Saturday, October 27, 2007


Autonomy is the right of individuals to take action for themselves. Beneficence is duty to help others by doing what is best for them, whereas negligence is a legal term. Veracity is truthfulness. Privacy is the nondisclosure of information by the health care team.

A Nurse Practice Act serves to protect the public by setting minimum qualifications for nursing in relation to skills and competencies. One way it fulfills the responsibility to protect the public is by defining the scope of nursing practice in that state. The state’s board of nursing approves schools to operate but does not accredit them. It does not enforce ethical standards.

Braxton-Hicks contractions are probably caused by stretching of the myometrium. They are usually relieved by position changes, frequent emptying of the bladder, resting in a lateral recumbent position, and walking or light exercise.

The dye used in angiography is nephrotoxic, and a client should have adequate fluids after the procedure to eliminate the dye. The client should lie with the affected leg extended for 6 to 8 hours. Leg exercises are not recommended because exercise could disrupt the clot that formed at the insertion site. Option 1 is incorrect because it gives false reassurance to a client who could be at risk if fluids are not taken in.

Compression stockings exert pressure on the veins of the lower extremities, promoting venous return back to the heart. Stockings are removed for at least an hour per day to allow for inspection and ensure blood flow through small, superficial vessels. Flexing the extremities does not aid tissue perfusion, although it maintains joint range of motion. However, after this surgery clients are taught to either stand or lie down and avoid flexing at the hip and knee. Numbness is a temporary or rarely permanent complication of surgery. Briskly scrubbing the extremities will not aid tissue perfusion.

The final stage of the atherosclerotic process is the development of atheromas, which are complex lesions consisting of lipids, fibrous tissue, collagen, calcium, cellular waste, and capillaries. The calcified lesions may rupture or ulcerate, stimulating thrombosis. The other options are not consistent with the ultimate or final changes in the atherosclerotic process.

Leg pain (also called intermittent claudication) is a primary manifestation of peripheral arterial disease. Intermittent claudication is muscle pain caused by interruption in arterial flow, resulting in tissue hypoxia. Peripheral edema and brownish discoloration to the skin on the leg would be consistent with venous disease, not arterial disease. Widened pulse pressure would be an unrelated finding.

Nicotine in cigarettes promotes vasoconstriction. The three most significant risk factors for development of peripheral arterial disease are smoking, hyperlipidemia, and hypertension. The presence of dysrhythmias, low-protein intake, and exposure to cool weather are not risk factors for the disease, although cool weather could worsen the symptoms when disease is already present.

Aneurysms vary by size and location. Signs of rupture depend on the location of the aneurysm. Dissection can occur anywhere but most often occurs in the ascending aorta where pressure is the highest. The medication the client is receiving is vague and is not directly related. The blood pressure relates to whether the aneurysm may rupture, not to the associated signs and symptoms. The age and gender of the client are unrelated to the size and symptoms of aneurysm rupture.

An important outcome in care of the hypertensive client is the ability to identify and counteract personal risk factors that the client has the ability to change. Modifiable risk factors for hypertension include smoking, hypercholesterolemia, diabetes mellitus, sedentary lifestyle, obesity, stress, and alcohol use. Option 1 is not likely to be an issue. Option 3 may or may not be sufficient. Option 4 is contraindicated.

The client should avoid long periods of standing or sitting to promote adequate blood flow. The legs and feet should be below heart level to increase peripheral circulation. Regular exercise enhances development of collateral circulation, increases vascular return, and is recommended for clients with either arterial or venous insufficiency. Moist heat is helpful for venous problems.

The client is exhibiting symptoms of acute arterial occlusion. Without immediate intervention, ischemia and necrosis will result within hours. The nurse should first wrap the leg to maintain warmth and protect it from further injury, and should then quickly notify the physician. The leg should not be elevated above heart level because doing so would worsen the tissue ischemia, and passive range of motion will also increase ischemia by increasing tissue demand for oxygen.

The client with venous ulcers must keep the legs elevated above the level of the heart as much as possible. Elevation of the extremities enhances venous return and improves circulation, providing oxygen and nutrients to the lower extremities. The client with a leg ulcer should avoid exercise to prevent further damage to tissues at risk. Option 1 may or may not be indicated. Asepsis is important, but no ulcer will heal unless the edema and stagnant tissue metabolites can be reduced through leg elevation.

Heat may relieve pain caused by increased joint mobility resulting from hormonal changes. Aspirin (option 3) should be avoided in the last trimester because it increases bleeding time. Option 1 is not a therapeutic communication. Option 2 may not be helpful for maternal–fetal circulation because the gravid uterus may cause pressure on the great vessels in the abdomen. The client should lie on one side; often the left is advised.

A major risk factor for formation of thrombophlebitis is oral contraceptive use in women who smoke. Being 1-week postpartum does not place a client at risk since mobility is usually restored. Anticoagulant therapy is used to prevent development of thrombi. Laparoscopic surgical procedures are associated with more rapid recovery times with reduced immobility, keeping this client at lower risk than the client in option 3.

The open ductus arteriosus will allow a small amount of mixing of oxygenated and unoxygenated blood. Stress will increase the cardiac workload and therefore is a priority for the nurse to avoid. Maintaining caloric intake and comfort are the next priorities using Maslow’s hierarchy. Documenting vital signs is a routine activity and not a priority when compared to actual care activities.

The main complication of rheumatic fever is carditis. The nurse must assess for early signs of bacterial endocarditis. The client should be encouraged to rest during the acute phase, and hydration needs may not be sufficiently met with sips of water. Narcotic analgesics may not be necessary, although NSAIDs are likely to be ordered.

Decreased circulation to lower extremities would contribute to muscle fatigue and pain in the legs. Many of the children returning from recess will have increased respiratory rate secondary to play activities. Blurred vision and bruises are not related to coarctation.

Salicylates prevent platelet agglutination. Gastrointestinal bleeding is often a side effect of aspirin therapy. It is not necessary to avoid other children. Tingling of extremities is not a concern, although ringing in the ears could be a sign of salicylate toxicity. A low-calorie diet is not indicated.

Allowing mobility is helpful to promote growth and development in the toddler. Strategies should be discussed to promote mobility while maintaining the supplemental oxygen. Options 1 and 4 are unnecessary. Signs of oxygen toxicity are not the priority based on the information in the question.

The client would exhibit pain, pallor of the affected skin, diminished or absent radial pulse, parasthesias (altered local sensation), paralysis (weakness or inability to move extremity), and poikilothermia (cooler temperature). The client would not have a bounding radial pulse (opposite finding is true) or pitting edema, indicating a fluid volume excess or heart failure.

A positive Kernig’s sign is common in intracranial hematomas, which is described in option 1. Option 2 is a negative Babinski; with a hematoma, the nurse should expect a positive Babinski (dorsiflexion of the toes in an adult). Option 3 is common in many illnesses; option 4 is specific to Parkinson’s disease.

Corneal abrasion in the client with myasthenia gravis is caused by dryness of the cornea from inability to close the eyelids and blink. It can be prevented by application of artificial tears every 1 to 2 hours. The other options do not address this need.

The nurse should first encourage the client experiencing a loss to express his or her feelings. This answer acknowledges the client’s feelings, is open-ended, and promotes further discussion. Option 2 provides false reassurance. Options 3 and 4 do not address the client’s feelings as shared with the nurse.

The doula is a trained professional who provides physical and emotional support during labor. A doula does not replace either the father or the labor and delivery nurse in the delivery room. The doula is not responsible for clinical tasks and will not deliver the baby.

When the muscles involved in chewing and swallowing as well as the diaphragm and intercostal muscles are weak, the client may aspirate or experience poor gas exchange; both increase the risk for pneumonia. Options that protect the airway always have highest priority. The client is not at risk for hemorrhage (option 1) or pneumonia (option 2). Option 4 may be an element of routine care.

A stiff sore neck is a sign of meningeal irritation and possible meningitis. The nurse may further inquire if flexion of the neck causes pain and the hip and knee to flex (Brudzinski’s sign) and how high the fever is. The other symptoms are typical of influenza.

The first signs of increased intracranial pressure are often subtle changes in level of consciousness. Other changes (including rising systolic BP, irregular respiratory rate, and bounding pulse) come later as intracranial pressure rises further.

It is essential that the client recovering from bacterial meningitis take all of the prescribed antibiotic as directed. Failure to do so puts the client at risk for a relapse of symptoms and contributes to development of bacterial resistance to antibiotics. Options 2, 3, and 4 are important aspects of self-care during recuperation but are not as essential as the completion of antimicrobial therapy.

Urinary retention in the client with multiple sclerosis is a sequela of impaired conduction of nerves innervating the bladder. Performing self-catheterization will drain the bladder and help prevent urinary tract infection. The client with multiple sclerosis will be encouraged to increase fluid intake to prevent constipation. Because urinary retention is incomplete emptying of the bladder, neither running water nor caffeinated beverages would be useful.


Fluid restriction may be needed in the period immediately following a stroke, but this is not necessary after discharge to home. Keeping urine dilute will help prevent urinary tract infection. A fluid intake of 2,000 mL per day will also improve bowel elimination.

What the client describes is a classic ascending progression of Guillain-Barré syndrome. The muscular weakness may ascend to include the diaphragm. Total respiratory paralysis can occur, requiring ventilatory support. The incorrect responses refer to chronic problems, not an acute one.

The client is showing signs of rising intracranial pressure, and infusion of IV fluids leads to hypervolemia and worsens the intracranial pressure. Following Maslow’s hierarchy, choose physiological before psychological answers. A Dilantin level would not be relevant to CVA status. The nurse would want to avoid adding to the client’s volume status by offering fluids, and dehydration is not a concern at this time.

It is important to collect more data to meet client needs. A picture of multiple sclerosis may be unfolding. The nurse takes the time to be therapeutic without providing false reassurance or limiting responses. Open-ended, nonjudgmental responses are ideal.

The LDRP room provides for all phases of the delivery process in one room with the added safety of full hospital services for both mother and infant that home delivery and a freestanding birthing center cannot provide.


The nurse would want to monitor the pin sites for redness, edema, and drainage and would want to ensure that the vest fits snugly. Following the nursing process, a data collection answer would precede an implementation answer (options 3 and 4).

Hemisection of the anterior and posterior portions of the spinal cord results in loss of position sense (proprioception) on the same side of the body as the trauma, below the level of injury. Option 3 is seen in anterior cord syndrome; option 1 is incorrect.


The nurse’s priority is to protect the client from injury. To promote drainage, it is more effective to secure an airway by turning the client onto the side (option 1). Inserting a tongue blade can cause trauma (option 2); the tongue blade may move during the seizure and obstruct the airway. Oxygen should be available but does not have to be applied (option 4).

Mosquitoes, the vectors that transport encephalitis, are found in large numbers in swampy areas. Meningitis can be attributed to overcrowded conditions; Parkinson’s has an uncertain etiology; and risk factors for multiple sclerosis include genetics and family history.

Guillain-Barré syndrome is an acute demyelinating disorder that less commonly may present with initial weakness in the cranial nerves that progresses downward. Impairment of cranial nerves IX and X will affect swallowing.

At this age, a 1-year-old is beginning speech. This child will have trouble developing language because of the spasticity. Urinary incontinence occurs in all 1-year-old children, as does feeding self-care deficit. Thought processes are difficult to evaluate in a 1-year-old.

Observation and documentation of seizure activity can provide valuable information to help in diagnosis and treatment. Once a seizure is in process, it would be dangerous to attempt to insert an airway. Administration of medication would require a physician’s order. Actually restraining the extremities is more likely to inflict injury than prevent it.

In most children, by age 6, the cranial suture lines have fused and the fontanelles are closed, so the first three symptoms would not be common. An altered level of consciousness would be a symptom of shunt malfunction for the older child.

Probable signs of pregnancy are those that are detected by the examiner and are usually related to the physical signs of pregnancy. Amenorrhea and chloasma are reported by the client (presumptive signs) and can be caused by conditions other than pregnancy. Fetal heartbeat on ultrasound is a positive sign of pregnancy.

Drainage of cerebrospinal fluid (a clear fluid) from the ear is a symptom of basilar skull fracture. Children with linear skull fractures are often asymptomatic. Subdural and epidural hematomas present with signs of increasing intracranial pressure.

While families may need education about seatbelts and sources of support, it is not the optimal time to implement such teaching at this point in the crisis. It is optimal to find out what the family’s perception is of what is going on and what they feel their needs are. The best way to determine this is to encourage them to ask questions and express their feelings. Timelines for visitation are appropriate but of less priority than option 3.

In a grade 1 concussion, the client exhibits transient confusion with no loss of consciousness and a duration of abnormal mental status for less than 15 minutes. Grades 2 and 3 concussion consist of more severe neurological symptoms, with increasing levels of loss of consciousness and more significant abnormalities of mental status.

Many salt substitutes use potassium chloride. Potassium intake is carefully regulated in clients with renal failure, and the use of salt substitutes will worsen hyperkalemia. Increases in weight (option 1) do need to be reported to the health care provider as a possible indication of fluid volume excess. The control of hypertension (option 2) is essential in the management of a client with renal failure. An AV fistula does need to be protected from injury that could be caused by constricting clothing, venipunctures, and other items (option 3).

Nephrotoxic drugs, such as aminoglycoside antibiotics (tobramycin), can damage the nephrons and cause intrarenal (within the kidneys) failure. There is no condition called extrarenal failure.

The drug makes the urine reddish orange in color, and the client should be advised that this might stain the underwear and other clothing. The client should also be reassured that it should not be confused with blood in the urine. The use of Pyridium in UTI is controversial because it does not target the cause of the infection. However, it offers relief of UTI symptoms such as pain, frequency, and urgency (option 1). Taking the drug after meals minimizes GI symptoms associated with the use of this drug (option 3). Option 4 is incorrect because the indiscriminate use of a urinary analgesic can mask symptoms and delay initiation of treatment.

Emptying the reservoir bag every 2 hours prevents overfilling and possible leakage of urine into the skin surface. The urine collection device should be changed as needed to maintain integrity of the system. Self-catheterization is not appropriate for this nursing diagnosis. Monitoring for foul-smelling urine and monitoring for signs of infection are more appropriate interventions for the diagnosis risk for infection.

Chocolate, smoked fish, milk products, beans, lentils, and dried fruits are high in calcium. In calcium phosphate and calcium oxalate calculi, dietary management includes an acid-ash diet and limiting foods high in calcium and oxalate.

Peritonitis is a grave complication of peritoneal dialysis caused by bacteria that may enter through the catheter or dialysate solution. Hypotension is a common complication of hemodialysis but not peritoneal dialysis (option 2). Pulmonary embolism and dyspnea are not common complications of peritoneal dialysis.

Urge incontinence is the unpredictable passage of urine soon after a strong urge to void is felt. Option 1 describes total incontinence, option 2 describes stress incontinence, and option 3 describes urinary retention. The pathophysiology, contributing factors, and therapeutic and nursing interventions for the different types of incontinence differ.

Trauma and the use of substances other than water can cause nipples to crack during lactation. The pinch test is to determine if nipples are inverted and need only be done one time.

The symptoms are typical of acute glomerulonephritis. Hematuria and proteinuria are caused by a damaged glomerular capillary membrane, which allows blood cells and proteins to escape into the renal filtrate. A urinary tract infection usually manifests with signs of infection including fever, malodorous urine, frequency, and urgency. Clients with urinary calculi usually present with renal colic. Prostatitis, or inflammation of the prostate gland, also has presenting symptoms similar to a urinary tract infection.

Prerenal failure is caused by factors such as hypovolemia and decreased cardiac output that affect renal blood flow and perfusion. Urethral obstruction (option 2) can cause postrenal failure. Vascular disease and glomerulonephritis may be factors in the development of intrarenal failure.

To reduce the risk of nephrotoxicity, the client who receives aminoglycoside antibiotics should report signs of edema or hypertension and maintain a fluid intake of 2,000 to 2,500 mL per day.

Hypotension is the most common complication during hemodialysis and is related to several factors, including changes in serum osmolality and rapid removal of fluid from the intravascular compartment. Dialysis dementia is a progressive, long-term complication. Infection and fever should be an ongoing evaluation for a hemodialysis client. Hyperglycemia could occur in peritoneal dialysis because of the composition of the dialysate, but it is not of great concern unless the client has diabetes mellitus.

The peritoneum acts as a semipermeable membrane, allowing substances to move from an area of high concentration (the blood) to an area of lower concentration (the dialysate). Metabolic waste products and excess water can be eliminated through osmosis and diffusion utilizing the peritoneum as the semipermeable membrane.

Creatinine is the metabolic end product of creatine phosphate and is excreted via the kidneys in relatively constant amounts. BUN, a measurement of the nitrogen portion of urea, is also excreted in urine and is a good indicator of renal function. However, conditions that increase protein catabolism also cause a rise in BUN levels. Therefore, the serum creatinine levels are more appropriate to evaluate in determining the return of renal function. Neutrophils and lymphocytes are not used to monitor the return of renal function.

Adult polycystic kidney disease is an autosomal-dominant disorder, and the client should be advised to have family members screened for the disease. The management of clients with polycystic kidney disease is mainly supportive. Eventually, clients with this disease require dialysis or transplantation.

The upper abdominal incision site in clients with nephrectomy predisposes them to the development of respiratory complications, particularly atelectasis and pneumonia. The proximity of the incision to the muscles involved in breathing and coughing makes the client breathe shallowly and avoid coughing because of the fear of pain. Adequate pain control is necessary in the care of this client. The other options are not accurate statements.

Clients with renal transplant need to be on long-term immunosuppressive drugs. This predisposes them to infection. The client must verbalize factors that potentially expose him or her to infection. Dietary restrictions must be discussed with the physician and the dietician. The client with renal transplant also needs to verbalize understanding of his or her medications to prevent rejection, including the use of immunosuppressants. However, he or she must adhere to the dose prescribed by the physician. The success of transplantation is not guaranteed.

Maintaining an intake of 8 to 10 glasses of fluid daily will help prevent UTI. Cotton underpants are best, and nylon should be avoided because synthetic fibers dry and irritate the perineal area. Irritation of the perineal area can promote the growth of bacteria. The client should not delay voiding when the urge is felt. Emptying the bladder every 2 to 4 hours while awake is recommended to prevent urinary stasis.

The client who is not eating meat may have a problem with decreased iron intake, which could impact her hemoglobin level. Polymorphonuclear cells, lymphocytes, and platelets are unrelated to iron intake.

Anemia is common in clients with renal failure. Among the factors causing the anemia are decreased production of erythropoietin by the kidneys and shortened RBC life. Erythropoietin is involved in the stimulation of the bone marrow to produce RBCs.

Clients with potassium levels of 6.5 and greater are predisposed to develop cardiac arrhythmias, muscle cramps, and gastrointestinal symptoms. The client should be admitted to a nursing unit with telemetry or cardiac monitoring capabilities because of the risk of developing life-threatening cardiac dysrhythmias. Typical ECG abnormalities associated with hyperkalemia are prolonged PR interval; wide QRS; tall, tented T-wave; and ST segment depression. Major cardiac dysrhythmias common in clients with highly elevated potassium levels include heart block, ventricular standstill, and ventricular fibrillation.

Clients with renal failure retain sodium, and any decrease in the serum level will most likely be caused by hemodilution from the excessive fluid retention. A sodium level of 20 mEq/L is lower than normal.

Typical symptoms of nephrotic syndrome are clear, frothy urine that is diminished in volume. AGN presents with smoky urine that is also diminished in volume. AGN is a postinfectious disease with no genetic basis. Antibiotics are not used in nephrotic syndrome. Oliguria is usually defined as 0.5 to 1.0 mL/kg/hr.

Nephrotic syndrome involves the loss of protein in the urine. Gamma globulins, which help the body fight infections, are proteins. Skin that is not clean and dry is more prone to breakdown, which could lead to infection. The child is oliguric and therefore does not urinate frequently. The only restrictions on the child’s intake are fluid and perhaps sodium. There is no electrolyte deficiency.

Potatoes, tomatoes, and oranges have a high level of potassium content. The others have less potassium in them.

An elevated ASO titer indicates a recent streptococcal infection, which is a precursor to AGN. The elevated ESR indicates inflammation in the body and is associated with many diseases. Hematuria is simply blood in the urine, which has many possible causes. Creatinine concentrations reflect the functioning of the kidney.

Radiological evaluations done after a documented UTI in children reveal structural abnormalities in 1% to 2% of girls and 10% of boys. Radiological tests cannot confirm bacterial colonies, determine the site of an old infection, or help predict whether infection will reoccur.

The minimal urine output by the kidneys per hour is 30 mL. It is prudent for the nurse to report a drop below this amount if it persists for 2 hours or longer so that corrective treatment can be undertaken.

The loss of parietal cells that secrete intrinsic factor results in Vitamin B<sub>12</sub> (cyanocobalamin) deficiency postgastrectomy, because intrinsic factor is needed for absorption of Vitamin B<sub>12</sub>. For this reason, clients require Vitamin B<sub>12</sub> injections for life. The other options identify other B-complex vitamins.

