PCC 3 Final
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with Multiple Sclerosis which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder where killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?
A positive reaction indicates that the client has been exposed to the disease
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
A urine output consistently above 40 ml/hour
An 8-year-old boy and his father visit the pediatrician's office with reports of a sudden onset of abdominal pain and reddish-brown urine. A urinalysis shows 4+ protein. On taking the boy's health history, the nurse learns that he had strep throat a little over a week ago. Which condition should the nurse suspect?
Acute glomerulonephritis
Which of the provider's orders should be implemented immediately?
Administer D5½NS at 125 mL/hr
Which action by the nurse is most effective to prevent becoming exposed to the human immune deficiency virus (HIV)?
Always use Standard Precautions with all clients in the workplace.
Which statement is accurate regarding the Mantoux skin test?
An induration of 10mm or greater indicates a positive skin test
Match each chemotherapy side effect below with the correct intervention
Anemia- Administer epoetin alfa subcutaneously once a week Neutropenia- Inspect IV sites every 4 hours for signs of infection. Thrombocytopenia- Avoid IM injections and venipunctures.
A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL) and has begun a treatment regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of the following actions should the nurse implement?
Applying standard precautions conscientiously to reduce the patient's risk of infection
The nurse is conducting a seminar about breast cancer at a community center for women from diverse backgrounds. Which of the following would the nurse include about cultural risks of breast cancer to encourage breast self-exam?
Asian, Hispanic, and Native American women have a lower incidence of breast cancer.
A client who is positive for HIV presents with confusion, fever, headache, blurred vision, nausea, and vomiting. What does the nurse do first?
Ask the client to place his chin on his chest The client's 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 chest) helps confirm the diagnosis. An IV line may be started after the neurologic assessment is completed.
Which of the following is a term used to describe excessive nitrogenous waste in the blood, as seen in acute glomerulonephritis?
Azotemia
A nurse is assessing a neonate with sepsis. The nurse understands that most commonly the cause involves:
Bacteria
A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of the body. Admission vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.
Begin an intravenous (I.V.) infusion of lactated Ringer's solution, Administer 6 mg of IV morphine, and Administer tetanus prophylaxis, as ordered.
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?
Begin early feedings either by the breast or bottle.
The nurse is caring for a new infant and notes on assessment the newborn is small for gestational age and also has indications for intrauterine growth restriction. Which assessments should the nurse prioritize for the mother as a potential cause for the infant's condition?
Blood glucose levels
A client who has sustained partial-thickness or second-degree burns to 70% of total body surface area is arriving via ambulance to the emergency department. What aspects of care will the nurse prioritize for this client? Select all that apply.
Blood pressure support, Infection control and Pain management Hemodynamic stability after a burn injury is a priority, so blood pressure support is needed to prevent organ failure. Once hospitalized, the immediate treatment regimen focuses on continued maintenance of cardiorespiratory function, pain alleviation, wound care, and emotional support. The client is at high risk for developing sepsis due to the loss of protection from the integumentary system and other possible infections (e.g., pneumonia), so infection control is also a priority.
A hospitalized Hispanic child is diagnosed with lactose intolerance and is place on a lactose-restricted diet. Which dietary supplement should a nurse anticipate being added to the child's diet?
Calcium
Which of the following is a common complication of an electrical burn injury?
Cardiac dysrhythmias
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?
Check blood glucose.
For an HIV positive client, toxoplasmosis is an opportunistic infection. One way to prevent this infection is to avoid which of the following.
Cleaning cat litter
A young adult female who was admitted to the psychiatric hospital 2 months ago with an eating disorder is being discharged. Which of the following indicates the clients understand discharge instructions?
Client returns to the lab for routine lab tests
The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for:
Curling's ulcer. Curlings ulcer or gastrointestinal ulceration occurs in about half of the clients with a burn injury.
A nurse cares for a client who has secondary obesity. Which condition is the most likely to result in secondary obesity?
Cushing's
Which disorder is a result of excess cortisol?
Cushing's
The nurse administers mitotane (Lysodren) to the patient with Cushing's disease. What is the desired therapeutic effect?
Decreased cortisol levels
Which symptom, if found in the patient being treated for Cushing's disease, indicates medication therapy is therapeutic?
Decreased peripheral edema
A client with a personality disorder has a nursing diagnosis of Impaired Social Interaction. Applying the principles for caring with this client, which of the following nursing interventions is essential to the care plan?
Demonstrate honesty and sincerity in interactions with client.
A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin's lymphoma. Because of the effects of the radiation treatments, what will the nurse assess for?
