Nursing Care Scenarios, Exams of Nursing

Download Nursing Care Scenarios and more Exams Nursing in PDF only on Docsity!

hesi-exit-exam-mental-health-pdf

HESI Exit Exam 1 Mental Health

Assessing Clients with Diabetes Mellitus

While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. The additional assessment that provides further data to support this finding is: c. Observe the appearance of the skin on the client's legs.

The absence of hair growth on the legs can be an indicator of peripheral vascular disease, which is a common complication of diabetes mellitus. Observing the appearance of the skin on the client's legs can provide additional evidence to support this finding.

Medication Dosage Calculation

The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. The amount of Streptomycin the infant will receive is: c. 27 mg.

To calculate the dosage, we need to convert the infant's weight from pounds to kilograms. 4 pounds is approximately 1.8 kilograms. The prescribed dose is 15 mg/kg, so the total dose would be 15 mg/kg x 1.8 kg = 27 mg.

Monitoring Clients Receiving Magnesium Sulfate

In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. Based on these findings, the intervention the nurse should implement is: b. Decrease the magnesium sulfate infusion by one-half.

The findings indicate that the client is experiencing magnesium toxicity, which can occur with prolonged use of magnesium sulfate. The decreased deep tendon reflexes, respiratory rate, and urinary output, along with the elevated magnesium level, suggest the need to decrease the infusion rate to prevent further complications.

Monitoring Clients Receiving Neuromuscular Blockers

A client is on a mechanical ventilator. The client response that indicates the neuromuscular blocker tubocurarine chloride (Tubarine) is effective is: a. The client's extremities are paralyzed.

Tubocurarine chloride is a neuromuscular blocker that causes paralysis of the skeletal muscles, including the extremities. This indicates that the medication is effectively blocking neuromuscular transmission and the client is adequately paralyzed.

Monitoring Clients Receiving Acetaminophen

An elderly female client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. The previous lab values the nurse should compare with today's lab report are: b. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage.

Prolonged use of high doses of acetaminophen can lead to liver damage. Monitoring the client's liver enzymes, such as LDH (lactate dehydrogenase), can help detect any signs of liver injury.

Administering Aspirin to Clients with Rheumatic Fever

Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. The most important intervention for the nurse to implement is: b. Administer the aspirin with at least two ounces of water or juice.

Administering aspirin with adequate fluid is important to prevent gastrointestinal irritation and potential bleeding, which can be a side effect of aspirin therapy.

Identifying Signs and Symptoms of Cushing's Syndrome

The signs or symptoms characteristic of an adult client diagnosed with Cushing's syndrome are: d. Central-type obesity, with thin extremities.

Cushing's syndrome is characterized by central obesity, with a rounded, "moon-faced" appearance and thin extremities. Other common signs include a husky voice, easy bruising, and purple striae on the abdomen.

Prioritizing Client Assessments

A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided, the client the charge nurse should check first is the client: d. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.

The client with a pneumothorax and low oxygen saturation should be the highest priority, as this condition can be life-threatening and requires immediate intervention.

Evaluating Outcomes for Peripheral Vascular Disease

An outcome for the treatment of peripheral vascular disease is, "The client will have decreased venous congestion." The client behavior that would indicate to the nurse that this outcome has been met is: a. Avoids prolonged sitting or standing.

Decreased venous congestion in peripheral vascular disease can be indicated by the client's ability to avoid prolonged sitting or standing, which can exacerbate venous pooling and swelling.

Monitoring Clients After Paracentesis

The healthcare provider performs a paracentesis on a client with ascites, and 3 liters of fluid are removed. The assessment parameter most critical for the nurse to monitor following the procedure is: d. Vital signs.

After a large volume of fluid is removed during a paracentesis, the client's vital signs should be closely monitored for signs of hypotension or other hemodynamic changes.

Explaining the Action of Sevelamer (RenaGel)

The nurse is administering sevelamer (RenaGel) during lunch to a client with end-stage renal disease (ESRD). The nurse should describe the action of RenaGel as: b. Binds with phosphorus in foods and prevents absorption.

Sevelamer is a phosphate binder that works by binding to dietary phosphorus in the gastrointestinal tract, preventing its absorption and helping to control serum phosphorus levels in clients with ESRD.

