SIMCLEX #1
The parents of a one-week-old with a cleft palate demonstrate understanding of the diagnosis by making which of the following statements?
"Our child will need to have surgery between six and 24 months" Cleft palates are surgically repaired within this timeframe. "Our child will need to have surgery between three to six months of age Cleft palates are surgically repaired between six and 24 months. "Our child will not need surgery" Cleft palates are surgically repaired between six and 24 months. "Our child will need surgery as soon as possible" Cleft palates are surgically repaired between six and 24 months. Test taking tip: Focus on the common theme of the answers, which is the timeframe in which a child with a cleft palate will need surgery. Recall information about cleft palate surgery timeframes.
A student nurse is studying electrocardiogram graph paper and understands the large boxes measure how many seconds?
0.5 The large box measures 0.2 seconds. 0.04 The large box measures 0.2 seconds. 6 The large box measures 0.2 seconds. 0.2 The large box is made up of 5 smalls boxes that measure 0.04 seconds each. Therefore, the large box measures 0.2 seconds.
The nurse is caring for an adult client who requires Demerol IM. Which sized needle would the nurse choose?
23 gauge An IM injection must be performed using a needle suitable to puncture directly into a muscle. A 20-25 gauge needle is appropriate for an IM injection. (The higher the gauge, the thinner the needle.) 16 gauge This needle is quite large. A nurse would use this size when starting a large bore IV for rapid fluid administration, not to give an IM injection. 18 gauge This needle is also quite large. A nurse would use this size when starting a large bore IV for rapid fluid administration, not to give an IM injection. 26 gauge This size would be used for a subcutaneous injection.
A nurse is on the code team and is caring for a client who is coding. The nurse administered epinephrine at 22:40. When can the next epinephrine be administered?
2:43 Epinephrine during a code can be pushed every 3-5 minutes. 22:50 This time frame is incorrect. Epinephrine can be given every 3-5 minutes. 22:41 This time frame is incorrect. Epinephrine can be given every 3-5 minutes. 22:55 This time frame is incorrect. Epinephrine can be given every 3-5 minutes.
A newborn nursery nurse has just received shift report. Which baby should be seen first?
A 90-minute old newborn weighing 4200g that has not eaten This baby is at risk for hypoglycemia because he is large for gestational age so this infant needs to be seen to have a blood sugar checked and be fed to prevent hypoglycemia. A 2-day old newborn ready for discharge home This is not a priority because this infant would be stable if ready for discharge. Instead, the priority would be a potentially unstable infant. A newborn born at 38 weeks with a temperature of 97.8 This is a stable temperature so not a priority. A newborn that spit up some yellow secretions Spit up occurs in newborns and yellow is typically a normal finding of colostrum.
A nurse is caring for a 12-year-old girl who has been diagnosed with Rett syndrome. Based on the nurse's understanding of this condition, the nurse knows that Rett syndrome is caused by which of the following?
A defect in the MECP2 gene Rett syndrome is a disorder that results from a single-gene defect during development, in which there is a mutation on one of the X chromosomes, MECP2. The condition almost exclusively affects girls. Rett syndrome causes difficulties with social and language skills, as well as problems with activity and coordination. Most persons with Rett syndrome are never able to live independently and they may not live past middle age. Chronic exposure to elevated lead levels Rett syndrome is caused by a mutation on a specific gene. Administration of aspirin to an infant Rett syndrome is caused by a mutation on a specific gene. An injury that causes lack of oxygen to the brain Rett syndrome is caused by a mutation on a specific gene.
A nurse is caring for a client who has had a central line placed for long-term antibiotic therapy. Which best describes the difference between a tunneled and non-tunneled central venous catheter?
A tunneled catheter has a separate exit point under the skin, while a non-tunneled catheter exits near the vessel into which it is inserted Central lines can be inserted as tunneled or non-tunneled catheters. A tunneled catheter is inserted and then tunneled under the skin, while a non-tunneled catheter is inserted directly into a vessel. A tunneled catheter exits the chest and is associated with a lower risk of infection and can stay in place for several months but it must be inserted as a surgical procedure. A tunneled catheter is associated with a higher risk of infection while a non-tunneled catheter is associated with a lower risk of infection The tunneled catheter is further from the vessel and is, therefore, the bloodstream is less likely to be exposed to pathogens. A tunneled catheter can be placed at the bedside while a non-tunneled catheter requires surgical intervention A tunneled catheter is a surgical procedure. A tunneled catheter can only stay in place for a few weeks
The nurse caring for a child diagnosed with the measles knows that which of the following are classic symptoms of this diagnosis?
Coryza, cough, conjunctivitis These are known as the 3 C's and are a classic triad of symptoms associated with the diagnosis of measles. Polydipsia, polyuria, polyphagia These symptoms are classic symptoms seen with the diagnosis of Type 1 Diabetes. Mouth sores, blood in stool, weight loss These symptoms are often found in clients diagnosed with Crohn's disease. Strawberry tongue, high fever, sandpaper rash These signs and symptoms are associated with the diagnosis of Scarlet fever.
A nurse is caring for a pregnant client that has a prior diagnosis of herpes. What should the nurse expect to be included in her plan of care?
Acyclovir to begin at 35 weeks Acyclovir should be started prophylactically at 35 weeks until delivery to prevent active lesions during delivery. Acyclovir during the entire pregnancy Acyclovir is needed during pregnancy prophylactically but not until around 35 weeks. Nothing, because it was prior to pregnancy Acyclovir will be given prophylactically to ensure there is no active lesions during delivery. Antiretroviral therapy This would be the management for an HIV infection.
A nurse is working on a telemetry unit and notices a client in 2nd degree AV heart block type 2 and knows that which of the following is the priority nursing intervention?
Administer adenosine IV asap This is not indicated in 2nd degree AV heart block type 2, it is indicated in tachycardia or SVT. Administer amiodarone 150 mg IV It is not indicated for 2nd degree AV heart block type 2. Prepare the client for a temporary or permanent pacemaker This is the priority nursing intervention when recognizing this rhythm after notifying the healthcare provider. Prepare to defibrillate the client This is not an indication for 2nd degree AV heart block type 2.
Mrs. Jones, a 62-year-old female, is admitted to the hospital with severe pneumonia. She is started on antibiotics and receives oxygen therapy via a non-rebreather mask. After 48 hours, her condition deteriorates rapidly, and she is intubated and transferred to the intensive care unit. A chest x-ray reveals bilateral infiltrates, and she is diagnosed with Adult Respiratory Distress Syndrome (ARDS).
