to uncontrollable drooling. c. This disease is associated with anxiety causing increased perspiration. d. He may have trouble chewing, so I will offer bite-sized portions.

d. He may have trouble chewing, so I will offer bite-sized portions. Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A mask like face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients mask like face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson's disease and is associated with the autonomic nervous systems response.

A nurse plans care for a client with Parkinson's disease. Which intervention should the nurse include in this client's plan of care? a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

d. Keep the head of the bed at 30 degrees or greater. Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson's disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylprednisolone Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patients requests. d. Observe for depression and suicidal ideation.

d. Observe for depression and suicidal ideation. Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

d. Residential program Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

d. Risk for injury clouded sensorium, agitation, sensory perceptual distortions, and poor judgment increase the risk for injury. Disturbed sensory perception is an applicable diagnosis, but safety has a higher priority. The scenario does not provide data to support the other diagnoses.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

d. Storing the CPM machine under the bed after removal For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

A patient with a history of daily alcohol abuse says, Drinking helps me cope with being a single parent. Which response by the nurse would help the individual conceptualize the drinking more objectively? a. Sooner or later, alcohol will kill you. Then what will happen to your children? b. I hear a lot of defensiveness in your voice. Do you really believe this? c. If you were coping so well, why were you hospitalized again? d. Tell me what happened the last time you drank.

d. Tell me what happened the last time you drank. The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurses frustration with the patient.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four side rails up. c. Restrain the clients hands. d. Use an abduction pillow.

d. Use an abduction pillow. Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow the directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four side rails may be considered a restraint. Hand restraints are not necessary in this situation.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

d. Use aseptic technique for dressing changes. Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

A new patient in an alcoholism rehabilitation program says, I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening. Which response by the nurse will help the patient view the drinking more honestly? a. I see, and use interested silence. b. I think you may be drinking more than you report. c. Being a social drinker involves having a drink or two once or twice a week. d. You describe drinking steadily throughout the day and evening. Am I correct?

d. You describe drinking steadily throughout the day and evening. Am I correct? The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

A student nurse is learning about human immunodeficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

A,B,C,D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immunodeficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

A,B,C,D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? (Select all that apply.) a. Client is a white woman with a body mass index (BMI) of 19.4. b. Client fractured her wrist badly in a fall last year. c. Client drinks at least four cans of diet cola every day. d. Client does tai chi exercises for 45 minutes every morning. e. Client has smoked two packs of cigarettes a day for 40 years. f. Client has taken estrogen (Premarin) 0.625 mg daily since menopause.

A,B,C,E Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that the clients bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise helps reduce the risk of osteoporosis.

The nurse is preparing to administer a medication when the client states, Im allergic to that. How will the nurse proceed? (Select all that apply.) a. Check the chart for allergies. b. Notify the health care provider. c. Ask what reaction the client gets. d. Continue to give the medication. e. Perform a skin test first. f. Notify the pharmacist. g. Document the allergy on the chart.

A,B,C,F,G If a client states that he or she has an allergy to a medication, the nurse should not administer the medication. The nurse should find out what reaction the client experiences from the medication and then should notify the health care provider and the pharmacist of the client's response. The nurse should document the allergy on the chart, including the reaction to the medication and notification of the provider and the pharmacist, and should indicate what other drug was ordered in its place. Before administering any drug, the nurse should have already checked the chart for allergies.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

A,B,D,E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis

A,C,D Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies.

Which medications can be taken by postmenopausal women to treat and/or prevent osteoporosis? (Select all that apply.) a. Calcium b. NSAIDs c. Fosamax d. Actonel e. Calcitonin

A,C,D,E Calcium, Evista, Fosamax, Actonel, and Calcitonin can be used by postmenopausal women to treat or prevent osteoporosis. Parathyroid hormone and estrogen may also be of value. NSAIDs may provide pain relief; however, these medications neither prevent nor treat osteoporosis.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

A,C,E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

The nurse recognizes that the risk of osteoporosis is higher in an individual with which risk factor? A. White or Asian race B. African-American race C. History of participation in active sports D. Obesity

A. White or Asian race Risk factors for postmenopausal osteoporosis include white or Asian descent, slender body build, early estrogen deficiency, smoking, alcohol consumption, low-calcium diet, sedentary lifestyle, and family history of osteoporosis.