Diarrheal stools Side effects of radiation therapy are limited to the area being irradiated. Clients who have abdominal radiation therapy may experience diarrhea.
The nurse has concluded that an assigned client's anxiety has reached the panic level as evidenced by which of the following manifestations?
Dizziness, palpitations, nausea
A client returns from the operating room with a partial-thickness skin graft on the left arm. The donor tissue was taken from the left hip. In planning immediate postoperative care, which interventions should the nurse include? Select all that apply.
Elevate the left arm and provide complete rest of the grafted area, Administer pain medication every 4 hours as ordered for pain at the donor site, and Monitor the pulse in the left arm every 4 hours. The left arm should be elevated to reduce edema. Complete rest of the arm is needed to allow the graft to adhere. The donor site is usually more painful than the graft site, and the client will require pain mediation to obtain relief. Because adequate circulation is needed for graft healing, it is important to monitor for the presence of a pulse.
Which assessment findings support that the patient with HIV currently has AIDS? (Select all that apply.)
Esophageal candidiasis, Recurrent infectious pneumonia, Kaposi's sarcoma, Wasting syndrome
A client diagnosed with obsessive-compulsive disorder is newly admitted to an in-patient psychiatric unit. Which cognitive symptom would the nurse expect to assess.
Excessive worrying about germs and illness
A nurse should perform which intervention for a client with Cushing's syndrome?
Explain that the client's physical changes are a result of excessive corticosteroids
Which of the following medications would the nurse expect to administer to a client who is experiencing ritualistic behavior that interferes with job performance and activities of daily living?
Fluoxetine (Prozac) - SSRI to balance serotonin
Chemical burns of the eye are immediately treated by:
Flushing the lids, conjunctiva, and cornea with tap water or normal saline.
Skin grafts are necessary for which of the following burns?
Full-thickness
During a physical examination of a 13-year-old boy, the nurse observes a single, enlarged, rubbery-feeling cervical lymph node in the armpit. The boy also reports unexplained loss of weight and malaise. Which condition should the nurse most suspect in this client?
Hodgkin lymphoma
A nurse is meeting with a client who is being discharged after hospitalization for suicidal ideation. Based on knowledge of expert consensus of warning signs for suicide, the nurse should plan to advise the client to seek help by contacting a mental health professional or calling the national suicide prevention hotline if experiencing: Select all that apply.
Hoplessness, Severe anxiety/agitation, Feeling of being trapped, Increasing alcohol/drug use
A client with leukemia has developed stomatitis and is on neutropenic precautions. Mouthwash every two hours has been ordered for the client. The nurse would question which of the following if ordered by the physician?
Hydrogen peroxide Hydrogen peroxide has a tendency to cause dryness in the oral mucosa and further aggravate the condition.
During the early phase of burn care the nurse should assess the client for?
Hyperkalemia
The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies?
Hyperkalemia Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction.
A nurse is caring for a preschooler who sustained deep partial-thickness burns on the hands as a result of touching a hot pot on the stove. What is most important for the nurse to consider in discharge teaching?
Include the child in the teaching process.
The nurse is assessing a client who cannot synthesize suppressor T-cells. For what other condition does the nurse assess the client?
Increased Seasonal allergies
The nurse is caring for a client who is in the hospital for diagnostic testing. On physical assessment, the nurse notes an enlarged spleen, oral ulcerations, and a decreased level of consciousness. Which of the following laboratory results would the nurse anticipate for this client?
Increased white blood cell count The client exhibits signs of leukemia, and the nurse would anticipate a high white blood cell count.
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?
Initiate seizure precautions with padded siderails.
The nurse reviews the laboratory results of a client and finds that the white blood cell (WBC) count is 1500/mm3. What is the priority action of the nurse?
Institute reverse isolation precautions.
A nurse is educating a client about prescription antidepressant medications and the appropriate expectations when taking these. Which statement by the nurse is accurate?
It is important to continue taking antidepressant medication even after you feel better
The nurse is planning care for a client who has just undergone a radical mastectomy. Which of the following would the nurse include in that plan?
Keep the affected arm above the level of the heart. The arm is kept elevated after a mastectomy to reduce edema.
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?
Lactated Ringer's solution
An HIV-positive client is taking lopinavir/ritonavir (Kaletra) and reports nausea, abdominal pain, and diarrhea. What orders does the nurse anticipate?
Liver enzymes
The nurse is teaching a client diagnosed with Hodgkin's lymphoma about metastasis. What type of cancer is the most likely to appear as a secondary malignancy in clients with Hodgkin's lymphoma disease?