Administer bronchodilators Initiate side positioning Provide mechanical ventilation Administer corticosteroids Administer diuretics Positive end expiratory pressure Administer bronchodilators due to the higher cumulative doses of inhaled albuterol that are strongly and independently associated with a survival benefit in clients with moderate to severe ARDS. Bronchodilators improve oxygenation and peak and plateau airway pressures and significantly reduce inflammatory markers. Mechanical ventilation and Peed prevent alveolar collapse, reduce injurious alveolar shear stresses and improve ventilation-perfusion matching and arterial oxygenation. Provide mechanical ventilation with ARDS dues to assist in prevention of secondary lung injury and prevent client outcomes. Administer corticosteroids in ARDS can assist in decreasing morbidity in ARDS as well as reducing mechanical ventilation duration. Corticosteroids suppress systemic inflammation in clients with unresolving ARDS. Administ
The nursing student completing her clinical rotation in a Med-Surg unit is caring for a client with multiple renal calculi. Which nursing interventions should be included in her plan of care? Select All That Apply:
Administer morphine 2mg IV push Q6 hours Encourage fluid intake of at least 3000ml a day Place the client on strict bed rest Offer the patient flank massage Strain all urinary output for the presence of stones Monitor the patient's complete blood count Morphine: Kidney stones are incredibly painful and usually are treated initially with IV opiates, like morphine or dilaudid. Fluids: Force-flushing the kidneys will easily dislodge stones under 5 mm in diameter. Straining urine: Straining all urine ouput not only confirms that it has passed, but the stone is then sent to pathology to determine the type of stone. Example = some stones can prevented from recurring with dietary changes. CBC: Kidney stones are often corrected with kidney infection. The WBC's and nitrates are unusually high in this situation.
A nurse is caring for a 4 year-old child with nausea and vomiting. The child is lethargic, reporting pain in the stomach and being very tired, and has just vomited. What is the nurse's priority concern for this child?
Airway clearance Any time a client has vomiting accompanied by lethargy, aspiration is a concern. Maintaining a patent airway is essential and will always be a priority. **Test taking tip: Remember your ABC's! Electrolyte balance While the child could possibly experience an electrolyte imbalance due to excessive vomiting, the priority will always be to maintain a patent airway. Nutritional status The impact of vomiting on nutritional status in an acute setting is minimal, therefore it would certainly not take priority over airway. Fluid volume status The child is likely dehydrated and will certainly need rehydration. However, maintaining a patent airway (A-airway) will always take priority over volume (C-circulation).
In the table below, please drag options from column 1 to column 3 to match the following medications with their respective therapeutic actions (based on the EHR):
Albuterol: Bronchodilation Furosemide: Diuretic Methylprednisolone: Anti-inflammatory Peep: Optimize Oxygenation Albuterol doses are strongly associated with increased survival rates with moderate to severe ARDS. As a bronchodilator albuterol relaxes and opens the alveoli decreasing respiratory work of breathing. Albuterol decreases airflow resistance and peak airway pressure and increases dynamic compliance. Furosemide decreases uric acid excretion and causes vasodilation, resulting in decreased pressure in the heart and lungs. As furosemide increases water excretion through interference with the chloride-binding cotransport system, it inhibits sodium and chloride reabsorption in the ascending loop of Henle and the distal renal tubule. Methylprednisolone suppresses systemic inflammation in patients with unresolved acute respiratory distress syndrome. They attenuate NF-kB by the glucocorticoid receptor a. Peep or positive end expiratory pressure prevents the collapse of alveoli, r
A nurse is caring for a client receiving fluoroquinolones for a respiratory infection. The client begins to have severe burning pain. This concerns the nurse because the nurse knows that which of the following types of ruptures could be occurring as a side effect of this medication?
Aortic Fluoroquinolones can use tear or rupture to the aorta as a cardiovascular side effect.
While eating dinner in a restaurant, a customer develops an anaphylactic reaction. A nurse nearby notices the problem and stops to help. The first action of the nurse should be which of the following?
Ask the client if they are ok The priority when assisting a person in anaphylactic shock is to first assess airway. This can be done by asking a question. If the person can talk, they are breathing and the airway is open. In anaphylaxis, the airway can quickly close, so having the client continue to talk helps the nurse to be aware of the airway patency while doing other tasks like checking a pulse. The nurse should also ask if the client has an Epipen because administering epinephrine as soon as possible will buy valuable airway time for the client while they wait for help to arrive. The subsequent interventions are to have someone call for help, and assist the client with Breathing, Circulation, Disability (level of consciousness), and Exposure to the allergen. Check the client's pulse The nurse can check the pulse but first must assess the airway. Lowering the client to the ground The client may be lowered to the ground, or may already be on the ground. Priority one is the airway.
A nurse is assessing a client who is being admitted to the hospital from home for knee surgery. Which part of the assessment would be included with an admission assessment but not with a routine focused assessment?
Assessment of the cause of the client's knee injury A comprehensive assessment is one that is performed as an initial assessment at admission. Alternatively, a focused assessment is performed to assess a specific area and is done when a change in the client's status has occurred, such as the following surgery. Asking about what caused the injury would not be repeated regularly, but only when gathering history on admission. Assessment of knee range of motion Assessment of the client's pain Assessment of the client's vital signs These are done as part of the focused assessment of the client, and would be done with every nursing assessment going forward in this client's situation. vcg
The nurse and primary care provider are reviewing current orders to determine a diagnosis. Which 4 orders should the nurse plan to implement first? Highlight your answers in the list below:
CBC Urinalysis Chem profile Guaiac stool ESR Vitamin D level Stool for giardiasis
The nurse working in the outpatient dialysis center is assisting in performing hemodialysis and notes the client's BP has decreased to 81/50 mm Hg during treatment. The nurse intervened by reducing the temperature of the dialysate, adjusting the rate of the dialyzer blood flow, placing the client in Trendelenburg position, and administering albumin as prescribed. The BP after these interventions was 80/52 mm Hg, and the client reports chest pain that is relieved when leaning forward. Based on
Certain adverse effects can occur during hemodialysis, including hypotension, disequilibrium syndrome, cardiac events, and reactions to dialyzers. Hypotension is a common complication caused by heat transfer resulting in vasodilation. Initially the nurse would reduce the temperature of the dialysate; adjust the rate of the dialyzer blood flow; place the client in Trendelenburg position; and administer a fluid bolus, albumin, or mannitol as prescribed. If these interventions do not resolve the problem and if hypotension persists, the nurse would consider myocardial injury and possible underlying pericardial disease as a cause, when pain is elevated leaning forward. The other conditions noted can occur with hemodialysis; however, the client findings in this clinical scenario and the fact that the interventions were ineffective indicate a cardiac event.
A client with severe depression is undergoing electroconvulsive therapy. The client has a hemodynamic monitor and a monitor of intracranial pressure in place during the procedure. As the client receives the electrical stimulus, the nurse notes that the intracranial pressure increases. Which action is the best response of the nurse?