A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimeton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

B,C,D,E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.

Which statement(s) might the nurse appropriately include when teaching a client about calcium intake for osteoporosis? (Select all that apply.) a. You should try to increase your protein intake when you are taking calcium. b. It is best to take calcium in one large dose. c. Tums are the most soluble form of calcium. d. You should take calcium with vitamin D because vitamin D helps your body better absorb calcium. e. Its okay to take calcium if you have had a history of kidney stones.

C,D Teaching the client to take calcium with vitamin D is accurate. Excessive protein should be avoided. Calcium is best taken in divided doses to increase absorption. Calcium should be taken with vitamin D to increase absorption. Calcium is contraindicated in women with a history of kidney stones.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

C,D,E Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

C,D,E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

A 51-year-old woman will be taking selective estrogen receptor modulators (SERMs) as part of treatment for postmenopausal osteoporosis. The nurse reviews potential contraindications, including which condition? A. Hypocalcemia B. Breast cancer C. Stress fractures D. Venous thromboembolism

D. Venous thromboembolism SERMs such as raloxifene are contraindicated in women with venous thromboembolic disorder, including deep vein thrombosis, pulmonary embolism, or a history of such disorders. The other options are incorrect.

The nurse is caring for a postoperative client on the medical-surgical unit following a total left hip replacement the previous day. During the assessment, the nurse notes that the client's left leg is cool, with weak pedal pulses. What is the nurse's first action? a. Assess circulatory status of the right leg. b. Notify the surgeon immediately. c. Measure leg circumference at the calf. d. Check for bilateral Homans signs.

a. Assess circulatory status of the right leg. The symptoms may represent impaired circulation or may be normal for this client. Before the surgeon is notified, the status of the nonoperative leg should be assessed and assessment findings on both legs compared with the client's baseline. Homans sign (pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein thrombosis and should not be evaluated until other assessments are made. Measuring calf circumference would provide additional data related to deep vein thrombosis.

Which instruction is most important for the RN to provide to the nursing assistant assigned to care for a client with primary osteoporosis? a. Clean up the clutter in the room. b. Encourage the client to bathe herself or himself. c. Monitor urinary output. d. Perform passive range-of-motion exercises.

a. Clean up the clutter in the room. Clients with osteoporosis are at risk for fracture when they fall. Clutter in the room is a risk factor for falls. The other choices have nothing to do with prevention of bone fracture in a client with primary osteoporosis.

Which intervention is most important for the nurse to teach the client who is recovering from an allergic reaction to a bee sting? a. How to use an EpiPen b. Wearing a medical alert bracelet c. Avoiding contact with the allergen d. Keeping diphenhydramine (Benadryl) available

a. How to use an EpiPen If an anaphylactic reaction starts, the client will need to self-medicate very rapidly with the EpiPen. He or she should carry it at all times and should be proficient in its assembly and use. This is the highest priority intervention. The client should get a medical alert bracelet and keep away from bees if at all possible. It is also advised that diphenhydramine be kept on hand in case of a less severe reaction.

An older adult client is scheduled for knee replacement surgery. Which statement by the client indicates a need for further preoperative instruction? a. I need to keep my leg positioned away from my body. b. I may have a continuous passive motion machine for a few days. c. I may need more pain medicine than I did with my hip replacement. d. I probably can get back to work within 2 to 3 weeks.

a. I need to keep my leg positioned away from my body. Dislocation is not a problem with knee replacement surgery, so the client does not need to keep his or her leg abducted. The other statements indicate accurate understanding of the instructions.