Lung
A hospital client with a diagnosis of sepsis is in need of a specific response to microorganisms and a long-lasting immunity to the pathogens in question. Which component of the client's immune system is most able to meet these criteria?
Lymphocytes
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
Mafenide (Sulfamylon) The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns.
What dietary intervention will best help the patient being treated for Cushing's disease?
Maintain an American Diabetic Association diet.
The nurse is required to manage and minimize sepsis in a client with severe infection. Which would be an appropriate nursing intervention?
Monitor the client's vital signs.
A client is receiving baclofen for the management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following?
Muscle spasms
After being treated in the ED for self-inflicted lacerations to wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority?
Observe client frequently
A client with an eating disorder is admitted to the acute admission unit of the psychiatric hospital. The nurse is scheduling the weights for Monday and Thursday mornings. In order to obtain an accurate weight, the nurse should do which of the following?
Observe for attempts to put weights into clothing or body
A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. The mother also has a low-grade fever. What are the most appropriate nursing interventions? Select all that apply.
Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis, Provide blow-by oxygen and monitor the neonate's respiratory status, and Inform the parents that she wants to monitor the neonate closely.
The nurse is reviewing the medical record of a child diagnosed with Hodgkin's lymphoma. Which would the nurse identify as typically the first sign reported by the child?
Painless, enlarged lymph node
Which statement is true about a patient at risk for increased Increased Intracranial Pressure?
Papilledema, edema, and hyperemia of the optic disk are always signs of increased ICP
What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?
Perform a heel stick to obtain a blood sample for testing for glucose level. If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level.
The nurse is assessing a patient who was struck in the head several times with a bat. There is a clear fluid that appears to be leaking from the nose. What action does the nurse take?
Place a drop of the fluid on a white absorbent background and look for a yellow halo.
A client with AIDS has been admitted with fever, night sweats, and weight loss of 6 pounds in 2 weeks. The client's purified protein derivative (PPD) test, placed 3 days ago in the clinic, is negative. Which action by the nurse is most appropriate?
Place the client in Airborne Precautions
The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.
Poor skin turgor, Sparse or absent hair and Diminished muscle tissue
A 51-year-old woman has been diagnosed with Cushing syndrome after a diagnostic workup that reveals cortisol hypersecretion. The nurse knows which assessment finding would be inconsistent with her diagnosis?
Poor stress management and hyperpigmentation
A patient has sustained a traumatic brain injury. Which nursing intervention is best for this patient?
Position to avoid extreme flexion
The nurse caring for a client with obsessive-compulsive disorder (OCD) will expect to assess this client for which of the following?
Potential to harm others
Which determination must be made first in assessing a patient with traumatic brain injury?
Presence of a patent airway
When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority?
Preventing hypoglycemia with early feedings
A client who has had a mastectomy and her spouse are asking the nurse questions about reconstructive surgery. Which of the following is the best response by the nurse?
Reconstructive surgery may require multiple surgeries.
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective?
Reduced muscle spasticity
A client diagnosed with obsessive-compulsive disorder has been hospitalized for the past 4 days. Which intervention would be a priority at this time?
Reinforce the use of learned relaxation techniques
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 nurse's face. Which drug regimen does the nurse prepare to initiate?
Retrovir (zidovudine) and Epivir (lamivudine) for 28 days
The nurse is performing discharge teaching for the family and patient who has had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motorcycle accident. What elements of instruction does the nurse include? (Select all that apply.)
Review seizure precautions, Develop a routine of activities with consistency and structure, Attend follow-up appointments with therapists, Encourage the family to seek respite care if needed
A patient with non-Hodgkin's lymphoma (NHL) will be starting a course of doxorubicin shortly. When planning this patient's care, what nursing diagnosis should the nurse prioritize?
Risk for Infection related to suppressed bone marrow function Because doxorubicin suppresses bone marrow function, the patient is at risk of leukopenia and subsequent infection.
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?
Rotate the sites where you will be giving the injections.
The nurse is caring for a client diagnosed with systemic inflammatory response syndrome. Which illness is likely responsible for this diagnosis?
Sepsis
During the acute phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation?
Serum creatinine level of 2.5mg/dL Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine
Select the common routes by which HIV can be transmitted. Select all that apply.
Sexual Contact with an HIV-positive person and Contact with blood infected with HIV
A client is to have an amputation. The client is acutely ill and diagnosed with a gangrenous limb and related fever, disorientation, and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client
Signs of sepsis
The nurse is caring for a client with burns in a pediatric hospital. The child is scheduled to be discharged the following day and the nurse is going over discharge teaching with the parents. Which is the best intervention for the parents when removing an old dressing?
Soak the old dressing in tepid water before attempting to remove.