Rubella titer higher than 1:16 is indicative of immunity to rubella. Rubella is a mild illness, and the client may or may not be aware of past infection (option 1). A rubella titer of 1:8 or less does not demonstrate immunity, and avoidance of those with rubella infection is indicated. A level of 1:12 is midway between susceptibility and immunity, so a client with this level is not at greatest risk.

Bowel perforation is a possible result of colonoscopy if the colonoscope accidentally pierces the bowel wall. Perforation could lead to symptoms of peritonitis, such as guarding and rebound tenderness. The other options are incorrect, because diarrhea (option 1), nausea and vomiting as signs of obstruction (option 2), and redness and warmth of abdominal skin (option 4) are not of concern.

A client with an ileostomy has no control over bowel movements and must always wear a collection device. The drainage tends to be liquid but becomes pastelike with intake of specific foods.

Dumping syndrome, in which gastric contents rapidly enter the bowel, can occur following gastrectomy. Dietary fats and proteins are increased, and carbohydrates, especially simple carbohydrates such as fruits, are reduced. This helps slow the GI transit time and reduce the GI cramping, diarrhea, and vasomotor symptoms associated with dumping syndrome.

The pain of a gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as is the pain from duodenal ulcer. The pancreatic juices that are high in bicarbonate are released with food intake and relieve duodenal ulcer pain when the client eats. Chronic aspirin use is irritating to the stomach (option 2). The manifestations in options 3 and 4 are unrelated.

Steatorrhea is often present in the client with Crohn’s disease. Diarrhea is also a key feature, but unlike ulcerative colitis, the loose stool usually does not contain blood and is usually less frequent in number of episodes.

It is suggested that adults consume at least 100 grams of fat per day for 3 days before the test and throughout specimen collection. The other responses provide incorrect information.

Perforation of an obstructed diverticulum can cause abscess formation or generalized peritonitis. The manifestations of peritonitis are abdominal guarding and rigidity and pain. Sigmoidoscopy is contraindicated in cases of perforation. Because treatment of this complication is beyond the scope of independent nursing practice, the physician must be notified.

Lifestyle modifications can minimize symptoms of GERD. Anything that increases intra-abdominal pressure should be avoided, such as lifting weights. Obesity also aggravates symptoms, but a body mass index of 23 is normal. Being a vegetarian does not increase risk, and calcium carbonate tablets often aid in symptom relief.

<i>H. pylori</i> infection is a major cause of peptic ulcers. Treatment includes eradicating <i>H. pylori</i> with antibiotics. The other responses are incorrect.

Many clotting factors are produced in the liver, including fibrinogen (factor I), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The client’s ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood clotting ability; the others will not.

Day care workers are frequently exposed to the virus. Exposure to cat litter can result in toxoplasmosis exposure. IV drug use increases the risk for HIV or hepatitis. Giving blood does not increase the client’s risk.

Manifestations of chronic pancreatitis include nausea, vomiting, weight loss, flatulence, constipation, and steatorrhea (fatty stools) that result from a decrease in pancreatic enzyme secretion. Weight gain (option 1) is the opposite of what occurs with this disorder, while options 2 and 4 are unrelated.

Hemolytic jaundice is caused by excessive breakdown of red blood cells, and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Unconjugated bilirubin is insoluble in water and is not found in the urine.



The T-tube may drain 500 mL in the first 24 hours and decreases steadily thereafter. If there is excessive drainage, the nurse should further monitor the drainage to be able to describe it accurately and notify the physician immediately. Option 1 would be contraindicated; options 2 and 4 are of no help.


Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels, predominantly in the paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. Bleeding gums would indicate insufficient Vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis. Hypothermia is an unrelated finding.

Spironolactone (Aldactone) is used in clients with ascites that show no improvement with bedrest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes potassium retention by inhibiting aldosterone. The other options do not address this rationale.

Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are extended. Option 1 reflects hypocalcemia. Option 2 refers to spiderlike abdominal veins that are also commonly found in clients with cirrhosis who have portal hypertension as a complication. Option 3 is a specific odor noted in liver failure.

It is a common finding that when the infant with an umbilical hernia cries, the hernia protrudes. It is not going to rupture. The family is instructed not to apply tape, straps, or coins to the umbilicus to reduce the hernia.

Indications for cesarean section are presence of a herpes lesion or prodromal symptoms. If there are no herpes symptoms or lesions, a vaginal delivery is recommended.

Pain management is a high priority following gastric surgery, and the nurse should use age-appropriate tools to assess for pain, such as the Wong FACES rating scale. A gastrostomy tube or nasogastric tube placed during surgery is kept in place to maintain gastric decompression. The child is kept NPO until bowel function returns. The use of a pH probe to measure gastric acidity is not necessary.


Measuring urine specific gravity provides data about the concentration of urine and provides information regarding hydration. Urine specific gravity is elevated in dehydration and would be decreased with high fluid intake. The other tests listed are not indicated in the care of the dehydrated client.

In severe diarrhea, excess bicarbonate (base) is lost, which predisposes to metabolic acidosis. There is also carbohydrate malabsorption and depletion of glycogen stores, resulting in fat metabolism. Ketoacids are the by-products of fat metabolism, which add to the metabolic acidosis. It is not a respiratory problem.

ESSR is the abbreviation for the four key steps in feeding the infant or child with cleft lip or palate. These steps are to <i>E</i>nlarge nipple; <i>S</i>timulate suck reflex; <i>S</i>wallow fluid; <i>R</i>est after each swallow. It does not refer to treatment of gastroesophageal reflux, pyloric stenosis, or Hirschsprung’s disease.

It is important that any signs of infection be reported at once. After Soave procedure, the colostomy is usually closed and normal bowel function is expected (options 1 and 4). No rectal irrigations are necessary (option 2).

Acute episodes of celiac disease are characterized by bulky, frothy stools; anorexia; and irritability. Pain does not occur in waves prior to mealtimes.

Parents often react to a child’s illness with feelings of guilt for not recognizing the severity of the condition sooner. A response that provides emotional support and reduces parental anxiety encourages parents to feel confident in their abilities as caregiver. The other responses ignore the parent’s feelings (option 1) or add to the parent’s guilt or stress (options 3 and 4).

Finger foods are helpful in encouraging children with failure to thrive to increase food intake. The parent should also be taught to encourage increased food intake and to make mealtimes regular, nonstressful, but structured family events.

Manifestations of appendicitis often include generalized abdominal pain progressively worsening and localizing in the right lower quadrant at McBurney’s point, nausea and vomiting, fever, chills, anorexia, diarrhea or acute constipation, and elevated WBC count: 15,000 to 20,000 cells/mm3. Fatty stools and indigestion are not part of the clinical picture.

The best way that the nurse can effectively self-evaluate performance of his or her job is to compare individual performance against the written job description. Job descriptions help identify activities that each staff member may perform. The ANA standards of care help set the parameters for minimal standards and should be used as guidelines. Individual state boards of nursing identify the legal boundaries of nursing practice to safeguard the public. The state nurse practice act assists nurse leaders in knowing what tasks are within the scope of their state’s nurse practice act and the scope of practice for their staff members. The job descriptions are designed to support the organization’s work and aid in standards of performance.

All partners have been exposed and should be made aware, tested, and treated as indicated. Cesarean section would be appropriate only if there were symptoms of a herpes lesion or prodromal symptoms. Genetic evaluation and more than routine observation of hematocrit and hemoglobin are not indicated.

Side effects of thyroid hormone replacement medication may mimic symptoms of hyperthyroidism. After the client has reached normal serum T<sub>4</sub> levels, the normal metabolic rate may help the client lose the weight gained during the hypothyroid state, but this is not the purpose of the replacement medication. Usually, the medication should be taken on an empty stomach, 1 hour prior to a meal or 2 hours after a meal.

Bending the knees and squatting is preferred to bending at the waist to reach the floor as a means of preventing rises in intracranial pressure (ICP) following pituitary surgery. Holding the breath as well as leaning over will increase ICP. Clients should be taught to avoid holding the breath for any reason and to avoid leaning forward or bending at the waist to prevent an increase in intracranial pressure. To tie shoes, the client should sit on the couch or bed, bend the knee, and place his or her foot on the couch or bed to reach the shoelaces. Alternatively, the client can sit on the floor to tie shoes or can avoid shoes that tie until there is no risk for increased ICP.

The numbness of the upper lip and gum near the incision as well as a decreased sense of smell are normal and should resolve in 3 to 4 months. The movement of the small rugs suggests an unsteady gait or foot drop; both this and the headache are signs of increased intracranial pressure. In-depth assessments of neuromuscular function and incision site are needed, and then the surgeon should be consulted immediately. The other responses are either excessive or insufficient.

Headache, restlessness, anxiety, sweating, and increased pulse are signs of hypoglycemia. Resolution of symptoms should occur after the client drinks the juice. The other options either delay treatment (options 1 and 3) or fail to recognize the real problem (option 4).

Increased preload caused by the intravenous infusion at 250 mL/hr may exceed the myocardium’s workload capacity, leading to signs of decreased cardiac output and congestive heart failure. The other options focus on inappropriate information.

Decreased level of consciousness, weak hand grasp, and peripheral pulse with increased heart rate and decreased BP result from acidosis. These are signs of respiratory acidosis secondary to hypoventilation from the midazolam. For this reason, option 4 is the appropriate diagnostic reasoning process.

During the first 48 hours after adrenalectomy, clients are at risk for adrenal insufficiency and hypovolemic shock. The lack of cortisol production can cause fluid and electrolyte loss and hypoglycemia. Elevated cortisol does place the client at risk for delayed wound healing and infection, but adrenal insufficiency is more life threatening and more common in the first 2 days following surgery.

The client’s complaints of lack of energy and weight gain are consistent with hypothyroidism, which is diagnosed with a serum T<sub>4</sub>. Considering the client’s complaints of energy deficit, the recent fall causing the sprain, and information about the thyroid medication, the nurse is obligated to consult the physician for T<sub>4</sub> evaluation to prevent further injury. Encouraging the client to rest and investigating the need for a walking splint are appropriate actions but not the first priority.

Clients with either diabetic mellitus or other conditions that have arterial insufficiency as a component of the disorder must constantly protect their feet from injury; observe the skin condition daily; prevent dry, cracked skin; and avoid crossing the legs in order to maintain tissue perfusion and prevent infection. These clients have delayed wound healing and poor sensation in their feet, increasing risk for injury and undetected injury with infection.

Usually, with thyroid surgery, there is minimal bleeding postoperatively. Blood on the gown indicates excessive incisional bleeding. Breath sounds, including auscultating over the tracheal area, and respiratory effort should be checked first to determine if edema is present in the tissues, thus compromising the airway. After thoroughly examining the client and reinforcing or changing the dressing per protocol, the nurse should inform the surgeon of the amount of bleeding and all other nursing data. Options 2 and 3 do not protect the client from possible harm. Option 4 ignores the client’s airway, a high priority following this surgery.

Carrier status of Group B streptococcus is variable, so identification several weeks before delivery may not identify a woman who is positive at the time of delivery. The current recommendation is screening during the 36th to 37th week of gestation. Rash and history of STI do not alter this recommendation.

HHNK is associated with hyperglycemic response to infection or other disease or illness, some medications, dehydration, stress-induced hyperglycemia, or a combination of these factors. HHNK occurs in clients with type 2 diabetes mellitus, primarily the elderly, and thus insulin is not part of the usual treatment plan (option 1). Option 2 is insufficient; 6 to 8 glasses of water are recommended for general health. Option 4 does not demonstrate an understanding of prevention of HHNK.

Diabetic ketoacidosis can occur in diabetic clients with infection and is characterized by elevated blood glucose and ketonuria. Deep, rapid, unlabored respirations are called Kussmaul respirations. Kussmaul respirations, fruity odor, and dry skin are signs of hyperglycemia. Option 2 represents the opposite problem, not the hyperglycemia being displayed. Options 1 and 3 do not address hyperglycemia and ketoacidosis, which is the issue of the question.

Hypothyroidism is associated with fatigue, weight gain, and decreased activity tolerance. There is not enough data to conclude decreased cardiac output or sleep alterations. The client stated she is able to socialize during the day at work.

Myxedema is characterized by severely decreased cardiac output, fluid and electrolyte imbalance, acidosis, decreased respiratory function, tongue edema, and hypothermia. Skin breakdown is a significant risk that needs to be managed concurrently with promotion of oxygenation, but airway and circulation have highest priority.

Hyperparathyroidism causes hypercalcemia. Large doses of saline infusions concurrently with Lasix will stimulate a decrease in serum calcium through renal excretion. In acute situations requiring rapid reduction, clients can be given IV calcitonin and phosphates.

Clients with hypoparathyroidism have low serum calcium levels, paresthesia, mood disorders, muscle spasms, and hyperactive reflexes placing them at risk for falling. They must actively seek to increase their intake of calcium and Vitamin D to maintain therapeutic serum levels in addition to taking their prescribed medication. The other options do not address safety as the critically important need.

Clients with SIADH are usually on a strict fluid restriction to correct water overload; therefore, all fluids (including the enteral feeding and the flush solution) should be considered when planning the fluid restriction. Clients are also encouraged to drink fluids high in sodium, so clients being treated for SIADH should have their feeding tubes flushed with normal saline and not water. To prevent electrolyte loss, all of the residual that is aspirated from a feeding tube should be returned to the client.

The BUN and sodium are elevated because of dehydration and deficient fluid volume, since the creatinine is normal, thus supporting normal renal function. The potassium and chloride are at the higher end of the normal range, which also supports dehydration and fluid volume deficit. Clients with Cushing’s syndrome are at risk for infection because of an impaired immune function related to an elevated cortisol level.

Florinef and other adrenal replacement drugs cause sodium and fluid retention. Clients are at risk for excess sodium and fluid retention leading to fluid volume excess. Risk for infection could apply but is not timely if the client has completed this course of therapy. Impaired gas exchange may result from extensive fluid volume excess that can lead to ineffective breathing pattern. The highest priority is the risk for fluid volume excess.

Glucocorticoid replacement medication can cause fluid and sodium retention, leading to weight gain and fluid volume excess. These medications need to be increased during times of stress and can impair the body’s ability to recover from an infection. Therefore, the physician must be consulted for weight gain or signs of a cold or infection. These medications should be taken in the morning with food and will increase BP (thus are not safe for clients with hypertension), and the medication will not affect cardiac rhythm.

Menstrual blood can affect the results of a gonorrheal culture. Douching within 24 hours can affect results, but diagnosis/treatment of herpes and persistent vaginal discharge would not affect the results, and therefore do not interfere with specimen collection.

A low-phenylalanine diet reduces the amount of toxic metabolites in the body, thus reducing or preventing additional damage. There is no indication of a need to admit the child to a long-term care facility, and babies with PKU have normal life expectancy. No medications are currently being used to treat PKU.

Some teens develop type 2 diabetes, especially those who are overweight. They might need to take an oral hypoglycemic with or without accompanying insulin. Insulin is not used for those who won’t take oral medication. Sweets and complex carbohydrates still need to be restricted. Option 1 does not offer the information that the teen needs about the treatment options.

The child should be seen by the physician because there might be secretion of sex hormones, and precocious puberty may affect linear growth. Although she may be teased in school by the other children (option 3), the main reason for seeking treatment is health promotion. Options 1 and 4 are incorrect statements.

Adolescents need to feel like part of their group, even if it means impairing their health. Displaying risk-taking behaviors is not likely the primary motivation, but rather a secondary event. Option 3 is true but is not likely to be the motivating factor. There is no information to support a self-destructive wish (option 2).

A karyotype is simply a study of the chromosomes. A blood sample may be used to provide the cells for analysis. Options 2 and 3 are incorrect. Option 4 provides no information at all for the child and does not address the client’s concern.

The client with hyperpituitarism will exhibit the following: tall stature if onset in childhood; large hands and feet with prominent jawbone; joint changes consistent with arthritis; deep voice and possible dysphagia; hypertension; organomegaly; and skin changes leading to rough, oily texture. The client would not have a soft voice or be short in stature.

Dead skin and exudates often collect under the cast, and efforts to remove it should be done gradually. The client should be instructed to avoid any vigorous scrubbing of the skin to avoid breaks, which increase the risk for infection. The use of undiluted peroxide is too harsh for the skin. There is no reason why the leg cannot be touched after removal of the cast.

Impaired physical mobility is the appropriate priority nursing concern for a client with Paget’s disease. The client needs to remain active to decrease the complications associated with immobility and to maintain the ability to perform self-care activities. The other concerns, although appropriate, are not the priority in clients with Paget’s disease.

This symptom suggests neurological injury caused by pressure on nerves and soft tissue because of swelling. Other symptoms of neurovascular compromise should be monitored and reported to the physician.

Elevated temperature is a classic symptom seen with osteomyelitis as a systemic response to the invading organism. Pain, swelling, and tenderness may also accompany the fever. Acute respiratory distress (option 3) is more suggestive of embolism but not infection. The extremity does not shorten.

Urine-specific gravity is a measure of the concentration of particles in the urine. Urine-specific gravity rises when the client is dehydrated. Hematocrit would also rise when dehydrated, but is an indirect measure. Hemoglobin measurements are not as greatly affected. Platelet count and IgG levels are not affected.

Aspirin therapy for this condition is continuous and is effective only after a therapeutic level is reached. It should not be taken intermittently (option 1). The other options are correct statements about self-care measures when taking aspirin for degenerative joint disease.

Immediately after surgery, the client will be inclined not to move because of pain and fear of disturbing the operative site. Minimal scarring results from this surgery, so body image disturbance is not likely to be appropriate (option 1). The psychosocial concerns in options 2 and 3 have less priority than option 4 because option 4 is a physiological concern.

Elevating the limb on a pillow facilitates venous return, decreases swelling, and promotes comfort. The stump dressing is usually a compression type to mold the stump and to decrease the edema associated with inflammation, so option 2 is an inappropriate intervention. The other options are also inappropriate because option 3 increases risk of edema and option 4 is done as ordered.

Traction, to be effective, must have an opposing force (countertraction). The aim in traction is to maintain a constant force to align the distal and proximal ends of a fractured bone. Options 1, 2, and 4 violate this principle of traction in the treatment of fractures. Centering the client in bed maintains the line of pull and ensures that countertraction is maintained.

Prolonged sitting or standing aggravates back injury because of the additional stress placed on the structures supporting the back. Lifting objects close to the body, shifting positions frequently, and providing back support are appropriate actions to maintain good body mechanics.

The physician orders the client’s activity after a laminectomy. After a laminectomy procedure, a client should be assisted to logroll from side to side. The principle is to maintain the alignment of the vertebral column at all times. Clients with lumbar laminectomy should be kept flat or with head of bed slightly elevated to minimize stress on the suture line. Using the side-rails to get out of bed causes shifting of the vertebral column. Sitting up in a chair or on the side of the bed is usually done the evening of the surgery or the first day following surgery, and it is for brief periods only.

Smoking has been found to contribute to disk deterioration. Lack of exercise predisposes the muscles of the back to strain. The extra weight of obese individuals imposes more strain on the back and also interferes in maintaining good body mechanics in lifting. Occupations that require prolonged sitting or standing predispose those individuals to exacerbation of back pain. Option 1 is the only answer that accurately reflects risk factors associated with chronic low back pain for the client described in the question.

A combination of calcium and Vitamin D is recommended for the prevention of osteoporosis. Vitamin D increases the intestinal absorption of calcium and mobilizes calcium and phosphorus into the bone. Vitamin D alone does not prevent osteoporosis (option 2). Whereas some elderly might be deficient in Vitamin D, a postmenopausal state does not necessarily cause the deficiency (option 3). There are other interventions for the prevention of osteoporosis, including lifestyle modifications (e.g., smoking cessation), which makes option 4 inaccurate.

A complication of cast application is skin breakdown underneath the cast. If this occurs, infection can set in and can cause the area over the breakdown to be warmer than other areas. A bad odor coming from the area may also be noted. Option 1 is inaccurate because generally plaster casts dry in 48 hours or less and fiberglass casts in 30 minutes to 1 hour. If a cast is too tight, symptoms associated with neurovascular compromise will be noted, which include pain, paresthesia, pallor, diminished pulse distal to the cast, and paralysis (option 4).

The client’s knee will externally rotate if there is insufficient space between the client’s hip and the machine. The knee should be upright, facing the ceiling, as the machine moves the leg back and forth.

Because it frequently involves tissue trauma that facilitates invasion of pathogens, anal intercourse is considered a high-risk sexual behavior. As such, it could lead to contraction of an STI. The other factors listed here do not increase the client’s risk for contraction of an STI.

Pain and absent pulse in the affected extremity are urgent signs requiring immediate intervention. Impairment of circulation in the affected limb initiates various pathophysiologic processes, including destruction of nerves and tissues. If this state is uninterrupted, loss of the limb may occur. The nurse needs to ensure that the leg is not above heart level so no further damage occurs. The physician needs to be notified immediately so medical interventions can be instituted before irreversible tissue and nerve damage occurs.