The nurse is teaching a community health class about health promotion techniques. Which statement by a student indicates a strategy to help prevent the development of osteoarthritis? a. I will keep my BMI under 24. b. I will switch to low-tar cigarettes. c. I will start jogging twice a week. d. I will have a family tree done.

a. I will keep my BMI under 24. Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease. Smoking does not decrease risk for osteoarthritis. Jogging increases the risk because of increased wear and tear on the joints. There is a genetic link to osteoarthritis; creating a family tree might help the client discover if there is any familial link but will not help prevent the disorder.

The nurse is caring for a client who is HIV positive. The client has become confused over the course of the shift, and the client's pupils are no longer reacting to light equally. The nurse anticipates an order for which medication? a. Prednisone (Deltazone) b. Trimethoprim/sulfamethoxazole (Bactrim) c. Pentamidine isethionate (Pentam) d. Ketoconazole (Nizoral)

a. Prednisone (Deltazone) Confusion and changes in pupillary assessment in an HIV-positive client indicate increased intracranial pressure (ICP). Increased ICP in these clients is managed with corticosteroids like prednisone. Bactrim is an antibiotic, Pentam is an antiprotozoal, and Nizoral is an antifungal medication.

***The nurse is caring for a young woman at the primary health care clinic. Which assessment finding leads the nurse to question the client about risk factors for HIV? a. Six vaginal yeast infections in the last 12 months b. Unable to become pregnant for the last 2 years c. Severe cramping and irregular periods d. Very heavy periods and breakthrough bleeding

a. Six vaginal yeast infections in the last 12 months Persistent or recurrent vaginal candidiasis may be the first symptom of HIV in women. Decreased immune function allows overgrowth of this fungus. Infertility, heavy periods, and cramping are not generally indicative of HIV.

The nurse is caring for a client who is 1 day post total hip replacement. The nurse is instructing the client about how to perform quadriceps-setting exercises correctly. Which direction does the nurse provide to the client? a. Straighten your legs and push the back of your knees into the mattress. b. Straighten your legs and bring each leg separately off the mattress 6 inches. c. Raise each leg 10 inches off the bed, keep it straight, and make ankle circles. d. Bend each knee, and rapidly point your toes downward and then upward.

a. Straighten your legs and push the back of your knees into the mattress. Quadriceps-setting exercises are done by straightening the leg as much as possible by attempting to push the back of the knees into the mattress. The other exercises may be performed by the client as tolerated, but these items do not describe quadriceps-setting exercises.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

a. Ask the client about fear of falling. Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

a. Assess neurovascular status in both legs. This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

a. Checking emergency equipment each morning All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

a. Truvada does not reduce the need for safe sex practices. Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immunodeficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first? a. Assess the client's deep tendon reflexes. b. Ask the client to place his chin on his chest. c. Start an IV line with normal saline. d. Assess the client's pupil reaction.

b. Ask the client to place his chin on his chest. The clients symptoms are associated with cryptococcal meningitis, so the nurse should first ask the client to place the chin on his or her chest. The presence of nuchal rigidity (pain when flexing the chin to the chest) helps confirm the diagnosis. An IV line may be started after the neurologic assessment is completed.

What is most important for the nurse to teach the client with allergic rhinitis and glaucoma? a. If your heartbeat increases, be sure to contact your health care provider. b. Avoid allergy drugs containing pseudoephedrine or phenylephrine. c. Be sure to drink plenty of water with antihistamines. d. You should use an eye-moistening agent such as Restasis.

b. Avoid allergy drugs containing pseudoephedrine or phenylephrine. Ephedrine, phenylephrine, and pseudoephedrine may cause vasoconstriction, increased blood pressure, and increase intraocular pressure. The client should avoid these drugs. An increased heart rate is not a reason to call the health care provider. The client may be thirstier when on allergy medications, or the client may need an eye-moistening agent, but these are not the most important things for the nurse to teach.