Identifying the Etiology for Ineffective Airway Clearance in

Myasthenia Gravis

The nurse formulates a nursing diagnosis of "High risk for ineffective airway clearance" for a client with myasthenia gravis. The most likely etiology for this nursing diagnosis is: b. Diminished cough effort.

In myasthenia gravis, the weakness of the respiratory muscles, including the diaphragm and intercostal muscles, can lead to a diminished cough effort, which can result in ineffective airway clearance.

Questioning Prescriptions for Clients with Dysphagia After

a CVA

Following a CVA, the nurse assesses that a client developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. The prescription the nurse should question is: b. Total parenteral nutrition to be infused at 125 ml/hour.

The client's presentation of dysphagia and abdominal distension suggests the potential for gastrointestinal complications, and the administration of total parenteral nutrition at a high rate may not be the most appropriate intervention.

Anticipating Assessment Findings in Ventricular

Fibrillation

A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. The assessment finding the nurse should anticipate is: d. No palpable pulse.

Ventricular fibrillation is a life-threatening cardiac arrhythmia that results in the complete disorganization of the ventricles, leading to the absence of a palpable pulse.

Interventions for Cracked Corners of the Mouth in

Alzheimer's Disease

In assessing a 70-year-old female client with Alzheimer's disease, the nurse notes that she has deep, inflamed cracks at the corners of her mouth. The intervention the nurse should include in this client's plan of care is: d. Ensure that the client gets adequate B vitamins in foods or supplements.

The cracked corners of the mouth, known as angular cheilitis, can be a sign of B vitamin deficiency, which is common in clients with Alzheimer's disease. Ensuring adequate B vitamin intake through diet or supplements can help address this issue.

Responding to an Angry Client in the Emergency

Department

A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. The best nursing response is: c. "You are upset that this incident has brought you here."

This response acknowledges the client's feelings of anger and validates her emotional state, which is the most appropriate approach in this situation.

Assessing and Addressing Inappropriate Touching by an

Elderly Client

An 85-year-old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The best assessment of the situation is: c. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.

The client's behavior may be a result of touch deprivation, a common issue in elderly individuals, and the appropriate response is to educate the client on appropriate ways to express his need for touch, rather than immediately labeling it as sexual harassment.

Providing Information about Surgical Correction of

Hypospadias

The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. The information the nurse should provide is: b. Repairs typically should be done before the child is potty-trained.

Surgical correction of hypospadias is usually performed before the child is potty-trained, typically between 6 and 18 months of age, to ensure proper urethral development and function.

Evaluating Client Understanding of Holter Monitor Use

In evaluating the teaching of a client about wearing a Holter monitor, the statement made by the client that would indicate to the nurse that the client understands the procedure is: a. "I must record any symptoms occurring with my activity."

This statement demonstrates that the client understands the importance of recording any symptoms that occur during the Holter monitoring period, which is a key aspect of the procedure.

Identifying Symptoms of Newly Diagnosed Diabetes

Mellitus in a Child

A 9-year-old female client was recently diagnosed with diabetes mellitus. The symptom her parents will most likely report is: b. Drinks more soft drinks than previously.

Increased thirst and fluid intake, including consumption of sugary beverages, is a common symptom of newly diagnosed diabetes mellitus in children.

Prioritizing Interventions for Clients with Various

Conditions

The nurse is caring for four clients: Client A with emphysema and oxygen saturation of 94%, Client B with a postoperative hemoglobin of 8.7 mg/dl, Client C with a potassium level of 3.8 mEq/L, and Client D scheduled for an appendectomy with a white blood cell count of 15, mm3. The intervention the nurse should implement is: b. Determine if Client B has two units of packed cells available in the blood bank.

The client with the most immediate need is Client B, who has a low postoperative hemoglobin level, which may require a blood transfusion to address the anemia.

Maintaining Confidentiality and Ensuring Safety for a

Suicidal Client

A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has "little reason to live." She describes one previous suicidal gesture and admits to having a gun in her home. The action that is best for the nurse to implement to maintain the client's confidentiality and ensure her safety is: b. Notify the client's healthcare provider of the availability of the weapon.

