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A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching? "Obtain a pneumococcal vaccination every 2 years." "Contact your provider if you have a fever that lasts 18 hours." "Wash your hands when you return home from running errands." "Avoid exposure to cold air by shopping inside enclosed malls." - ✔✔ Correct Answers- "Wash your hands when you return home from running errands." The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia. A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make? "Let's talk about a few ways you have dealt with stress in the past." "I believe that you will regret that decision. Your family needs your support." "I agree that you have to do what is best for your well-being at this time." "I think you should try to put your feelings aside and focus solely on your child." - ✔✔ Correct Answers-"Let's talk about a few ways you have dealt with stress in the past." This statement by the nurse combines two therapeutic responses, active listening and focusing. Used together, these techniques facilitate communication by letting the parent know one's feelings are heard and taken seriously, which conveys acceptance and respect. Therefore, the parent feels the nurse validates the concerns and becomes comfortable asking the nurse sensitive questions about the child.
A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - ✔✔ Correct Answers-The nurse should first call 911 and examine the amputation site. Next, the nurse should apply direct pressure with layers of dry cloth to slow or stop the bleeding. Then, the nurse should elevate the affected extremity above the client's heart to slow the bleeding. Next, the nurse should find the toe and wrap it in sterile gauze or a clean cloth to decrease contamination for possible surgical reattachment. Finally, the nurse should place the wrapped toe in a bag and place the bag in 1 part ice and 3 parts water to maintain tissue integrity for possible reattachment. A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management? "Wash your child's exposed clothing in cold water using powder detergent." "Keep your child away from other children for 10 days after lesions appear." "Scrub your child's affected areas with an antibacterial soap every other day." "Place your child in an oatmeal bath using tepid water for 15 minutes." - ✔✔ Correct Answers-"Place your child in an oatmeal bath using tepid water for 15 minutes." The nurse should instruct the parent that tepid baths containing oatmeal or mineral oil can decrease itching and evenly disperse the antipruritic solution. The parent should not place the child in a hot bath as this can aggravate the child's condition and increase itching. A nurse in a provider's office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse's intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) - ✔✔ Correct Answers-Coagulation time The nurse should report the client's coagulation time, or INR, to the provider immediately because it is above the expected reference range, which predisposes the client to intraoperative and/or postoperative hemorrhage. The nurse should expect the provider to postpone the joint arthroplasty until the client's clotting time is within the expected reference range. A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion?
Minimal vomiting Intermittent cramping in the lower abdomen Visible peristaltic waves in the upper abdomen - ✔✔ Correct Answers-Visible peristaltic waves in the upper abdomen The nurse should identify that visible peristaltic waves in the upper and middle abdomen are a manifestation of a small-bowel obstruction. The client might also have abdominal discomfort or pain. A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? Urine output 0.5 mL/kg/hr Capillary refill 3 seconds Heart rate 148/min Brisk skin turgor - ✔✔ Correct Answers-Brisk skin turgor The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective. A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? Apply ice packs to the client's axillae, neck, groin, and chest. Administer aspirin to the client Initially offer the client cool, oral fluids. Continue cooling measures until the client's rectal temperature is 37.2º C (99º F). - ✔✔ Correct Answers-Apply ice packs to the client's axillae, neck, groin, and chest. The nurse should recognize that treatment for heat stroke involves cooling the client's core body temperature quickly. The nurse should apply ice to the client's axillae, neck, groin, and chest while also spraying the client's body with tepid water. A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. The client's ABG results are pH 7.28, PaCO2 36 mm
Hg, and HCO3-14 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis - ✔✔ Correct Answers-Metabolic acidosis With this acid-base imbalance, the client's pH is below the expected reference range, the PaCO2 is within or below the expected reference range, and the HCO3- is below the expected reference range. Diabetic ketoacidosis is a common cause of metabolic acidosis. A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3- 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for this client? Apply oxygen therapy to the client. Administer an anti-inflammatory medication. Check the client's nail beds. Initiate IV fluid therapy. - ✔✔ Correct Answers-Apply oxygen therapy to the client. The first action the nurse should take when using the airway, breathing, circulation approach to caring for a client who has respiratory acidosis is to improve the client's oxygenation. When the client's airway is patent, oxygenation and ventilation are the priorities. A nurse in an emergency department was caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit? The sibling believes the client will wake up in a few hours. The sibling is curious about what will happen to the client's body. The sibling will continue to treat the client as though he were still alive. The sibling will alienate themselves from her family and friends. - ✔✔ Correct Answers- The sibling is curious about what will happen to the client's body.
