Pass-Point Client Needs

A father brings his 4-week-old son to the clinic for a checkup, stating that he believes his son's testicle is missing. Which explanation would be most appropriate?

"Although the testes normally descend by 1 year of age, I can understand your concern."; Normally the testes descend by 1 year of age; failure to do so may indicate a problem with patency or a hormonal imbalance. By age 4 weeks, descent may not have occurred.

A client with no history of cardiovascular disease comes to the ambulatory clinic with flulike symptoms and a report of chest pain. What question should the nurse ask this client first?

"How would you describe the pain?"; Chest pain is assessed by using the standard pain assessment parameters such as characteristics, location, duration, intensity, precipitating factors, and associated symptoms. Beginning with a broader question allows the client to describe the experience with the pain, which directs the nurse on how to clarify this description.

A client in labor asks the nurse about Reiki, an alternative therapy that she's heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of

energy from light touch; Reiki is based on the principle that energy from hands being placed lightly on or at a distance from the body can be used to heal.

After 2 days of breast-feeding, a postpartum client reports nipple soreness. Which client statement indicates an understanding of measures to help relieve nipple soreness?

"I should lubricate my nipples with expressed milk before feedings."; Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

While looking out the window at trees, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which statement by the nurse is best?

"That sounds scary. I don't see any creatures at the school; A therapeutic statement by the nurse should focus on the client's feelings and provide factual information. Using "I" statements focuses on the nurse when the focus should be the client. Do not explore hallucinations. Stating the creatures are untrue is a confrontational statement.

The nurse manager is developing an assessment guide for clients on the urology unit. Which client is at the highest risk for catheter-associated urinary tract infection (CAUTI)?

Client with diabetes mellitus; Clients who are immunosuppressed, have diabetes mellitus, or have undergone multiple courses of antibiotic therapy are prone to bacterial, fungal, and parasitic infections. Taking one course of antibiotic therapy or having a family history of UTIs does not place a client at high risk for the development of a CAUTI. A predisposing factor for a UTI is ongoing problems of urinary calculi; one calculus would not place a client at high risk.

The adult child of a dying client is surprised at a parent's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what my parent really wants. My parent has never been a religious person in the least." What is the nurse's best action in this situation?

Contact the chaplain to arrange a visit with the client; The nurse's primary duty is to honor the client's request for a meeting with a spiritual adviser.

Which sound should the nurse expect to hear when percussing a distended bladder?

Dullness; A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drum-like sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

A nurse is providing care for a neonate during the first 4 hours following delivery. Which intervention should the nurse perform first?

Give the vitamin K injection; The American Academy of Pediatrics (AAP) and the Canadian Pediatric Society (CPS) recommend that vitamin K be given within 1 hour of birth (AAP) and by 6 hours of birth (CPS). The head should not be covered until the hair is dry.

What are expected client outcomes the nurse would include in a plan of care for a client with allergic rhinitis? Select all that apply.

The client will wear a dampened mask if dust is a problem, The client reports no symptoms of peripheral tingling, The client controls outdoor precipitating factors; Wearing a dampened mask if there is a dust problem, reporting no symptoms of peripheral tingling, and controlling outdoor precipitating factors are all expected client outcomes that would be included in a plan of care. Lungs should be absent of crackles or rhonchi.

A client is learning to care for an eye prosthesis. Which instruction by the nurse for the client is correct related to irrigation of the prosthesis?

The prosthetic eye can be irrigated with artificial tears.; The client would need to learn care of the prosthetic device, which does not need to be removed for irrigation. Use of saline, artificial tears, or hard contact lens solution is appropriate for the irrigation and should be performed daily, not weekly. The client can also use an eye lubricant or ointment for comfort if eyes are dry.

A client comes to the emergency department complaining of a fast and irregular heartbeat. After examining the client, a physician gives a verbal order for digoxin, 1 mg I.V. in four divided doses over the next 24 hours, with the first dose administered stat. How should the nurse respond to this order?