Informing the healthcare provider about the client's access to a weapon is the most appropriate action to take, as it allows for the provider to assess the situation and take necessary steps to ensure the client's safety while maintaining confidentiality.

Providing Direct Supervision for Nursing Tasks

It is most important for the registered nurse (RN) working on a medical unit to provide direct supervision in the situation where: c. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside.

Performing a lumbar puncture is a complex and invasive procedure that requires the direct supervision of an RN, as it carries significant risks and potential complications.

Obtaining Allergy History from Clients

A nurse is completing the health history for a 25-year-old male client who reports that he is allergic to penicillin. The question the nurse should ask after receiving this information is: d. "What happens to you when you take penicillin?"

Asking the client to describe their specific reaction to penicillin provides more detailed information about the nature and severity of the allergy, which is important for determining appropriate medication alternatives.

Identifying Diabetes Insipidus in a Child with Meningitis

A 10-year-old child with meningitis is suspected of having diabetes insipidus. The laboratory finding indicative of diabetes insipidus is: a. Decreased urine specific gravity.

Diabetes insipidus is characterized by the production of large volumes of dilute urine, which results in a decreased urine specific gravity.

Prioritizing Interventions for a Client Receiving

Autologous Bone Marrow Transplantation

A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). The priority intervention the nurse should implement when the bone marrow is repopulating is: d. Maintain a protective isolation environment.

During the period of bone marrow repopulation after a BMT, the client is at high risk for infection due to profound immunosuppression. Maintaining a protective isolation environment is the top priority to prevent life- threatening infections.

Prioritizing Nursing Actions for a Client in Shock

A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to the ICU are BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, and skin cool to the touch. Pulmonary artery (PA) pressures are PAWP 1, PAP 8/2, RAP -1, and SVR 1600. The nursing action with the highest priority is: b. Increase the client's IV fluid rate to 200 ml/hr.

The client's presentation, including hypotension, tachycardia, and low urine output, indicates hypovolemic shock. Increasing the IV fluid rate to restore intravascular volume and improve perfusion is the most urgent intervention.

Assessing and Responding to a Pregnant Client with Type 1

Diabetes

A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. The action the nurse should take first is: a. Check the blood glucose level.

The client's symptoms, such as headache, nausea, and feeling shaky, could be indicative of hypoglycemia or hyperglycemia, both of which are common issues in pregnant clients with Type 1 diabetes. Checking the blood glucose level is the first priority to determine the appropriate intervention.

Responding to a Prolapsed Umbilical Cord During Labor

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. The action the nurse should perform first is: a. Administer oxygen via face mask.

When a prolapsed umbilical cord is present, the priority is to maintain fetal oxygenation by administering oxygen to the mother, as this helps to preserve the fetal circulation until the healthcare provider can intervene.

Determining Fluid Retention in a Child with Nephrotic

Syndrome

The nurse is planning care for a non-potty-trained child with nephrotic syndrome. The intervention that provides the best means of determining fluid retention is: a. Weigh the child daily.

In nephrotic syndrome, fluid retention can lead to weight gain. Weighing the child daily is the most accurate way to monitor for changes in fluid status.

Advising a Mother about Exposing an Infant with RSV to

Other Children

The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. The response the nurse should provide is: c. The child will still be contagious and should not be around other children.

Infants with RSV remain contagious for several days after the onset of symptoms. Attending a birthday party and exposing other children to the virus would be inappropriate and could lead to the spread of infection.

Respiratory Syncytial Virus (RSV) Precautions

Preventing Spread of RSV

Make sure there are no children under the age of 6 months around the infected child, as RSV is very contagious even without direct oral contact. Do not expose other children to the infected child, as RSV is highly transmissible.

Medication Administration for a Client with a

PICC Line

Prioritizing Medication Administration

When administering four medications prescribed for 9:00 a.m. to a client with a single-lumen, peripherally-inserted central catheter (PICC), the nurse should administer the following medication first:

a. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q hours.

This medication should be administered first as it is an antibiotic that needs to be given in a timely manner to treat the client's urinary sepsis.