It is essential to monitor the condition of the skin under traction, as well as bony prominences, because these areas are at risk for breakdown due to continuous friction and pressure from the skin traction device. Option 2 is incorrect because Buck’s traction is a type of skin traction. Skeletal tractions use pins, wires, or tongs to aid in realignment. Option 3 is appropriate, but the most essential assessment to be documented for a client with skin traction is the condition of the skin underneath the straps.

Balanced suspension allows for ease with bedpan use and skin care without disturbing the line of traction. In this type of traction, the client’s injured extremity is lifted off the bed and a straight pull is accomplished by the application of several forces and several weights. Skin breakdown is not eliminated with this type of traction because any immobile client can be at risk.

Colchicine is used in treating the acute attack of gout. The symptoms described are signs of toxicity. The client should be instructed to stop the medication and be seen for follow-up treatment. The expected effect of colchicine is to diminish the joint pain associated with the acute attack.

Age, site of the fracture, and blood supply to the affected area all affect the rate of bone healing. Young and healthy individuals prior to the injury will have faster bone healing than the elderly and those with chronic illnesses. Although physical therapy will assist in mobility, it does not directly enhance bone healing. The weight of the client, unless accompanied by malnutrition, does not have a direct bearing on bone healing.

In a closed reduction procedure, the physician applies traction and manipulates the bone until the broken ends are realigned. Open reduction is a realignment of bone with surgery (option 2), and internal fixation devices are surgically inserted during an open reduction to immobilize the fracture during the healing process (option 4). Endoscopy (option 1) is not a surgical modality for reducing fractures.

The history of a child with osteomyelitis may include a recent upper respiratory infection (which may include an ear infection or sinus infection), skin infection, or blunt trauma to a bone. Gastroenteritis would not be found in the recent history of this child that would lead to this illness. LCPD and CHD do not lead to osteomyelitis.

A very swollen hand despite application of ice and elevation is a grave concern, especially with the child complaining of numbness. Such swelling can lead to compartment syndrome, which can lead to neurological damage. This is a medical emergency, and the physician should be called immediately. The nurse can then provide diversional activities while waiting for definitive orders.

The infant who is carried with the hips abducted is at decreased risk for developing developmental dysplasia of the hip. Options 1, 2, and 4 are all factors that would possibly increase the incidence of this defect.

Pain must be managed properly in the child after spinal fusion in order for the client to participate in respiratory exercises. Logrolling and repositioning, as well as coughing, deep-breathing, and use of incentive spirometry should be done every 2 hours around the clock with this postoperative client. Providing adequate pain relief will enable the client to carry out these important activities.

Closed-ended questions are a barrier to communication in many nurse–client interactions. They are best used when trying to elicit very specific pieces of data collection. Use of open-ended questions, framed in a culturally sensitive and nonjudgmental approach, tends to establish a trusting and open relationship with the client and enhance client disclosure. Conducting the interview with the client dressed may also increase overall client comfort and aid in client disclosure.

The symptoms described are symptoms of osteomyelitis. This disease can result from a penetrating wound, but it also may result from an infection elsewhere in the body that traveled to the bone. Osteomyelitis may follow an upper respiratory infection, which is common in school-aged children.

6. Assume a <i>tripod position</i> (crutches out laterally in front of feet, approximately 6 inches, with feet slightly apart for balance before moving; not part of original answer).

Tanning and sun exposure can increase susceptibility to skin cancers. This is a potentially harmful activity and should not be included in client teaching. The other items are important to discuss with clients who are trying to maintain healthy skin.

Methotrexate is used for severe and nonresponsive cases of psoriasis. It is not a first-line form of therapy. Options 1, 2, and 3 are first-line treatments for psoriasis.

Whiteheads are classified as closed comedones. Blackheads are open comedones. Options 3 and 4 are irrelevant.

No medication is indicated for seborrheic keratosis (options 1, 2, and 3). These lesions may be treated with electrocautery or liquid nitrogen for removal.

Contact dermatitis is an inflammatory response following prior sensitization to an antigen with production of a specific IgE antibody. Skin manifestations occur with subsequent exposures. The other options are false.

Fungal infections such as tinea corporis may be transmitted by direct contact with animals and other persons. Therefore, it is contagious from person to person. It does require treatment, is not malignant, and is not treatable by sunlight.

A full-thickness burn involves all layers, including the epidermis and dermis, and may extend into the subcutaneous tissue and fat. The other options indicate varying depths of burn injury.

The most important question for this office visit for evaluation of a skin rash would be to get information about the chief complaint. In this case, it would be to investigate additional information about the presenting rash. The other options are either unrelated or could be asked at a later time.

Bloody mucus is often called <i>bloody show</i> and becomes more profuse during the late active phase and into the transition phase of the first stage of labor and during the second stage of labor. Fetal bowel movements are not blood-tinged. Rupture of the amniotic sac would produce a clear watery fluid. There is no correlation of blood-tinged mucus during labor with injury sustained through walking.

When examining petechiae, pressure applied to the site will not produce blanching of the skin. For other lesions, blanching may occur. Options 1, 3, and 4 are false.

Skin care for eczema should include keeping the skin well hydrated and avoiding harsh soaps (option 2). This can be done by using mild bath soaps and applying emollients immediately after bathing (option 4). Option 3 is false.

Antihistamines are useful to help relieve itching. The other options do not explain the rationale for the use of this type of medication with psoriasis.

Coal tar shampoos are recommended for seborrheic dermatitis of the scalp. Over-the-counter shampoos may not control symptoms. Seborrheic dermatitis cannot be cured. Symptoms can be controlled with proper treatment.

The most common form of skin cancer is basal cell carcinoma, with approximately 400,000 new cases per year. Protecting the skin with sunscreen SPF 15 or higher, along with avoiding the sun during the peak hours of 10:00 a.m. to 2:00 p.m., is recommended to help prevent skin cancer.

Infection may be manifested by fever, chills, erythema, tenderness, and drainage at the site, especially if it is cloudy or serous. The physician must be notified if these symptoms occur.

Clients with cellulitis experience pain at the local site. Controlling the pain is the priority nursing concern for this client. Option 1 may not apply unless the client is in pain. Options 2 and 3 may or may not apply, but would have lower priority than the physiological need (option 4).

Current treatments for psoriasis include coal tar shampoo and topical steroids. Folliculitis, cellulitis, and furuncles are bacterial infections of the skin and would be treated with antimicrobial therapy.

The initial outbreak of herpes is the most uncomfortable or painful. Recurrent episodes of herpes infection present with a prodrome of symptoms, such as tingling and burning. Herpes is a virus that may lie dormant for periods of time, and repeated episodes may occur during periods of stress.

To meet all four criteria for removal of a lesion, the lesion will be asymmetrical (A) with an irregular border (B), have color change or more than one color (C), along with an increased diameter (D).

Vasodilation occurs with epidural analgesia and anesthesia, which can result in hypotension. The client who is hypotensive after epidural administration should be turned to a left lateral position and have the IV fluid rate increased. This will increase the circulation to the fetus and increase circulating volume, respectively.

Spider angiomas are red lesions with vessels radiating from the center. A venous star is a flat, blue lesion with radiating linear veins. Petechiae appear as red “freckles” or dots. A port wine stain is a flat, irregular-shaped lesion that does not have radiating vessels.

Stage 4 ulcers result in full-thickness skin loss with extensive damage to the muscle and bone.

Coughing and wheezing may indicate that the child has inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this situation. Skin color changes are expected. Thirst may be present but does not require immediate nursing action.

Eczema is a chronic inflammatory skin disorder. School-aged children are very aware of their own and others’ skin appearance. Children with eczema will feel different from other children, and this may affect their body image. Food allergies do not relate to decreased nutrition. Eczema does not affect the skin’s ability to maintain temperature, and it does not affect blood flow to the area.

Infants with eczema frequently have food sensitivities. Slow introduction of new foods allows the parents to recognize food sensitivities and eliminate the offending item from the diet. The mother is taught to avoid scratchy clothing such as wool. Childhood immunizations would be given as scheduled but do not reduce risk. Eczema is not an infectious disease. Avoiding infectious personnel is appropriate for all children but does not prevent the development of eczema.

The nurse should encourage parents to identify and discuss their feelings and concerns. Changing the topic or giving false reassurance is inappropriate. Merely not blaming parents does not give them the opportunity to discuss what is important to them.

Until a complete examination and treatment plan are initiated, the child should be kept NPO. A complication of major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be provided.

The best method to improve communication with the client is to eliminate background noises that could interfere with hearing. The client should be approached from the front so as not to frighten him or her. The nurse should use normal pronunciation of words, speak in normal tones, and refrain from shouting, which is demeaning and not helpful.

Ear pain is the most common symptom of otitis media that motivates clients to seek health care; secondary or associated symptoms include fever, nausea and vomiting, dizziness, and hearing impairment.

Myringotomy is a surgical procedure that perforates the tympanic membrane to allow drainage from the middle ear. Postoperatively, the client should avoid getting water into the ear canal, which could potentially enter the middle ear. The other activities are not risks to the client.

Narcotics given for pain relief in labor are most often given intravenously so that the medication will have a rapid onset and a relatively short half-life. This desired drug profile will provide maternal benefit while preventing neonatal respiratory depression.

Presbycusis is the most common form of sensorineural hearing loss in older adults. Otalgia is an earache; otitis externa is infection in the external auditory canal and can occur in clients of any age. Meniere’s disease is an inner ear disorder that primarily affects middle-aged adults.

The client should avoid lying on the operative side following eye surgery in order to minimize edema and intraocular pressure. Options 3 and 4 pose no risk to the client. Option 1 is not a problem given the information in the question. Some clients with severe visual impairment or other health problems may need assistance to move about in the environment.

When hearing loss is characterized by distortion of sounds, amplification of sound is of little help because it only increases the intensity of distorted sounds. The other options are incorrect.

Vertigo, tinnitus, hearing loss, and a sense of fullness in the ear are classic symptoms of Meniere’s disease. Nystagmus also occurs with acute attacks. Headache, double vision, and pain are not part of this clinical picture. Purulent drainage suggests infection.

Antivertigo and antiemetic medications, such as meclizine, are used to control symptoms associated with Meniere’s disease. Diuretics are used between acute attacks to reduce the volume of endolymph and prevent attacks. Glucocorticoids (option 2), beta-blockers (option 4), and analgesics (option 3) are not part of an effective treatment plan.

Pilocarpine is a miotic agent, which constricts the pupil and thereby stimulates the ciliary muscles to pull on the trabecular meshwork surrounding the canal of Schlemm, which increases the flow of aqueous humor and decreases intraocular pressure.


Clients with retinal detachment frequently report flashing lights and loss of vision, commonly described as a veil or curtain being drawn across the eye. Retinal detachment is not associated with increased lacrimation or tearing (option 1), eye pain (option 3), or change in ocular movements (option 4).

Medications that end in <i>-olol</i> are beta-adrenergic blocking agents. When taken as ophthalmic preparations, they can produce systemic effects such as bradycardia, hypotension, and bronchospasm. Beta-adrenergic blockers act as CNS depressants and may also be used to treat anxiety, but this does not relate to the issue of this question, which is glaucoma.

Atrophic or dry macular degeneration results from atrophy and degeneration of the outer layer of the retina. In exudative or wet macular degeneration, blood leaks into the subretinal space and scar tissue gradually forms. The resulting loss of vision occurs rapidly and is more profound. Exudative macular degeneration accounts for 90% of all cases of legal blindness.

Paracervical block is given during the active and transitional phases of labor to block the pain sensations of the dilating cervix. It has no effect on the perineum and would offer no analgesic effect during episiotomy repair. The other options affect the perineum and would offer analgesia during suturing of the episiotomy.

Scleral buckling is correctly described in option 1. It is used in conjunction with laser photocoagulation or cryothermy to achieve the best results. Option 2 defines pneumatic retinopexy. Options 3 and 4 are incorrect.

Prevention or reduction of intraocular pressure (that may accompany blunt trauma to the eye) can be accomplished by the use of semi-Fowler’s position and administration of a carbonic anhydrase inhibitor, such as acetazolamide (Diamox). Semi-Fowler’s position also reduces edema formation at the site of injury when compared to lying flat. Constriction of the pupil with miotics is not indicated. Blunt trauma does not cause loss of intraocular contents; and no foreign body is present.

The client should avoid activities that raise intraocular pressure, such as bending over. The client should sleep on the nonoperative side. Activities involving the eyes are done at the advice of the surgeon. Typically, an eye shield is used at night, and dark protective glasses are worn during the day.

To perform the Weber test, the nurse places a vibrating tuning fork on the midline vertex of the client’s head. The sound should normally be heard equally in both ears. Sound that lateralizes to one side indicates either conductive hearing loss on that side or sensorineural hearing loss on the opposite side.

The client should lie on the affected side following the irrigation to allow gravity to further assist in draining the ear canal. The irrigant should be directed along the wall of the external canal, not the center (which could damage the tympanic membrane). Usually, 50 to 70 mL of solution are used, according to the size of the syringe used for the procedure. A single cotton ball is placed loosely into the external meatus to absorb any remaining irrigant after the procedure.

Warm compresses, not cold, should be used as part of the management of conjunctivitis. Warm compresses help relieve discomfort and reduce inflammation by increasing circulation to the area. The other options contain items that are part of the standard collaborative management for conjunctivitis. Dark sunglasses are helpful in reducing photophobia.

The nurse should apply pressure to the inner canthus (nasolacrimal duct) during and for at least 30 seconds following instillation, according to agency procedure. Doing so will help prevent systemic absorption of the medication. The medication should be dropped into the lower conjunctival sac. The eye should not be rubbed after instillation of the medication. The nurse should wait from 1 to 5 minutes between drops, depending on the medication and manufacturer’s recommendations.

It is appropriate to comfort the child following a painful procedure. Option 1 provides support and comfort. By fulfilling the child’s request, the nurse allows the child to regain some control over the situation. It is not appropriate to argue with the child.

A febrile infant is at risk for fluid volume deficit resulting from larger-than-normal insensible fluid losses and decreased fluid intake. It is contraindicated to sponge with cool water or add blankets. Intake of solid food is less important than preventing dehydration.

Symptoms of pharyngitis are sore throat and difficulty swallowing, which could lead to the refusal to drink. Thus, risk for deficient fluid volume is an appropriate diagnosis. Option 2 would apply when the client cannot clear secretions from the respiratory tract, which is not applicable to this question. Options 1 and 4 are not pertinent to this health problem.

The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning, and evaluation is the registered nurse. LPN/LVN functions include reinforcing teaching and removal of dressings. However, LPN/LVNs are not allowed to administer IV push medications and should refuse this assignment as it falls outside of their scope of practice.

Abdominal palpation will give limited information about uterine contractions, especially if the client is either very thin or obese. The client’s description of the contractions will be influenced by her culturally based expression of pain as well as by her previous pain experiences and pain threshold. The tocodynamometer, or external uterine transducer, will detect the onset and end of contractions in most women but does not assess intensity of the contractions. Additionally, if the client is either very thin or obese, the fetal monitor tracing will either exaggerate the contractions or minimize them. Internal contraction monitoring through the use of an intrauterine pressure catheter will objectively measure the contractions in mm of Hg and is the most accurate method of contraction monitoring.

Humidifying the air can prevent dry mucous membranes and recurrence of epistaxis. Other options do not correctly identify the benefit of humidity for a client with recurrent nosebleed.

Children of this age cannot understand the necessity of cooperating with medication administration. Mummying the child reduces the risk of injury from the ointment tip and promotes adequate dosing. Applying ointment to the eyes of a sleeping child would increase the child’s fears. The ointment is instilled in the lower conjunctival sac, not on the lids.

Typical instructions after fluorescein angiography include increased fluid intake to aid in dye excretion. The client should know that the dye causes temporary skin discoloration in the injected area and temporary green discoloration of urine that resolves when dye is fully excreted. The client should avoid sunlight or other bright light sources for several days until pupil dilation returns to normal. Although the client should rest after the procedure, it is not necessary to lie down with eyes closed for 12 hours. Headache and blurred vision are not expected.

Clients with polycythemia experience satiety and fullness resulting from hepatomegaly and splenomegaly. Frequent, small meals will help maintain adequate nutrition. Foods rich in iron are not appropriate because there is an increase in erythrocytes in this condition. Spicy foods will increase the gastrointestinal symptoms, which also include dyspepsia and increased gastric secretions.

Clients with thrombocytopenia have decreased platelet counts below 150,000/uL. The usual presenting manifestation of this condition is the appearance of petechiae, purpura, and ecchymosis. The other laboratory values will not explain the petechiae or support the presence of a clotting disorder.

Clients with aplastic anemia usually experience pancytopenia (decreased erythrocytes, leukocytes, and platelets). The client with this type of hypoplastic anemia should therefore have a room where reverse isolation can be instituted. The client with aplastic anemia is susceptible to infection as well as hemorrhage. Respiratory isolation requiring negative airflow (option 3) is not necessary in the care of clients with aplastic anemia.

In DIC, there is abnormal initiation and formation of blood clots. As clots are formed and then begin to dissolve, more end products of fibrinogen and fibrin are also formed. These are called fibrin degradation products or fibrin split products. Although the PT and PTT are prolonged and the platelet count is reduced in DIC, they could also be a result of other coagulation disturbances. Only the increase in FDP would occur because of the widespread accelerated clotting present in DIC.

Initially, there is an enhanced coagulation mechanism with resulting increase in fibrin and platelet deposition in arterioles and capillaries in DIC, resulting in thrombosis. Although it remains controversial in DIC, the use of heparin is aimed at preventing the formation of additional thrombotic clots that further complicate the bleeding disorder.

Clients with DIC should be protected from injury that will result in bleeding. An oral swab is least likely to cause tissue injury to the oral cavity during the performance of oral care. Mouthwashes containing alcohol should be avoided because they may cause discomfort and because they tend to dry the mucous membranes. Toothbrushes may be used only if they are soft-bristled, but a swab or toothette is the best option.

Hydrogen peroxide is not a good choice of mouthwash solution in clients with stomatitis because it tends to dry the oral mucosa and further aggravate the discomfort. The other three options are acceptable mouthwash solutions; diphenhydramine (Benadryl) or Maalox may also be used.

Women receiving intrathecal narcotics for labor analgesia often experience adverse effects such as urinary retention, nausea, vomiting, and pruritus (itching). A Foley catheter is routinely used to allow for urinary elimination. Fetal movement is not affected by intrathecal narcotics.


Histological isolation of Reed-Sternberg cells in lymph node biopsy examination is a diagnostic feature of Hodgkin’s lymphoma. Philadelphia chromosome is attributed to chronic myelogenous leukemia. Viruses are much smaller than can be visualized with cytology.


Clients with thrombocytopenia are at risk for altered cerebral perfusion from bleeding. Since a neurologic examination can assist in determining the presence of occult bleeding in the cerebrovascular system, it is a necessary nursing intervention to include in the care of these clients.

In anemia, there is a decrease in the viscosity of blood as a result of a decrease in the number of red blood cells. The increase in cardiac output and flow are compensatory mechanisms because of the decrease in the quantity of hemoglobin in circulating blood.

Activity intolerance in clients with anemia results from the imbalance between oxygen demand and supply. Activities should be planned to intersperse activity with periods of rest to decrease hypoxemic episodes and to decrease tissue demand for oxygen. All the other options are appropriate interventions for a client with anemia, but they do not relate to the nursing diagnosis of activity intolerance.

Clients with hemophilia should be taught to participate in noncontact sports and to avoid any activities that increase the risk of tissue injury and bleeding. Clients with hemophilia should never use aspirin because of the risk for bleeding. Joint pain may be caused by hemarthrosis (bleeding in the joints), a situation in which the client should be taught to seek medical care immediately. Iron-rich foods are not appropriate in clients with this condition unless there is an accompanying anemia.

Aplastic anemia may be congenital or acquired, but most cases do not have an identifiable etiology. It is known that aplastic anemia may follow exposure to chemicals (e.g., Benzene, DDT) or drugs (chloramphenicol, sulfonamides). It is therefore important that the nurse obtain exposure history on this client.

A client with neutropenia has a compromised immune system and is predisposed to infections. Fresh fruits and flowers in the client’s room are not allowed because they tend to harbor bacteria. All the other options are reasonable instructions to be given to visitors as well as health care personnel who come in contact with the client.

A platelet count below 20,000 indicates that the client is at risk for bleeding and necessitates the avoidance of activities and interventions that increase this risk. Nursing interventions such as the use of intramuscular injections, rectal temperatures, and shaving with a razor are activities that predispose the client to further injury. Reverse isolation is not appropriate for this client unless there is accompanying evidence of neutropenia.