Continue to monitor the client's condition throughout the procedure Electroconvulsive therapy involves administering an electric shock to produce a seizure effect in the brain, which may help to manage some conditions such as severe depression. During the initial stimulus, the client may experience an increase in intracranial pressure. This increase is temporary and should resolve quickly without intervention Administer a dose of IV mannitol as ordered Mannitol is a drug that decreases ICP, but is not indicated in this situation because the temporary increase in ICP during electroconvulsive shock therapy is normal. Administer a dose of epinephrine as ordered This is incorrect because this client does not need an intervention, and epinephrine does not effect ICP. Epinephrine is given in an advanced cardiac life support situation, but not in the situation described above Assist the client to wake up The procedure is going as expected based on the information given in the question, so
The nurse is hypothesizing a diagnosis based on the client's assessment data. For each disease process, click in the box next to the correct expected assessment data.
Crohn's Disease: Weight loss RLQ pain Mouth sores Ulcerative Colitis: LLQ pain Bloody Diarrhea Weight loss Pallor Irritable bowel disease can be divided into Ulcerative Colitis (UC) and Crohn's Disease. UC is caused by inflammation in the large intestine, causing LLQ pain, bloody diarrhea, weight loss, fever, pallor, tachycardia, and usually begins in the teenage years but can start at any age. Crohn's disease can be caused by inflammation anywhere in the GI tract (mouth to rectum), presents with RLQ pain, no bloody diarrhea , generally no fever, fatigue, weight loss, and involves other systems such as eyes and bones.
A nurse who spends a significant amount of time every shift documenting client care has developed symptoms of carpal tunnel syndrome in the left wrist. Which medical condition is most likely to contribute to development of carpal tunnel syndrome?
Diabetes Cardiomyopathy Depression Hyperthyroidism
A nurse is giving education to the client following a nuclear medicine study to diagnose reflux. Which of the following should be included?
Drink a lot of fluids today The client should drink a lot of fluids to flush the radioactive materials out of the system. The radioactive material will last for 12 hours Radioactive material stays in the system for 24 hours. You will stay overnight for monitoring The client can have this procedure outpatient and does not need to stay overnight. You can eat a regular diet starting tomorrow The diet can be advanced as tolerated. The client needs to drink a lot of fluids to flush the system.
A nurse is helping a 47-year-old client with getting up in the morning and performing activities of daily living. The client was diagnosed with myasthenia gravis 6 years ago. Which of the following would the nurse most likely expect the client to find difficult because of this diagnosis?
Eating breakfast Myasthenia gravis is an autoimmune disorder characterized by weakness of skeletal muscles and fatigue with exertion. The client would most likely have difficulties with performing activities of daily living that require exertion or use of muscles, including eating and grooming. It would be less difficult for a client to participate in more passive activities. Controlling bowel movements Maintaining bowel continence does not require skeletal muscles to accomplish in the adult client. Sitting in a chair Sitting in a chair is a passive activity that does not require skeletal muscles to accomplish. Listening to a radio program Listening to a radio program does not require skeletal muscles to accomplish.
For each medication in the table below, choose the best option of drug classification and client education from the dropdown list.
Ergocalciferol: Medication class- Vit. D Client Education- Take with meal Ciprofloxacin: fluoroquinolone antibiotic. Medication class- Client Education- Avoid milk/dairy Budesonide: Medication class- Corticosteroid Client Education- Avoid grapefruit The client is diagnosed with Crohn's Disease and prescribed three medications to begin therapy. The client is prescribed ergocalciferol, which is vitamin D for a low vitamin D level. It should be taken with a meal as vitamin D is fat-soluble, not water soluble. A side effect of many is dry mouth and should be reported to the primary care provider. Ciprofloxacin (quinolone) is prescribed for inflammation/infection in the GI tract and may cause tendon ruptures and a rash, which may be Stevens-Johnson Syndrome. This medication can be taken with a meal, but avoid milk/dairy products. Budesonide, a corticosteroid for inflammation, can be taken an hour before a meal, avoid grapefruit juice. Pedal edema is a side effect that should be r
What are the 3 atypical organisms that could be responsible for pneumonia with ARDS:
Herpes simplex virus Aspergillus Cytomegalovirus Viral infection accounts for ~22-40% of cases of ARDS. Influenza and rhinovirus are most commonly detected in viral pneumonias followed by parainfluenza, adenovirus, respiratory syncytial virus, coronavirus, and human metapneumovirus. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients.
A nurse working in the intensive care unit is receiving report on a client in the ED. The nurse learns that the client is showing signs of Stevens-Johnson syndrome following a barbiturate overdose. Which of the following is an expected finding of this condition?
Facial blisters This is correct. Stevens-Johnson syndrome is an adverse effect of barbiturate use. A characteristic sign is symmetrical, painful blisters on the face and upper torso. This condition affects the skin and mucous membranes, and an outbreak lasts from 2-4 weeks. The blisters are preceded by flu-like symptoms. Laryngospasm This is incorrect. Laryngospasm is a sudden spasm of the vocal cords. This is a side effect of barbiturate use, but does not describe Stevens-Johnson syndrome. Tardive dyskinesia This is incorrect. This is a side effect of sedative-hypnotics, but is not an expected finding in Stevens-Johnson syndrome. Photosensitivity This is incorrect. Photosensitivity, headache, and a feeling of a 'hangover' is a side effect of barbiturates, but is not associated with Stevens-Johnson syndrome.
An older adult client had a hip replacement one day ago. Which of the following is the greatest concern for the nurse?
Falling One day after surgery, the client is at greatest risk for falling due to pain and the necessity of learning to ambulate on the new joint. The client will be on hip precautions, which means the affected leg cannot be rotated or adducted. The nurse can help by assisting the client to ambulate early, toileting the client on a schedule, and managing the client's pain. Medication error Medication error incidences are not higher following hip surgery than other times. Infection Infection is a risk with hip surgery and any invasive surgery, but it usually takes longer than 24 hours for signs and symptoms of infection to appear. Pressure ulcer A pressure ulcer is a risk of older adult clients that have difficulty moving, but it is more likely for a client to fall in the first few days after hip surgery than get a pressure ulcer.
A child was injured in an accident and has become a paraplegic. The child must use crutches on a permanent basis. Which type of crutches would most commonly be used in this situation?
Forearm crutches Crutches are used as methods of support for children or adults who cannot bear weight on their legs, such as after an injury. There are various types of crutches available, which are utilized depending on their need. Forearm crutches have a cuff that encircles the lower arm. These types of crutches tend to be used for long-term use, such as with braces when a child suffers paralysis. Axillary crutches These are for short-term use. Platform crutches This is a subset of a forearm crutch, and is used when a person cannot grip. Whether the child has grip strength or not is unknown from the question, so the correct answer is forearm crutch. Leg support crutches These are used for lower leg injuries rather than spinal cord injuries.