•

•

Other Medications

The other medications prescribed are: b. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours. c. Pantoprazole (Protonix) 40 mg PO daily. d. Enoxaparin (Lovenox) 40 mg subq q24 hours.

Preventing Vesicant Extravasation during

Chemotherapy

Nursing Interventions

To reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy, the nurse should implement the following action:

d. Monitor the client's intravenous site hourly during the treatment.

Monitoring the IV site closely is the most important intervention to detect any signs of extravasation early and prevent further complications.

Benign Prostatic Hyperplasia (BPH)

Assessment and Management

Nursing Assessment

An elderly male client reports increasing nocturia, difficulty initiating urine stream, weak urine flow, and frequent dribbling after voiding. The appropriate nursing action is:

c. Advise the client to maintain a voiding diary for one week.

Obtaining a voiding diary can provide valuable information about the client's urinary symptoms and help guide further assessment and management.

Newborn Physical Assessment Findings

Reporting Concerning Findings

When performing a physical assessment on a newborn who is small for gestational age (SGA), the nurse should immediately report the following finding to the healthcare provider:

c. Widened, tense, bulging fontanel.

A widened, tense, and bulging fontanel may indicate increased intracranial pressure and requires prompt intervention.

Critical Laboratory Values Requiring

Immediate Intervention

Identifying Critical Values

The laboratory value that requires immediate intervention by the nurse is:

d. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday.

A significantly decreased neutrophil count in a client with cancer indicates a high risk of infection and requires prompt intervention.

Factors Influencing Pressure Ulcer Risk

Assessment

Pressure Ulcer Risk Assessment

When planning the turning schedule for a bedfast client, the most important assessment finding for the nurse to consider is:

b. A Braden risk assessment scale rating score of ten.

The Braden risk assessment scale is a validated tool used to determine a client's risk of developing pressure ulcers, and a score of 10 indicates a high-risk client.

Factors Affecting NSAID Effectiveness

Evaluating NSAID Response

When a client with osteoarthritis reports that the prescribed naproxen (Naprosyn) 500 mg PO twice a day is not helping the pain, the nurse should consider the following factor:

d. NSAID response is variable and another NSAID may be more effective.

Individual response to NSAIDs can vary, and if one NSAID is not effective, trying a different NSAID may be more beneficial.

Accessing State-Level Health Data

Obtaining Infant Mortality Data

To study the incidence of infant death in a particular city and compare it to the state's rate, the nurse should access the following state resource:

c. Bureau of Vital Statistics.

The Bureau of Vital Statistics is the most likely state-level resource to provide information on infant mortality rates.

Neurological Assessment for a Client with

Knee Pain and Edema

Neurological Assessment

For a 60-year-old male client admitted with right knee pain, warmth, and edema, the appropriate neurological assessment action is:

b. Pulses, paresthesia, paralysis distal to the right knee.

Assessing the pulses, sensation, and motor function distal to the affected knee can help identify any neurological complications related to the client's presentation.

Interventions for Anxiety in a Successful

Businessman

Nursing Interventions for Anxiety

To assist a highly successful businessman presenting with sleeplessness and anxiety over his financial status, the nurse should implement the following action:

a. Encourage him to initiate daily rituals.

Encouraging the client to establish daily routines and rituals can help reduce anxiety and improve sleep.

Normal Postpartum Findings

Postpartum Assessment Findings

The normal physical assessment finding for a primigravida client 12 hours postpartum is:

a. Soft, spongy fundus.

A soft, spongy uterine fundus is a normal finding in the immediate postpartum period.

Educating a Client about Antipsychotic

Medication

Medication Education

When educating a client about the purpose of the prescribed antipsychotic medication clozapine (Clozaril), the nurse should provide the following statement:

a. 'It will help you function better in the community.'

This statement accurately reflects the goal of antipsychotic medication in improving the client's overall functioning and ability to manage in the community.

Prioritizing Interventions for a Client with

Spinal Cord Injury

Immediate Nursing Intervention

For a male client with a C-5 spinal cord injury, the assessment finding that warrants immediate intervention by the nurse is:

d. Respirations are shallow, labored, and 14 breaths/minute.

Impaired respiratory function is a critical concern in a client with a high- level spinal cord injury and requires immediate nursing intervention.