A client is admitted for a total hip replacement. Past medical history includes diabetes mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering the client's medications, which action by the nurse is most appropriate? a. Take the client's blood pressure in both arms. b. Call the physician to clarify the orders. c. Schedule a preoperative electrocardiogram. d. Review the client's laboratory values.

b. Call the physician to clarify the orders. Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause serious adverse reactions such as myocardial infarction and renal problems. This client already has coronary artery disease and a past myocardial infarction, so the nurse should discuss the order with the physician before giving the medication. Reviewing laboratory results could indicate renal impairment, but taking the client's blood pressure and scheduling an electrocardiogram (ECG) would not take priority over discussion with the physician.

A client is in the clinic having had rhinorrhea and headache for the last 2 weeks. Which laboratory value alerts the nurse to the possibility of a type I hypersensitivity reaction? a. White blood cell count, 8900/mm3 b. Eosinophils, 10% c. Neutrophils, 65% d. Hemoglobin, 14 g/dL

b. Eosinophils, 10% An increase in eosinophils indicates an allergic reaction (type I) or allergic rhinitis. Normal eosinophil count is 1% to 2%. The other laboratory values are normal.

A client is receiving an IV infusion of an antibiotic. The client calls the nurse about feeling uneasy and uncomfortable owing to congestion. Which action by the nurse is most appropriate? a. Elevate the head of the clients bed to 45 degrees. b. Have another nurse call the Rapid Response Team. c. Prepare to administer diphenhydramine (Benadryl). d. Slow the rate of the IV infusion.

b. Have another nurse call the Rapid Response Team. This client has early signs of anaphylaxis. The nurse must notify the Rapid Response Team but also needs to stay with the client in case of cardiovascular collapse. The nurses best action is to ask another nurse to call the Team while he or she continues to assess the client. The nurse will prepare to administer epinephrine. Slowing the IV rate will not help the situation; if the client is reacting to the antibiotic, the nurse should change the IV tubing and solution. If the client is not hypotensive, the nurse can raise the head of the bed.

Which client characteristic places her or him at high risk for latex hypersensitivity? a. Allergic to shellfish b. History of spina bifida c. Total hip replacement d. Taking oral contraceptives

b. History of spina bifida People who have spina bifida have lifelong exposure to latex products and frequently develop latex hypersensitivity. An allergy to shellfish does not put a person at increased risk for latex allergies. A total hip replacement will not place a client at risk for latex hypersensitivity, nor does the use of oral contraceptives.

The nurse is teaching a client how to prevent transmitting HIV to his sexual partner. Which statement by the client indicates that additional teaching is needed? a. I can throw the condoms in the trash after I have used them. b. I will store my condoms in my wallet so they are always handy. c. Water-based lubricants are best to prevent condom breakage. d. The condom needs to stay on until I withdraw my penis.

b. I will store my condoms in my wallet so they are always handy. Condoms should be stored in a cool, dry place. Wallets are not recommended because body heat can weaken the latex in the condom. The condom should stay on the penis until it is completely withdrawn. Condoms should be used only once and then discarded. Oil-based lubricants can weaken latex, possibly causing tearing or leakage, so only water-based lubricants are recommended.

The nurse is teaching a seminar about preventing the spread of HIV. Which statement by a student indicates that additional teaching is required? a. A woman can still get pregnant if she is HIV positive. b. I wont get HIV if I only have oral sex with my partner. c. Showering after intercourse will not prevent HIV transmission. d. People with HIV are still contagious even if they take HAART drugs.

b. I wont get HIV if I only have oral sex with my partner. HIV may be transmitted via oral sex when mucous membranes or nonintact skin comes in contact with infected body fluids (semen or vaginal secretions) or blood. Women who are HIV positive may get pregnant, and showering after intercourse will not reduce the risk of HIV transmission. HAART will lower viral loads, but the client will still be able to transmit the HIV virus to others.