If a client is diagnosed with Crohn's disease, what complications are they at risk for? Select all that apply.
Fractured bones Glossitis Jaundice RUQ pain Dyspnea Back Pain Chest pain After a diagnosis of Crohn's disease, there are common extraintestinal complications that may occur in multiple systems. The client is at risk for osteoporosis, vitamin B deficiency, hepatobiliary manifestations such as cholelithiasis, cirrhosis and fatty liver. Other complications include bronchitis, abnormal pulmonary function tests, pericarditis, endocarditis, and anemia.
A healthcare provider orders a cat scan of a client, requesting all sagittal views. How would the nurse expect to see the images divide?
Front and back This would be frontal, or coronal plane images. The sagittal plane divides the body into right and left sides Right and left sides The sagittal plane divides the body into right and left sides, therefore this answer is correct. Upper and lower This is transverse plane images, therefore this answer is incorrect. The sagittal plane divides the body into right and left sides. Sections, based on systems Planes are not based on organ systems, therefore this answer is incorrect. The sagittal plane divides the body into right and left sides.
The nurse caring for a 4-year-old who has been admitted with the diagnosis of epiglottitis asks the mother about which of the following childhood immunizations?
Haemophilus Influenzae type B Epiglottitis is often caused by Haemophilus Influenza type B. Diphtheria, Tetanus and Pertussis Epiglottitis is often caused by Haemophilus Influenza type B. Pneumococcal Epiglottitis is often caused by Haemophilus Influenza type B. Measles, Mumps & Rubella Epiglottitis is often caused by Haemophilus Influenza type B.
To prevent the spread and recurrence of lice, a school nurse creates a leaflet to send home with school children. The nurse should include which of the following preventative measures in the document? Select all that apply.
Hair brushes and hair accessories should be boiled in water for 10 minutes These items either need to be soaked in a lice-killing product or boiled in water for 10 minutes to kill the bugs and eggs. Items that cannot be washed should be sealed in a bag for 14 days The nits usually hatch from the eggs in 7-10 days. Sealing them off for 14 days ensures they do not survive. Store clothing and headgear in separate cubicles This would reduce transmission between articles of clothing that are infected. Keep children out of school for a week Students may need to stay out of school until they have been treated but this would not require staying out of school for a full week. Parents should cut their child's hair short to prevent future infestations Lice is just as likely to infect short hair as they are long hair.
A nurse is working as part of a multidisciplinary team to help a 16-year-old client with cystic fibrosis. In addition to physical care, which activity is most important for a client of this age with cystic fibrosis?
Helping the teen to transition to adult care services by promoting independence in decision making A teen client with cystic fibrosis faces many challenges in association with a changing body and feelings as well as with physical health. The nurse who works with an adolescent who has a chronic disease such as cystic fibrosis can help the teen with physical needs but can also help as the client learns to make independent health decisions. A client this age will soon be transitioning to adult care and can learn to make more choices about what is best. Reminding the teen that despite the condition, he or she will still be able to stay in school This is true, but it is not the most important item for the nurse to discuss with this client. Assisting the client to play games with peers of the same age At this age, the client typically no longer needs assistance with socialization. Explaining and educating the client on facts surrounding the condition The client should have had many opportu
The nurse working on an orthopedic floor is reviewing the four clients that were assigned and knows that the client with which of the following is the priority?
Hip fracture and a hip posey in place The hip fracture client has the most restriction of movement and needs to be checked for their personal needs such as bathroom, and also needs to be checked for positioning to prevent pressure ulcers. Right ulnar fracture in a cast This client is stable and is not as restricted with movement as the hip fracture client with a hip posey. The hip fracture client needs to be checked for their personal needs and . for positioning to prevent pressure ulcers. Left calcaneouss green stick fracture in a walking boot This client is in a walking boot and able to move. The client with a hip fracture is the most restricted with movement and needs to be assessed first. The hip fracture client needs to be checked for their personal needs and for positioning to prevent pressure ulcers. A total right knee replacement in TED hose This client is stable and not as restricted in movement as the client with a hip fracture and hip posey. The hip fracture client needs
A client is taking antithyroid medication. The nurse knows that this medication is taken for which of the following conditions? Select all that apply.
Hyperthyroidism Hyperthyroidism occurs when the thyroid gland produces too much thyroxine. Antithyroid medication such as methimazole is given which reduces the amount of thyroxine in the body. Grave's disease This is caused by hyperthyroidism, so antithyroid medication is given to manage this disorder. Myasthenia gravis This is a neurological disorder that is unrelated to the thyroid. Thyroid storm This is a disorder in which too much thyroid hormones are being released causing a life-threatening situation with extremely high blood pressure, pulse, and temperature. Antithyroid medicine is appropriate for this situation. Hypercalcemia Hypercalcemia can occur when the parathyroid gland is disturbed. This can occur from surgery or a tumor, but is unrelated to overproduction of thyroid hormones.
A nurse in the emergency department is caring for a client who has suffered a myocardial infarction. The client tells the nurse that he is feeling worse. The nurse checks his vital signs and notifies the provider, who orders norepinephrine. Based on the nurse's knowledge of this medication, the nurse would expect to see which of the following client responses after administration?
Increased blood pressure Norepinephrine is a vasoconstrictor and increases blood pressure. Norepinephrine is a neurotransmitter in the body that is partly responsible for activating the fight-or-flight mechanism and, as in this case, can be administered as a synthetic medication when a client is in critical condition to improve blood pressure and cardiac output. Decreased chest pain Norepinephrine is a vasoconstrictor, which does not result in a decrease in chest pain. A drug that is given to relieve chest pain is Nitroglycerin. Reduction of edema This is not an effect of Norepinephrine, and edema is not a high priority in this situation. Decreased wheezing while breathing Norepinephrine is given for emergency management of blood pressure and cardiac output. There are other drugs called bronchodilators that are given for wheezing.
The nurse is developing a plan of care for managing developmental milestones for an adolescent. According to Erickson, what stage of development should the client be in?
Industry vs. inferiority Industry vs. Inferiority, Erikson's fourth psychosocial stage, occurs during childhood between the ages of five and twelve. Identity vs. role confusion Identity vs. Role Confusion During adolescence, the transition from childhood to adulthood is most important. Children are becoming more independent, and begin to look at the future in terms of career, relationships, families, housing, etc. The individual wants to belong to a society and fit in. Intimacy vs. isolation Intimacy vs. Isolation Intimacy versus isolation is the sixth stage of Erik Erikson's theory of psychosocial development. This stage takes place during young adulthood between the ages of approximately 18 to 40 yrs. Generativity vs. stagnation Generativity versus stagnation is the seventh of eight stages of Erik Erikson's theory of psychosocial development. This stage takes place during during middle adulthood (ages 40 to 65 yrs).