Objective signs of pain relief include decreased muscle tension as evidenced by unclenched fists; relaxed facial muscles and decreased grimacing, frowning, or creasing of the brow; and slightly lowered blood pressure, pulse rate, and respiratory rate. Frequency of uterine contractions would not be affected by relieving pain through nonpharmacological methods.

Application of direct pressure and pressure dressing should follow the withdrawal of the aspiration needle after a bone marrow aspiration. If the client has thrombocytopenia, pressure should be applied on the site for at least 3 to 5 minutes or until hemostasis has been achieved. The other options are not appropriate following a bone marrow aspiration. Continued observation of the site should be made to assure that there is no bleeding.

A shift to the left indicates an increase in immature neutrophils or bands. An increase in the number of bands indicates an increase in the production of granulocytes, which could be a compensatory mechanism in response to infection.

The morphologic characteristics of RBCs in iron-deficiency anemia is microcytic and hypochromic. Vitamin B<sub>12</sub> anemia produces a macrocytic and normochromic morphology. Aplastic anemia, hemolysis, and acute blood loss will reveal RBCs with normocytic and normochromic characteristics.

Reticulocytes are immature RBCs. An increase in the number of reticulocytes indicates the body is producing new RBCs. Iron intake does not indicate an improvement in anemia status, and the child with anemia is not cyanotic but pale. An increase in activity is hard to measure subjectively and would be a late finding.

Sickle cell is inherited as an autosomal recessive disorder. Both parents must carry the defective gene. The other statements are factually incorrect.

Hemophilia is characterized by a deficiency in one or more clotting factors, while ITP is a platelet disorder. Because the child with ITP is not deficient in clotting factors, this treatment would not be beneficial.

Clients with anemia will experience activity intolerance with even the simplest activities of daily living. There is no vaso-occlusion or abnormal platelet count with anemia. There may be insufficient cardiac output, but it will not be related to platelet count. There is no information in the question to indicate that the anemia is secondary to poor diet.

Frequent blood transfusion will lead to an overload of iron in the body. This iron is stored in tissues and organs and is called hemosiderosis. Blood transfusions do not lower the white count or cause petechiae or hemoglobin in the bile.

Clients with nutritional anemias require dietary sources of folic acid, such as green, leafy vegetables; fish; citrus fruits; yeast; dried beans; grains; nuts; and liver. Apples and carrots are not as rich in folic acid as the other food sources listed.

There is great potential for alteration in bowel function (adynamic ileus) because of surgery and radiation to the abdominal area and the use of chemotherapeutic agents. This is an intrarenal tumor, so neurological status and bone pain are not related manifestations. Activity level would not be a specific examination to make with this diagnosis.

The pain of labor and childbirth has both physiologic and psychologic components. A support person’s presence has been shown to decrease the perceived pain of childbearing. However, the expression of pain through nonverbal cues or verbalizations is highly culturally based (not universal), having been learned in early childhood.

Diabetes insipidus presents with symptoms of increased urinary output and very dilute urine. Urinary specific gravity will measure the concentration of the urine. Blood glucose and BUN are unrelated to the issue of the question. ACTH levels are not routinely monitored in any client.

Bone marrow suppression occurs with radiation therapy, which can lead to risk of infection when white blood cells are affected, bleeding when platelets are affected, and anemia when red blood cells are affected. Constipation and hemorrhagic cystitis occur after chemotherapy. If appetite is affected, it decreases rather than increases.

Because infant kidneys do not concentrate urine as well as the kidneys of adults, urine volume and specific gravity may not indicate fluid volume as accurately as will daily weight. Weight loss can be directly tied to fluid loss. Hemoglobin and hematocrit could rise and fall because of hemodilution or hemoconcentration, depending on fluid status, but these levels would be indirect indicators with large changes in fluid status and therefore not specific fluid balance measurements.

In leukemia, the WBCs that are present are immature and incapable of fighting infection. Increases or decreases in the number of WBCs can be related to the disease process and treatment and not related to infection. The only value that indicates the child is infection-free is the temperature. The use of proper handwashing technique is a measure or intervention used to meet a goal but is not a goal itself.

Only regular insulin is administered in solutions administered by the IV route. Monitoring blood glucose and I&O is appropriate. The child is usually anorexic but will be allowed to eat any food that appeals to him or her.

When a client is lying flat, the blood flow to the brain is greater, increasing the intracranial pressure. If the client sleeps in semi-Fowler’s position, less pressure will develop, which in turn should ease headaches. Excess liquids and blowing the nose could aggravate headache. Discouraging bowel movements will reduce straining but is not a helpful measure from a gastrointestinal perspective.

A person taking steroids may have increased blood pressure, increased appetite, and weight gain. Alopecia is related to chemotherapeutic agents that may be used to treat the leukemia.

While all of the above are potential risks to clients with cancer depending on site, edema of the face and arms results from obstruction of blood flow, which is indicative of superior vena cava syndrome. Spinal cord compression would give rise to neurological symptoms. SIADH would result in general fluid overload, and sepsis would be noted by signs of infection.

T2 indicates a measurable tumor, N0 indicates no regional node involvement, and M0 indicates no evidence of distant metastasis. Options 1, 3, and 4 are either partially or totally incorrect.

Radiation is palliative treatment for spinal cord compression to reduce the tumor size and relieve compression. Options 1, 3, and 4 are incorrect statements.

Prolonged latent phase of labor is defined as greater than 20 hours in primigravida women and greater than 14 hours in multigravida women. Encouraging rest and relaxation during this phase will help the client have enough energy to push effectively during the second stage of labor. Music is often used effectively to induce relaxation. Encouraging a well-rested client to ambulate will also facilitate the latent phase. Intravenous hydration is given to women who are unable to take oral fluids. Internal monitoring is indicated if labor is being augmented or induced, the amniotic fluid is meconium-stained, or there is evidence of fetal distress by external monitoring. During the first stage of labor, maternal vital signs are obtained every hour.

Oxygen and IV access are immediate interventions for the client with cardiac tamponade. Vasopressor agents will be administered to manage hypotension (option 1); a pericardiocentesis is performed, not a thoracentesis (option 3); and radiation therapy is not indicated for cardiac tamponade (option 4).

Prostate cancer has surpassed lung cancer in order of occurrence; colorectal cancer is the third-most common cancer. Options 1, 3, and 4 are incorrect.

Because of the immunosuppression, the client is at severe risk of infection. Precautionary measures such as a private room and protective isolation must be instituted to protect the client from sources of infection. The client with pneumonia (option 1) poses a risk of infection, contact isolation (option 2) is not necessary, and option 4 does not provide the client with the necessary isolation precautions.

Smoking and drinking large quantities of alcohol daily increase the risk of oral and esophageal cancers. Options 1 and 2 are risk factors of development of other types of cancers. Option 3 is unrelated.

The lymph node biopsy is performed to assess any metastasis from the primary site of cancer, and a common metastatic site for breast cancer is regional lymph nodes. Options 1, 2, and 4 are incorrect statements.

The nurse should be concerned because painless bleeding not related to the menstrual cycle is often the only symptom of uterine cancer. Postmenopausal bleeding is not normal, with or without pain. Anemia is not an immediate concern. Pain is often considered to be a late sign related to the diagnosis of cancer.

A very dark red output character following prostatectomy may indicate venous bleeding or inadequate dilution of the urine. The Foley catheter is at risk for occlusion. Increasing the irrigation flow will prevent the formation of blood clots and occlusion of the catheter. If the urine does not clear, then it would be appropriate to notify the physician. Although reviewing the latest hemoglobin and hematocrit may be appropriate, it is not the most pressing intervention the nurse must do following prostate surgery.

Ovarian cancer generally causes no warning signs or symptoms in the early stages, which is why screening is important. Painful urination, pelvic pain radiating to the thighs, and low back pain are not associated with this health problem.

Option 2 describes stage II ovarian cancer. Option 1 describes stage I, option 3 describes stage III, and option 4 describes stage IV.

Option 2 describes a radical mastectomy. Option 1 describes a modified radical mastectomy; option 3 is a simple mastectomy; and option 4 is a lumpectomy.

Cultural beliefs and practices are inseparable from the labor and birthing experience. The LPN must consider culture when caring for the laboring client. Maternal hydration status would be indicated, but nutritional status is not indicated during the birthing admission. Choosing a nurse-midwife or physician is based on many factors, and the nurse’s role is to follow the protocols of the appropriate care provider, not to be judgmental or question a client’s decision. Asking about names can be a cultural taboo.

Clients with three-way Foley catheters usually complain of sensations of having to void despite the presence of the catheter. This urge to void is caused by the pressure exerted by the balloon in the internal sphincter of the bladder and the wide diameter of the catheter that is used for the purpose of irrigation. Antispasmodics may be prescribed for the client with a three-way irrigation catheter. A TURP involves the insertion of a resectoscope via the urethra. The complaint of having the urge to void is common with clients undergoing bladder irrigation. Local reactions to the catheter usually do not include bladder spasms.

The healing period after prostate surgery is 4 to 8 weeks, and the client should avoid strenuous activity during this period. Blood in the urine is fairly common after surgery. Continued increased fluid intake will help the urine to remain dilute and reduce the risk of clot formation. The client should not drive for 2 weeks, except for short rides.

The arm should be elevated above heart level following mastectomy to reduce the risk of edema after lymph node removal on the affected side. Warm, moist compresses could enhance edema formation, and IV lines should not be used on the affected side at any location (lab draws and injections and blood pressure readings should also be avoided). Gentle, simple range of motion exercises can be started immediately after surgery.

The total infused is 600 + 1,500 = 2,100 mL. The total drained was 800 + 1,050 + 950 = 2,800 mL. Subtract 2,100 from 2,800 to obtain 700 mL, the true urine output for the shift.

Zinc deficiency is associated with taste changes; therefore, supplementation may benefit a client experiencing altered taste perception. Drinking salty broth and fluids will not help with taste changes but may help restore electrolyte balance in clients experiencing diarrhea. Dairy products, fish, and poultry are better food choices than meat when taste is altered. Substitution of plastic utensils for metal ones is suggested to decrease possibility of taste perception of “metal.”

Small, frequent meals help lessen nausea because they require less work of digestion and do not overwhelm the client with food odors from a lengthy meal. High-fat foods are more difficult to digest and may distend the stomach. Lying down after eating can encourage reflux. Drinking liquids can give a sensation of fullness. High-fat foods, reclining after meals, and drinking large quantities of liquid all increase the risk of nausea and vomiting.

It is important to determine the psychosocial needs of a client on transmission-based precautions and to intervene to provide sensory stimulation for the client. Isolation procedures can cause clients to become depressed and withdrawn and to sleep excessively. Although it is important to maintain isolation precautions as ordered, attention must be given to include the client’s psychosocial needs as part of the plan of care. Limiting contact time may be indicated for infection control, but it does not provide psychosocial support.

Clients who have scleroderma usually have Raynaud’s phenomenon. Raynaud’s can be triggered by temperature changes, and prolonged water contact may cause activation. Use of gloves when washing dishes may prevent temperature changes yet still allow the client to participate in ADLs. Hotter water may increase the risk of scalding and so is not suggested. Physical therapy and H<sub>2</sub> receptor blockers are indicated for treatment of esophageal problems associated with scleroderma.

All identified diagnoses are concerns for a client with SLE. However, the results of the laboratory test demonstrate an increased risk for infection that is due to the disease process and/or possible treatment measures such as steroids and immunosuppressive agents. A shift to the left in a WBC differential indicates an increased number of immature cells, suggesting infection.

Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take this medication at the same time each day and to become aware of tapered-dose effect. Steroids are usually taken with foods to minimize GI upset. Steroids cause fluid retention, and therefore sodium intake may be restricted. Steroids also increase blood glucose, so insulin therapy dosages may have to be adjusted.

Late decelerations are caused by uteroplacental insufficiency and are always ominous. To optimize uteroplacental blood flow and therefore fetal oxygenation, the client should be positioned on her left side. Oxygen is appropriate but would be administered via mask at 7 to 10 liters per minute. A Foley catheter is unrelated to the fetus’s needs at this time.

Swan-neck deformity occurs at the proximal interphalangeal (PIP) joint and ulnar deviation occurs as a result of joint destruction with disease progression. Heberden’s and Bouchard’s nodes are commonly found in clients with osteoarthritis. Tophi (firm moveable nodules) are associated with gout. Charcot’s joint is considered a neuropathic disorder that falls under the broader category of rheumatism. It is not specific to RA and is more likely to be seen as a complication in clients with diabetes.

Heat and cold applications can provide analgesia and relieve muscle spasms. The individual client will have to determine whether heat, cold, or alternation of both is most effective. Pain medication should be taken on a regular schedule if the client has chronic pain so that the pain threshold can be raised and pain relief maintained at a constant level. Exercising in the presence of pain may only further exacerbate pain. Flexing of muscle groups is not related to effective pain control.

Methotrexate treatment takes several weeks to effect relief. Once relief is obtained, the dose is adjusted to achieve maximum response at the lowest dose. If the drug is discontinued, then symptoms of the disease do return.


Transfusion and Goodpasture’s are examples of type II cytotoxic hypersensitivity reactions and are involved with the activation of complement. Lupus is an example of a type III hypersensitivity reaction, which involves IgG and IgM with the activation of complement.



Prolonged morning stiffness is associated with RA. Occasional use of NSAIDs is not by itself a direct link to the development of RA. Complaints of pain with movement are more likely to be associated with degenerative joint disease (osteoarthritis).

Pregnancy can be associated with an exacerbation because of increased estrogen levels. Hypotension, fever, and GI upset do not exacerbate SLE.

A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be tested at once, and the results can be obtained in 30 minutes.

The role of the nurse is to be informative, supportive, but never judgmental. Thus, the reliability of the boyfriend and the appropriateness of names chosen are not assessments that the labor and delivery nurse should perform. Because the client is in labor, it is too late to address nutritional needs of pregnancy. This might also be perceived by the client as judgmental behavior of the nurse. Adolescents commonly misunderstand the functions of their body parts and additional teaching may be needed so the adolescent client in labor understands how birthing will take place.

Diseases with HLA associations have poorly understood etiologies, are usually chronic or subacute in nature, and have limited effect on reproductive capacity.

The priority intervention is to maintain a patent airway in a potential anaphylactic reaction. Therefore, the nurse should assess for swelling of the tongue and stridor, which could indicate impending respiratory obstruction. The other interventions are supportive measures that can be used during an allergic response.

Gold salts may cause anaphylaxis. Sulfasalazine may cause nausea and vomiting, but fluids should be encouraged (option 2). Acetaminophen does not provide the same anti-inflammatory effects as ASA and NSAIDs (option 3). Penicillamine cannot be used during pregnancy (option 4).

Skin manifestations are a common finding in clients with scleroderma and therefore require preventative and supportive nursing care as the priority. As the disease progresses, dermatologic effects may lead to disturbances in body image. In addition, with disease progression, there may be an impact on respiratory and musculoskeletal function, leading to activity intolerance. Similarly, hopelessness can develop with new and worsening symptoms. Therefore, the nursing diagnoses in options 2, 3, and 4 are of lesser priority in the early phase of the disease process.

Altered temperature, jaundice, and respiratory distress are all symptoms of sepsis in infants. Respiratory function is the highest priority because without an adequate airway and breathing, the client cannot maintain life.

Body fluid-contaminated liquids may contain the human immunodeficiency virus (HIV) and can be absorbed through the eye mucosa. The other activities do not expose the nurse to blood and/or body fluids of the client and therefore pose no risk of contracting HIV.

The first infection often seen in these children is oral candidiasis (thrush). That symptom, along with the low WBC count, would be warning symptoms of SCID. A 2-year-old is unlikely to have survived this long undiagnosed. ELISA tests evaluate HIV infection, and a TORCH titer is unrelated. A newborn is too young for symptoms to have manifested.

Maintaining an open airway is always the highest priority. With anaphylactic shock, the airway may constrict, mucous membranes swell, and air trapping occurs. The second priority would be airway access, followed by renal examination, and finally site care.

The family has stated multiple concerns, and demonstrating acceptance of the child is the best way to foster acceptance of the child and development of further coping skills. Prevention of transmission, handwashing, and drug therapy are all important, but none of these individually targets the global concerns of the family.

The client needs to discontinue use of antihistamines for 72 hours (3 days) prior to allergy testing to avoid false negative readings.

Gradual decelerations that begin and end with contractions are early decelerations and are caused by fetal head compression. Variable decelerations result from umbilical cord compression and are characterized by a sudden drop from baseline during contractions with a sudden return to baseline as the contraction ends. Late decelerations are caused by uteroplacental insufficiency and are characterized by gradual decrease in the fetal heart rate after the contraction begins and gradual return to baseline after the contraction has ended. Fetal movement usually results in fetal heart rate accelerations.

The prodromal period is the time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. All the other statements are correct.


Koplik’s spots are associated with measles (rubeola) and appear on the buccal mucosa 2 days before and after the onset of the rash. Mumps, chickenpox, and rubella are not associated with the presence of Koplik’s spots.

Caladryl will reduce itching and discomfort and therefore diminish scratching and skin breakdown. Acetylsalicylic acid should not be given to young children with a viral disease because of the relationship to Reye syndrome. Immunoglobin will not decrease skin eruptions. Nubaine is a narcotic analgesic.

Tepid baths allow heat to be removed from the body. Aspirins are avoided because of the risk of Reye syndrome. The child should wear only light clothing to allow heat to escape. Antibiotics are not usually ordered for this viral infection.

Mumps is a viral infection and thus antibiotics will not be effective. The other statements are true. Acetaminophen, fluids, and soft foods are helpful, and the mother should watch for vomiting and headache.

The child has a stuffy nose, which can impair air exchange. Nursing care involves use of a cool-mist vaporizer and gentle suctioning of the nose. The rash does not cause skin impairment. A 2-year-old will not have a disturbed body image. Disturbed sleep pattern would have less priority than gas exchange if this problem developed.

The upper respiratory symptoms may be early prodromal symptoms of chickenpox. The incubation period of chickenpox is 10 to 21 days. The other responses are either too short (option 1) or too long (options 3 and 4).

Cool fluids will help decrease the swelling of the glands around the mouth and neck. Acidic foods are too irritating and difficult to swallow. Warm, chopped foods may be difficult to swallow (option 1), and spices are also likely to be irritating (option 2). The child should be given small, frequent meals with soft foods rather than a regular diet (option 4).


Delivery appears imminent and priority should be given to the safety of the woman and her newborn through a controlled and attended birth. Another person can be summoned to contact the health care provider and perform assessments. The history provides helpful information but can be obtained at a later time.

The route of transmission of roseola is unknown. It is not known to be transmitted by the respiratory tract (option 2), contact with contaminated articles (option 3), or body secretions such as urine or stool (option 4).

Pertussis is most infectious early in the course of the disease, so it is not necessary for the client to self-isolate following discharge from the hospital. Coughing bouts may be still triggered by irritants, so these should be avoided. Frequent handwashing and increased fluid intake are generally helpful measures that should also be continued in the home setting.

Koplik’s spots are seen with rubeola, not scarlet fever. Reddened edematous pharynx, red strawberry tongue, and rash in the axillae and groin are findings consistent with scarlet fever.

Fifth disease is characterized by flulike symptoms such as fever, malaise, nausea, and vomiting, and by the characteristic “slapped cheeks” appearance. This finding is not characteristic of chickenpox, measles, or diphtheria.

Anthrax is caused by a bacterium and is therefore amenable to treatment with antibiotics. Antivirals and immune globulin play no role in treating this disease, and the statements in options 1 and 2 are incorrect because they indicate no treatment is available.

The incubation period for infectious mononucleosis is up to 6 weeks (with a minimum of 4 weeks). This has important implications for the nurse and the client, since the source of the exposure may be difficult to determine after several weeks.

The jaw thrust maneuver is used whenever head or cervical spine injury is suspected to avoid causing further physiological damage. The head tilt-chin lift method (option 1) is the standard method for opening the airway when there is no suspected cervical spine injury. The tongue-jaw lift (option 3) aids in visualizing foreign bodies in the airway. The client does not need emergency intubation (option 4).

The proper ventilation rate for a child or infant is 12 to 20 breaths per minute, which is the same as delivering one breath every 3 to 5 seconds. Ventilation rates of 8 (option 1) or 10 (option 2) do not provide sufficient oxygenation for the child during cardiopulmonary arrest. A rate of 30 breaths/min (option 4) is excessive and could be harmful.

The brachial artery is the correct location for determining whether an infant under 1 year of age has a pulse. The radial artery would not generate enough pulsation in an infant to be reliable (option 2) and is also more difficult to palpate. The carotid pulse is not as easily located in an infant with a small neck and neck folds (option 3), while the temporal pulse is not used in CPR for an individual of any age.

In an adult, the sternum should be depressed during CPR to a depth of 1.5 to 2 inches. The head tilt-chin lift method of opening the airway is used for the client who has no head or neck injury (option 1). The nurse should deliver two breaths to initiate ventilation (option 2). The nurse should reevaluate the client’s status after approximately 1 minute (option 4).