Medication Administration for a Preterm

Infant

Medication for Preterm Infant Transport

The medication the transport team is most likely to administer to the 30- week preterm infant with respiratory distress is:

d. Beractant (Survanta) 100 mg/kg per endotracheal tube.

Surfactant replacement therapy, such as Beractant, is a common intervention for preterm infants with respiratory distress syndrome.

Appropriate Client Assignment for an

Obstetric Nurse

Client Assignment

The appropriate client assessment for the charge nurse to assign to the obstetric nurse working on a medical-surgical unit is:

c. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.

As an obstetric nurse, the nurse would be best equipped to assess and monitor a client who has had a recent neurological event, such as a stroke.

Biophysical Profile (BPP) Procedures

Biophysical Profile Preparation

When a primipara at 38-weeks gestation is admitted for a biophysical profile (BPP), the nurse should prepare the client for the following procedures:

c. Ultrasonography and nonstress test.

A BPP typically involves ultrasound imaging and a nonstress test to evaluate fetal well-being.

Nursing Interventions for an Aggressive

Client

Appropriate Nursing Intervention

When a male client in the day room becomes increasingly angry and aggressive when denied a day-pass, the nurse should implement the following action:

b. Put the client's behavior on extinction.

Ignoring the aggressive behavior and not reinforcing it is an appropriate nursing intervention to de-escalate the situation.

Therapeutic Use of Silence in Counseling

Rationale for Nurse's Silence

The most likely reason for the nurse's silence when the client says, "I don't know how I will go on," is:

d. Silence allows the client to reflect on what was said.

Allowing silence provides the client with the opportunity to process their feelings and thoughts without interruption.

Postpartum Nursing Intervention

Immediate Nursing Action

When an unlicensed assistive personnel (UAP) reports that a client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache, the charge nurse should implement the following action first:

a. Notify the healthcare provider of the assessment findings.

A severe headache in the immediate postpartum period may indicate a serious complication, and the healthcare provider should be notified promptly.

Chest Tube Management

Essential Nursing Intervention

When developing a care plan for a client with a chest tube due to a hemothorax, the nurse should recognize that the following intervention is essential:

c. Encourage the client to breathe deeply and cough at frequent intervals.

Promoting deep breathing and coughing helps to expand the lungs and facilitate drainage through the chest tube.

Postoperative Care for Abdominal Aortic

Aneurysm Repair

Appropriate Nursing Interventions

The immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include the following interventions:

a. Assessing pedal pulses frequently and monitoring the nasogastric drainage.

Monitoring peripheral perfusion and assessing for any gastrointestinal complications are essential in the immediate postoperative period.

Incentive Spirometer Use

Technique for Sustained Maximal Inspiration

When teaching a client postoperative breathing techniques using an incentive spirometer (IS), the nurse should encourage the client to:

b. Inspire deeply and slowly over 3 to 5 seconds.

Slow, deep inspiration is the most effective technique to achieve sustained maximal inspiration with an incentive spirometer.

Medication Error Management

Nurse's Legal Status

In the scenario where the nurse accidentally administers 10 mg of morphine sulfate instead of the prescribed 4 mg to a client with shortness of breath and chest pain, the nurse's legal status is:

c. The nurse is protected by the Good Samaritan Act.

The Good Samaritan Act provides legal protection for healthcare providers who provide emergency care in good faith, even if a medication error occurs.

Conditions Requiring Immediate Nursing

Intervention

Most Urgent Condition

The client condition that requires the most immediate intervention by the nurse is:

b. Increasing sharp pain related to compartment syndrome.

Compartment syndrome is a medical emergency that requires prompt recognition and intervention to prevent irreversible tissue damage.

Appropriate Response to Observed

Unprofessional Behavior

Nurse's Intervention

The charge nurse should intervene when the following behavior is observed:

b. A hospital transporter is reading a client's history and physical while waiting for an elevator.

Accessing a client's medical information without a legitimate need is a breach of patient confidentiality and requires immediate intervention by the nurse.

Readiness for Bronchoscopy

Appropriate Assessment Finding

The assessment finding that indicates a client's readiness to leave the nursing unit for a bronchoscopy is:

d. Oxygen at 2 L/minute per nasal cannula.