A nurse reports a client's condition to the authorities because of evidence that the client is being physically abused by the client's spouse. Which actions of the nurse are most important just after making the report? Select all that apply.
Insist that the client leave the abuser The client may not be ready for the life-altering step of leaving the abuser, so it is best for the nurse to present options, assist in making a safety plan, and respecting the client's wishes. Help the client develop an appropriate safety plan When reporting an abuse situation, the nurse must follow up with the client to provide support and care. This will likely be a difficult time for the client and the nurse should be present to support and respect the client's choices, keep the client safe, and present options if the client wants to make a change. Respect the wishes of the client When reporting an abuse situation, the nurse must follow up with the client to provide support and care. This will likely be a difficult time for the client and the nurse should be present to support and respect the client's choices, keep the client safe, and present options if the client wants to make a change. Encourage the client to seek support for self a
Which best describes the difference between nursing certification and nursing licensure?
Licensure is mandatory to practice while certification may be optional Licensure and certification are two areas where registered nurses apply their knowledge to be credentialed for the care they are allowed to give. In order to practice nursing at all, an RN must have taken a test and qualified for a license. The license sets the standards for the nurse to be able to practice as well as the scope that he or she can practice in. Alternatively, certifications may or may not be an optional part of a work environment. Certifications are above and beyond standard licensure and are more focused in one area. For example, a RN in the postpartum unit may have a license to practice but may also be certified as a breastfeeding educator. Licensure refers to a specific type of care, while certification refers to general practice The opposite is true. Licensure refers to general practice of the discipline of nursing, while certification refers to a specific type of care. Licensure is associated w
A nurse who works in the emergency department has been caring for a client who is angry and complains about the care given. Before leaving the room, the client tells the nurse, "I'm going to sue this hospital. This has been terrible!" What actions could the nurse take that would best prevent litigation? Select all that apply
Listen to the client and respond with empathy Unfortunately, nurses, doctors, and hospitals are at risk of being sued when a client has a bad experience and decides to file a lawsuit against a facility. While a nurse cannot stop someone from suing, the chances can be reduced by providing good client care, and letting the client know that the nurse respects and wants to help the client. Confront the client about the inappropriateness of suing an emergency department Confrontation can lead to increased anger. Listening and giving empathy is the best way to respond to a client who is upset. Tell the client what the nurse is going to do and follow through The nurse can defuse the situation and reduce the chance of litigation by utilizing excellent communication with the client. Document the client's statements If a client says they are going to sue, this should be documented by the nurse so there is a record of the conversation. Approach the client using appropriate body language tha
Which medical condition has been shown to cause dementia in some adults?
Lyme disease Some infectious illnesses, beyond causing certain physical symptoms, may also cause symptoms of mental illness. Infection with Lyme disease, for example, has been shown to cause cognitive changes that are similar to dementia in some adults.
The nurse is caring for a client who was just diagnosed with acute pancreatitis. Which of the following is the priority nursing intervention?
Maintaining NPO status Pancreatic rest (NPO) is key in pancreatitis. Pain occurs due to the release of pancreatic enzymes needed to digest the food. Therefore, NPO is essential. Promoting a clear liquid diet The client should be kept NPO for pancreatic rest. Monitor for hypoglycemia Hyperglycemia is the major concern, not hypoglycemia. Pain management Pain management is a concern, but the pain is usually caused by "using" the pancreas when trying to digest food. Therefore it would be a higher priority to implement and maintain NPO status first.
A postpartum client complains that she gained a lot of weight during her pregnancy and that her ankles are swollen. The nurse assesses her feet and lower legs for edema. Which actions would be part of assessing peripheral edema? Select all that apply.
Measure above bony prominences in the feet and ankles Measurements may be taken to determine baselines from which to compare future measurements to. Assess shape of the area Peripheral edema may occur for some women during pregnancy. When assessing edema, the nurse may measure the circumference of the lower legs in the feet and ankles as well as perform an assessment to check the client's overall size and shape of the lower legs and feet, and press the skin against a bony prominence to assess for pitting. Press the skin to assess for pitting edema Pressing the skin against a bony prominence is performed to assess the extent of edema present. Ask the client to keep the foot in dorsiflexion This does not provide any information about peripheral edema. Have the client press the feet against the nurse's hands and assess for calf pain Calf pain is not correlated with peripheral edema.
A client who complains of upper respiratory illness symptoms for the past week is being seen in the healthcare clinic. The nurse checks this client's vital signs and notes his temperature is 102.1 F. Which nursing interventions are most appropriate in this situation? Select all that apply.
Minimize heat loss by keeping the client covered When a client is febrile, there is no need to minimize heat loss unless the client feels chilled. If the client feels chilled, the nurse should keep the client comfortable unless the fever is continuing to increase. Provide supplemental oxygen therapy as needed A client who has a fever is at risk of some complications, including dehydration and decreased oxygenation. Nursing interventions for a client with an upper respiratory tract infection and fever include providing supplemental oxygen, administering fluids, emphasizing frequent handwashing, and allowing the client time to rest as needed. Encourage oral intake and promote hydration A client who has a fever is at risk of some complications, including dehydration and decreased oxygenation. Nursing interventions for a client with an upper respiratory tract infection and fever include providing supplemental oxygen, administering fluids, emphasizing frequent handwashing, and allowing th
A nurse is caring for a client with generalized muscle pain, sleep disturbances and constant diarrhea. After multiple tests show no concrete cause, the nurse knows that this client is likely suffering from which of the following?
Myasthenia gravis This has a known cause, which is a chronic, progressive disorder that causes a disconnect between the peripheral nervous system and the muscles. Failure to thrive This is a diagnosis usually given to children who are not meeting adequate growth standards. Fibromyalgia This condition has no known cause at this time. It is characterized by muscle pain and weakness. Guillain Barre syndrome This is an autoimmune disorder that can be caused by infection or possibly the flu vaccine.
A client has a nasogastric tube placed after developing a paralytic ileus following surgery. The nurse maintains the NG tube and performs interventions to ensure adequate hydration for the client. Which intervention is most closely associated with assessment of fluid intake and output in a client with an NG tube?
Noting insensible fluid losses from the client's perspiration, hyperventilation, and wound drainage Placement of a nasogastric tube often means that the client is unable to take in food and fluids by mouth. When this occurs, the client is at high risk of fluid loss because of decreased intake. The nurse must ensure that the client takes enough fluid and should closely monitor intake and output. The nurse should also consider other potential losses of fluid, such as through respiration and wound drainage. Assessing daily for peripheral edema Peripheral edema is an important part of the nursing assessment, but is not a part of intake and output. Instead, if edema is present, the intake and output may show a positive fluid balance, because more fluid went in than came out of the client. Monitoring for cognitive changes in the client's neurological system While monitoring for cognitive changes is important, it is not a part of intake and output. Determining whether the client has abdomi
Based on the EHR data, click to indicate whether each of the findings for this client's assessment are associated with pancreatitis, hepatitis or irritable bowel disease.