An incident report must be completed because of the inaccurate narcotic count. Narcotics are controlled substances and fall under federal law and regulation. Both the pharmacy and nursing administration must be notified. If the staff nurse is found to be using a controlled substance, this finding must be reported to the state board of nursing. Individual state boards of nursing identify the legal boundaries of nursing practice, including disciplinary action, through nurse practice acts (which differ among the states). The American Nurses Association, through the Code of Ethics for Nurses, provides guidance to nurses and protection for clients and their families but does not have the authority to discipline nurses.

The second stage of labor begins when the cervix is completely dilated and pushing begins. Most women make a low-pitched, guttural, grunting sound when they push spontaneously. When the client begins to make these sounds, she is pushing. The nurse should immediately inspect the perineum for bulging and the appearance of the presenting part. If neither of these is occurring, the nurse should perform a vaginal examination to assess for complete dilatation of the cervix.

On an adult client, chest compressions should be done to a depth of 1.5 to 2 inches to be effective. Options 2 and 4 are excessively deep and could lead to injury, while option 4 is not deep enough to provide effective circulation.

The rate of compressions for an infant during CPR is at least 100 per minute. Options 1 and 2 are higher than the minimum number of compressions per minute, while option 4 does not deliver a sufficient number of compressions per minute.

The client should not be lying in water or other liquid, which could lead to burns or to defibrillating another individual who comes in contact with the liquid during AED shock delivery. The electrodes should not be placed on hairy areas, or the site should be shaved (option 1). All people should stand clear of the individual during an AED shock to avoid being defibrillated themselves (option 2). CPR is initiated after 1 minute or whenever the series of shocks is terminated, as indicated by client condition. However, 5 minutes is too excessive and could lead to permanent brain damage if the client survives (option 3).

In a pregnant client, the Heimlich maneuver is performed in a manner that avoids causing injury to the fetus. For this reason, the hand placement is at the midsternum rather than at the abdomen (options 3 and 4). The lower sternum (option 1) should be avoided to prevent accidental fracture of the xiphoid process, which could lead to internal injury.

There is a specific sequence of actions that is performed as part of basic life support when a client is choking. After positioning the client on the back, the nurse would observe the oral cavity to detect any foreign body that may be removed immediately. Next, the nurse would open the airway and attempt to ventilate (option 1). If unsuccessful, this process would be repeated. Finally the nurse would perform abdominal thrusts (option 3). Chest thrusts (option 4) are performed in the adult only for pregnant or obese clients.

The first action of the nurse is to establish unresponsiveness. This can be done by shaking the shoulder and asking if the client is okay. The subsequent actions of the nurse would be to call for help (option 1), open the airway (option 2), and ventilate the client (option 4).


The nurse ensures that the UAP understands the importance of reporting immediately any difficulties during the procedure, such as bleeding. This provides for safe and effective care. Option 1 is incorrect because the client cannot do the procedure because of arthritis. Option 3 is unnecessary if the UAP is qualified to do the procedure. Option 4 is a function of the nurse, not the UAP.

Only option 4 relates to the client’s physiological integrity. Options 1 and 2 pertain to the psychological aspects of client care, while option 3 relates to the safety in the environment.

Obesity, hypertension, and smoking are modifiable risk factors for stroke. Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but this client’s level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for stroke.

The average duration of the second stage of labor for primigravidas is 2 hours. Many women feel rectal pressure, as if they were having a bowel movement, as the baby descends deeper into the pelvis. The use of vacuum extraction or forceps to assist delivery is not routine.

Options 1, 2, and 5 are core principles of medical asepsis. Option 3 violates principles of medical asepsis. Option 4 uses principles of surgical asepsis but the question asks specifically about medical asepsis.

Red blood cells, white blood cells, and platelet counts may be decreased during the nadir period following administration of chemotherapy that has hematological toxicity. Medications that inhibit platelet aggregation should be avoided during the nadir period following antineoplastic therapy. Aspirin, ibuprofen, and indomethacin are examples of some of these agents. Tylenol is the drug of choice for mild pain and fever. Benadryl is often used for sinus drainage or as an antihistamine and Robitussin is used to manage cough.

Hand hygiene is a core principle of standard precautions. Using gloves is appropriate when there is a risk of exposure to blood, body fluids, secretions, and excretions. However, handwashing should be done after removal of gloves. Not all clients require transmission-based precautions (option 3) or a private room (option 4).

The white blood cell count is elevated (normal 5,000–10,000/mm<sup>3</sup>), as is the BUN (8–22 mg/dL). These changes would be expected with infection (noted by fever) and possibly accompanying dehydration from diarrhea. The sodium (135–145 mEq/L), potassium (3.5–5.1 mEq/L), and serum creatinine (0.8–1.6 mg/dL) are all within normal limits.

According to Erikson’s stages of development, a 10-year-old child is experiencing industry vs. inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other developmental levels.

Low-dose heparin therapy is indicated in many postoperative clients to prevent the development of thromboembolic episodes. It is not used in every postoperative situation (option 1), but it is usually used for clients who have orthopedic surgery or are anticipated to be immobilized for a time following surgery. Short-term therapy is not given to maintain adequate blood clotting levels (option 2) but merely to intervene as a preventative measure. While the statement that heparin is given SubQ in the abdomen and is not usually painful is factual, it is not the reason for the medication being given to the client (option 3).

A client in any degree of respiratory distress should always be the first priority. Pain would indicate second priority, especially because it is of unknown origin. A client with congestive heart failure who has gained weight, although in no reported distress, must be third priority because of the potential for both respiratory and circulatory problems. A newly admitted client would be fourth priority because this client may require additional examinations, while a terminal client would be fifth priority because the client’s needs would more likely be psychosocial than physical. Once the nurse completes the physiological priorities, the nurse can then plan to spend time with the client who is terminally ill.


Crowning is the point in time when the perineum is thin and stretching around the fetal head both between and during contractions. Delivery is imminent when crowning occurs. Crowning occurs later than the first sight of the infant’s head. A head that recedes upward between contractions is not crowning. The mouth and nose cannot be suctioned during crowning because they are not accessible, nor is it timely.

Option 4 gives the client an opportunity to explain to the nurse the reason for asking the question. This helps the nurse understand the client’s frame of reference and allows the nurse to best address the client’s concern. Options 1 and 3 offer false reassurance and can give the impression that the nurse did not listen to or address the client’s concerns. Option 2 is a closed-ended question and may not help the nurse explore the client’s concerns.

Although all of the nursing actions presented are important after delivery, clearing the airway is the highest physiologic need and ensures safe adaptation to the extrauterine environment.


The UAP is qualified to complete simple procedures, such as bathing a client and changing bed linens. While the UAP could possibly administer mouth care to this client, the nurse must assess the oral cavity (option 2) and should be the one to assess tube feeding residual (option 1). UAPs are not trained in therapeutic communication skills and techniques (option 3).

A client in metabolic acidosis may also be hyperkalemic. As the hydrogen ions shift from the ECF to the ICF, potassium enters the ECF, leading to an increased serum potassium. PH values of &lt; 7.35 are associated with acidosis (option 2). Options 3 and 4 have K+ levels above 5.5 mEq/ L that are associated with acidosis, but option 3 contains the higher value. Option 1 has a normal pH and serum potassium level.

Potassium (KCL) is contraindicated in clients with renal dysfunctions. It cannot be filtered out if there is decreased renal filtration. With increased damage in tissues additional potassium is released, causing an even greater level of potassium that can be life threatening. Encouraging protein, ambulation, and taking vital signs do not safeguard the client from the danger of this potential electrolyte imbalance.

In Piaget’s theory on development, conservation is a hallmark sign in the concrete operational stage. Options 2, 3, and 4 are not characteristic of this stage.


While LPNs/LVNs may reinforce teaching, they cannot perform discharge teaching and they do not assess. They may collect data to contribute toward the RN’s assessment of a client, but assessment is in the RN’s scope of practice.

Anxiety or anger increases peristalsis leading to subsequent diarrhea. Excessive intake of cheese or eggs, ignoring the urge to defecate, and lack of exercise can lead to the development of constipation.

The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, particularly the position of the head, present larger diameters to the maternal pelvis, which contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery.

Mental status changes and concentrated urine are common signs of dehydration in the elderly. Tenting and dry, flaky skin are consistent changes seen with normal aging. Hand veins that fill within 3 to 5 seconds and clear lungs sounds with unlabored breathing are normal findings.

The nurse should immediately assess the fetal heart rate to detect changes, which may be associated with prolapse of the umbilical cord. Ambulation is appropriate if the fetal heart is determined to be within normal parameters and the presenting part is engaged. Documentation is important but is not the priority intervention. The membranes may rupture at any time during labor; preparing for delivery may not be indicated at this time.

Liver function includes the regulation of blood clotting and corticosteroids can impair wound healing and irritate the GI tract. Thus, the client should be instructed to report signs and symptoms of bleeding. Option 1 is a side effect of corticosteroids but is not the priority from a physiological basis. Options 2 and 3 do not reflect the associated risk of bleeding with corticosteroid medications.

Frequent coughing and deep breathing is an easy maneuver that has great benefit to optimize ventilation in the postoperative client. Good pain management facilitates effective coughing and deep breathing. Getting the client out of bed and administering oxygen and bronchodilators are all appropriate interventions for preventing or treating atelectasis, but clearly the best option is to prevent its occurrence by simple maneuvers such as coughing and deep breathing.

Children with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD. Intense mood swings (option 1), inflated self-esteem (option 2), and spending sprees (option 3) occur more often in adults.

The laboratory value given is within normal limits (12–16.5 grams/dL). All the other statements are inaccurate. The client is not malnourished (option 1), at nutritional risk (option 3), and does not have polycythemia (high level) as indicated by option 4.

Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the child’s vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and they need to be disposable to reduce the risk of transmitting the infection to others in the home. Oral antihistamines, ophthalmic corticosteroids, and topical anesthetics are not indicated in the management of bacterial conjunctivitis.

After the seizure, the client will be postictal, which is a deep sleeping state. She or he could aspirate secretions unless side-lying to promote drainage from the upper airway. Positioning the client on the back (option 1) increases risk of aspiration. Positioning the client on the abdomen (option 3) or upright in chair (option 4) is unrealistic given the client’s postictal state.

A client fall is a potential medical emergency; however, the nurse’s responsibility is ensuring the safety of the client being attended to. Option 2 ignores the safety of the potentially injured client. Option 3 wastes supplies. Option 4 could lead to a contaminated sterile field.

The American Diabetes Association Exchange Lists divide food into groups with similar content (milk, vegetables, fruit, starch/bread, meat, and fat). All foods within a list are similar in calories, protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be exchanged within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, and orange is fruit.

Genetic screening can identify markers for several types of cancer. One method to remind men to perform self-checks for cancer is to mark a calendar to check monthly for changes. Self-exams as well as regular medical tests and exams uncover tumors. After a total mastectomy, women do not need mammograms. Skin cancer risk increases with age.

The nurse should speak privately to the coworkers about their behavior and the impact on the nurse overhearing them. It does not help the climate of the unit to let it pass (option 1). The nurse is not in a position to confront and reprimand coworkers (option 3). Option 4 is somewhat plausible but option 2 personalizes the discussion between the nurse and the coworkers, and thus is best to diffuse the situation.

Bonding occurs best when parents have direct and prolonged contact with their newborn in a supportive environment. Although the other answers may be appropriate, they would not be the priority in facilitating bonding.



Adolescents tend to feel that they are invulnerable and that if anything bad will happen, it will affect others but not themselves. They also tend to feel immortal, as it is difficult for them to comprehend their own death. Option 1 is a factor often related to the adult, option 3 is related to school-age children, and option 4 is related to the elderly.

A full bladder is necessary to bounce the sound waves off to compare other tissues or structures that are being assessed. If done during pregnancy, the fetus must be over 26 weeks to not have the restriction for the full bladder, since the amniotic fluid would be used at that point. It would not be helpful to be NPO, because this would deprive the client of fluids. Enemas and refraining from medications are unnecessary.

Children at 10 years of age are egocentric and concerned with themselves. Asking about interests and hobbies is likely to foster establishment of rapport. Focusing on behavioral symptoms (option 1) could lead to an adversarial relationship. Children often are uncomfortable talking about friends and family (option 3) until they get to know a person better. Most children are unconcerned about past medical problems (option 4); they are focused on the here and now.

Spironolactone is a potassium-sparing diuretic used to treat hypertension. Gynecomastia is one of its adverse reactions. Adverse reactions usually disappear after the drug is discontinued; however, gynecomastia may persist after discontinuing spironolactone.

It is part of the nurse’s role to measure vital signs as ordered and document them properly in the client’s chart. The LPN/LVN does not assess clients (option 2). The registered nurse (RN) is responsible for creating quality improvement plans (options 1 and 4).

Option 3 is best because it represents a communication with the client and is open-ended. Options 1 and 2 are not the most appropriate initial approaches since the client is not encouraged to share her concerns, although later on in the interaction these may be appropriate. Option 4 ignores the client and does not address the client’s concerns.



Regression to previous behaviors is normal in young children when a new sibling is brought into the family. An example for a 2 year old is drinking from a bottle again, which is characteristic of an earlier stage of growth and development. The other options represent items that are expected to happen in future growth and development, but would not be characteristic of the expected regression.

Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 is incorrect because the client is young and therefore the age is insignificant. The smoking history (option 1) is not an issue; in fact, smokers metabolize theophylline more quickly and may need increased doses. There is no data about the client’s weight (option 4) in the stem.

The LPN/LVN is trained to collect data that is then reported to the registered nurse (RN). However, assessment remains the responsibility of the RN. For these reasons, the LPN/LVN can be expected to take vital signs, report drainage, administer medication, and elevate the casted limb. The RN should retain the responsibility for assessing neurovascular status to the casted extremity in the immediate postoperative period.

Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 microns in size.

The potassium level is abnormally high (normal 3.5–5.1 mEq/L). Since potassium is an intracellular ion, higher levels will alter the electrical pattern of the EKG. “Peaking of a T wave” is an indication that potassium is too high. With <i>hyperkalemia</i> (higher than normal potassium levels), muscle weakness, flaccidity of muscles, diarrhea, abdominal cramping, and cerebral irritability/restlessness are present. Therefore, <i>bowel sounds</i> would be <i>hyperactive</i> and not <i>silent</i>, such as with an ileus. Muscles are weak and flaccid, not in a <i>cramping</i> state. Cerebral functions are stimulated and <i>somnolence</i> (sleeping, sluggishness) is not present.

The client should be NPO before the procedure in order to be given anesthesia for the procedure (options 3 and 4). The client, not the husband, should sign the consent form (option 1). The client should be wearing loose-fitting clothing (option 2).

Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be administered over 12 to 15 seconds to separate the muscle fibers more gradually. Cold compresses to the injection site would delay absorption of the drug (option 1). Aspiration for blood return with all IM injections is necessary for safety since muscles contain larger blood vessels (option 3). Injection into the deltoid may also result in prolonged discomfort resulting in limited motion of the upper extremities (option 2). Rotating sites, light massage, and warm compress to site may also be employed to limit discomfort.

Teaching and assessment are within the domain of the registered nurse (RN) and cannot be delegated to a UAP. The UAP is also not trained in therapeutic communication or counseling techniques. These ancillary caregivers can complete tasks under the supervision and direction of the nurse, and report simple data when asked to do so. With this in mind, the only activity that can be delegated is the simple direction to the client to remain upright after eating.

Clients should remain NPO upon admission to the clinical setting with a major burn. Initial fluid replacement is started via the parenteral route. NPO status is maintained because the client may be in shock with blood flow directed away from the digestive organs to more vital tissues. In addition, it is possible that the client suffered burn injuries that could cause internal damage to body structures, and aspiration is also a risk initially. Options 2, 3, and 4 are incorrect—fluids and food via the mouth would be restricted at this time.

Every time a child enters the health care system, the immunization status should be checked. Some children have uncertain history of immunization because of parental noncompliance or special circumstances such as being refugees. Once immunization status has been determined, the nurse can go on to assess growth and development and hearing, and to teach the parents about dental care as necessary.

The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. This position reduces pressure caused by contact of the inflamed pancreas with the posterior abdominal wall.

It is possible that a significant amount of lochia could pool beneath the client after delivery. The highest priority at this time is risk for hemorrhage, and this should be the initial assessment. Options 1 and 3 could then follow. Option 2 is irrelevant to the question as stated.

Although many chemotherapy agents can cause stomatitis, the antimetabolites are commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid.

Safe and effective delegation is based on knowledge of the laws governing nursing practice and knowledge about job duties and responsibilities. Nurses must understand the competencies and training of unlicensed assistive personnel.


Packing the sample in ice will minimize the changes in gas levels during the transportation of the specimen to the lab. The arterial site should be held for 5 minutes or longer if the client is receiving anticoagulant therapy. The blood is drawn originally in a heparinized syringe and does not need to be transferred to one. A second specimen is not necessary.

For clients with dysthymia, a major concern is social isolation. Option 1 is contraindicated, as is option 3. If the client has a poor appetite, assigning 2 liters of liquid intake (option 4) is not therapeutic, nor is planning three regular meals per day (option 3).

The effectiveness of a heparin protocol is monitored by trending aPTT results to achieve a therapeutic level. An aPTT of 140 is above the therapeutic level of anticoagulation and therefore the infusion should be stopped per protocol, and resumed at a decreased dose in 1 hour’s time with a repeat aPTT ordered in 2–3 hours per protocol. The dose should not be increased, as this would cause serious consequence to the client. Stopping the medication for a total of 6 hours would undermine the anticoagulation control that the physician is trying to achieve. Ordering another aPTT and continuing to run the infusion could also cause serious consequences to the client.

The UAP can perform tasks or nursing care activities under the direct supervision of the registered nurse (RN). The RN retains responsibility for assessment (options 2 and 5) and teaching (option 4).

The client’s right to withdraw consent is necessary to be part of the consent and it means that coercion was not utilized in obtaining the signature. It is the physician’s responsibility, not the nurse’s, to explain the diagnosis (option 1) and the need for the surgical procedure (option 2). Cost (option 2) is not an important aspect for informed consent. The technical aspects of the procedure are not needed by the client, although an overview of the procedure should be included (option 3), but again this is the role of the physician. All preparation for the procedure should include information about what the client will see, feel, and hear.

The correct area is the center stoma, not the distal one that is nearer to the distal colon and rectum. Coming from the small bowel in the center of the diagram, the stomas represent, in anatomical order, an ileostomy, cecostomy, ascending colostomy, transverse colostomy, descending colostomy, and sigmoidoscopy.

Children with growth hormone deficiency are smaller than their peers and frequently experience problems with self-esteem and body image. Option 1 would be the opposite problem of what the client is experiencing. The nursing concerns in options 3 and 4 are unrelated to the client in this question.

Uterine atony is the most common cause of early postpartum hemorrhage. This client is at greater risk for hemorrhage because she had an overdistended uterus with a large baby, and she is a grand multipara. Parity does not influence dehydration. The client may be at risk for thromboembolism, but there is no indication passive range of motion should be implemented rather than early ambulation. Nutritional evaluation is important, but there is no indication the client is anemic and this action is not the priority for the client.

Administering oxygen or a diuretic requires a physician’s order. While calling the client’s family may help to relieve the client’s distress, it is not a priority action. The greatest priority would be notifying the nursing supervisor. Once the health care provider is notified, orders for oxygen and diuretics may be available. Calling the family is a helpful action that could be done once the client’s physiological status is determined to be stable.

Effects of hypomagnesemia are mainly due to increased neuromuscular responses. Paralysis, flaccidity, and decreased reflexes may be present with hypermagnesemia.

Troponin is a sensitive test that indicates damage to the myocardial cells. A CK-MM isoenzyme elevation would indicate skeletal muscle damage. The LDH<sup>4</sup> isoenzyme is utilized to determine hepatic function, and amylase is a digestive enzyme.

The client’s level of risk for self-harm is a major concern. The client may need a private room (option 1) and restricted visitors (option 3) if in a manic state. The client should not be overstimulated (option 4).



Abuse of laxatives and diuretics is a frequent <i>purging</i> behavior for bulimic clients. Options 2 and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a reward.

Lifestyle modifications and recognition of risk factors are important parts of prevention of long-term complications. Family history is a very strong risk factor but encouraging the client to maintain his current lifestyle and following up with health screening would be the best plan of action. False reassurance that he will never be hypertensive and prophylactic antihypertensive medications are inappropriate.

When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be covered to prevent skin irritation. This can be done by petaling the cast edges with strips of adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the outside of the cast.


Mothers who are bottle-feeding should be encouraged to suppress milk production by wearing a snug bra or breast binder, applying cold compresses, and avoiding breast stimulation until primary engorgement subsides. Pumping the breasts and applying lotion to them (options 1 and 2) are forms of breast stimulation that should be avoided; option 2 is not helpful anyway. Applying heat via a warm bath (option 3) will also stimulate the breasts and should not be done.