Hypertonicity - ✔✔ Correct Answers-Hypoglycemia The nurse should expect an infant who has hypothermia to have hypoglycemia. Other manifestations of hypothermia include apnea, central cyanosis, hypotonia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia. A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect? Flat anterior fontanel Capillary refill 2 seconds 5% weight loss Absence of tears - ✔✔ Correct Answers-Absence of tears The nurse should expect an infant who has severe dehydration to have an absence of tears when crying. Other manifestations include tachycardia, hypotension, intense thirst, and oliguria or anuria. A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? Becomes angry when it is time to perform colostomy care Touches the colostomy stoma when the bag is changed Looks away as the nurse empties the colostomy bag Tells others that it will be nice to have a normal bowel movement again - ✔✔ Correct Answers-Touches the colostomy stoma when the bag is changed The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief. A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings should the nurse expect? Circumoral tingling Hypoactive reflexes
Fatigue Anorexia - ✔✔ Correct Answers-Circumoral tingling The nurse should identify that hypocalcemia causes paresthesias, which is circumoral numbness and tingling of the fingers, toes, and around the mouth. A nurse is assessing a client who has a potassium level of 2.6 mg/dL and is receiving potassium chloride by continuous IV infusion. Which of the following findings should the nurse identify as an indication that the potassium infusion has brought the client's potassium level back to the expected reference range? The client's ECG shows inverted T waves. The client's bowel sounds become hyperactive. The client's hand grasp becomes stronger. The client's standing systolic BP is within 30 mm Hg of her sitting systolic BP. - ✔✔ Correct Answers-The client's hand grasp becomes stronger. The nurse should identify that hypokalemia can cause a decrease of skeletal muscle strength. An improvement in the client's hand grasp indicates that the potassium chloride infusion is correcting this electrolyte imbalance. A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? WBC 16,000/mm³ Board-like abdomen Nausea and vomiting Temperature of 38° C (100.4° F) - ✔✔ Correct Answers-Board-like abdomen When using the urgent vs. nonurgent approach to client care, the nurse should identify that a board-like abdomen is the priority finding indicating peritonitis. The nurse should notify the provider immediately. A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? Diminished peripheral pulsations in the right lower leg
A nurse is assessing a client who has developed type 1 herpes simplex virus. Which of the following images should the nurse identify as this type of viral infection? - ✔✔ Correct Answers-Picture of lips. Herpes simplex virus infection is a common viral infection in adults. The nurse should identify that this image indicates the type 1 herpes simplex viral infection because the infection causes a recurring cold sore. A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect? Somnolence Cold intolerance Exophthalmos Dry, scaly skin - ✔✔ Correct Answers-Exophthalmos The nurse should expect a client who has Graves' disease, an autoimmune form of hyperthyroidism, to experience exophthalmos, which is protrusion of the eyeballs. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all that apply.) Nocturia Dependent edema Dyspnea Hacking cough Anorexia - ✔✔ Correct Answers-Nocturia Dyspnea Hacking cough is correct A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? Numbness of hands Gingival hyperplasia Clay-colored stools Carotid bruits - ✔✔ Correct Answers-Numbness of hands
The nurse should identify that pernicious anemia is caused by a lack of vitamin B12 and can have neurologic manifestations, such as numbness and tingling of the client's extremities. Other manifestations include pale or yellow-tinged skin, glossitis, weight loss, fatigue, and problems with balance. A nurse is assessing a client who has social phobia and reports feelings of fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe? Carbamazepine Risperidone Paroxetine Quetiapine - ✔✔ Correct Answers-Paroxetine Paroxetine is a selective serotonin reuptake inhibitor that is used to treat social anxiety disorder. A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? The stool is a dark green liquid with a small amount of blood. The ileostomy output is 1,000 mL for the past 24 hr. The stoma is purple in color. The output from the NG tube has decreased over the past 24 hr. - ✔✔ Correct Answers- The stoma is purple in color. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the color of the stoma. Stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply. A nurse is assessing a client who is 1 hr postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider? Urine color is light pink. The suprapubic area is soft to palpation.