The nurse is caring for a client with AIDS who has just been diagnosed with cryptococcal meningitis. Which is the best nursing intervention for this client? a. Initiate respiratory isolation for the next 72 hours. b. Initiate seizure precautions with padded side rails. c. Thicken the clients liquids to honey consistency. d. Administer IV pentamidine isethionate (Pentam).

b. Initiate seizure precautions with padded side rails. Cryptococcosis is a debilitating form of meningitis that can cause seizures, so seizure precautions should be initiated. Respiratory isolation is not indicated. Dysphagia is not seen with cryptococcal meningitis, so thickened liquids are not indicated. Pentam is given for Pneumocystis jiroveci pneumonia (PJP).

An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate? a. Renal function studies b. Liver enzymes c. Blood glucose monitoring d. Albumin and prealbumin

b. Liver enzymes Kaletra can cause liver complications, and clients taking it should have liver function studies. The clients symptoms could indicate a liver problem. Renal function and blood glucose are not affected by Kaletra. The client may have an albumin and prealbumin drawn if he or she has lost a great deal of weight and malnutrition is suspected, but the more common diagnostic test for a client taking Kaletra would be liver function studies.

The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan? a. Feed the client when he will not do it by himself. b. Make sure that a clock and a calendar are easily visible. c. Remove locks from bathroom and bedroom doors. d. Do not allow the client to smoke when he is alone.

b. Make sure that a clock and a calendar are easily visible. Having a clock and a calendar easily visible will help the client keep track of the date and time and will assist with reorientation. Banning smoking, removing locks, and feeding the client will not facilitate reorientation when the client is confused.

***Which characteristic is common to all types of hypersensitivity reactions? a. Decreased inflammatory responses b. Presence of tissue-damaging reactions c. Enhanced natural killer cell activity d. Inability to recognize extraneous cells

b. Presence of tissue-damaging reactions The defining difference between a normal immune response and that termed hypersensitivity is that the immune system reacts excessively or inappropriately, with resultant tissue damage and pathology.

A client verbalizes a fear of contracting HIV because she has a history of intravenous substance abuse. What instructions does the nurse provide to the client to help minimize this risk? a. Boil all needles and syringes for at least 20 minutes before using them again and be sure not to share them. b. Rinse used needles and syringes with water followed by laundry bleach after using them. c. Rinse used needles and syringes with rubbing alcohol before and after using them. d. Run all needles and syringes through the dishwasher with an extra rinse cycle before using them again.

b. Rinse used needles and syringes with water followed by laundry bleach after using them. To minimize the risk for HIV transmission, needles should be cleaned with laundry bleach after use. Boiling needles and syringes and rinsing with alcohol are not recommended. Running needles and syringes through the dishwasher will not sanitize them sufficiently. The client should be encouraged not to share needles and syringes.

The nurse is caring for a newly diagnosed HIV-positive client who will be taking enfuvirtide (Fuzeon). Which precaution is important for the nurse to communicate to this client? a. Stop taking the medication if you develop a fever. b. Rotate the sites where you will be giving the injections. c. Take this medication with a snack or a small meal. d. Do not drive or operate machinery while taking this drug.

b. Rotate the sites where you will be giving the injections. Fuzeon is available only as a subcutaneous injection and can cause injection site reactions and nodules. The client should be taught the subcutaneous technique, including rotation of sites. The client should not stop taking this medication for fever, it can be given without regard to food, and the drug will not make the client sleepy or drowsy, so caution with driving or operating machinery is not needed.

