Unit 5 Managing/Coordinating Care

A newly pregnant client tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:

take the vitamin on a full stomach. Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this adverse effect. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.

What is the most important goal of nursing care for a client who is in shock?

Manage inadequate tissue perfusion Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock.

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's beststrategy in which to provide care in labor and birth when confronted with a cultural conflict?

"I will make every effort to work with your cultural beliefs." The nurse knows they must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of their baby may be inaccurate information, and the language used by healthcare providers can have a powerful effect on clients and families. Educating the family surrounding the physician's on-call schedule does not facilitate open communication or culturally sensitive care. Nurses should refrain from encouraging convincing or changing health behaviors and needs of clients and avoid assuming that a person and family will conform to a particular form or pattern of care.

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonte also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.

The nurse is caring for a client with acute mania who is euphoric and flirtatious. The nurse overhears the client describing a sexual exploit with a group of clients seated at a table. What immediateaction should the nurse take?

Tell the client others may not want to hear about sex, and invite him to play a game of ping-pong. Telling the client that others may not want to hear about sex and inviting him to play a game of ping-pong with the nurse informs the client that even though his behavior is unacceptable, the nurse considers him worthy of help. The client's thoughts and actions are out of control, and directing him to an activity with the nurse is an appropriate way of regaining control. The nurse is responsible for providing safety and security to this client and others on the unit. Continuing to walk down the hall while ignoring the conversation does nothing to meet the needs of this or other clients. Doing so also diminishes trust in the nurse. Speaking to the client later in private while saying nothing at the time allows the client to continue his provocative behavior instead of focusing his energy toward productive activity. Informing the client that if he continues to talk about sex, no one will want to be around him is not helpful because his behavior is a symptom of his illness and the statement diminishes his self-worth.

A client is in the emergency department with sneezing and coughing. The client is in the triage area, waiting to be seen by a health care provider. To prevent spread of infection to others in the area and to the health care staff, what should the nurse do?

Give the client a surgical mask to wear. In order to prevent infections in hospitals, the nurse institutes measures to contain respiratory secretions in symptomatic clients. The nurse gives the client a mask to wear, and tissues; the nurse instructs the client to dispose of used tissues in a no-touch receptacle. It is not necessary to place the client in isolation. It is not appropriate to ask others to move away from the client, but the nurse can ask the client to keep 3 feet away from others in the waiting room, if there is room. The nurse instructs the client to perform hand hygiene after blowing his nose or touching his nose or face, but doing so is not a prerequisite for being examined by the HCP. The nurse and HCP also use hand hygiene practices when caring for this client.

The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and reports have been received about each of these clients. To provide the safest care and bestmanage time, the nurse should plan to see which client first?

a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid The client at 42 weeks' gestation is the greatest concern, and the nurse should make rounds on this client first based on the length of the pregnancy and the green color of the amniotic fluid. Bloody show is a normal sign of impending labor as the cervix may be beginning to dilate. Not having contractions after rupture of membranes is not unusual within a 1-hour time frame. The green amniotic fluid indicates that fetal distress has recently occurred to the point that the fetus had a bowel movement in utero. This occurrence, along with the 42-week gestation, places this fetus at greatest risk. The nurse can see the primipara in active labor at 5-cm dilation last; this client is in pain, but nothing about her situation indicates anything but a normal labor process, and as a primipara, her labor process will be slow. The client who is completely effaced, 8-cm dilated, and at +2 station is also a primipara, and thus will move through labor at a slower pace than a multiparous client. She is experiencing nausea that is an expected situation as a laboring client enters transition. The client with no prenatal care is a cause for concern because the nurse knows nothing about her background. Her blood pressure is elevated, an indicator of mild preeclampsia, but there are no other indications of worsening preeclampsia, such as headache, visual disturbances, or epigastric pain.

Which client would be considered to be at the highest risk for respiratory failure?

A client with Guillain-Barré syndrome Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.

A 22-year-old primigravida approaches the nurse during the prenatal clinic and states that her partner is saying hurtful comments about her weight gain. What is the most appropriate response from the nurse?

"Tell me how you are feeling about your partner's comments." This response allows the client to express her feelings so the nurse can assist her. Asking the client how much she has gained or how she feels about her changing shape implies that the nurse is making an assumption that the client has gained weight, which may appear to the client as though the nurse is not supportive. While appropriate weight gain during pregnancy is important, making that statement does not provide the opportunity for the client to express her feelings.

