passpoint 1

opioids

Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

overdose of amphetamines can cause

Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea, not constipation, is a common adverse effect.

Nursing care for a client in addisonian crisis should include which intervention?

The client in addisonian crisis has a reduced ability to cope with stress as a result of an inability to produce corticosteroids. A private room is easy to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

Which foods should the nurse teach the client not to consume when taking phenelzine? Select all that apply.

When taking phenelzine, the client should not consume foods and beverages containing tyramine or tryptophan, or drugs containing pressor agents. Tyramine-containing foods/fluids include aged cheeses, tofu, beer, and smoked meats. Tryptophan-containing foods include chocolate, cottage cheese, milk, and yogurt. Strawberries and pasta are safe for this client to consume.

The client is taking risperidone to treat the positive and negative symptoms of schizophrenia. Improvement of which negative symptoms indicate the drug is effective?

-Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. -Abnormal thought form, bizarre behavior, hallucinations, and delusions are positive symptoms of schizophrenia.

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?

A child has been exposed to varicella. Which precaution should the nurse institute for infection control?

Children with varicella or suspected varicella should be treated under airborne precautions in addition to standard precautions. Varicella is transmitted by airborne nuclei. Droplet precautions are indicated for conditions such as pertussis, meningococcal pneumonia, and rubella. Contact precautions are indicated for conditions such as draining major abscesses, acute viral conjunctivitis, and Clostridium difficile gastroenteritis. Indirect contact is not a method of controlling infection. Rather, it is a mode of transmission involving contamination via some intermediate object, such as an instrument, needle, or dressing, or by hands that are not washed or gloves that are not changed between clients.

A client is admitted with chest pain, fever, and joint pain 4 weeks after experiencing an acute inferior wall myocardial infarction. Which laboratory value should the nurse address?

Dressler syndrome is pericarditis with effusion and fever that develops 4 to 6 weeks after MI. It is thought to be caused by an antigen-antibody reaction to the necrotic myocardium. The client experiences pericardial pain, fever, a friction rub, pericardial effusion, and arthralgia. Laboratory findings include an elevated white blood cell count and sedimentation rate. The WBC of 10,000 and CPK of 132 are within normal range. An altered magnesium level will not cause the symptoms and is not a laboratory test for Dressler's Syndrome.

A 4-year-old child with hydrocephalus is scheduled to have a ventriculoperitoneal shunt in the right side of the head. When developing the child's postoperative plan of care, the nurse should place the preschooler off of the operative site with the head of the bed in which position immediately after surgery?

For at least the first 24 hours after insertion of a ventriculoperitoneal shunt, the child is positioned off of the operative site with the head of the bed flat to prevent too rapid a decrease in cerebrospinal fluid pressure. Although elevating the head in Fowler's or semi-Fowler's position increases cerebrospinal fluid drainage and reduces intracranial pressure, a rapid reduction in the size of the ventricles can cause subdural hematoma. Elevating the foot of the bed in Trendelenburg position could increase intracranial pressure.

A child with heart disease starts on oral digoxin. When preparing to administer the medication, what should the nurse do first?

It is most important to know the child's serum potassium level when administering digoxin. Digoxin increases contractility of the heart and increases renal perfusion, resulting in a diuretic effect with increased loss of potassium and sodium. Hypokalemia increases the risk of digoxin toxicity. Verifying the dosage is specified by facility policy and varies among facilities. Although the child may take the medication better from the mother than from the nurse, asking the mother to give the medication is not necessary. In addition, this would be done after the nurse has checked the electrolyte levels. Teaching the parent how to measure the child's heart rate can be done at any time, not necessarily when preparing to give digoxin.

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record?

Multiple sclerosis (MS) is a progressive disease characterized by demyelination of the brain and spinal cord. This disease causes a number of manifestations including muscle spasticity. Therefore, baclofen will be given on a routine basis. Antibiotics are not routinely needed. Sinemet is given for Parkinson's disease, not for MS. Methotrexate is given for rheumatoid arthritis.

A client is reporting shortness of breath. The nurse finds the client's assessment includes dyspnea, diaphoresis, and slight confusion. Concerned that the client may have an air embolism, how should the nurse position the client?

Positioning the client on the left side in the deep Trendelenburg position keeps the air in the right atrium and out of pulmonary circulation, preventing obstruction of the right ventricle. The other choices are not correct based on movement of an air embolism and care to stop it from moving further.

A client was recently prescribed sucralfate for short-term treatment of a duodenal ulcer. At follow-up, the client reports taking aluminum hydroxide tablets along with the sucralfate 90 minutes before meals. What teaching should the nurse reinforce with the client?

Sucralfate is taken on an empty stomach 1 hour before meals and at bedtime to allow a protective coating to form over the ulcer before high levels of gastric acidity occur. It is not to be taken every 4 hours. Antacids (such as aluminum hydroxide) can reduce the effectiveness of sucralfate if taken together; they should be taken 30 minutes apart to prevent interaction. As long as this precaution is followed, there is no need to completely suspend antacid use.

A client with a history of varicose veins has just delivered her first baby. A nurse suspects that the mother has developed pulmonary embolus. Which symptoms would confirm this suspicion? Select all that apply.

Sudden dyspnea along with diaphoresis and confusion are classic symptoms that develop when a thrombus from a varicose vein becomes an embolus that lodges in the pulmonary circulation. Chills and fever would indicate infection. A client with an embolus usually develops tachycardia.