Which exercise does the nurse recommend to a client at risk for osteoporosis? a. High-impact aerobics 45 minutes once weekly b. Walking 30 minutes three times weekly c. Jogging 30 minutes four times weekly d. Bowling for 1 hour twice weekly

b. Walking 30 minutes three times weekly Weight-bearing, non jarring exercises have been proven to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

The nurse is teaching a postmenopausal client about the risk of acquiring HIV infection. The client states, I'm an old woman! I cannot possibly get HIV. What is the nurse's best response? a. Your vaginal walls become thicker after menopause, which increases your risk. b. Women in your age-group are the fastest growing population of AIDS clients today. c. Hormonal fluctuations after menopause make it harder to fight off infection. d. You might be right. How often do you engage in sexual activities?

b. Women in your age-group are the fastest growing population of AIDS clients today. Women are the fastest growing group with HIV infection and AIDS. Infection with HIV can occur at any age, and postmenopausal women experience thinning of vaginal tissue along with an age-related (not hormonal) decline in immune function. This places the older woman at higher risk of acquiring HIV infection. The frequency of sexual activity is not as relevant as the sexual activities the person practices.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

b. Correctly identifying the client prior to a blood transfusion A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

b. Ensure that a consent for transfusion is on the chart. The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. Are you compliant with following the diabetic diet? b. Have you been taking glucosamine supplements? c. How much exercise do you really get each week? d. You're still taking your diabetic medication, right?

b. Have you been taking glucosamine supplements? All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the client's bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.

b. Instruct the client not to get up without help. Antihistamines can cause drowsiness, so for the clients safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.

***A client has a bone density score of 2.8. What action by the nurse is best? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

b. Planning to teach about bisphosphonates A T-score from a bone density scan at or lower than 2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

b. Prepare to administer epoetin alfa (Epogen). This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.

A mother brings her child to the clinic requesting genetic testing to determine whether her child suffers from the same multiple allergies as herself. What action by the nurse is most appropriate? a. Provide a referral to an allergist so the child can be tested. b. Refer the mother to a geneticist for genetic testing on the child. c. Ask the mother about specific symptoms the child may have had. d. Have the mother list her allergies and the symptoms they cause her.

c. Ask the mother about specific symptoms the child may have had. Allergic tendencies can be inherited, but no single gene has been identified that causes allergies, and allergies to specific items are not inherited. The nurse should ask the mother about any symptoms the child has that seem related to allergies. The child will not be tested by an allergist simply because the mother has allergies, and a geneticist will not be able to identify an allergy gene in the child. Because specific allergies are not inherited, having the mother list her allergies will not be beneficial.

A client states that he is allergic to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? a. Drinking 3 liters of water a day will prevent kidney damage. b. I will always wear a medical alert bracelet for this allergy. c. I need to try to avoid coming into contact with poison ivy. d. I should carry diphenhydramine (Benadryl) with me at all times.

c. I need to try to avoid coming into contact with poison ivy. Reactions to poison ivy are a type IV hypersensitivity reaction. They are cell mediated by T-lymphocytes in the skin. Avoidance of the offending allergen is the most appropriate intervention. The complexes do not form or precipitate in the kidney. This type of hypersensitivity does not represent an immediate life-threatening emergency and does not respond to histamine antagonists (diphenhydramine).

The nurse asks a young adult client if she is sexually active. The client asks why the nurse needs to know. What is the nurse's best response? a. I just need to make sure that the information you are providing is reliable. b. I have to fill in answers to all of the questions on the health history form. c. If you are sexually active, we should talk about ways to prevent getting HIV. d. I will have to notify your partner if you have a sexually transmitted disease.

c. If you are sexually active, we should talk about ways to prevent getting HIV. The nurse should assess whether the client is sexually active to determine whether it is appropriate to teach about safer sex practices. The nurse would not notify the clients sexual partners if a sexually transmitted disease were diagnosed.

How does the type V hypersensitivity reaction differ from other reactions? a. It is cell mediated rather than antibody mediated. b. It is an immediate response rather than a delayed response. c. It produces a stimulatory response to normal tissues. d. It results in more severe tissue damage than is caused by other types of reactions.

c. It produces a stimulatory response to normal tissues. Type V hypersensitivity reactions are known as stimulatory responses. The classic example of type V hypersensitivity is Graves disease, in which the person makes a large amount of antibody that binds to the thyroid-stimulating hormone receptor antibody (TSHr-Ab) on thyroid tissue. The binding of this antibody to the TSH receptor activates the receptor, greatly stimulating the thyroid gland and causing severe hyperthyroid symptoms. This type of reaction is not cell mediated. It is not an immediate response, nor does it cause more severe tissue damage.