During an insight group on a mental health unit, a client is demanding attention, interrupting others, and talking most of the time. What would be the best response by the nurse?

"I invite you to summarize your point briefly so that we can then hear from others." Inviting the client to summarize assists in refocusing and making a point, and acknowledges that others require time for the group as well. Ignoring the behavior does not facilitate group communication and process. The other options are judgmental and focus more on the client's opinions than on the group process.

The nurse is caring for a client who had a cerebrovascular accident (CVA) and needs to be fed. What instruction would the RN give the unlicensed assistive personnel (UAP), who will feed the client?

"Position the client in a sitting position before feeding." Instructions to the UAP should include positioning the client in a sitting position, which will decrease the risk of aspiration for the client with CVA. The nursing assistant does not have the additional education to assess gag/swallow reflexes. The client with CVA would need to take extra time to eat and would not be rushed. The client that needs suctioning performed between bites should not be fed, as this increases the risk of aspiration, and needs further assessment by the RN.

The family of a 22-year-old client with bipolar disorder is having difficulty coping with the client's rapid mood swings, irritability, grandiose delusions, and overly inclusive behaviors. Following a visit to the unit, the parents and the nurse discuss how the family can deal with the client's behaviors and help their child. Which response, if made by the family, would indicate to the nurse that the teaching was effective?

"We need to help our child establish a routine for work and school and monitor their mood." A normal routine and careful monitoring of the client's mood assists the client in taking action when their routine or mood becomes disrupted. Maximum independence within a supportive community is a priority. Advising the family to follow the client's medications and to monitor their spending, or to restrict spending and driving, will create a controlling relationship and promote tension. This will increase caregiver burden and create disagreements over illness management and financial responsibilities. Waiting to call the police is also incorrect and indicates that the situation has spiraled out of control. The parents may resort to this to protect themselves and their property, but a more proactive solution is to teach the client to keep a routine and monitor their mood.

A hospitalized adolescent diagnosed with anorexia nervosa refuses to comply with her daily before-breakfast weigh-in. She states that she just drank a glass of water, which she feels will unfairly increase her weight. What is the nurse's best response to the client?

"You must weigh in every day at this time. Please step on the scale." In responding to the client, the nurse must be nonjudgmental and matter of fact. Telling her that weight gain is in her favor ignores the client's extreme fear of gaining weight. Putting off the weigh-in for 2 hours allows the client to manipulate the nurse and interferes with the need to weigh the client at the same time each day. Threatening to call the health care provider is not likely to build rapport or a working relationship with the client.

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care?

Involve the client in usual at-home activities. It is best to involve the client in usual at-home activities as much as the client can tolerate them. Discouraging visitors may not be in the client's best interest because visits with supportive significant others will help reinforce supportive relationships, which are important to the client's self-worth and self-esteem. Providing for a schedule of activities outside the home may be overwhelming for the client initially. Involving the client in planning for outside activities would be appropriate. Encouraging the client to sleep as much as possible is nontherapeutic and promotes withdrawal from others.

A client has been admitted to the emergency department with alcohol withdrawal delirium. The nurse is assessing the client for signs of withdrawal. At 0900 hours on 10/25, the nurse notes that the client is confused. Vital signs are T = 99°F (37.2°C), P = 50 bpm, R = 10 breaths/min, and BP = 100/60 mm Hg. The nurse compares these findings to the nurses' progress notes from admission 24 hours ago (see exhibit). What should the nurse do first?

Contact the health care provider (HCP). The nurse should first contact the HCP. The client's vital signs and level of consciousness are deteriorating, indicating complications of withdrawal, which can be life threatening. Increasing the rate of the infusion may cause fluid overload and has not been prescribed by the HCP. Arousing the client will not address the underlying problems. Magnesium sulfate is used to treat seizures precipitated by alcohol withdrawal, but the client is not demonstrating signs of actual or impending seizures.

A client with bipolar disorder, manic phase, is yelling at visitors. The client's face is flushed and his fists are clenched. Which nursing action should be taken first?