Ensuring the client is receiving the appropriate level of supplemental oxygen is an important safety consideration before the client leaves the unit.

Physical Therapy Regimen for Juvenile

Rheumatoid Arthritis

Recommended Physical Therapy

The physical therapy regimen the nurse should encourage a 16-year-old with juvenile rheumatoid arthritis (JRA) to implement is:

a. Exercise in a swimming pool.

Aquatic therapy is an effective way to strengthen and mobilize the joints while minimizing stress on the affected areas.

Age-Related Hearing Changes

Likely Condition

The age-related condition that is likely occurring in the 89-year-old male client who complains that people are whispering and mumbling is:

c. Presbycusis.

Presbycusis, or age-related hearing loss, is a common condition in the elderly that can lead to difficulties understanding speech.

Evaluating Antitussive Medication

Effectiveness

Indicator of Effective Antitussive

The assessment data that indicates the antitussive medication benzonatate (Tessalon) is effective for the client with a cold is:

b. Denies having coughing spells.

Reduced or absent coughing is the primary indicator that the antitussive medication is effectively suppressing the client's cough.

Prioritizing Visits for Clients with

Schizophrenia

Priority Client Visit

The community mental health nurse should see the following client first:

c. The newly diagnosed client who needs to be evaluated for medication compliance.

Ensuring medication compliance in a newly diagnosed client with schizophrenia should be the highest priority to prevent further deterioration.

Cocaine Withdrawal Symptoms

Likely Withdrawal Symptoms

The behavior the client is likely to exhibit during cocaine withdrawal is:

a. Intense cravings.

Intense cravings for the drug are a hallmark symptom of cocaine withdrawal.

Nursing Intervention for a Client at Risk of

Seizures

Appropriate Nursing Action

When the nurse observes the unlicensed assistive personnel (UAP) securing pillows against the side rails to protect a client with a history of seizure activity, the nurse should implement the following action:

b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

Using soft blankets or padding is a more appropriate and effective way to protect the client during a seizure.

Sickle Cell Crisis Management

Intervention for a 5-year-old Child with Sickle Cell Crisis

When a 5-year-old child with sickle cell disease is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis, the nurse should implement the following intervention first:

a. Initiate normal saline IV at 50 ml/hr.

The priority is to provide intravenous fluid resuscitation to prevent dehydration and maintain adequate tissue perfusion during the sickle cell crisis.

Discharge Instructions for a Compound

Fracture

Discharge Instructions for a Client with a Below-the-Knee

Cast

Before discharging a client with a compound fracture of the left ankle and a below-the-knee cast, the nurse should provide the following instruction:

c. Do not attempt to scratch the skin under the cast.

This instruction is important to prevent complications, such as skin irritation or infection, that can occur if the client tries to scratch under the cast.

Topical Antimicrobial Application for

Electrical Burns

Preparing to Administer Mafenide Acetate (Sulfamylon) for

Electrical Burns

When preparing to administer the first application of the topical antimicrobial agent mafenide acetate (Sulfamylon) to a client with 2nd degree electrical burns on both upper extremities, the nurse should implement the following intervention first:

b. Use sterile gloves when applying this medication.

Proper aseptic technique, including the use of sterile gloves, is crucial to prevent infection in the burned areas.

Primary Prevention Programs in the

Community

Addressing Primary Prevention Needs in the Community

To provide a primary prevention program in the community, the nurse should implement the following type of program:

c. Incorporate an exercise program at a local Hispanic community center.

A primary prevention program that focuses on promoting healthy behaviors, such as an exercise program, addresses the community's needs for disease prevention.

Factors Affecting Blood Pressure Changes

Clients Likely to Have Increased Blood Pressure

Among the clients described, the one most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago is:

b. A middle-aged male receiving prazosin hydrochloride (Minipress).

Prazosin hydrochloride, an antihypertensive medication, can cause a rebound increase in blood pressure if the medication is not taken as prescribed.

Preventing Painful Shoulder in Hemiplegia

Interventions to Prevent Painful Shoulder in a Hemiplegic

Client

To prevent a hemiplegic client from experiencing a painful shoulder, the nurse should include the following intervention in the plan of care:

b. Position the affected arm on pillows while the client is seated in a chair.