A client returns to the medical-surgical unit after a total hip replacement with a large wedge-shaped pillow between his legs. The client's daughter asks the nurse why the pillow is in place. What is the nurse's best response? a. It will help prevent bedsores from developing. b. It will help prevent nerve damage and foot drop. c. It will keep the new hip from becoming dislocated. d. It will prevent climbing out of bed if he becomes confused.

c. It will keep the new hip from becoming dislocated. Adduction of the operative leg beyond the midline could dislocate the new hip. The wedge pillow will help prevent this from happening. The wedge will not prevent bedsores from developing because it does not prevent pressure. The pillow will not prevent foot drop, because it is placed between the legs. The pillow is not a restraining device, and it will not prevent the client from climbing out of bed.

When obtaining a sexual history from a client in a clinic setting, the nurse notes that the client appears very uncomfortable and pauses for long periods before answering the nurses questions. What is the nurse's best response? a. I am sorry that my questions are making you very uncomfortable. b. Don't worry. Well be done with these questions in no time at all. c. Take your time. I realize that this is a very private topic to talk about. d. These questions are making you uncomfortable, so we'll finish next time.

c. Take your time. I realize that this is a very private topic to talk about. The client should be given time to collect his or her thoughts and composure before answering questions. The nurse should not apologize for asking pertinent questions about the client's health history. The sexual history should not be deferred until the next appointment. Recognizing the difficulty the client may be experiencing is helpful in establishing a therapeutic relationship.

The nurse is working with a client at a public health clinic. The client says to the nurse, The doctor said that my CD4+ count is 450. Is that good? What is the nurse's best response? a. Your count is high so you can cut back on your medication. b. Your count is normal because your medications are working well. c. Your count is a bit low and you are susceptible to infection. d. Your count is very low and you actually now have AIDS.

c. Your count is a bit low and you are susceptible to infection. A CD4+ T-cell count of 450 cells/mm3 of blood is low, and the client is at increased risk for developing an infection. Normal CD4+ counts range from 800 to 1000 cells/mm3. To be diagnosed with AIDS, a client must have a CD4+ T-cell count of <200 cells/mm3 (or a CD4+ T-cell percentage of <4%) and/or an opportunistic infection.

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago b. Client taking ibandronate (Boniva) who cannot remember when the last dose was c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia

c. Client taking raloxifene (Evista) who reports unilateral calf swelling The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A nurse is discharging a client after a total hip replacement. Which statement by the client indicates good potential for self-management? a. I can bend down to pick something up. b. I no longer need to do my exercises. c. I will not sit with my legs crossed. d. I won't wash my incision to keep it dry.

c. I will not sit with my legs crossed. There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

c. Lose weight if needed. Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower side rail on the affected side. d. Remind the client to do quad-setting exercises.

c. Raise the lower side rail on the affected side. Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the side rail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

c. Severe osteoporosis Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

Which risk factor would the nurse recognize as being frequently associated with osteoporosis? a. African-American race b. Low Protein intake c. Obesity d. Cigarette smoking

d. Cigarette smoking Smoking is associated with earlier and greater bone loss and decreased estrogen production. Women at risk for osteoporosis are likely to be Caucasian or Asian. Inadequate calcium intake is a risk factor for osteoporosis. Women at risk for osteoporosis are likely to be small boned and thin. Obese women have higher estrogen levels as a result of the conversion of androgens in the adipose tissue. Mechanical stress from extra weight also helps preserve bone mass.