UAPs are trained to feed clients, measure and document vital signs, and perform morning hygiene. However, they do not receive training in working with sterile technique or pharmacology and should not be asked to perform outside of their level of ability.

The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding. The other organ systems would not be located in this area.

The client will, in most cases, return to the unit with barium still present in the bowel. The physician will order laxatives or enemas if the client is potentially not able to expel the barium on his or her own. The nurse should encourage the client to increase fluid intake if possible as well. This is a common concern for many clients undergoing this procedure, and their feelings should not be ignored or belittled.

The only respectful therapeutic response here is option 1. The others are contraindicated for any group process. Everyone does not need to participate in every session (option 2). It is inappropriate to focus the group’s attention on one individual because of level of participation (option 3). The client should be allowed to remain part of the group until the client is ready to participate (option 4).

Phenytoin is a first-line anticonvulsant medication that is used to control seizure activity. Selegilene (option 1) is used to treat Parkinson’s disease. Diclofenac (option 2) is an NSAID, while sumatriptan (option 4) is used to treat headaches.

After burn injuries, an elevated potassium level (normal 3.5–5.1 mEq/L) is expected because of cellular tissue damage with release of intracellular potassium into the bloodstream. The hematocrit will be elevated (not decreased as in option 4) due to hemoconcentration, and the white blood cell count will be elevated as part of the inflammatory response to injury.


Chinese clients may perceive an imbalance in the hot and cold forces in the body after delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if warmed) to regain a sense of balance between these extremes. A client’s culture plays a very important part in who they are, and nurses should respect the client’s wishes as long as it will not result in harm to the client or others.

When a client’s level of anxiety markedly increases the nurse can relieve the anxiety by altering the focus of the discussion. Asking the client more details or abruptly stopping the interview will probably increase the client’s anxiety level. Asking the client to relax may or may not be effective in reducing the client’s anxiety.

Option 4 is correct because the client is honest, has an understanding of how to take the medication and what the side effects are, and knows that the side effects will subside eventually. Options 1 and 2 indicate that the client is feeling forced to take the medication but has no desire or understanding of the benefits of the daily routine and dosages. Option 3 indicates that the client has memorized the actions but does not understand the benefits or side effects of the medications.

It is important for a breastfeeding mother to break the infant’s suction on the nipple before removing the baby from the breast. This will help prevent the nipples from becoming sore and the skin from cracking. The nipples should be cleansed with water after each feeding, but soaps can be harsh or irritating. The client should alternate between the right and left breasts for first use at each feeding. Milk production and supply is enhanced when no supplementation is used.

For 6 hours following intravesicular chemotherapy, the toilet should be disinfected after each use. This will help ensure that the biohazard of excreted chemotherapy drug is contained. The toilet may also be double-flushed. Options 1 and 3 are insufficient, while option 4 is unnecessary and does not address the biohazardous aspect of chemicals remaining in the toilet.

It is important that circulation is checked regularly. Typically the restraints are removed, one at a time, every 2 hours to evaluate skin condition and circulation. Although options 3 and 4 are correct, they are not the best responses as they do not have to be checked as regularly as the circulation and skin condition. Option 2 applies to an elbow restraint.

Emergency airway and resuscitation equipment should be readily accessible whenever allergy testing is administered because of the potential for hypersensitivity response and anaphylactic reaction. Because of the potential for a serious reaction, the client will be asked to wait in the office for a period of time so he or she can be monitored for any untoward responses. Visibility of the tested areas is important but not immediately essential. The room should be set up prior to the arrival of the client but it is not a priority.

Symptoms associated with a number of medical conditions are very similar to the symptoms associated with panic attacks. When a medical condition is present, it should be identified and treated. The other options are inaccurate responses to the client’s question.

Norethindrone (Micronor) contains only progestin and no estrogen. Because estrogen may decrease lactation, progestin-only pills are commonly used in lactating women. The other options do not address the issue of contraception during lactation.

It is essential that the client’s spinal cord be immobilized to prevent further injury and loss of function. Assessing for lacerations, exposure of the client, and performing a full mental status exam are all part of the secondary assessment.


The football, or clutch, position provides the mother with more control of the newborn’s head and full view of the face. The lying-down position is usually done in bed (option 1). The cradle position often causes the newborn’s head to wobble around on the mother’s arm (option 2). Options 1, 2, and 4 do not allow full view of the infant’s face.

PEA is associated with what appears to be a normal electrical conduction pattern, but there is no mechanical pumping of the myocardium. Ventricular fibrillation, ventricular tachycardia, and asystole will not demonstrate an effective electrical conduction pattern on the cardiac monitor.

To promote absorption, the client should not blink for 30 seconds after the administration of dipivefrine. Options 1, 2, and 4 are incorrect for the administration of dipivefrine.

Client satisfaction surveys are an important tool to monitor and evaluate patient and family needs. This information helps health care organizations meet those needs. Options 1, 2, and 4 are extremely helpful but do not improve client satisfaction and outcomes. Tracking supplies, documenting nursing time, and reporting on client acuity provides information that can be used in preparing a budget or unit staffing requirements.

Application of heat to the perineum 2 hours after delivery will cause vasodilation and increase the client’s risk of edema and hematoma formation. Ice should be applied for the first 24 hours. Other interventions presented are appropriate.

The client with Alzheimer’s disease would be an appropriate client for the UAP to care for. A terminally ill client, and family of the client, will require attention to psychosocial needs and would not be appropriate for a UAP. The client with CHF and the client with COPD are demonstrating early signs of worsening conditions and should be monitored closely, so they would not be appropriate for the UAP.

Pulmonary edema occurs as a result of fluid shifts caused by the ingestion of the hypertonic salt water. The result is fluid collecting in the interstitial spaces, causing pulmonary edema. Hypoxia, hypovolemia, and acidosis occur as a result of near-drowning incidents.

Speaking slowly and softly reduces stress-related emotions. Instructing the clients to ignore the behavior will not assist them in reducing anxiety. A client experiencing severe or panic anxiety will be unable to focus on identifying behaviors of anxiety. Reminding a client of the need to use good manners when talking with other clients ignores the client’s anxiety and may only increase the symptoms of anxiety.

Jaundice in the dark-skinned client can best be observed by inspecting the hard palate. Normally, fat may be deposited in the layer beneath the conjunctivae that can reflect as a yellowish hue of the conjunctivae and the adjacent sclera in contrast to the dark periorbital skin. In these clients, palms and soles may appear jaundiced, but calluses on the surface of their skin can also make the skin appear yellow.

A client with GERD should limit (or possibly eliminate) the intake of coffee because this can relax LES pressure and lead to symptoms. The other options would not be warranted because all would contribute to the development of symptoms: large meals, spicy foods (extra garlic), and peppermint (which would relax LES pressure).

The child should be included in planning for the new baby. Children may feel threatened by a new sibling and so may need extra time and attention. Parents should avoid putting too much responsibility on the child.


A client at risk for nausea should not lie down for at least 30 minutes after meals to avoid aspiration. The physician should be notified of excessive weight loss (option 1). Foods and beverages are better tolerated when they are neither hot nor cold (option 2). Option 4 is a good client action if other measures fail (option 4).

The movement of the fluid, also referred to as tidaling, in the water indicates normal lung expansion. The physician should not be called unless the movement ceases. Coughing will increase the movement and repositioning the chest tube will have no effect on the oscillation.

The normal calcium level is 9.0–11.0 mg/dL, making this client hypercalcemic. Muscle weakness is a key feature of hypercalcemia due to alterations in excitable membranes. This occurs as a complication in some clients with cancer. Peaked T waves, muscle spasms, and increased gastric motility are signs of hyperkalemia.

A steady trickle of blood in the presence of a firm uterus could indicate the presence of a vaginal or cervical laceration. The physician should be notified immediately so further evaluation can be initiated. The other findings are normal.

Anxiety can be a healthy protective response to an actual threat. Defense mechanisms are unconscious psychological responses designed to diminish or delay anxiety. Anxiety, at times, cannot be avoided and is a healthy adaptive reaction when it alerts the person to impending threats.

Apresoline is a vasodilator and if the client becomes dehydrated, hypotension will result. In other words, during dehydration both preload and afterload are reduced, causing the tank to get larger with less volume. The normal dose of hydralazine is 5 to 25 mg PO. Serum potassium is high but unrelated to apresoline. The increased heart rate is a reflexive response to the low cardiac output to compensate with decreased preload and afterload.

Older clients need time to digest the information and ask questions. Option 2 is incorrect because most older clients are able to make decisions for themselves. Option 3 can be considered coercion, while option 4 can be appropriate but is not the best option since clients need more than reading material for an informed consent.

To begin life, the infant must make the adaptations to establish respirations and circulation. These two changes are crucial to life. All other body systems become established over a longer period of time (options 1, 2, and 3).



Simple activities and nursing procedures can be delegated to the UAP. For this client, this would include ambulation and documentation of intake and output. The RN retains responsibility for assessment, teaching, and counseling the client. For this reason, the nurse should not delegate assessment of the skin at the treatment site, patterns of fatigue, or how the client is coping with the diagnosis and treatment.

Visual difficulty caused by distortions and impairment of central vision is common with macular degeneration. Peripheral vision in most cases is normal. The symptoms are not characteristic of glaucoma (loss of peripheral vision), cataracts (gradual deterioration of vision with opacity of lens), or detached retina (sudden change in vision with a sense of a curtain falling over the field of vision).

An ultrasound is the only noninvasive procedure listed. The others require swallowing (option 2) or injecting (option 4) contrast, or insertion of an endoscope (option 3).

When a client with a somatization disorder does not receive symptom relief, anxiety increases (as evidenced by her current symptoms). Although the client may experience pain, hopelessness, and disturbed body image, the major issue is anxiety.

The first step of the nursing process is data collection. Increased perineal pain in a client with a vaginal delivery could be a normal process as delivery anesthetics administered locally wear off. It could also indicate abnormal processes, such as the development of a hematoma. Assessment of this client is needed prior to intervention.

Bismuth-containing preparations, such as Pepto-Bismol, can cause all the listed side effects, but transient darkening of the tongue and stool is a specific side effect to bismuth.

Acute episodes are characterized by bulky, frothy stools and steatorrhea because of malabsorption, anorexia, and irritability. The client would not exhibit increased appetite (option 2), vomiting (option 3), or soft, formed stools (option 4).

Regular exercise can help to normalize bowel function. Cigarette smoking and gum chewing increase swallowed air; fresh vegetables are gas-producing.

The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother perceives sensations of movement of the fetus from 16 to 20 weeks’ gestation. A primigravida usually perceives movement closer to 20 weeks.

A double-diapering technique will help to protect a urinary stent following repair of hypospadias or epispadias. The inner diaper collects the infant’s stool, while the outer one collects urine.


The nurse would determine that the client understood the information if the client stated rubella is transmitted by the droplet route. Clients with rubella are placed in droplet precautions, as the causative agent is transmitted by particle droplets larger than 5 microns. The other responses are factually incorrect.

A pH of 7.6 indicates an alkalotic state. The administration of bicarbonate would be the best answer. Anaerobic metabolism and the production of lactic acid lead to an acidotic state, explaining why blood gases drawn during a code usually show acidosis. This pH is not within normal limits.

Characteristics of a client with pain disorder include believing there is a physical cause for distress when there is no organic basis, the need to use analgesics or drugs to reduce pain, and impaired role performance.

The client must understand the medication information as a priority item. Option 2 is a false statement. Effective medication dosing should control seizure activity (option 4). Teaching that urine may turn pink to brown may be included if appropriate, but is not the highest priority.


The child with the low white blood cell count (normal 5,000–10,000/mm<sup>3</sup>) and the child receiving chemotherapy are at risk for infection and could be cohorted together because they should both be on neutropenic precautions. The child who underwent appendectomy should be separated from the children with viral encephalitis and scarlet fever. The children with infections should not be cohorted because one is viral (encephalitis) and one is bacterial (scarlet fever) in origin.

A client who is HIV-positive (regardless of sex) is likely to lose weight due to a repeated cycle of wasting and malnutrition. The client, who may be unable to merely increase caloric intake, should be instructed in dietary techniques that maximize quality of intake. Option 1 is incorrect—even though a food diary would provide pertinent information, the response allows for a delay in treatment that could result in further weight loss for the client. The priority is to intervene early on to prevent the onset of wasting. Option 2 is incorrect because it provides the client with a false belief that fluid retention changes associated with the menstrual cycle may have an impact on nutritional status. Option 3 is incorrect—even though increased salt in the diet can lead to fluid retention and weight, it does not address the underlying issue of nutritional balance.

Polypharmacy is using multiple doctors and multiple pharmacies to get the health care needed, often from a variety of specialists. The overall problem is that different doctors may not know what other doctors had ordered. Some drugs may interact with others and others may be the same drug in a different form. Overdosing and interactions become more common with this problem.


Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. Their effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy.

Measuring vital signs is a standard procedure before calling a physician, who will inevitably ask for this information. The charge nurse should be informed immediately and someone should stay with the client while the nurse calls the physician in case the client’s condition worsens. Because symptoms indicate cardiac pain, placing the client on a monitor would be prudent. The nurse does not have the authorization to prescribe, and administering oxygen or nitroglycerine without an order would be outside the scope of practice.

The priority nursing intervention is one that maintains contact of the retina with the choroid by positioning the client so the detached area falls against the choroid. It is unnecessary to darken the client’s immediate environment. A preoperative medication may be ordered, but has lesser priority than maintaining proper position of the head to protect the eye. Both eyes, not just the affected eye, are patched to minimize eye movement.

Loss of potassium caused by vomiting and diarrhea, in addition to lack of replacement intake, will lead to a risk for hypokalemia (normal range is 3.5–5.1 mEq/L). Calcium levels (normal 9–11 mg/dL) are not affected by vomiting and diarrhea and the sodium level (normal 135–145 mEq/L) will be elevated with the loss of potassium.

The client who has many physical complaints with no organic basis is not conscious of conflicts and stressors, and is, therefore, unable to use other means to cope with anxiety. There is no evidence of impaired adjustment or verbal communication. Nothing in the stem of the question specifically states that the client is in pain.

Epinephrine is a beta-adrenergic agent that has beta 1 adrenergic action, causing increased heart rate and increased force of myocardial contraction. The results of subcutaneous epinephrine should be seen in 5 minutes. The effects may last up to 4 hours. The other options are incorrect.

Iron absorption is enhanced when taken with Vitamin C, and orange juice is a good source of Vitamin C. Darker colored stools and constipation (not diarrhea) are common side effects of iron administration. Iron should not cause impaired judgment or dizziness that would impair safety while driving.

Glycosylated hemoglobin is elevated due to long-term hyperglycemia. Values greater than 8 percent indicate consistently poor control of blood glucose and the need to assess the client’s dietary pattern for the past several months in relation to the treatment plan. The other options do not apply.


An android pelvic structure is narrow in both the anterior-posterior diameter and the lateral diameter, and can cause a prolonged labor with a large fetus or a malpositioned fetus.

Physical exercise, within the client’s ability level, reduces muscle tension and pain. Additionally, exercise creates a feeling of greater self-efficacy. Verbal expression of conflicts and minimal use of analgesics are also indicated. Complete bed rest would not be indicated unless required by incapacitating conditions, but there is no evidence that this is the case in this question.


The employee should limit the amount of time in the client’s room to minimize exposure. In option 1, the employee is wearing the correct combination of personal protective equipment. In option 3, the employee has followed the correct procedure for exiting the client’s room. Equipment required for the care of the isolation client should remain in the client’s room to limit exposure to other clients on the nursing unit.

Eosinophils are responsible for responding to allergic reactions. Neutrophils and monocytes are primary responders to infection and tissue injury and inflammation. Lymphocytes assist in immune responses.

All family members are affected by dissociative identity disorder. Children must also find ways to understand and deal with what is occurring to a parent, rather than denying what is obvious or proceeding on incorrect assumptions that are not challenged by accurate information.


Potatoes, tomatoes, and oranges have a high level of potassium content. The others have lesser amounts of potassium in them, when considering the groupings of foods in each option.

Homan’s sign is tested for by extending the leg and dorsiflexing the foot. This assessment is indicated in the postpartum because of the increased risk for thromboembolism. Sharp pain in the calf is a positive sign. Uterine infection would be indicated by fever, pain, and foul-smelling lochia. Joint mobility is best maintained by early ambulation. This sign has no effect on afterpains during breastfeeding.

A client who receives a diagnosis of SLE will be profoundly affected by the chronic nature of this autoimmune disease process. The establishment of a health care team using a multidisciplinary approach will help the client to identify and realize individual goals. Even though the initiation of advance directives is important, it is not the priority concern at this point in time—there is no information provided to suggest that the client requires immediate activation of advance directives. Even though it is important to discuss the progressive effects of the disease, the priority is to establish a multidisciplinary team to assist the client. Option 3 is incorrect—telling the client to limit her work pattern may not be financially feasible or physically indicated at this time.

Allowing independence as long as possible gives dignity and self-worth to clients. Option 1 is not helpful because it does not foster independence within the scope of remaining abilities. Option 3 could result in harm to the parents. Option 4 could be degrading and does not foster maintaining independence within limits of current ability.

One of the major functions of the placenta is provision of nutrients to the fetus across the placenta membrane. An interference with the placenta circulation, such as abruptio placentae, impairs this ability. Another important function is removing metabolic waste from the fetus. While this takes place metabolically, the fetus produces and excretes urine independently of the placenta. Hydrops is gross fetal edema related to hemolytic action, not placenta dysfunction. Anomalies usually occur in the first trimester when organogenesis occurs.

Clients who are taking cholestyramine (which is a bile resin) should be monitored for fat-soluble vitamin deficiencies (Vitamins A, D, E, and K), as the gastrointestinal side effects of the medication can lead to reduced absorption. Niacin, thiamine, folic acid, cyanocobalamin, and Vitamin C (options 1, 2, and 4) are all examples of water-soluble vitamins.

Either convert milligrams to micrograms or micrograms to milligrams; 0.25 mg = 250 mcg. In order to administer 250 mcg using tablets that contain 125 mcg, the nurse must give two tablets.

The client in the photograph is receiving oxygen through a Venturi mask. Oxygen administered by a Venturi mask can be regulated to deliver between 24% and 50%, which is a benefit for clients who require higher oxygen supplement without mechanical ventilation. The Venturi mask does not prevent rebreathing of carbon dioxide, as does a nonrebreather mask. Oxygen concentration of 100% would be administered to COPD clients only in rare circumstances via mechanical ventilation.

MRI is the only diagnostic examination listed that does not possibly require the ingestion or administration of contrast or radioactive material. Options 2 and 4 involve the use of contrast dyes or agents, while option 3 uses a radioisotope.

Fugue states are characterized by wandering or moving away from one’s familiar place with an amnesia for the complete past, including self. The person often assumes a new identity for the duration of the fugue. Amnesia is simply a loss of memory owing to brain damage or to severe emotional trauma. Akathisia is an abnormal condition characterized by restlessness and agitation. Confabulation is replacement of gaps in memory with imaginary information.

Understanding how the medication acts to slow the heart rate would require the nurse to check a pulse rate. The nurse would hold the medication and notify the physician if the client’s heart rate was less than 60 beats per minute. Abnormal potassium levels also affect the action of this medication and would be important to follow on clients receiving digoxin (Lanoxin). It is not necessary to perform an ECG every time the medication is administered (option 1). While documenting the administration of the medication would be necessary, this would come after administration. The question asks what the nurse should do before administering the medication. It is never proper to document administration before the medication is actually given (option 3).

A client who is recovering from Guillain-Barré syndrome will need a diet that promotes positive nitrogen balance in order to counteract the effects of long periods of immobility on the body. Option 1 is incorrect—there is no evidence to support that the client is experiencing malabsorption at this time. Option 3 is incorrect because there is no clinical reason to limit fresh fruit. Even though the client may experience difficulty in chewing and swallowing, this is usually in the acute phase of the disease process. There is nothing to suggest that the client is experiencing problems in this area or is at risk for aspiration (option 4).

The baby should be positioned with the head midline and with the abdomen toward the mother’s abdomen. Positive reinforcement will facilitate the development of maternal competence and confidence in infant care.

A healthy 30-year-old has the greatest risks of safety related to lifestyle behaviors: multiple sexual partners, “on the edge” lifestyle (thrill seekers), haphazard dietary intake, speeding, not sleeping enough.

All of these nursing diagnoses are appropriate for the client with COPD; however, the primary alteration is related to impaired gas exchange because of the abnormal blood gas results. The breathing pattern is satisfactory because the rate is within normal limits, and there is no data to support activity intolerance, although it is plausible. The client is at risk for infection, but actual problems take priority over potential ones.

Graves’ disease is caused by elevated levels of thyroid hormone. Clients experience tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication therapy with an agent such as propylthiouracil will help control the disorder. Option 1 is irrelevant, while option 2 is indicated for hypothyroidism. A client with this disorder does not need insulin, because the pancreas is not affected by Graves’ disease (option 3).