A client diagnosed with borderline personality disorder coyly requests diazepam (Valium) When the physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the client using?
Splitting
The nursery nurse is providing shift handoff on a newborn documented as small for gestational age. Which clinical manifestations would be communicated? Select all that apply.
Sunken abdomen, Poor muscle tone over buttocks and Dry or thin umbilical cord A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.
A young adult woman is reporting an unusual deposit of fat on her upper back, a rounded appearance to her face, increasing weakness, and development of "stretch marks." The nurse should anticipate what treatment given these manifestations?
Surgical removal of the client's pituitary tumor
A client experiencing a panic attack would display which physical symptoms?
Sweating and palpitations
A nurse should wear a fit-tested HEPA mask when entering the room of a patient with which disease?
TB
To decrease the risk of developing resistance to the antiretroviral medication, the client should:
Take at least three different antiretroviral medications at one time
An undetectable viral load means:
The amount of virus in the client's blood is so low it cannot be found using the current lab tests
The nurse is teaching a client who has AIDS how to avoid infection at home. Which statement indicates that additional teaching is needed?
The client should avoid eating raw fruits, vegetables, and salads because of the risk of infection.
A suicidal client is diagnosed with borderline personality disorder. Which short-term outcome is most beneficial for the client?
The client will express feelings without inflicting self-injury by discharge
A nurse is planning care for a client diagnosed with acute mania. What situation must occur prior to initiating treatment with lithium carbonate?
The client's history and physical results, including laboratory results are reviewed
At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?
The infant was a preterm, low birth weight and small for gestational age Born at 36 weeks gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500g) and small for gestational age at the 8th percentile (under the 10th percentile).
Tuberculosis responds well to long-term treatment with a combination of three or more antitubercular drugs. Which is true regarding the duration of treatment for clients with tuberculosis? Select all that apply.
The initial treatment phase should last for a minimum of two months, the continuation treatment phase should last for four to seven months and Prophylactic treatment should be given for six to 12 months.
The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select all that apply.)
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.
Which action indicates to the nurse that the patient with Cushing's disease is adhering to teaching goals for medication therapy?
The patient reports weight gain while on the medication.
Which patient should not receive ketoconazole (Nizoral) as ordered for Cushing's disease?
The patient with elevated liver function tests
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?
Thick white patches on the client tongue and oral mucosa
A client's absolute neutrophil count (ANC) is 550/mm3. What is the nurse's best action?
Use Standard Precautions.
Which of the following would the nurse recognize as a sign of a local infection during data collection?
Warm skin
A client is placed in isolation for suspected tuberculosis. Which action should the nurse take when entering the client's room?
Wear an N95 respirator.
A nurse is caring for a client diagnosed with acute mania. the nurse observes course hand tremors and learns that the client's serum lithium level is 1.8 mEq/L
Withhold the medication and notify the physician (notify if level is above 1.5)
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?
Your count is a bit low and you are susceptible to infection.
The nurse is admitting four clients with infections to the medical-surgical unit, but only one negative pressure room is available. Which client is it most appropriate to assign to the negative pressure room?
a client with a cough who may have tuberculosis (TB)
A client is admitted with glomerulonephritis. Which psychosocial problems could likely affect this client?
anxiety related to poorly functioning kidneys and body image disturbance
A home health nurse is evaluating a parent's dietary management of a child with celiac disease. Which foods, or food-containing products, should the parent eliminate from the child's diet?
barley, wheat, oats
After plotting a postterm neonate's weight and length on a growth chart, the nurse determines that the infant is large for gestational age (LGA). Which laboratory value is most important for the nurse to assess next?
blood glucose LGA neonates are at risk for hypoglycemia soon after birth because they frequently have increased insulin levels. All LGA infants should have blood glucose testing soon after birth. Accelerated growth states can lead to increased hemoglobin production in utero.
A nurse is caring for a 52-year-old client who has been diagnosed with a latent tuberculosis infection. The health care provider is considering ordering isoniazid (INH). The preexistence of what condition would require cautious use of INH in this client?
cirrhosis of the liver
A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:
collaborate with the social worker to investigate possible availability of funds.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:
dislodge the autografts.
Which clinical manifestations are consistent with active tuberculosis (TB)? Select all that apply.
dyspnea (Late sign), Night sweats, fatigue, low-grade fevers, productive bloody sputum (late sign) a dry cough or mucopurulent sputum is more common, Unexplained weight loss, anorexia (WHEEZING IS NOT A SIGN)
An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which condition should the nurse most expect to find in this infant?
hypoglycemia
The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?
jitteriness Jitteriness is evident with a newborn with hypoglycemia as well as poor feeding with feeble sucking. The newborn would have tachypnea.