Proper positioning of the affected arm can help prevent the development of a painful shoulder, which is a common complication in clients with hemiplegia.

Preventing Medication Errors

Verifying Medication Orders to Prevent Errors

If the pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client's medication administration record (MAR), the nurse should take the following action to prevent a medication error from occurring:

c. Compare the medication administration record (MAR) to the prescription.

Comparing the MAR to the original prescription is the most effective way to identify and correct any discrepancies in the medication order.

Assisting a New Mother with Breastfeeding

Interventions to Support a New Mother's Breastfeeding

Goal

To assist a primipara who wishes to breastfeed her infant immediately after delivery, the nurse should implement the following intervention:

a. Permit privacy for the mother and infant to bond.

Providing privacy and allowing the mother and infant to initiate bonding and breastfeeding without interruption is the best approach to support the new mother's goal.

Addressing Gastroesophageal Reflux (GERD)

Symptoms

Recommendations for a Client with Nighttime Heartburn

Regarding the male client with gastroesophageal reflux (GERD) who experiences nighttime heartburn, the nurse should provide the following information:

b. 'Drinking milk before bedtime can increase your symptoms at night.'

Milk, despite containing tryptophan, can actually worsen GERD symptoms due to its high fat content, which can exacerbate reflux.

Insulin Administration for a Diabetic Client

NPO

Interventions for a Diabetic Client NPO Requiring Insulin

When a client with Type 1 diabetes is NPO for a diagnostic test and the nurse is preparing to administer 24 units of 70/30 insulin, the nurse should implement the following intervention first:

c. Contact the healthcare provider to adjust the insulin dose.

Since the client is NPO, the nurse should contact the healthcare provider to determine the appropriate insulin dose adjustment to prevent hypoglycemia.

Dietary Folic Acid Sources

Identifying the Snack with the Most Folic Acid

The evening snack that contains the most folic acid is:

b. Whole grain cereal and milk.

Whole grains and dairy products are good sources of folic acid, making this snack the most suitable option to improve dietary folic acid intake.

Hypovolemic Shock Management

Interventions for a Client with Hypovolemic Shock

Given the client data provided (BP 85/70, HR 140, UO 10 ml/hr, PAWP 2, RAP -3, Hct 20%, Hgb 7 g/dl), the nurse should take the following action:

b. Infuse blood and IV fluids to correct the hypovolemia.

The priority is to restore the client's intravascular volume and improve tissue perfusion, which is the appropriate intervention for hypovolemic shock.

Informed Consent for Emergency Surgery

Obtaining Informed Consent for an Unresponsive Client

When an unresponsive female victim of a motor vehicle collision requires immediate surgery, and the client is accompanied by a close friend but no family members are available, the nurse should take the following action:

d. Maintain continuous monitoring of the client until a family member can be located.

Without a legal guardian or family member present, the nurse should not proceed with the surgery without a signed informed consent. The nurse should continue to monitor the client until a family member can be located to provide consent.

Appropriate Toys for a Child with a Spica Cast

Selecting a Toy for a 3-Year-Old with a Spica Cast

The toy that is best for the nurse to provide for a 3-year-old child with a spica cast is:

a. Set of cloth hand puppets.

Cloth hand puppets are an appropriate toy for a young child with limited mobility due to a spica cast, as they can be manipulated without requiring extensive movement.

Choking Management for a Pregnant Woman

Intervention for a Choking Pregnant Woman

When a gravid woman begins to choke and is unable to speak, the nurse should take the following action:

c. The Heimlich maneuver using subdiaphragmatic thrusts.

The Heimlich maneuver with subdiaphragmatic thrusts is the appropriate intervention for a choking pregnant woman, as it avoids compression of the uterus.

Newborn Care in an Isolette

Interventions for a 36-Week-Gestation Newborn in an

Isolette

After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, the nurse should implement the following intervention next:

c. Remove the wet blankets and linens from the isolette.

Removing the wet blankets and linens is important to maintain the infant's body temperature and prevent heat loss.