A client with right hemisphere stroke has left-sided paralysis or paresis and may have unilateral neglect. The UAP should keep all items on the right side so that the client is aware they exist in the environment.

Transmission-based precautions are required for all of these organisms. Only penicillin-resistant <i>Streptococcus pneumoniae</i> is transmitted via respiratory droplets. The organisms specified in options 1, 3, and 4 are transmitted by direct contact.

HDL is felt to be a beneficial lipoprotein because of its protective function against coronary artery disease. An elevation in this level is healthy and indicates compliance with diet and exercise recommendations. LDL and HDL are fractions of the total cholesterol level. Triglycerides and LDL have proven to be major contributors to and predictors of coronary artery disease, making elevations in all three remaining options threats to cardiovascular health in the future.

When the client realizes the connection between stress, anxiety, and dissociation, he or she becomes able to modify his stressors or his response to them, thus preventing the dissociative process. The other responses in options 1, 2, and 4 do not reflect this concept.

Anticipatory prevention of nausea with antiemetics is effective if medication is taken 30 to 60 minutes before any activity causing nausea. The other options indicate incorrect time frames.

The client who had a hemorrhagic stroke and has a headache could be about to have another bleed. Headache is a classic sign with intracranial bleed, and a second bleed carries a higher mortality rate than the first. The other clients have less severe needs that can be attended to after the client who is at risk for a fatal complication is seen.

Contaminated foods are not a source of HIV/AIDS infection. While contaminated foods may cause GI symptoms and food poisoning due to various etiologic agents, they do not cause the transmission of this disease. The nurse should clarify this statement by the client in order to provide accurate information. All of the other client statements reflect information that is appropriate for the management of the client with HIV/AIDS.

Once the mother’s milk comes in, typically after the third postpartum day, breastfed babies should have 6 to 8 wet diapers each day. This would indicate the baby is getting enough milk. The other options address the mother, not the intake of the newborn. Red, tender areas or sore, bleeding nipples contribute to infection such as mastitis. Tingling is often used to describe the feeling mothers experience with the let-down reflex.

The RN is responsible for delegating tasks appropriately and is responsible for the actions of unlicensed employees. Ambulating a postoperative client is the only task that the RN could delegate from those listed. The other tasks require higher level assessment and critical thinking skills and should be performed by the RN.



The UAP can perform procedures and nursing care activities. Client care that requires assessment (options 2, 3, and 5) are not within the scope of the functions of the UAP.

With exophthalmos, the eyelids may not cover and protect the cornea of the eye. Thus, eye protection from the sheets or preventing the hands from accidentally touching the eyes is needed while the client is in bed. With Graves’ disease, clients usually experience heat intolerance, thus less covering and a cool room are preferred (option 1). Hyperglycemia is not usually associated with Graves’ disease. The head of the bed should be elevated 30 degrees to minimize eye pressure (option 3).

Most chemotherapeutic agents cause some degree of bone marrow suppression. This results in a decrease in leukocyte and erythrocyte counts, both components of a hematology testing. Calcium, phosphorus, and serum PSA levels are not specifically affected by bone marrow suppression. The calcium level could change because of the underlying bone cancer, and this in turn could affect phosphorus, but this is not the focus of the question.

All of the options are dissociative responses. However, only localized amnesia is the inability to recall events in a circumscribed time period.

Option 3 is correct because it acknowledges the client’s feelings and addresses his concerns while still allowing him to make decisions for his present and future. Options 1 and 2 disregard and negate the client’s feelings. Option 4 acknowledges his concern but takes away his decision-making options by having someone else (the nurse) make a plan for his daily activities, rather than have him participate and make decisions for himself with help.

Fluid and electrolyte replacement is the highest priority. Hyperglycemia is treated with regular insulin rather than NPH insulin (option 3). Concurrent administration of IV regular insulin would also be done as a priority. The items in the other options can be done after definitive treatment for dehydration is done.

Malnutrition is seen as a consequence of the HIV/AIDS virus because the disease process has a progressive effect on client’s nutritional status. Option 1 is incorrect—even clients who are asymptomatic may already have nutrient deficiencies and could be experiencing subclinical signs of malnutrition. Option 2 is incorrect because wasting syndrome occurs early in the disease process; current clinical research states that the maintenance and preservation of nutritional status is a priority in the clinical management of this condition. Option 4 is incorrect—clients can experience vitamin and mineral deficiencies early on during the disease process.

Diaphragms need to be refitted after each delivery and a change in body weight of greater than 10 to 15 pounds. Night sweats are common and need not be reported. Sexual intercourse can be safely resumed once the episiotomy is healed and the lochia stops in about 3 weeks. Perineal pads should be changed after each elimination.

Bladder and sphincter weakness are normal with the aging process. Decreased tolerance to spicy foods also is reflected by decreased acidity and motility of the digestive processes that are common in the aging process. Circulatory instability can occur when getting up too quickly since the vasoconstriction process of the legs can be slower as one ages. Also, dehydration can lead to slight dizziness when moving about. Increasing the process of isolation from others is not a healthy adaptation, although it is common when one spouse dies that the other seems totally lost, since most events include whole couples rather than newly singled again individuals.

Clients who are diagnosed with a personality disorder most frequently perceive their personality patterns as ego-syntonic or a natural part of themselves rather than as ego-dystonic (option 3). This is one reason it is difficult to motivate individuals with personality disorders to try to change their maladaptive behavioral patterns. Individuals with personality disorders display problems living rather than clinical symptoms. Personality disorders are associated with concomitant disorders including substance abuse.

Calcium channel blockers should be administered with a high-fat meal; grapefruit should be avoided before and after dosing due to its ability to alter drug effects. The foods listed in the other options will not have a dose-altering effect.

Tachycardia, hypertension, and tachypnea increase stroke volume and tissue demand for oxygen, leading to increased cardiac workload and possible heart failure. If fluid volume deficit is present, there is an additional risk for decreased cardiac output. There is insufficient data to determine fluid volume status. The tachypnea is a symptom of the increased metabolic rate.

Equipment for client care is dedicated to the client on contact precautions and kept in the client’s room. Any other action does not uphold principles of infection control.

Clients with gout will usually have elevated serum uric acid levels. Laboratory findings as well as physical examination will confirm the diagnosis. The joint of the great toe is usually involved in initial attacks of acute gouty arthritis. There are many other factors that will affect the results of hematocrit, serum calcium, and sodium levels. Erythrocyte sedimentation rate (ESR or sed rate) and white blood cell (WBC) counts will also be elevated in cases of gout.

It is difficult for individuals diagnosed with dependent personality disorder to make decisions on their own (options 1 and 3); rather, they try to get others to make decisions for them. This characteristic is reflected in DSM-IV diagnostic criteria. They would be disinclined to make critical remarks (option 2) related to their need for support from others.

Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol stimulates beta 1 and beta 2 receptors and therefore is contraindicated and should not be used with clients with tachydysrhythmias.

Dry mouth can be a common complaint of clients undergoing radiation therapy. Using sugar-free candies or gum will help to stimulate the flow of saliva and ease the discomfort that the client is experiencing without contributing to dental caries or lack of appetite from sugar intake. Option 1 is incorrect—eating meals prior to radiation therapy may lead to increased nausea because the client would be lying down after eating the meal. It has no effect on complaints of a dry mouth. Option 2 is incorrect—eating larger portions of food will not help to ease complaints of a dry mouth. Furthermore, the client may not be able to increase the size of meals due to side effects experienced as a result of radiation therapy. Option 3 is incorrect—the use of mouthwash can further cause the mouth to be dry and intensify the client’s symptoms.


A hemoglobin level of 10.5 is low and indicates anemia. Because of this, the client should eat foods high in iron, such as red meat. The other foods are important to a well-balanced diet but are not high in iron.

Knowledge of the cardiovascular disease risk factors and associated symptoms can assist in determining the origin of chest pain and direct the nurse to prioritize and implement appropriate care. Diabetes, smoking, and hypertension are known modifiable and non-modifiable risk factors to cardiac disease. Chest pain that occurs during activity may indicate cardiac ischemia due to the increased oxygen demand. Associated symptoms of nausea and diaphoresis are known warning signs of cardiac ischemia. Chest pain that increases with breathing, especially taking a deep breath, is most likely pleuritic pain and travel out of the country is an unrelated factor.

These characteristics are reflected in DSM-IV diagnostic criteria for paranoid personality disorder. They must be considered in planning and implementing care. Delusions and hallucinations are consistent with schizophrenia or other psychotic disorders. Options 2 and 4 describe behavior traits but they are not consistent with paranoid personality disorder.

Nutritional goals for a client with hepatitis are aimed at providing a diet that is high in calories (3,000–4,000 kcal) and high in quality protein (1.5–2.0 g/kg). The diet should also be adequate in carbohydrates to spare protein and fat, provide concentrated calories, and improve the taste of food. Option 1 is incorrect—the nutritional management of hepatitis is the same for all types. Option 2 is incorrect—there is no clinical indication to place the client on tube feedings given the information that is provided. If the gut works, then the usual clinical model is to use it. Option 3 is incorrect because dietary fat should not be limited unless the client is experiencing problems with malabsorption (steatorrhea) and there is no evidence to support this.

The illustration shows the typical appearance of skin that has eczema. Use of a mild soap such as Dove<sup>®</sup> or Tone<sup>®</sup> prevents the skin from excessive dryness. Hot water is drying to the skin so should be avoided. Fabric softeners and many lotions contain perfumes that are irritating to the skin so should also be avoided.


All symptoms listed are clinical manifestations of developmental dysplasia of the hip, although the only one that would be found in a 5-year-old would be the telescoping of the femoral head into the pelvis. Other clinical signs in an older child would be lordosis and a waddling gait with a marked limp. A positive Ortolani-Barlow maneuver is found in the infant younger than 2 to 3 months of age. Limited abduction is the sign most often used for an infant older than 3 months, along with asymmetry of thigh and gluteal folds.

The standard protocol is to administer up to three doses of NTG 5 minutes apart as long as the vital signs remain stable. After three doses, the physician should be called if pain is unrelieved. An electrocardiogram (ECG) may be ordered, but not an EEG (to measure brain waves). Using NTG paste, a longer acting form of the medication, is not appropriate at this time.

<i>Pediculosis capitis</i> is head lice. The nits (eggs) are usually found at the nape of the neck or behind the ears. Head lice do not move away from the scalp to lay eggs; therefore, other choices are not appropriate.


Standard precautions are used with all clients, regardless of the medical diagnosis. Clients with AIDS or <i>Pneumocystis carinii</i> pneumonia are not contagious and do not require transmission-based precautions.

Staff education is essential to maintaining clinical competence and client safety; therefore, options 1 and 2 are incorrect. Information technology is important to all nurses not just to nurse managers to organize and manage nursing and health care delivery. Option 4 is incorrect as well.

Kegel exercises are designed to strengthen the muscles of the perineum. By alternately tensing and releasing the muscles of the perineum, as if to start and stop the flow of urine, muscle tone and strength is enhanced. Bearing down is the opposite type of exercise for this set of muscles. Options 3 and 4 are incorrect statements of technique.

The MMR vaccine contains live virus that could harm the growing fetus. Stop the administration of the MMR vaccine to a pregnant woman and consult the physician for further orders for this client. Documenting the medication as refused and not consulting the physician would potentially endanger the client who may come in contact with someone infected with rubella.

Benign prostatic hyperplasia (BPH) is the most common disorder of the aging male client. Testicular cancer is the most common cancer in men between the ages of 15 and 35. Testicular torsion occurs at any age and gonorrhea is highest in occurrence during the sexually active years. Women 15 to 19 years old and men 20 to 24 years old have the highest rate.

PMS occurs only during the luteal phase of the menstrual cycle (7 to 10 days before menstrual flow begins). Increasing sexual activity doesn’t prevent PMS, and caffeine can worsen the symptoms.


When a client is on contact precautions, items that the client uses must be either kept in the room, disposed of, or subjected to terminal cleaning upon the client's discharge. The nurse should ensure that disposable meal trays are delivered. It is an inappropriate infection control measure to place a used meal tray in the dirty utility room. The client does not have dishes washed in the room between meals, and the tray items are not disinfected after each meal.

Pulses are measured frequently to ensure adequate circulation is present and an occlusion or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has a comparison point postoperatively. Pulses may be absent for a short-term postoperatively due to vasospasm or hypothermia. Anticoagulant therapy is not indicated. Trendelenburg position could reduce blood flow to the affected lower extremities. Elastic stockings may or may not be ordered because they could interfere with neurovascular assessment of the lower extremities; however, pneumatic boots would help to prevent deep vein thrombosis and allow visualization of lower extremities.

Elevation of the extremities promotes venous return. Pulses are measured to ensure adequate circulation. Option 3 is unnecessary because the Unna boot is treating the ulcer and is changed every 1 to 2 weeks.

The thyroidectomy is the third alternative treatment used when medication and iodine-based radiation therapy are unsuccessful. There is a great concern of causing hypothyroidism in the client. The other statements are not reflective of the underlying concern with performing a thyroidectomy in a child.

Option 2 recognizes the client’s emotional state and allows the client to make a choice to talk or not. It helps to build a trusting therapeutic relationship. When using therapeutic communication, don’t make assumptions about what is bothering the client and avoid questions that can be answered with yes or no responses. Option 1 is patronizing and isn’t helpful. Option 3 is a corrective statement and will eliminate the trust needed to build a therapeutic relationship. If the nurse asks the client if they are crying because something hurts the client may respond “yes” because it is easier than explaining what is really bothering them. Do not lead to clients the answer you are looking for, but instead let them explain for themselves (option 4).


Establishing an emotional bond with the newborn includes responding to behavioral cues, attempting to provide comfort, and meeting the infant’s needs. Holding the newborn and consoling the baby when he or she cries meets the infant’s need for comfort and helps to establish trust. The other observed maternal behaviors are positive signs of attachment.

A client with tuberculosis must wear a particulate respiratory mask if transportation to another hospital department is unavoidable. This is an element of airborne precautions necessary to limit the transmission of the microorganism. Tuberculosis is not transmitted via eating utensils (option 3) or urine (option 4). Removal and disposal of respiratory secretions is important but does not require the client to wear gloves.

Presentation refers to the part of the fetus that is coming through the cervix and birth canal first. Thus, a face presentation occurs when the face is coming through first.

A positive TB test means that the organism is present in the body in either an active or a dormant state. It should not be ignored nor should further testing be deferred for several months. The client can expect to be scheduled for sputum tests for the presence of the bacillus and a chest x-ray to determine the presence of lesions or active disease. Medications and isolation are not instituted until a probable or definitive diagnosis has been made.

While it may become important to notify the nursing supervisor and physician, it is pointless to do so until vital data is collected to relay to them. Vital data includes vital signs, oxygen saturation, and breath sounds. Once this data is collected, it would be appropriate to consult with the nursing supervisor for help in how to proceed. The bath becomes a low priority secondary to physiological distress.

According to standard precautions, the caregiver should wear goggles when contamination from splashing is possible, as when the membranes are artificially ruptured (amniotomy). The other options place the nurse at risk for contamination from skin contact, necessitating the use of gloves.

LPNs/LVNs are never to administer IVP medications, so the prudent LPN/LVN would ask the RN to administer this medication. All of the other tasks are appropriate for the LPN/LVN to perform.

To coach is to give direction and suggestions for improvement. Option 4 illustrates this concept. Option 1 is threatening rather than coaching. Option 2 is a criticism without a suggestion for improvement. Option 3 is helpful as a statement of positive reinforcement but does not specifically give direction for future actions.

Shared governance is based on the philosophy that nursing practice is best determined by nurses. Option 1 represents standard nursing practice. Option 2 is unrelated to governance. Option 4 represents leadership input into decision making for the organization.

The nurse should delegate the activity that is procedural in nature, which is within the scope of training of the UAP. The nurse does not delegate teaching (options 1 and 3) or interventions for chest pain (option 4).

The nurse can delegate procedures to the UAP and retains responsibility for the outcomes of those tasks that are delegated. Clearing the room of unnecessary objects and remaining with the client during ambulation are among those that can be delegated. The nurse needs to retain responsibility for assessment (option 2), teaching (option 5), and collaborating with the interdisciplinary team (option 4).

By the second to third postpartum day, mothers are moving into the taking-hold phase of adjustment and are eager to care for the baby and self independently. The other behaviors are characteristic of the taking-in phase, which occurs earlier and reflects greater dependence on the part of the mother.

Although this client is not demonstrating positive signs of bonding at this time, it is important to look at her history before concluding that she is not bonding well with her infant. This client just experienced a long labor and the influence of fatigue on the attachment process should be considered. It is important to continue to assess infant bonding with this client throughout her hospitalization to reach a nursing judgment based on evidence.


The client that is the most stable and with the fewest needs that the nurse must attend to is the client who is 6 days postoperative and awaiting placement in a rehabilitation facility. The nurse could attend to this client’s discharge paperwork later in the shift. The nurse needs to monitor the pain and neurovascular status of the client in option 1, since the client could be experiencing a complication of an overly tight cast. The nurse also needs to examine the client with the new spinal fracture. The nurse would need to help teach and counsel the client who has phantom limb sensation.

The definition of moderate sedation is that there is a minimal depression of the level of consciousness in which the client is able to maintain a patent airway and respond appropriately to verbal and physical stimuli. The pain threshold is increased so that the client can tolerate pain (option 2). Amnesia is induced partially with conscious sedation (option 3). Option 4 is false because the client is awake.

The most important action is to stop infusing more fluid into an infiltrated site. Once the infusion is stopped the nurse will follow agency policy as to whether or not to discontinue the IV, restart the IV, or notify the RN to perform these procedures. While a warm soak may help to improve the site, it would not be initiated until after the IV is discontinued.

The LPN/LVN should accept the assignment with the care of the 81-year-old client with heart failure and emphysema. This client was admitted 3 days ago and has a stable medical status. The RN would want to care for the client recently admitted with exacerbation of COPD and the 25-year-old with a concussion less than 24 hours ago. The newly diagnosed diabetic client would require initial teaching that should not be delegated to the LPN/LVN.

Although all of the options may be appropriate, demonstrating newborn care will allow the client to ask questions and gain confidence as she cares for her baby. Having her return the demonstration will allow the nurse to evaluate the teaching.

The postoperative care of the child undergoing repair of clubfoot would not include administering pain medication immediately when due and covering the cast with blankets. Medication for pain should be administered as needed, and the cast should not be covered with blankets because this will interfere with the cast drying and could enhance swelling if excessive heat is retained under the blanket. Use of ice bags, elevation, diversional activities, and assessment of neurovascular status, swelling, and drainage or bleeding are all appropriate interventions.

All of the information above is needed by the adolescent undergoing a spinal fusion, but the physician, not the nurse, should explain the actual procedure. The nurse should focus on the care of this child following surgery: the exercises for breathing, turning, moving extremities, and the tubes that will be placed—the nasogastric tube, urinary catheter, and intravenous lines. Ways that pain will be dealt with should also be explained in the preoperative period.

Individuals diagnosed with paranoid personality disorder frequently are critical or argumentative to maintain a safe distance between themselves and others related to their inability to trust others. Nursing staff may need to remind themselves that criticism of nursing care may be a manifestation of a personality disorder. The other statements listed do not reflect behavior that is typical of a client with this disorder.

Meconium stools are tarry, black, or dark green and are usually passed within 8 to 24 hours of birth (option 1). It is unusual to pass meconium at birth unless there has been hypoxia or trauma (option 2). Transitional stools are thinner in consistency with a brown to green appearance and consist of part meconium and part fecal material. They are expected a few days later after food has been digested (options 3 and 4).

If there are 250 mg in 5 mL, then there are 50 mg in 1 mL. Because 225 mg are needed, divide 225 by 50 to arrive at the proper answer of 4.5.

The development of ascites (third spacing) is a common complication of cirrhosis. With the development of ascites, sodium restriction is instituted. Depending on the extent and response to clinical treatment, the restrictions may be 500 to 1,000 mg per day if the client does not respond to customary diuretic therapy. Option 1 is incorrect—sodium is necessary for all individuals and the development of hyponatremia carries its own metabolic consequences. Option 2 is incorrect—even though paracentesis may sometimes be indicated, it is not the primary solution to the problem. It is important to look at the underlying fluid and electrolyte disturbances and correct them in order to prevent the recurring problem of ascites. While low-salt diets are often unpalatable, there is nothing to suggest that the client would be noncompliant with sodium restriction therapy. In addition, other seasonings can be used to provide taste to the client’s diet.


For absolute determination of tasks that fall within the scope of practice for LPNs/LVNs, consult with the State Board of Nursing. Consulting with anyone else would be considered obtaining an opinion at best.

Wound infection is decreased by skin preparation when debris and transient microbes from the skin are removed. The other possibilities are all incorrect since skin preparation will not prevent complications such as positioning injury or pressure ulcers. Dermatitis does not result if surgical skin preparation is omitted.