Which client does the nurse assess more carefully for risk of developing primary osteoporosis? a. African-American client b. Residents of a nursing home c. Client who eats meat with every meal d. Client who drinks 6 cups of coffee daily

d. Client who drinks 6 cups of coffee daily Excessive consumption of caffeine and alcohol has been shown to be a risk factor for primary osteoporosis because of loss of calcium in the urine. Being white or Asian has been identified as causing a higher risk for developing osteoporosis at an earlier age compared with African-American ethnicity. Being a resident of a nursing home who is not exposed to sunlight could be a risk factor, but just being a resident does not predispose to osteoporosis. Meat is high in protein. Protein deficiency has been identified as a risk factor.

The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed? a. I will wash my hands whenever I get home from work. b. I will make sure to have my own tube of toothpaste at home. c. I will run my toothbrush through the dishwasher every evening. d. I will be sure to eat lots of fresh fruits and vegetables every day.

d. I will be sure to eat lots of fresh fruits and vegetables every day. The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection. Hands should be washed whenever returning home, and immunocompromised clients should not share toothbrushes or toothpaste. Toothbrushes should be run through the dishwasher nightly.

The nurse is teaching a client who has osteoarthritis ways to slow progression of the disease. Which statement indicates that the client understands the nurses instruction? a. I will eat more vegetables and less meat. b. I will avoid exercising to minimize wear on my joints. c. I will take calcium with vitamin D every day. d. I will start swimming twice a week.

d. I will start swimming twice a week. Swimming is an excellent form of exercise for clients with arthritis because it involves minimal weight bearing and stress on the joints from gravity. Eating more vegetables will not decrease the progression of osteoarthritis. Taking calcium with vitamin D will decrease the risk of osteoporosis, not osteoarthritis. Gentle exercise is important to help slow progression of the disease.

The nurse has been exposed to HIV through splashing of urine from a client who is HIV positive with a low viral load. The urine came into contact with the nurses face. Which drug regimen does the nurse prepare to initiate? a. Retrovir (zidovudine) for 14 days b. Retrovir (zidovudine) for 28 days c. Retrovir (zidovudine) and Epivir (lamivudine) fōr4 days d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days

d. Retrovir (zidovudine) and Epivir (lamivudine) for 28 days The Centers for Disease Control and Prevention have developed guidelines for postexposure prophylaxis (PEP). This nurses exposure requires basic PEP with two drugs for 28 days.

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS? a. Generalized lymphadenopathy b. HIV-positive status for 8 years c. Low-grade fever for the last 10 days d. Thick white patches on the clients tongue

d. Thick white patches on the clients tongue Candidiasis, which presents with thick white patches on the tongue and oral mucosa, is associated with the development of AIDS after HIV infection. The fact that the client has been positive for 8 years or has a low-grade fever is not significant.

After the administration of each dose of zoledronic acid (Zometa), it is most important for the nurse to determine which finding? a. Capillary refill b. Pain relief c. Level of consciousness d. Urine output

d. Urine output Zoledronic acid is a bisphosphonate that helps protect bones and prevent fractures. Urine output and serum creatinine should be monitored because this drug can be toxic to the kidneys. Zometa does not relieve pain or affect capillary refill or level of consciousness.

***The RN has assigned a client with severe osteoporosis to an LPN. Which information about the care of the client is most important for the RN to provide the LPN? a. Provide passive range of motion (ROM) to all weight-bearing joints. b. Position the client upright to promote lung expansion. c. Place a pillow between the client's knees when in the side-lying position. d. Use a lift sheet to reposition the client.

d. Use a lift sheet to reposition the client. Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a client. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the client to promote lung expansion and positioning with a pillow for side-lying are important interventions for any client. The most important intervention for this client is to prevent bone fractures.

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL b. Client who recently fell and has vertebral compression fractures c. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up

d. Client with a spinal cord injury who cannot tolerate sitting up Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drugs. Poor renal function also makes clients bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the client's chart. d. Ensure the information is relayed to the surgical team.

d. Ensure the information is relayed to the surgical team. A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.