Administering Antibiotics to a Muslim Client

Addressing a Muslim Client's Refusal of Intravenous

Antibiotics

When a male Muslim client with pneumonia refuses to allow the nurse to administer an intravenous antibiotic due to his religious beliefs, the nurse should implement the following action:

d. Ask the pharmacist to supply an oral form of the antibiotic for the client.

Providing an oral form of the antibiotic, if available, allows the client to receive the necessary treatment while respecting his religious practices.

Assessing Somatic Complaints

Focusing the Admission Interview for a Client with

Recurring Somatic Pain

When interviewing a newly admitted adult client with a six-month history of recurring somatic pain, the most important problem for the nurse to question the client about is:

b. Feelings of depression.

Exploring the client's emotional state, particularly feelings of depression, is crucial in assessing the underlying cause of the recurring somatic pain.

Risks Associated with Nalbuphine (Nubain)

Administration

Etiology Placing the Client at Risk for Injury with

Nalbuphine (Nubain)

The etiology, secondary to the medication's effects, that places a postoperative client at risk for injury when the nurse administers nalbuphine (Nubain) is:

b. Adverse CNS effects.

Nalbuphine, as an opioid analgesic, can cause adverse central nervous system (CNS) effects, such as sedation and impaired cognitive function, which increase the client's risk of injury.

Evaluating the Effectiveness of Epoetin Alfa

(Epogen, Procrit)

Parameters to Assess the Effectiveness of Epoetin Alfa

(Epogen, Procrit)

When evaluating the effectiveness of the biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) in a client with end-stage renal disease (ESRD), the nurse should assess the following parameters:

b. RBCs, hemoglobin, and hematocrit.

The primary purpose of epoetin alfa is to stimulate red blood cell (RBC) production, so monitoring the client's RBCs, hemoglobin, and hematocrit is the most important way to assess the medication's effectiveness.

Client Education for Epididymitis

Key Information to Include in the Teaching Plan for

Epididymitis

The most important information for the nurse to include in the teaching plan for a 25-year-old male client diagnosed with epididymitis and a positive culture for Escherichia coli is:

a. Avoid penile contact with the rectal area.

Avoiding contact between the penis and the rectal area is crucial to prevent reinfection and the spread of the causative organism, Escherichia coli.

Interventions for Hyponatremia

Appropriate Intervention for a Client with Hyponatremia

For a client admitted with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles, the nurse should implement the following intervention:

d. Hold the client's loop diuretic.

The client's presentation, including hyponatremia and fluid overload, indicates that the loop diuretic is contributing to the electrolyte imbalance, and holding the medication is the appropriate action.

Handling Blood-Saturated Clothing as

Forensic Evidence

Proper Handling of Blood-Saturated Clothing as Forensic

Evidence

After collecting a young adult male's blood-saturated clothing as forensic evidence for the medical examiner, the nurse should implement the following action:

c. Place the clothes in a paper bag and transfer bag to a red biohazard bag.

Placing the clothing in a paper bag and then transferring it to a red biohazard bag is the proper way to preserve the forensic evidence while maintaining blood-borne precautions.

Determining Hospital Stay Duration

Resources to Guide the Nurse in Responding to a Client's

Question about Hospital Stay Duration

The resource that provides the best guide for the nurse in responding to a client's question about the length of their hospital stay following a scheduled surgery is:

a. Critical pathway for the scheduled surgery.

The critical pathway, which outlines the expected course of care and recovery for the specific surgical procedure, is the most appropriate resource to determine the anticipated length of stay.

Priority Nursing Problem for a Client with

Dementia

Identifying the Priority Nursing Problem for a Client with

Dementia

The priority nursing problem for a client diagnosed with dementia who is disoriented, wandering, has a decreased appetite, and is having trouble sleeping is:

d. Risk for injury.

The client's disorientation and wandering behavior, combined with the potential for falls or other accidents, make the risk for injury the priority nursing problem.

Identifying Symptoms of Impending Shock

Symptoms Indicating the Beginning of a Shock State

The findings that the new graduate nurse should identify as symptoms most likely indicating the beginning of a shock state in a critically ill client are:

d. Tachycardia, mental status change, and low urine output.

These findings, including tachycardia, altered mental status, and decreased urine output, are early indicators of the onset of a shock state.