Pancreatitis: Epigastric pain Nausea/vomiting Weight loss Fever Hepatitis: RUQ pain Jaundice Nausea/vomiting Anorexia Inflammatory Bowel Disease: RUQ pain Nausea/vomiting Weight loss Bloody stools Fever
A nurse is caring for a client with a pressure ulcer. Which of the following interventions is appropriate to prevent infection at the pressure ulcer site?
Perform hand hygiene when touching bodily secretions Preventing infection at the site of a pressure ulcer utilizes the same principles as preventing infection anywhere else. Hand hygiene after touching bodily secretions is the number one preventive action to stop the spread of infection. Cover the site with gauze A pressure ulcer should never be covered with gauze because this can cause friction and can worsen the ulcer. Use antibiotic ointment on the ulcer Antibiotic ointment is not necessary unless there is an existing infection. Cover the site with an ACE wrap An ACE bandage is used to provide compression to an area, or to hold bandages in place. Added pressure to a pressure ulcer could make the wound worse.
The nurse in the trauma bay is caring for a client brought in after falling off of a roof onto a car. During the initial assessment, the resident states the client has a positive FAST exam. The nurse knows this indicates which of the following?
Poor air exchange A FAST exam does not evaluate breathing. FAST is Focused assessment with sonography in trauma so using portable ultrasound to identify fluid in the abdomen would be part of the FAST exam. Fluid present in the abdomen The FAST exam is a portable ultrasound device that is used for identifying the presence of blood or fluid in the abdomen. FAST is Focused assessment with sonography in trauma. Low hemoglobin and hemarocrit The FAST exam will not evaluate hemoglobin and hematocrit. FAST is Focused assessment with sonography in trauma and does not deal with obtaining blood work. A positive C-Spine injury The FAST exam is not used for the detection of skeletal injuries. FAST is Focused assessment with sonography in trauma. This would include ultrasounds and not x-ray. An x-ray would be done to determine a C-spine injury.
An immobile client is at risk of aspiration because of difficulty with chewing and swallowing food. Which of the following nursing interventions is most appropriate?
Provide oral care before and after the client eats This is good nursing management for the client with aspiration risk, but it indirectly prevents aspiration. It is more effective for the nurse to crush medications and give them in a pureed substance like applesauce. Crush medications and put them in applesauce A client who has difficulties with chewing and swallowing needs help before, during, and after eating to ensure that he or she does not aspirate food. The client should avoid talking while eating and should sip liquids during eating to moisten food to make it easier to swallow. Crushing pills for administration in applesauce makes swallowing them easier and therefore reduces the risk of aspiration. Offer liquids to drink before the client tries to eat The client with dysphagia should consume liquids in small sips, or in a thickened form. Drinking a large amount at a time could cause the client to aspirate. Talk to the client while he eats There should not be distractions duri
A nurse is providing newborn care education to first time parents. The parents ask how to take the baby's temperature. Which is the most recommended and most accurate route for taking an infant's temperature that can be suggested to the parents?
Rectal For best results in babies and toddlers up to 3 years of age, the American Academy of Pediatrics advises taking the temperature in the rectum. This is done by placing a thermometer in the baby's anus. This method is accurate and gives a quick reading of the baby's internal temperature. For infants and toddlers, be sure to use a rectal thermometer correctly. A rectal thermometer may accidentally poke a hole in (perforate) the rectum. It may also pass on germs from the stool. Follow the product maker's directions for proper use. Axillary This is called axillary measurement. It may be used as a first way of checking to see if a child may have a fever. If this shows a fever, the temperature should then be checked by rectum or forehead. Axillary temperatures are less reliable than rectal. Oral It is unsafe to use oral temperatures in infants and usually not obtainable due to the child not keeping their mouth closed. Tympanic A tympanic thermometer uses the ear. Rectal or temporal a
Which best describes the condition hemiplegia alternans?
Recurring paralysis that affects different sides of the body Hemiplegia alternans is a rare neurological disorder that often develops during childhood. The condition causes recurring episodes of paralysis that can affect one side of the body or the other. At times, the person may have paralysis of one limb at a time. Physical activity may be difficult for a person with this condition, but it is not a degenerative disease. There is currently no cure for the condition. Paralysis from the waist down that comes and goes This does not describe hemiplegia alternans. Weakness and paralysis that causes periodic pain This does not describe hemiplegia alternans. Weakness and numbness on one side of the body and complete paralysis on the other side This does not describe hemiplegia alternans.
A nurse is caring for a client who delivered a baby via cesarean section four hours ago. The mother has an epidural in place that provides pain medication and anesthesia below the waist. The nurse notes that the machine alarms frequently and the mother complains of ineffective pain control. Which action of the nurse is most appropriate?
Replace the epidural unit with another machine A nurse who uses the equipment must always be safety conscious to avoid harming the client because of inappropriate use. When an epidural machine does not work, the nurse should first try replacing the machine. This may involve contacting anesthesiology or the provider to set up the machine. If the situation is still not fixed, the nurse must then call for further orders. Send the epidural unit to maintenance to be fixed Since this answer does not include the nurse replacing the epidural unit with another pain relief method, it is incorrect. Reset the epidural unit and program the settings When an epidural unit is programmed, the provider or two nurses typically must sign off on the settings before the unit is restarted. Remove the epidural if it is not working The epidural should only be removed after discussing it with the provider and obtaining an order.
A nurse works in a hospital that has developed a culture of safety as described by the Joint Commission. Which elements would be included as part of developing this type of environment? Select all that apply.
Safety is everyone's first priority A culture of safety helps provide safe and effective client care. It emphasizes transparency and a non-punitive approach to reporting and learning from adverse events, close calls, and unsafe conditions. Behaviors that undermine the culture of safety are addressed in a non-punitive way A culture of safety is described by the Joint Commission as a way to provide safe care to clients. To develop a culture of safety, the hospital would ensure that safety is a priority and educate others about the importance of upholding safe practices in a non-punitive environment. When staff members don't feel afraid to report their own errors, it results in an increased reporting of errors, and a better chance to address and fix them. This greatly increases safety in an organization. Staff are committed to promptly changing unsafe conditions Safety is a top priority when a culture of safety is adopted by organizations. This means that staff recognize the importance
The client is admitted to the telemetry unit. After assessing the client, the nurse prepares to update the provider. Click to highlight the four highest priority assessment findings to report to the provider:
Temperature 99.0F Heart rate 105 beats per min Respiratory rate 28/min Blood pressure 144/78 mm Hg Oxygen saturation 89% on room air Edema 2+ in bilateral ankles Diffuse crackles bilaterally Non productive cough S1 and S2 auscultated A temperature of 99.0F is slightly elevated, but does not warrant intervention. Heart rate of 105 beats per minute is elevated for an adult, but may be expected in a patient with respiratory distress. The other symptoms suggesting fluid overload are higher priority. Respiratory rate of 28 breaths per minute is abnormal and should be reported as it is a breathing concern. Blood pressure 144/78 mm Hg is elevated for an adult, but may be expected in a patient with respiratory distress. The other symptoms suggesting fluid overload are higher priority. Oxygen saturation of 89% on room air is abnormal and requires prompt intervention as it indicates an oxygenation problem. Edema 2+ in the bilateral ankles is consistent with a presentation of fluid volume overlo
The parents of a 4-year-old are concerned that their child is not on target with developmental activities. Which activity should the nurse recommend that the parents observe for to determine if this child is developing appropriately?