Direct the client to his room for a time-out. The client is in the escalation phase of the assault cycle. Applying the principle of the least restrictive alternative, such as a time-out, is the nurse's first action.Calling security to forcibly escorting the client to his room is more restrictive and not indicated at this time because the client has not lost control.Administering IM lorazepam is not indicated because the client has not lost control. The nurse might offer oral lorazepam if the client is having trouble calming down while in time-out.Discussing the problem is not appropriate in the escalation phase but is appropriate in the triggering phase.

The nurse is planning care for a client admitted for vascular dementia. Which action is mostappropriate in assisting the client with activities of daily living?

Encourage client to complete as many activities as possible, and provide ample time to complete them. By fostering independence and providing as much time as possible, the nurse is helping the client to continue to complete as many tasks as possible. Performing activities for the client is counterproductive. A list may cause the client to become frustrated if the list is not completed or if it becomes lost. Informing the client that the UAP will complete activities may be perceived as a threat.

For a client with chronic obstructive pulmonary disease who has trouble raising respiratory secretions, which intervention would help reduce the tenacity of secretions?

Help the client maintain an adequate fluid intake. A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions.A low-salt diet, continuous oxygen therapy, and maintaining a semi-sitting position do not help reduce the viscosity of mucus.

A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block? Select all that apply.

Make sure oxygen is available. Monitor vital signs frequently. Monitor fetal heart rate and contractions closely. The nurse should make sure that oxygen is available in case hypotension occurs. IV fluid should be infusing to prevent dehydration, which might cause hypotension. The client should be positioned on her side and her position should be alternated from side to side every 30 to 60 minutes. Fetal heart rate and contractions must be monitored closely, because the client may be unaware of changes in the strength of contractions or the descent of the presenting part.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. What is the intended outcome of the traction?

Reduce and immobilize the fracture. Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

.A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses. Visual acuity is usually measured with a Snellen chart. A client with 20/40 vision is able to read the same sized letters from 20 feet away as a person with "normal" vision would be able to read at 40 feet away. The client with 20/40 vision would be referred to a healthcare provider for the possible need for corrective lenses, as 20/20 vision is considered normal. The client would need to be evaluated by a healthcare provider prior to suggesting the purchase of corrective lenses for reading. In most jurisdictions, 20/40 vision qualifies for an unrestricted driver's license, so corrective lenses may not be required. However, the client must first see the healthcare provider before that can be determined.

A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate?

Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born. This statement respects the decision of the family and facilitates open communication among the nurse, the client, and the client's partner during labor and birth.

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication?

Wait for a short time and then attempt to administer the medication A flexible care plan is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and at different times and is sometimes in control of self, the nurse must be able to adjust nursing care as the situation warrants, such as offering the medication again after waiting for a short period of time. Forcing the client to take the medication now and calling the client "Honey" may anger the client.

The nurse is assigned to care for the following clients. Which client should the nurse see first?

a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute A heart rate of 48 beats per minute may have significant implications for cardiac output and hemodynamic stability. Clients with Graves disease usually have a rapid heart rate, but 94 beats per minute is a normal finding. The diabetic client may need sliding-scale coverage, which is not urgent. Clients with Cushing disease frequently have dependent edema.

The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately?

a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria The nurse should refer the preeclamptic client with 3+ proteinuria to an HCP. The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks' gestation with insulin-dependent diabetes and who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tablets until she can obtain an appointment with the care provider. The client at 10 weeks' gestation with nausea and vomiting and +1 ketones should also be seen by an HCP, but at this point, although this client is uncomfortable, her life is not in danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancy, and this would not be considered a problem that requires immediate referral to an HCP.

For which client is the nursing assessment of pain most likely to result in undertreatment?

an older adult who grimaces and states no pain after a gastrostomy tube placement Clients at risk for insufficient pain control are older adults and those of ethnic origins that hold the tradition of stoicism, such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally appropriate care. Clients who request medication, or are allowed to regulate their own medications, are more likely to have their pain controlled.

The nurse is caring for a child with a newly diagnosed allergy to latex. List, in order of priority, the nursing interventions for this client. All options must be used.

assessment of respiratory effort assessment of heart rate and blood pressure assessment of skin education of the family According to Maslow's hierarchy, physiological needs must be met first and a basic need for oxygenation and perfusion comes first. Oxygenation has a higher priority than perfusion. Skin integrity would be next, and then, knowledge deficit.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should asses the client for which changes?

cardiac arrhythmias Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.