A client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the client most at risk?

The client who has a significant cigarette smoking history and an operative manipulation close to the diaphragm (the gallbladder is against the liver) is at increased risk for atelectasis and pneumonia. Postoperatively, this client will be reluctant to deep breathe because of pain, in addition to having residual lung damage from smoking. Therefore, the client is at greater-than-average risk for pulmonary complications. The client does not have an increased risk of prolonged immobility (unless slowed by a respiratory problem), deep vein thrombosis (as long as the client performs leg exercises), or delayed wound healing (as long as the client maintains appropriate nutrition).

The nurse is assessing a client newly transferred from the recovery room and notes a low-grade temperature, tachycardia, tachypnea, and crackles. Which action is the nurse's priority?

The nurse is assessing a client newly transferred from the recovery room and notes a low-grade temperature, tachycardia, tachypnea, and crackles. Which action is the nurse's priority?

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order

A client with atrial fibrillation is prescribed warfarin. How should the nurse explain the purpose of this medication to the client?

Warfarin prevents vitamin K from synthesizing certain clotting factors and is used to reduce thrombus formation in the atria of people with atrial fibrillation. This reduces the risk of stroke. Warfarin and other anticoagulants do not alter the viscosity of the blood despite being commonly referred to as "blood thinners." Warfarin does not alter the rhythm associated with atrial fibrillation. Warfarin does increase the client's risk for bleeding, but this is a side effect, not the purpose of the medication.

The nurse auscultates the lungs of a client who has been diagnosed with a tumor in the lung and notes wheezing over one lung. What additional assessment should the nurse make?

Wheezing over one lung in the presence of a lung tumor is most likely caused by obstruction of the airway by a tumor. Exudate would be more likely to cause crackles. The client's history of smoking would not cause unilateral wheezing. Pleural effusion would produce diminished or absent breath sounds.

The nurse is preparing a teaching plan for a client about crutch walking using a two-point gait pattern. What information should the nurse include?

A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead.

The client is diagnosed with bipolar disorder and is in the manic phase. The healthcare provider orders lithium therapy. Which intervention should the nurse stress with the client on lithium therapy?

The nurse should stress that the medication is to be taken with meals to decrease GI upset. Decreased sodium intake with decreased fluid intake may lead to lithium retention; increased sodium and fluids may decrease lithium retention. Weight should be checked daily, and water intake should be 2 to 3 L/day.

A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit?

The priority assessment is that the client has a firm fundus when gentle massage is used. This indicates that the client's fundus may be soft or "boggy" when it is not massaged. The receiving nurse should assess the client's fundus soon after admission and continue to monitor the client's fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal. The temperature and pulse are within normal limits.

working phase

The therapeutic nurse-client relationship consists of three phases: introduction or orientation, working, and termination. During the working phase, the nurse and client evaluate and refine the goals established during the orientation phase. In addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the client, formulating a contract, exploring feelings, and establishing expectations about the relationship. During the termination phase, the nurse prepares the client for separation and explores the client's feelings about the end of the relationship.

The nurse is planning the order of client assessments at the beginning of the shift based on the risk for skin breakdown each client presents. The nurse should assess the clients in which order? All options must be used.

1.a paraplegic client admitted with dehydration and ordered bedrest 2.an older adult client with a diagnosis of left hip fracture 3.a client with diverticulitis who is occasionally incontinent 4.a client with sickle cell disease who is reporting pain - The client who is paraplegic with dehydration and on bedrest has the most risk factors for skin breakdown because of limited motion and is ordered bedrest. The older adult client with a hip fracture will require help with mobility and has risk factors due to mobility and age. The client with occasional incontinence has a risk factor due to wetness and how long the wet garment remains on. While the client with sickle cell disease is in pain which may affect mobility, there are no other factors that would indicate a risk for skin breakdown.

A client who is taking sildenafil has been prescribed tamsulosin. What is the nurse's best action?

Sildenafil may potentiate the hypotensive effect of the alpha blocker tamsulosin, resulting in symptomatic hypotension in some clients. The medications should not be taken together. The client should contact the healthcare provider before taking these medications together. Teaching should be completed once verification of medication administration is completed.

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client?

A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained.

A client with schizophrenia who is receiving antipsychotic medication reports feeling nervous. The client paces, fidgets, and can't seem to stay still. Which disorder is the most likely cause?

Akathisia is an extrapyramidal adverse effect of some antipsychotic medications. It manifests as restlessness and an inability to stay still. Tardive dyskinesia refers to involuntary abnormal movements of the mouth, tongue, face, and jaw. Akinesia is absence of movement. Anxiety is an unpleasant state of inner turmoil, often accompanied by nervous behavior, somatic complaints, and rumination.

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy?

Providing a bed that is low to the floor complies with the least restraint policy and prevents falls from the bed. Raising all side rails on the bed would be considered excessive restraint and could contribute to greater risk of injury if the client tried to climb out of bed. The other options do not fully ensure the safety of the client.

Which finding in a client diagnosed with heart failure would require a nurse to take immediate action?

Stridor, even though unrelated to heart failure, indicates partial obstruction of the airway and is of primary concern. Fine crackles indicate fluid accumulation. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation. Sonorous rhonchi are typically caused by secretions in the bronchi.