The child is dressing without much help When parents are concerned about physical development, the nurse can assess whether the child is able to perform certain tasks before considering further evaluation. A 4-year-old child should typically be learning how dress and undress independently, brush teeth, and walk up and down stairs without help. The child is losing her baby teeth This begins to happen around age 6. The child learns to tie shoes This begins to happen around ages 6-8 The child can go up the stairs holding a hand This begins to happen around ages 2-3.
Which best describes a Jacksonian seizure?
The client experiences stiffness and tingling in one extremity with no loss of consciousness Clients who suffer from seizures may manifest various forms, which are classified according to their characteristics and behaviors that occur during the seizure. A Jacksonian seizure is one form in which the client experiences changes in one part of the body, often an extremity. The client may have numbness and tingling in the extremity and it often becomes stiff, but the client does not lose consciousness. The client has a blank stare and twitching at the mouth A blank stare is present with an absence seizure, but not a Jacksonian seizure. The client falls, loses consciousness, and has general muscle spasms This describes a tonic-clonic seizure, not a Jacksonian seizure. The client wanders aimlessly and picks at his skin This is not descriptive of seizure activity.
A nurse is caring for a mother who is 35 weeks' pregnant. The client's medical record states that she tested positive for group B Streptococcus infection. Which of the following precautions should be given in this situation?
The client should be given antibiotics during labor Group B Streptococcus is a type of infection that may be found in the vagina, even in a healthy pregnant woman. The bacteria can be transferred to the baby during delivery to cause an infection. The test for the bacteria is performed at approximately 35 weeks' gestation, but antibiotics are typically not given until the mother is in labor to reduce the chance that she will pass the infection to her child. The client should receive antibiotics right away The infection is passed from mother to baby during vaginal delivery, and antibiotics are given to the mother during labor and birth. The fetus should receive antibiotics as a prenatal infusion The fetus is not infected in-utero. There is no treatment necessary Group B streptococcus is life threatening for the infant and can cause serious complications for the mother if infection occurs and is not treated.
A nurse is caring for a 30-year-old client who states, "I am overwhelmed by stress in my life and I don't know how to change." Which suggestions could the nurse make to this client that would help with stress management? Select all that apply.
The client should seek cognitive-behavioral therapy Cognitive-behavioral therapy is designed to treat distorted thinking, which is not the same as having an overwhelming amount of stress. The client should determine the source of the stress Stress management is an important component of nursing, because helping a client to manage stress helps to prevent long-term health consequences. The nurse can help a client with stress management by assisting the client to determine what areas are causing stress, helping the client prioritize, and looking for ways to reduce life stressors. The client should look for ways to reduce life stressors Once the sources of stress have been identified, the nurse can discuss with the client ways in which the stressors can be reduced or eliminated. The client should prioritize stress management Since ongoing stress has long-term health consequences, stress management should become a priority for the client. The client should seek medication therapy for th
A premature infant in the NICU requires a blood transfusion for ongoing apneic episodes as a result of anemia. The parents refuse to sign the consent, stating that they do not want the child to receive a blood transfusion because they do not think it is necessary. Which of the following interventions is allowed when this situation occurs?
The court can issue an order that the child may receive the blood, despite the parents' objections In most cases, parents make decisions about the care and treatment that their child receives, signing consent when needed for procedures. When a child needs a blood transfusion, the parents need to sign the consent, particularly when the child is an infant. When the parents refuse the consent, the hospital could get a court order for the baby to receive the blood anyway, particularly if the child needs the blood to prevent apneic episodes, which could be life threatening. In this case, the failure of the parents to approve medical care for the child could be considered a form of neglect. The nursing staff must abide by the parent's wishes and not transfuse the blood In this situation, the medical treatment is not experimental, nor is there an uncertain outcome, so the baby is entitled to this lifesaving measure. The parents must sign an affidavit stating that they are harming their chil
A client has been given a prescription for PRN allergy relief to take at home. Which of the following considerations would the nurse include when teaching this client about taking the drug at home? Select all that apply.
The drug should be taken every day whether the patient needs it or not PRN medication is to be taken only if needed. When the client is not exhibiting any symptoms that the drug would relieve, he does not need to take the drug. The medication instructions should list how long to wait in between doses The nurse should include in the instruction how long to wait in between doses, if the client still feels the symptoms. The patient should understand signs and symptoms that prompt him to take the medication The client should be aware of what symptoms would warrant taking the medication. The drug can only be filled at the pharmacy that filled the original prescription If a certain pharmacy is used the first time, this does not mean that the client must return to the same pharmacy each time they need the prescription filled. Clients may use any pharmacy they wish to use. The patient will need to check in with the nurse if he needs to take the medication more than twice Since the medicati
Please drag answers into the 3 blanks below to complete the paragraph: A client began is experiencing chest pain and developed a third-degree AV block. The client is emergently taken to the cardiac catheterization lab. The nurse anticipates that the mostly likely cause of the new AV block is due to blockage in the right coronary artery that supplies blood to the AV nodes, ..... and .....
The left main coronary artery supplies blood to the left ventricle and left atrium. The left anterior descending (LAD) artery and the circumflex artery are both branches off the left coronary artery. The LAD supplies blood to the interventricular septum, left anterior surface of the heart while the circumflex artery supplies blood to the lateral and posterior heart. The right coronary artery (RCA) supplies blood the right atrium and ventricle, the SA node, the AV node,
A nurse is preparing to administer one unit of packed red blood cells to a client. Which nursing action demonstrates that the nurse is reducing the risk of a potential transfusion error? Select all that apply.
The nurse matches the blood component to the order The nurse matches the client to the client's room number The nurse matches the client to the blood component The nurse checks the blood before administration The nurse who checks the blood with another person is also the transfusionist
A physician has given the following order to the nurse: "Acetaminophen 625 mg pr now." Based on the nurse's understanding of the order, which of the following is correct?