Which client is the best candidate for a vaginal birth after a caesarean (VBAC)?

client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy The best candidate for a VBAC is a woman who had a cesarean section in her last birth because of a problem related to the infant that is not repeated in this pregnancy. The woman with the breech presentation in her last birth and a vertex pregnancy in this pregnancy would be the best candidate, especially if she had other vaginal births. The woman who was unable to dilate beyond 6 cm (failure to progress) may try a VBAC but is likely to experience the same problem with this birth. The woman with the very large infant is likely to experience cephalopelvic disproportion with this birth if she experienced cephalopelvic disproportion with her last infant who was large. A classic cesarean birth scar is a contraindication for a VBAC because that type of scar may not be strong enough to withstand the stress of hours of uterine contractions and may result in a uterine disruption.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

Which is a priority nursing action for a child with croup?

continually assessing respiratory status Respiratory status should be assessed continually as the child may have laryngeal spasms without notice. Antipyretics may be given as well as oxygen, but respiratory status takes priority. Parents would be encouraged to stay with their child but this is not an immediate priority.

A client has undergone a left hemicolectomy for bowel cancer. Which combination of activities is most effective in preventing the occurrence of postoperative pneumonia in this client?

coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Activities that help to prevent the occurrence of postoperative pneumonia are coughing, breathing deeply, frequent repositioning, medicating the client for pain, and using an incentive spirometer. Encouraging fluid intake and administering oxygen will not directly prevent pneumonia. Maintaining bed rest will increase the risk of pneumonia.

The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:

decreased blood flow. A client with PVD and heart failure will experience decreased blood flow. In this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen supply) may be related to less blood being ejected from the left ventricle into the systemic circulation. Decreased blood supply to the tissues results in pain. Increased blood viscosity may be a component, but it is of much less importance than the disease processes.

Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's:

electrocardiogram (ECG). Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Lidocaine level will be monitored but it is not the primary focus; troponin level monitors myocardial damage. Blood pressure, which can drop on lidocaine, does need to be monitored but the focus should be the ECG to evaluate the effectiveness of the medication.

The nurse is caring for a client with unsuccessful laboring who is anticipating a caesarian section. What is the final assessment the nurse should make in the birthing room immediately before the client is transported to the operating room?

fetal heart tones The purpose of a cesarean section (C-section) is to preserve the life or health of the mother and her fetus and may be the best birth choice when there is evidence of maternal or fetal complications. The final assessment the nurse should make in the birthing room before transporting the client to the operating room is to assess fetal heart tones. This information should be communicated to the operating room staff so they are aware of the presence or absence of fetal distress. Abdominal palpations may be performed to assess uterine activity and fetal position. Vaginal exams are performed to assess cervical readiness and labor progression. At this time, the physician has already determined a need for a C-section; therefore, these assessments are not required. Maternal temperature is not an immediate assessment required prior to entering the operating room.

The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective?

having the client discuss needs with the staff person assigned For the client with attention-seeking behaviors, the nurse would institute a behavioral contract with the client to help decrease dysfunctional behaviors and promote self-sufficiency. Having the client approach only the assigned staff person sets limits on the attention-seeking behavior. Telling the client to stay in the client's room until staff approach, limiting the client to a certain area, or giving the client a list of permissible requests is punitive and does nothing to help the client gain control over the dysfunctional behavior.

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action would the nurse include in the care plan?

involving the client and family in planning care For a client with a nursing diagnosis of Social isolation, interventions include involving the family and the client in planning care and encouraging visits from family members and friends. Banning personal belongings from the bedside would increase the client's feelings of isolation. The nurse would provide simple, not detailed, explanations to the client and family because stress may have diminished their comprehension. The nurse would encourage the family to visit as often as the client's condition permits.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

massaging the uterus gently If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

A client prescribed an antipsychotic medication develops a high fever, muscle rigidity, and hypertension. The nurse immediately notifies the health care provider with concerns that the client is experiencing which life threatening condition?

neuroleptic malignant syndrome High fever, muscular rigidity, and altered consciousness are symptoms of neuroleptic maligany syndrome, a potentially fatal complication of antipsychotic medications and major tranquilizers. Malignant hyperthermia has similar symptoms but is associated with anesthesia. Extrapyramidal side effects involve movement disorders, including rigidity, but do not include a fever and are not considered to be life threatening. Hypertensive crisis refers to a systolic blood pressure over 180 or diastolic blood pressure over 110.

Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision?

providing for dietary needs and nursing in a dark quiet room Providing for the client's dietary needs is not appropriate because the client should not eat or drink anything pending surgery. Nursing the client in a dark quiet room is not appropriate for a client with ectopic pregnancy. Assessing vital signs for indicators of potential shock, managing pain, assessing per vaginal loss, and providing emotional support are essential nursing interventions in caring for a client with an ectopic pregnancy.

A physician orders an infusion of whole blood for a client. When planning the client's care, a nurse should include which intervention?

staying with the client for 15 minutes after starting the infusion Because most hemolytic reactions occur during the first 15 minutes of a blood transfusion, the nurse should plan to stay with the client for this length of time. During this time, the nurse should monitor the client's vital signs frequently, in accordance with facility policy. The nurse should start the infusion with normal saline solution only and should use at least a 19G catheter to prevent hemolysis of red blood cells. The nurse shouldn't warm the blood because refrigerating blood until infusion prevents bacterial growth.

A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN?

the 2-year-old child who has started eating soft, solid foods following a tonsillectomy The nurse can delegate care of the child who had the tonsillectomy to the LPN because that child is stable and likely preparing for discharge. The infant with a WBC count of 34/μl and fever requires close monitoring for additional signs of infection. Infection could lead to sepsis or septic shock. Although the infant with contusions from the motor vehicle accident may be stable, children sometimes experience delayed reactions to injury. This infant requires close monitoring for signs or injury or shock. The RN should care for the infant with type 1 diabetes, who could become ill very quickly.

A nurse suspects that a client has digoxin toxicity. The nurse should assess for

vision changes. Vision changes, such as halos around objects, are signs of digoxin toxicity. Hearing loss can be detected through hearing assessment; however, it isn't a common sign of digoxin toxicity. Intake and output aren't affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.

A medication nurse is preparing to administer 0900 medications to a client with liver cancer. Which consideration is the nurse's highest priority?

metabolism of the medication The rate and ability of the liver to metabolize medications will be altered in a client with liver cancer. Therefore, it is essential to understand how each medication is metabolized. The other considerations are important but not as vital.

The nurse is caring for a very anxious child whose pain has not been manageable. The parents stay in the child's room, crying and yelling at each other. Grandparents and other family members are also constantly in attendance. To effectively help the child with pain management, which action should be a priority for the nurse?

Develop a visitation schedule with the family that allows the child to rest. Establishing limits with the family can facilitate needed rest for the child and help decrease anxiety and pain. It may also decrease the anxiety of the family and provide them with clear directions. Although the behavior of the parents needs to be addressed, it must be done in a more tactful way.

Which finding is normal for a client during the icteric phase of hepatitis A?

yellowed sclera Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy. Profound anorexia is also common. Tarry stools are indicative of gastrointestinal bleeding and would not be expected in hepatitis. Light- or clay-colored stools may occur in hepatitis owing to bile duct obstruction. Shortness of breath would be unexpected.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule. A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 4 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing, despite the amount of helpers.

A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client's room to review discharge instructions with the client when the client tells the nurse that they want help to quit drinking. How should the nurse respond?

"I'll notify your physician and call the social worker so they can discuss treatment options with you." The nurse should notify the physician and call the social worker so the social worker can discuss treatment options with the client. The social worker may be able to arrange inpatient treatment for the client immediately after discharge if the client wishes. Telling the client to wait to discuss their concerns minimizes their feelings. Telling the family about the client's wishes breaches client confidentiality.

Clients with schizophrenia often experience nonadherence to prescribed medication protocols. Nurses collaborate with these clients to develop a program of successful adherence. How are long-acting decanoate injections a helpful treatment option for these clients?

Decanoate injections improve adherence and sustained therapeutic drug levels despite possible client ambivalence. Long-acting decanoate injections are a good treatment option for clients with a known pattern of nonadherence, ambivalence about their treatment, and limited insight into their illness. These injections share the same side effects as oral forms of the drug. Injections are not implemented until oral medication tolerance and effectiveness is established. Clients do not necessarily recognize side effects or realize that they are related to medications or dosage. Decanoate injections have the same side effect profile as the oral version of the medication.