Early in the course of osteoarthritis, joint pain begins with exercise and then quickly improves when the client rests the joint. As the disease progresses, osteoarthritis pain can occur with limited exercise or even at rest. A nurse is assessing a client who reports gastrointestinal distress. Which of the following findings should indicate to the nurse that the client has cholecystitis? Abdominal pain triggered by spicy food Abdominal pain that radiates to the right shoulder Abdominal pain in the right lower quadrant Abdominal pain that is continuous over several days - ✔✔ Correct Answers-Abdominal pain that radiates to the right shoulder The nurse should expect a client who has cholecystitis to have abdominal pain that is episodic, typically occurring after fatty or large meals, and can radiate from the client's right upper quadrant to the right shoulder or scapula. A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect? Progressive loss of peripheral vision Opacity of the lens of the client's eye Impaired central vision Report of seeing floating dark spots - ✔✔ Correct Answers-Progressive loss of peripheral vision The nurse should expect a client who has POAG to report a progressive loss of peripheral vision. The nurse should perform visual field testing to determine the severity of the peripheral vision loss. The nurse should also expect diagnostic assessment to indicate increased intraocular pressure. A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3- 24 mEq/L. Which of the following findings should the nurse expect? Paresthesias Bradycardia
Muscle flaccidity Respiratory depression - ✔✔ Correct Answers-Paresthesias One of the manifestations of respiratory alkalosis is numbness and tingling, or paresthesia, due to a decrease in calcium ionization. Other manifestations include lightheadedness, tachycardia, and cardiac dysrhythmias. A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? Abdominal distention Bradycardia Hyperactive bowel sounds Slow, deep breathing - ✔✔ Correct Answers-Abdominal distention The nurse should identify that peritonitis is an inflammation of the lining of the abdominal wall. This inflammation, along with the ileus that develops, causes abdominal distention; therefore, the nurse should identify this as a manifestation of peritonitis. A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect? Hyperreflexia Fruity breath odor Sweating Shallow respirations - ✔✔ Correct Answers-Fruity breath odor The nurse should expect a child who has a blood glucose level of 250 mg/dL to have a fruity or acetone breath odor. Other manifestations include lethargy, thirst, and confusion. A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect? Periorbital edema Diaphoretic skin
Astraphobia - ✔✔ Correct Answers-Agoraphobia The nurse should document that the client is experiencing agoraphobia in the client's medical record. Agoraphobia is the fear of being outside and can be debilitating and limit a client's ability to function. A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.) Apply cold packs to the affected area. Treat the affected area with propranolol. Elevate the affected area 15.24 cm (6 in) above the heart. Place a dry heating pad over the affected area. Administer cefazolin intermittent IV bolus. - ✔✔ Correct Answers-Elevate the affected area 15.24 cm (6 in) above the heart is correct. Administer cefazolin intermittent IV bolus is correct. A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis - ✔✔ Correct Answers-Metabolic alkalosis The nurse should identify that with Cushing's disease, also known as hypercortisolism, adrenocorticotropic hormone levels are low due to hypersecretion of the adrenal cortex. This leads to an increase is renal excretion of potassium and, therefore, hypokalemia. This electrolyte imbalance puts the client at risk for metabolic alkalosis as the kidneys try to retain potassium by increasing hydrogen ion excretion, and as potassium moves out of the cells and into the extracellular fluid and hydrogen ions move into the cells. A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect? Chest pain
Hallucinations Feels unreal Follows directions - ✔✔ Correct Answers-Follows directions The nurse should expect a client who is experiencing a mild level of anxiety to be able to follow directions and focus on the nurse's instructions. Other manifestations the nurse should expect include restlessness, heightened perception, and ability to problem solve. A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client's ABG results are pH 7.48, PaCO2 50 mm Hg, and HCO3- 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis - ✔✔ Correct Answers-Metabolic alkalosis When a client is experiencing metabolic alkalosis, the pH is above the expected reference range, the PaCO2 is within or above the expected reference range, and the HCO3- is above the expected reference range. Common causes of metabolic alkalosis include overuse of antacids, prolonged vomiting, NG suctioning, total parenteral nutrition, and thiazide diuretic use. A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take? Use a gait belt and stand on the client's right side to assist with ambulation. Encourage the client to use wide-grip utensils when eating with the right hand. Place personal items on the bedside table close to the bed on the client's left side. Remove rolled toilet paper from the holder for easier access for the client - ✔✔ Correct Answers-Encourage the client to use wide-grip utensils when eating with the right hand. The nurse should encourage the client who has hemiparesis to use wide-grip utensils when eating with the right hand, which can accommodate a weak grasp and encourage independence in eating.