The nurse will give a suppository The abbreviation "pr" stands for "per rectum," which means that the nurse will give the client a suppository. This is not to be confused with "prn," which is an abbreviation for the latin term, "pro re nata", or "as needed". The nurse should give the medication ad lib This is a one time dose to be given as soon as circumstances allow. The nurse will give an intramuscular injection The route indicated in the order is per rectum. The nurse should give the medication within the next hour The timeframe indicated in the order is "now", so the nurse will give the medication as soon as circumstances allow.
A 36-year-old client has developed hypothyroidism after having part of her thyroid removed because of a large nodule. The provider has ordered levothyroxine (Synthroid) for thyroid replacement and has been titrating the dose over several months to ensure that it is effective. Which of the following factors would most likely require an increase in titration of the dosage of this medication?
The patient is pregnant Administration of levothyroxine following surgery requires titration of the dose to adjust for the client's symptoms. A client may start on a low dose of the medication but then need to have the dose increased if the current dose is not able to control negative symptoms. A client who is pregnant may also need to have a dosage increase because low levels of thyroid hormone are associated with fetal harm and miscarriage. The patient has developed muscle spasms Muscle spasms are associated with electrolyte imbalances and dehydration, but not thyroid hormone levels. The patient has increased iodine-containing foods If the source of hypothyroidism is a lack of iodine and the client increases her intake of iodine-containing foods, the dose could potentially be decreased, not increased. The patient is having pain Pain is not affected by levothyroxine.
A nurse is caring for a client who has been physically abused and threatened by her partner. Which statement describes the tension stage of abuse?
The victim feels they are "walking on eggshells" The four stages in the abuse cycle are: Tension, Incident, Reconciliation, and Calm. Walking on eggshells describes the tension stage, during which stress builds up and the victim might try to find ways to prevent abuse from occurring. The victim is hit during an argument. The four stages in the abuse cycle are: Tension, Incident, Reconciliation, and Calm. This describes the incident stage, not the tension stage. Display of loving and apologetic behavior by the abuser. The four stages in the abuse cycle are: Tension, Incident, Reconciliation, and Calm. This describes the honeymoon, or reconciliation, stage, not the tension stage. Both partners justify how the incident happened. The four stages in the abuse cycle are: Tension, Incident, Reconciliation, and Calm. This describes the calm stage, not the tension stage.
Based on the information in the EHR, which of the following is the rationale for initiating prone positioning for Mrs. Jones? Select All that Apply?
To decrease airway resistance To prevent ventilator-associated pneumonia To decrease sedation requirements To enhance FIO2 To improve oxygenation To decrease respiratory workload Initiate prone positioning in ARDS clients due to the enhancement of oxygenation and reduction in mortality. There is less overdistension in non-dependent lung regions and less cyclical opening and closing in dependent lung regions with prone positioning.
Which best describes how elevated stress levels in a client can worsen symptoms of acute coronary syndrome?
Too much stress leads to platelet activation and endothelial dysfunction Acute and chronic stress has a negative impact on health and can lead to worsening of cardiac diseases. Acute mental stress leads to platelet activation and endothelial dysfunction, which ultimately affects arteries, especially the coronary artery to increase CAD. Chronic stress can lead to chronic inflammation in the vascular system as well. This inflammation can weaken the vessels and can increase the risk of plaque rupture, which can cause an embolus if part of the plaque travels through the bloodstream and lodges in another vessel. Stress causes poor perfusion of the distal extremities Stress causes blood clots in the microvasculature of internal organs Too much stress leads to poor muscle tone and decreased activity tolerance -Stress does not cause these side effects.
A client must receive a number of injections of medication based on his medical condition. The nurse wants to take measures to reduce his discomfort as much as possible. Which of the following interventions can the nurse perform to minimize the client's discomfort from repeated injections?
Use the smallest gauge needle available Repeated injections may cause discomfort in a client who is subjected to numerous needle sticks for medication. The nurse can try to reduce discomfort by using the smallest size of needle available that will still work to provide the medication. Application of EMLA may reduce pain with an injection but it should be applied prior to the injection, not afterward. Administer the injections in approximately the same area each time The sites should be rotated if possible, because injecting into the same site will cause increased pain, and possible scarring and hardening of fatty tissue. Apply EMLA cream after giving an injection EMLA cream is applied before injection. Avoid administering any drug that could be irritating to the tissue Avoiding administering a drug for a medical condition is not good nursing practice, and based on the wording of the question, it is not an option for this client.
A client who has hypothyroidism takes a prescription of levothyroxine. Which of the following side effects is most closely associated with this medication?
Weight loss Levothyroxine (Synthroid) is a supplement taken for the replacement of thyroid hormone among people who have hypothyroidism. Some common side effects associated with this drug are weight loss, increased appetite, sweating, and hyperactivity. Ascites This is not a commonly reported side effect of levothyroxine. Bradycardia This is not a commonly reported side effect of levothyroxine. Confusion and aggression This is not a commonly reported side effect of levothyroxine.
A nurse is taking a health history of a client during the admission assessment. Which of the following statements indicates that the nurse is using reflection?
What do you think would be a good goal for your care today? Reflection is used when a nurse makes a statement to encourage the client to reflect on the situation and come up with a solution for themselves. I understand This is an example of accepting as a therapeutic communication technique. I noticed you took all your medications this morning This is an example of giving recognition. Can you explain what happened after you fell? This is an example of seeking clarification.
A 45-year-old client with schizophrenia has been brought to the hospital after trying to commit suicide. The client tells the nurse that the voices he hears told him to do it. He is extremely anxious and upset. Which assessment question would most likely help the nurse to assess the client's perception of this event?
What happened that has made you so upset? A client who is undergoing a mental health crisis may have difficulty focusing on the care and treatment needed to control his feelings and behavior. The nurse can initially assess the client's perception of the event by asking him what happened. This may motivate the client to talk about their experience and can help the nurse to better determine a reason for the behavior. Who do you live with? This can be perceived as a distraction to the client from the current issue. Have you had thoughts of hurting others? The problem is self-harm, and the client with schizophrenia may feel they are being interrogated. Do you know what today's date is? This question is typically asked to determine if the client is oriented, and could be viewed as changing the subject on the client.
A client is being monitored for hypertension at a primary care clinic. Select the most likely options for the missing information from the statement(s) by choosing from the dropdown lists of option provided:The client does not want to begin taking an antihypertensive medications but agrees to diet modifications. Teaching has been effective when the client identifies decreasing the intake of ... and increasing the intake of ...
steamed clams and whole grain rice A client diagnosed with hypertension should avoid foods which are high in sodium (NA) and consume < 1500 mg/day. Steamed clams and other shellfish are very high in sodium. A 3 ounce serving of steamed clams contains 1,022 mg of NA. Client should include foods on the DASH diet - whole grain rice (< 1% DV), nuts, seeds and low fat dairy.