Write and sign the order as dictated; then repeat it aloud for the physician's verification; In urgent situations the nurse should write and sign a verbal order as dictated by the prescriber and then repeat the order aloud for the prescriber's verification. The nurse should ask the prescriber to spell the drug name if necessary. Although verbally repeating the order for verification is appropriate, the nurse must write the order to prevent errors.

A 3-year-old is seen in the well child clinic. The parent is concerned that the child may be autistic. Which assessment data would indicate a concern to the nurse? Select all that apply.

lack of communication abilities, withdrawing into a private world, inability to develop social skills; Children with autism spectrum disorder (ASD) fail to develop interpersonal skills. The child withdraws into a private world and is not able to develop social skills and communication abilities.

The nurse is caring for an older adult who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which type of chair?

straight-back chair with elevated seat; It is important that clients with rheumatoid arthritis maintain proper posture and body alignment to support joints and decrease pain and stiffness. Clients with hip pain will be most comfortable when sitting in a straight-back chair with an elevated seat.

The nurse is caring for a client in labor. The client asks the nurse if she could labor in the tub. Which response by the nurse would be most appropriate?

"Yes, but the water must not be hot enough to raise your temperature."; The temperature of the water should be constantly maintained at body temperature (i.e., 98.6°F [37°C] or lower) to prevent hyperthermia. Warm tub baths can be relaxing and are often used by laboring clients. Soaking in water with ruptured membranes increases the client's risk of infection and would exclude her from the tub bath. The relaxation and warmth from the water could slow her labor, but this would not preclude her at this time.

A 9-month-old infant with eczema has lesions that are secondarily infected. Which recommendation is the most appropriate to help the parents best meet the needs of the child?

Play with the child every day; The parents can best meet the needs of their 9-month-old infant by playing with the child every day. All infants need time with their parents to develop trust and thus attain optimal development. The parents of a child with a chronic problem may need more guidance to meet the child's needs because of the focus on medical problems. The child's lesions are secondarily infected and therefore should not be contagious. Even with lesions that are infected, the child can still attend daycare, but the child needs attention from the parents as well.

A nurse is teaching accident prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents?

Place toxic substances out of the child's reach; Toddlers are extremely curious and explore everything. They are unable to differentiate between harmful and good substances. The parents should place all toxic substances, including detergent pods, up high where toddlers cannot reach them. If the child is a climber, then installing child safety locks on cabinets would be appropriate. Toddlers lack the cognitive development to understand water safety, but parents should adhere to all safety rules whether the child is in the bathtub or a swimming pool.

The chart entry reads:2/10/2017 @ 1000. The client is pacing the hallway and stated, "I'm feeling so bad that I could jump out of my skin." Vital sign: T 97.8, P 124, R 24. The client is sweating and trying to hold back tears. The client refuses to participate in relaxation exercises or to do deep breathing with the nurse.What is the best action for the nurse to initiate based on the information in this record?

contact the provider for a PRN medication; It would be most helpful to obtain an order and administer a PRN medication to assist the client with this intense anxiety. A therapeutic intervention is necessary, rather than a social conversation which minimizes the client's present situation.

A client who has been taking warfarin has been admitted with severe acute rectal bleeding and these laboratory results: international normalized ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). After starting an intravenous infusion, in which order should the nurse implement the prescriptions? All options must be used.

Administer IV dextrose 5% in 0.45% normal saline solution, Give 1 unit fresh frozen plasma (FFP), Administer vitamin K 2.5 mg by mouth, Schedule the client for sigmoidoscopy; Analysis of the client's laboratory results indicates that an INR of 8 is increased beyond therapeutic ranges. The client is also experiencing severe acute rectal bleeding and has a hemoglobin level in the low range of normal and a hematocrit reflecting fluid volume loss. The nurse should first establish an IV line and administer the dextrose in saline. FFP contains concentrated clotting factors and provides an immediate reversal of the prolonged INR. Vitamin K should be given next because it reverses the warfarin by returning the PT to normal values. However, the reversal process occurs over 1 to 2 hours. Last schedule the client for the sigmoidoscopy.