Dry, non-productive cough - ✔✔ Correct Answers-Increased menstrual flow The nurse should identify that warfarin is an anticoagulant used to prevent the development of thrombosis. It suppresses coagulation, which increases the risk for bleeding. The nurse should identify indications of bleeding and hemorrhage, such as increased menstrual flow, bruising, bleeding gums, and black, tarry stools, as adverse effects of warfarin therapy and notify the provider. A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? (Select all that apply.) Fears transmitting their disease to others Personifies death as being a type of monster Exhibits interest in what happens to the body following death Believes death is a temporary type of sleep Believes that their own thoughts can cause death - ✔✔ Correct Answers-Believes death is a temporary type of sleep is correct. The nurse should expect a preschooler to view death as a temporary condition, a type of sleep that is reversible. Believes their thoughts can cause death is correct. The nurse should expect a preschooler to believe that their thoughts can cause death to occur, which can lead to feelings of guilt and shame. A nurse is caring for a toddler who sustained a left lower leg fracture in a motor vehicle crash. The toddler, who has light-pigmented skin, received a cast 24 hr ago. Which of the following assessment findings from the casted leg should the nurse report to the provider? The toddler's toes are pink in color. The toddler's foot swells when dependent. The toddler's toe movement is limited. The toddler's capillary refill time is less than 2 second - ✔✔ Correct Answers-The toddler's toe movement is limited. The nurse should assess the toddler's ability to move the toes in the casted extremity. A limited or restricted ability to move the toes is an indication of neurovascular
compromise and should be reported to the provider immediately because permanent muscle and tissue damage can occur within a short period of time. A nurse is developing a plan of care for a preschooler who has heart failure. Which of the following interventions should the nurse include in the plan? Assess and record the child's blood pressure every 6 to 8 hr. Weigh the child once each week using the same scale. Place the child in a supine position for a minimum of 4 hr each day. Offer small, frequent meals based on the child's endurance level. - ✔✔ Correct Answers-Offer small, frequent meals based on the child's endurance level. The nurse should offer small, frequent meals based on the child's endurance level. The child requires an increase in caloric intake, but often has a low energy level. The nurse should choose times for meals when the child is most rested, and make sure those meals are high in calories. A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussing an adolescent's response to death? Adolescents cope with death better than children of other ages. Adolescents view funeral services as an opportunity for closure. Adolescents are more concerned with the past than the present or future. Adolescents often alienate themselves from their peers when grieving. - ✔✔ Correct Answers-Adolescents often alienate themselves from their peers when grieving. The nurse should identify that adolescents dealing with death often have difficulty communicating their feelings and alienate themselves from their peers and families. A nurse is discussing lactose-free foods with a client who is experiencing malabsorption due to lactose intolerance. Which of the following foods should the nurse recommend? Sour cream Soy milk Ice cream Plain yogurt - ✔✔ Correct Answers-Soy milk