A nurse is discharging a client after Billroth II surgery (gastrojejunostomy). To assist the client to control dumping syndrome, the client's discharge instructions should include:
lying down for 20-30 minutes after meals
When reviewing the medical record of a newborn who is large for gestational age (LGA), which factor would the nurse identify as having increased the newborn's risk for being LGA?
maternal pregravid obesity
A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused and reports minor pain. When assessing the client, which is an immediate priority for the nurse to evaluate?
patency of airway
A nurse is assessing the fluid status of a client with a second-degree burn who weighs 60kg. The client is 5 hours postburn. The nurse determines that the client's fluid status is inadequate and immediately notifies a physician when the client exhibits?
pulse rate 130 bpm and urine output 25mL/hr
A child diagnosed with acute glomerulonephritis will most likely have a history of:
recent illness such as strep throat.
An infection or the products of infection carried throughout the body by the blood is called:
septicemia.
The nurse is caring for a client with Cushing's disease. During change of shift report, which assessment laboratory data would the nurse anticipate communicating? Select all that apply.
serum sodium level, serum potassium level, blood glucose level, white blood cell count
A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?
temperature instability
A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?
term, small for gestational age, and low-birth-weight infant
After completing a wellness seminar at a local manufacturing business, a nurse is answering individual questions. One of the participants tells the nurse his mother has celiac disease and he is afraid he may also have the disease. The nurse agrees that this may be possible when the client states that he experiences diarrhea after eating:
whole wheat bread
A client diagnosed with mania tells a nurse, "I think you're very pretty. Maybe we could go to my room." Which response by the nurse is most therapeutic?
" It's time for occupational therapy."
A client with a diagnosis of sepsis has received intravenous immune globulin (IVIg) as partial treatment. The nurse knows that which client response would best suggest an accurate understanding of IVIg treatment?
"A big part of my IVIg treatment is actually stimulating and supplementing my immune system to do the work itself."
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
Which of the following statements indicates that the patient diagnosed with tuberculosis understands appropriate care measures?
"Medication will need to be taken for a 6-12 month duration."
Which statement should the nurse include in the teaching plan for a family learning about fire safety?
"Most people who die in home fires die from inhalation and not from burns."
You are discussing discharge instructions with a patient who has been diagnosed with Tuberculosis. The patient indicates that she is anxious to go home. Which statement by the nurse is correct?
"Patients are discharged after three negative acid-fast bacilli smears."
The nurse is giving discharge instructions to the mother of a child who bumped her head on a table. Which statement by the mother indicates an understanding of the instructions?
"She may have nausea or headache for the first 24 hours."
A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all medications. What is appropriate for the nurse to say to the client?
"Taking several medications can be difficult. Tell me about the difficulties you're having
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?
"The HAART medications are working well right now"
A child with leukemia who is being treated with chemotherapy is visited by a grandmother who has brought flowers from her garden for the child. Which of the following is the appropriate response by the nurse?
"The flowers are beautiful, but the child cannot have them right now."
Which statement by a student nurse needs follow-up regarding precautions for a patient with possible tuberculosis?
"The patient will wear a N95 mask when leaving the room."
The patient receiving ketoconazole (Nizoral) for Cushing's disease reports a headache. What is the best advice for the nurse to give the patient?
"This might be a reaction to the medication. Talk to your health care provider."
The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling, "Stella! Stella!" What is the best question for the nurse to ask the patient's friends?
"Was the patient using drugs or alcohol prior to the accident?
A client is being discharged after hospitalization for a suicide attempt. Which question asked by the nurse assess the learned prevention and future coping strategies of the client?
"What skills can you utilize if you experience problems again?"
A nurse has a client with multiple sclerosis who, after attending a meeting with the Multiple Sclerosis Society, states complementary therapies would work better. What is the best response by the nurse?
"You have a right to search out options and make decisions to help manage your symptoms. Share with me what you've learned."
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?
"You must avoid stress and extreme fatigue, because these can trigger a relapse."Stress, fatigue, and temperature extremes can trigger relapses of MS. The client should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress.
The nurse is providing care to a client who was brought to the emergency department by family. The client has full-thickness (third-degree) burns to the face and upper body and is having difficulty speaking. Place these nursing interventions in order the nurse will perform them. All options must be used.
1) Secure a patent airway 2) Insert a large-bore intravenous cannula 3) Start fluid resuscitation 4) Administer intravenous pain medication 5) Gently cleanse the burns with sterile water 6) Provide psychosocial support to the client and family