A client with a cocaine dependency is irritable, anxious, highly sensitive to stimuli, and overreacting to clients and staff on the unit. Which action is most therapeutic for this client?

providing the client with frequent "time-outs"; Providing frequent "time-outs" when the client is highly anxious, sensitive, irritable, and over reactive is needed to calm the client and reduce the possibility of escalating behaviors and violence. Secluding and restraining the client is not appropriate and would only be used if the client was threatening others and other alternative actions had been unsuccessful.

An Alzheimer's client has difficulty following instructions but listens intently to the voice of the nurse who is the primary caregiver. The physician orders an electrocardiogram (ECG) to ascertain cardiac status. The client becomes agitated when the ECG technician enters the room. What is the nurse's best course of action?

Sit next to the client and provide verbal support until the client calms down; Because the client recognizes and responds to the nurse's voice, the nurse should reinforce the client's comfort level by providing audible and physical assurance .

A registered nurse (RN) plans a conference to discuss the care plan for an infant admitted to the hospital with a diagnosis of nonorganic failure to thrive. Appropriate participants in the care conference include the:

registered dietitian, RN, health care provider, and infant's primary caregiver; Secondary failure to thrive results from inadequate nutrition related to an underlying disease or disorder. The dietitian can address nutritional needs, which are a central concern in failure to thrive. The primary caregiver can provide input. The social worker and occupational therapist may become involved after the infant's condition improves, but they aren't crucial members of the team at this point.

A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, "They said I was gay because I had sex with an older neighbor when I was 8 years old. I'm not gay!" Which nursing intervention would be appropriate? Select all that apply.

Monitor the client's level of anger and potential aggression, help the client express anger safely, assist the client in processing his feelings about the sexual abuse, ask the client if he would like to attend a support group; Safety of others is a priority, and the nurse must monitor the client's anger and potential for aggression. The nurse should also find safe ways for the client to express the client's anger and any other feelings about the abuse. A referral to a support group is appropriate because anger management groups are one way to assist the client in learning to manage anger.

A nurse is preparing a teaching plan for a newly married female client with a cervical (C5) spinal cord injury. The client does not want to become pregnant at this time. What sexuality teaching will be important for the nurse to include? Select all that apply.

Provide brochures on adaptations for sexual practice, Encourage her to be patient and practice a variety of sexual techniques, Instruct the client's spouse on how to properly insert a diaphragm; The C5 cervical injury client will have paralysis of the legs, torso, wrists, and hands. Patience and adaptations for sexuality practices are to be encouraged for the couple because of the cervical injury. This client will not be able to insert any form of contraception by herself. If the couple does not use condoms, it is vital to provide her husband with instruction on insertion of a diaphragm. Providing the couple with literature on sexual practice will help to pave the way for discussion.

A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which type of burns does the nurse determine are present?

Third degree (full thickness); Third-degree burns involve the epidermis, dermis, and sometimes subcutaneous tissue. They usually present as dry, pale, white, red brown, leathery, or charred.

A nurse is working in a rural health clinic that serves a large Amish population. The nurse is developing a program to address common health promotion strategies. Which aspect would be most important for the nurse to integrate into the program to promote its success? Select all that apply.

importance of the extended family in providing support, focus on being in tune with nature for health maintenance, need to ask for permission before physically touching a client; In the Amish culture, the extended family and community play important roles in supporting the client. They have a strong extended family social structure, and caring for the community is a strong value. Family structure is patriarchal, with the husband often the family spokesperson and decision maker. The Amish believe in the importance of nature to maintain health and often use natural remedies as a major part of care. Because touch is discouraged, permission is needed before touching a client.