It would be counterproductive to confront and challenge a client’s paranoid ideation until trust has been developed. A consistent program schedule will cut down on the number of surprises for the client and help develop trust in the staff (option 1). Orienting the client to the unit and introducing him to the staff will enable the client to start developing therapeutic relationships (option 3). Communicating clear expectations will prevent the client from being confused (option 4).

The nurse should assess for signs and symptoms of hypersensitivity reaction following the administration of all vaccines. Wheezing is a sign of hypersensitivity reaction and warrants immediate further assessment and emergency action to prevent possible death. Local discomfort (option 1) may be expected and is treated if necessary with acetaminophen. Anxiety and vomiting (options 3 and 4) are not associated with administration.


Abrasions, pustules, or other skin conditions have to be monitored and documented because these may interfere with wound healing. Hair growth—lack of it or presence of lanugo or fine hair—will not interfere with the skin preparation. Pulsation is not always visible or available to monitor depending upon the part of the body being operated on.

Option 4 provides the client with the choice of how he would like to take the medication, while being firm that he must take it; the choice gives the client a sense of control and helps to reduce the power struggle. Simply telling the client that the medication is not poison (option 1) would do little to persuade him to adhere. Option 2 provides no choice and implies punishment. The client should take the medication; therefore, option 3 would be inappropriate.



Prior to touching medications, the nurse’s first action would be to wash the hands. The medications should have been ordered when the physician wrote orders. While following the six rights of medication administration is important, clean hands take precedence. Medications should never be documented until they are administered.

Anxiety reduction is needed when a client is waiting for the outcome of tests to assist the client in processing his or her feelings and explore options based upon the results of the test.

COPD places a client at risk to develop malnutrition due to reduction in muscle mass and fat reserves. Option 1 is incorrect because COPD clients are more likely to suffer from respiratory infections due to altered immune response (decreased cell-mediated immunity, altered immunoglobulin production, and impaired cellular resistance). Options 3 and 4 are incorrect because COPD clients usually present with weight loss and are hypermetabolic (require additional calories due to increased energy requirements as a result of increased work of breathing).

In hypertensive urgencies, clients present with a systolic BP greater than 240 mmHg and diastolic BP greater than 120 mmHg. In hypertensive emergencies, the client’s diastolic BP is greater than 130 mmHg.

Atherosclerosis indicates the need to adopt a low-fat diet. Both butter and margarine have 4 grams of fat per serving, making the client’s statement incorrect and in need of further clarification. The responses in the other options are correct.

Medical asepsis requires clean, not sterile, technique. Only option 3 requires medical aseptic technique. Collecting a wound culture (option 1), suctioning a tracheostomy (option 2), and catheterizing the client (option 4) all require the nurse to use sterile asepsis.

Increased heart rate and/or respiratory rate within minutes to several hours following central venous line insertion are symptoms of a pneumothorax caused by puncture of the pleura. The client will require a chest x-ray to determine if a pneumothorax is present. If the client does have a pneumothorax, placement of a chest tube is likely. Pain at the central line insertion site, fever, and diminished breath sounds in lung bases will require intervention, but the etiology of these symptoms is not likely to be potentially life threatening as is the development of a pneumothorax.

Ideas of reference or misinterpretation occur when the client believes that an incident has a personal reference to one’s self when, in fact, it is not at all related. A hallucination is the occurrence of a sight, sound, touch, smell, or taste without any external stimulus to the corresponding sensory organ; they are real to the person (option 1). Delusions are false beliefs that cannot be changed by logical reasoning or evidence (option 3). Loose association is a vague, unfocused, illogical flow or stream of thought (option 4).

With increased age, there is an increased sensitivity to xanthines. Also, there could be other disease processes that may lead to this elevated value. The dose of theophylline should be decreased to get the blood level to the 10 to 20 mg/dL range. Theophylline doses should be based on lean body weight to prevent entering the medication into the adipose tissue.

The newborn’s body grows in a head-to-toe fashion; therefore, uncoordinated movements of the hands and arms are expected rather than abnormal (option 2). Mild hypertonia may be noted (option 3), and muscle tone should be symmetric (option 4). Diminished tone or asymmetric movement may indicate neurological dysfunction.

Immunizations interrupt the chain of infection by generating immunity in a susceptible host by introducing a weakened or killed antigen into the body. Immunizations do not affect the portal of entry, portal of exit, or the mode of transmission of a pathogenic organism.

Uterine prolapse is caused by weakened pelvic muscles, which can be strengthened by Kegel exercises. The other conditions are not treated with Kegel exercises.

With this client, being a danger only to himself (option 1) isn’t enough; he may not be a danger to himself but he still may want to harm his parents (others). Although the goal is for the client to continue to take his medication (option 3) and remain in treatment (option 4), safety is a priority. Depending on state law, the length of hold may be either 48 or 72 hours.


Sneezing and coughing are examples of modes of transmission, whereby droplet nuclei can be transmitted directly to a susceptible host.

The premature secretion of testosterone promotes the closure of the epiphyseal growth plates. Many of these children appear very tall around sixth grade, but their friends eventually catch up and surpass them in linear growth.

Calf-pumping exercises involve contracting and then relaxing the leg muscles in an alternating fashion. Options 2, 3, and 4 do not exercise the calf muscles, including the gastrocnemius muscles.

When intervening in delirium, highest priority is given to nursing interventions that will maintain life. Fluid and electrolyte loss caused by nausea and vomiting can be a life-threatening condition during alcohol withdrawal, requiring replacement by intravenous therapy.

A wound infection can be spread by direct contact with the wound. Scarlet fever, pertussis, and rubella involve the spread of infection by respiratory particle droplets larger than 5 microns.

The statements in the first three options correctly describe signs of BPH. Option 4 indicates the need for further teaching because the client should increase his fluid intake (unless contraindicated) to prevent urinary tract infections and lessen dysuria.

When an infant is stressed by cold, oxygen consumption increases and the increased respiratory rate is a response to the need of oxygen. Additional signs of cold stress are increased activity level and crying (option 1), and hypoglycemia as glucose stores are depleted (option 3). Newborns are unable to shiver as a means to increase heat production (option 4).


Elderly clients have slower metabolism and elimination of drugs, causing an increased susceptibility to side effects. Extrapyramidal side effects are most common with haloperidol, a high-potency antipsychotic. Frequent sedation of this elderly client with haloperidol can lead to the development of tardive dyskinesia, and requires careful monitoring by the nurse.

The state nurse practice act defines the scope of nursing practice in each state. Although there are general principles that apply to all, each state retains the right to formulate its own regulations about nursing practice, including delegation. The ANA standards of practice apply to care given to clients. Job descriptions and policy manuals are agency-specific and do not address the state regulations directly.

The gown is applied first, as it takes the most time to don. The mask is donned next, followed by eye protection. These items can be more securely applied with ungloved hands. Gloves are donned last, so the gloves can be pulled up to cover the cuffs of the gown.


The client who has had a positive PPD test in the past should be evaluated with a chest x-ray, which would then be the screening test of choice. The arm should be cleansed with alcohol and allowed to air dry prior to the administration of the test. The test is usually read in 48 to 72 hours and the client may wash the area as usual.

Initially, the delirious client is dazed, drowsy, and perceptions will be disturbed, making it difficult for the client to sustain attention to any mental task. Delirium is characterized by alternating periods of confusion with lucidity; therefore, option 3 is an appropriate initial outcome criterion. Options 1, 2, and 4 may or may not be appropriate outcome criteria once the client has been stabilized.

Severe scrotal pain, nausea, and absent cremasteric reflex are characteristic of testicular torsion. Severe pain and an absent cremasteric reflex are not typical symptoms of the disorders listed in the other options.

A goal of venous ulcer care is for the client to experience no signs of inflammation or infection. This is the goal directly related to tissue integrity. The other options are good outcomes but do not relate directly to the question as stated.

The onset of dementia symptoms for this client was at or before 58 years of age. When Alzheimer’s disease occurs in people under the age of 65, it is called presenile dementia.

Plantar creases are part of the physical maturity rating on the gestational age evaluation. Options 1, 2, and 4 may be observed but are not part of the gestational age evaluation.

The client has a right to confidentiality. Unless a nurse is assigned presently to care for an individual, the nurse should not seek nor share known details about a client’s status. Family members would need approval from the client and the physician prior to reviewing a medical record.

Negligence is defined as the failure to act as a reasonable person guided by ordinary consideration and situations, or doing something that a reasonable person would not do. The other answers are unrelated to the action.

Malpractice occurs when any form of negligence causes injury to the client. It is the failure to act as a reasonable person with the same knowledge and experience would do. A tort is a wrong or injury that a person has suffered from another’s actions. Fraud is deliberate deception and assault is the threat of harm or unwanted contact with a client that causes the client fear.

The nurse can decrease the risk of malpractice claims and litigation by maintaining expertise in practice by keeping up-to-date in knowledge and skills, understanding the effects and correct dosage of medication, and practicing within the statutory scope of practice. The nurse should not offer value judgments at any time nor discuss errors with the family. Incident reports should be kept on file but do not decrease the risk of malpractice litigation.

Law is not the sole source of the ethical practice of nursing as there are numerous legal sources influencing nursing practice. An individual should understand the ethics of a profession when entering it, as those ethics may differ from personal ones.

In this situation, there was no nurse-client relationship. Although the neighbor offering the aspirin was a nurse, this action did not occur as a component of the nurse’s employment. All of the other requirements were present.

Autonomy refers to the right to make one’s own decisions. Justice refers to fairness. Fidelity means being faithful to one’s obligations to the client. Confidentiality is the right of the client to privacy regarding personal health information, except as it needs to be shared in the course of providing nursing care.


The Good Samaritan Act provides freedom from liability for professional people providing first aid.

Autonomy is the right of individuals to take action for themselves. Beneficence is a duty to help others by doing what is best for them, whereas negligence is a legal term. Privacy is the nondisclosure of information by the health care team.

Prolactin and oxytocin, two hormones necessary for breast-milk production and let-down, are released from the stimulus of the newborn suckling. The mammary gland of each breast is composed of 15 to 20 lobes (where milk is produced and travels to the nipple) arranged around the nipple. Breast size is related to adipose tissue (option 2). Neither newborn weight (option 3) nor nipple erectility is directly related to breast-milk production (option 4).

This client’s condition is deteriorating and needs to be thoroughly assessed before calling the physician for additional orders. Assessment is not part of the role of the LPN/LVN so assistance is needed. When a client’s condition is deteriorating, the nurse needs a lot of support, especially from registered nurses. The registered nurse should complete a head-to-toe assessment. The nurse assigned to the client knows the client best and would be better able to reduce anxiety and can continue to monitor vital signs. The unit secretary could page RT to the room stat for assistance. The registered nurse should be used to complete tasks within the RN’s scope of practice, such as performing a head-to-toe assessment.

In this scenario, the licensed practical nurse/licensed vocational nurse (LPN/LVN) clearly has authority to insert a catheter, administer medications, and monitor vital signs. The RN is responsible for developing a teaching plan. Once developed, the LPN/LVN may help to reinforce teaching.

The scenario does not imply the nurse is disorganized or that the work environment is hostile. The nurse is not incompetent. Due to the lack of health care workers, the nurse is handicapped in the ability to delegate. The nurse cannot delegate tasks to staff, because people are not available.

The nurse should stop feeding the client in room 1, and medicate the client in room 3. While eating is a priority, it does not take precedence over an individual with pain. The client in pain is experiencing discomfort that should be addressed immediately. The task of feeding the client in room 1 can be delegated, but it should be delegated to an appropriate person, such as the nursing assistant. The charge nurse is busy overseeing the functions on the unit.

The nurse should irrigate the nasogastric tube and flush the clogged urinary catheter; these tasks are not in the unlicensed assistant’s scope of practice and job description. A BP of 100/60 is normal, and does not warrant further follow-up at this time. A client with an infected wound should have the dressing changed by the nurse for evaluation of effectiveness of wound therapy and complications. In general, the nurse should perform any task that might require advanced skills and critical thinking for solving problems.

The scope of practice for licensed practical nurses/licensed vocational nurses (LPNs/LVNs) allows them to flush Foley catheters and change dressings on diabetic ulcers. Blood administration must be delegated to the RN due to the complications that could arise during the transfusion. While LPNs/LVNs are allowed to irrigate nasogastric tubes, in this case the client has had a colectomy, and could have complications; the RN should perform this task. The client with a BP of 100/60 does not need to have vital signs rechecked at this time. When it is time to recheck the BP, it could be delegated to unlicensed assistive personnel, but does not require an RN to perform.

In this case, the delivery care system is team nursing. Due to scope of practice, the registered nurse should perform all assessments including the postoperative client and both stable clients. However, the nursing assistant should check vitals and complete bed baths on the clients. The LPN/LVN may check vitals and give bed baths, but the skill set of the LPN/LVN is better utilized in providing wound care and medications for the clients.

The scope of practice and most job descriptions for certified nursing assistants includes vital signs. CNAs are not allowed to change dressings, administer medications, or perform assessments.

Due to the risk for aspiration, the nurse should feed the client with dysphagia. The nurse should monitor drainage from a nasogastric tube for quantity of blood. When a client has an elevated or low blood pressure, the nurse should recheck and monitor the client for validity of information and changes in status. Of the four answer options, option 4 is the best choice. The UA is qualified to turn a client with multiple sclerosis and severe weakness.

In this scenario, the client is in distress, so the nurse should stay with this client and call for help from other members of the team. The charge nurse has expertise in handling emergencies, and the CNA can obtain the equipment necessary for data collection. Nurses caring for clients in distress should monitor the client’s vitals. In emergencies, the nurse should handle tasks such as vitals and obtaining oxygen saturation levels. In this case, the nurse wants to check not only the oxygen level but also the vital signs. The nurse should never leave the room of a client in distress.

The full-term infant exhibits greater than 90-degree flexion of the extremities and clenched fists. Stimulation will not relax the muscle tone (option 1). Placing in a supine position will not decrease the flexed position (option 2), and parental anxiety does not cause the flexed position (option 3).

The administration of IVP morphine for the client with pain is within the scope of practice for the registered nurse, but not in the scope of practice for the LPN/LVN. While the administration of oral medications for the client with CHF is in the scope of an LPN/LVN, this client might need comprehensive assessments due to the pathophysiology of CHF. The administration of vitamins for the client with wounds is in the scope of practice for the LPN/LVN; the client is stable, and does not require immediate assessment.

An LPN/LVN may administer insulin. Only a registered nurse may administer IV push medications and blood products. Administration of dopamine requires frequent assessments, so administration should not be performed by the LPN/LVN, although the LPN/LVN may assist in the care of this client.

In this scenario, various members of the nursing team are performing different elements of client care on the unit, a characteristic of task nursing. When primary nursing is utilized, the nurse assigned to the client performs most of the duties for the nurse’s assigned clients. In team nursing, a team of an RN and an LPN/LVN or CNA provides care to a group of assigned clients. Operational nursing is a distracter.

Of the answer options, the best option is 2; the skilled RN should get the postoperative client with the hip replacement and the abdominal hysterectomy. Postoperative clients are critical clients due to the risk for hypervolemia and shock. The experienced nurse should receive the surgical clients. The RN on orientation should care for the clients with medical conditions such as CHF, hypertension, and diabetes. In this case, the LPNs/LVNs should assume duties such as vital signs and assisting with ADLs.

The charge nurse does not need to assume total care for these clients. In this case, the charge nurse needs to assist in the care of these clients. The charge nurse should administer the IVP pain medications. The LPN/LVN can administer the IVPB medications and provide wound care. The CNA should not perform wound care, because CNAs are not trained to assess wounds.

In team nursing, a small group of nursing staff provides care to a small group of clients. In task nursing, each member of the nursing team has to perform specific tasks for clients on the unit. Operational nursing is a distracter. In primary nursing, the nurse assigned to the clients assumes the majority of care for most of the clients.

The nurse should complete an incident report, and document the fall in the client’s chart. The nurse should never place an incident report in the client’s chart. The incident report is an internal tool to monitor incidents within the facility. A copy of the incident report does not enter the nurse’s record, nor does the client’s caregiver receive a copy.

The float nurse should receive clients who are not compromised by chronic conditions exacerbated by acute conditions. The float nurse should not receive postoperative clients, due to their high acuity. Generally, geriatric clients can have fluctuations in status, placing them at higher risk for complications, which is not an ideal situation for the float nurse. The float nurse’s expertise is in obstetrics; the care of medical–surgical clients will be new to the nurse. The charge nurse should not overwhelm the float nurse. The best selection is option 1.

Health Insurance Portability and Accountability Act (HIPAA) regulations do not permit health care workers to disclose information about a client unless the client has signed a release of information form. The nurse does not have a method to verify the person’s identity over the phone. The nurse should respond truthfully in an effort to make the son aware of confidentiality policies, but the nurse should respond using a mild tone.

Options 1 and 4 make an assumption the nurse cannot confirm—that the client fell out of bed. While this is what the client said, the nurse did not actually observe the fall and cannot verify the veracity of the statement. Option 2 makes a diagnosis that the nurse is not allowed to make within the scope of practice. The only correct answer is option 3, which states exactly what the nurse observed and heard.

Priority setting can be implemented using a variety of models. The client who is postoperative should be seen first because the client is newly arrived on the unit and is at most risk of becoming unstable or experiencing a change in clinical condition. The client with pneumonia should be seen next because the infection involves the airway, although oxygen saturation levels are higher than the critical value of 90% or less. The client who is 4 hours post–cardiac catheterization should be seen next to evaluate the site and conduct general examination of the affected extremity. The client who will be discharged should be seen next to determine that there are no last minute needs or issues. The client who needs teaching should be seen last because this is not a physiological need.

The newborn should be brought to the breast, not the breast to the newborn; therefore, the mother would need further demonstration and teaching to correct this ineffective action. Options 1, 3, and 4 are correct actions for successful breastfeeding.

The nurse must provide feedback and evaluate performance to ensure the BG checks are completed every 2 hours. The nurse does not need to watch the UA to see that the BG checks are done; this defeats the purpose of delegation. The purposes of delegation are to allow the person who is assigned the delegated task to operate at his or her fullest level and to allow the individual delegating the task time to perform other critical tasks. The nurse gives the UA authority to complete the task; authority is not limited. Rotating BG checks limits the UA’s authority to complete the job.

The client is asymptomatic; there is a possibility this lab value is erroneous. The first action is to redraw the serum glucose. The health care provider should be notified after the serum glucose is confirmed. The nurse should not administer an amp of D50 without an order from the health care provider. The nurse should review the client’s medication record, but this is not a priority at this time.

This client needs a venipuncture for serum glucose. The nursing assistant may perform this task. The client is not in distress, so it is appropriate to allow the nursing assistant to draw the blood. The nursing assistant should not notify the health care provider of the serum glucose or review the medication record. The nurse should perform these duties. The nursing assistant may give orange juice, but the client’s serum glucose must be verified prior to such an intervention.

This nurse clearly is not managing time very well. Typically, a nurse listens to report first, takes a quick peek at the assigned clients, reviews AM lab results, checks the MAR, and proceeds from there. This nurse is meandering around wasting invaluable time. The concepts of communication, priority setting, and delegation are not applicable in this scenario. The stem of the question is focused on the nurse’s time-wasting behavior.

The nurse should start the day by listening to report. This allows the nurse to receive information about the status of each client. The next action is to check the clients. The nurse should check on each assigned client to determine his or her current status and assure they are not in distress. Next, the nurse should review AM labs to obtain pertinent information to help plan the day and detect subtle changes in the client’s status, which allows earlier treatment and preventative interventions. Lastly, the nurse should review the MAR to detect priority medications. The laboratory results can impact the medications given, which is why they need to be checked before the MAR.

The ABCs of care apply in this case. Emergency inhalers and emergency procedures take precedence over dietary implications and oral medications. Typically, people with COPD do not have atrophied respiratory muscles. The pathophysiology is at the level of the alveoli, bronchioles, and bronchi.

The first action by the nurse is to elevate the HOB to allow the lungs to expand. The nurse should then check the client’s oxygen saturation level. Option 2 indicates lowering the HOB will increase the blood pressure; this supposition is false. Lowering the HOB theoretically should elevate the blood pressure or prevent the blood pressure from dropping. Option 3 implies the application of oxygen will decrease respirations, but this is not true. The best answer in this case is option 1.

The nurse needs an order from the health care provider to obtain an arterial blood gas or to stop the intravenous fluid. This client is receiving intravenous fluid at a “keep vein open” rate, which should not contribute to fluid volume overload. The nurse first should check the client’s oxygen saturation level and then call the health care provider with all of the data collected.

Due to the safety risk of physical restraints, the nurse should examine the client in physical restraints first. The nurse then should check the dialysis schedule, which will provide the nurse with dialysis times for clients. The nurse then could change the surgical dressing. However, the nurse should not inform the client’s friend of the client’s condition, as this is a breach in confidentiality.

The nurse should make every attempt to actively listen to the caregiver’s concerns and attempt to resolve them. The city police should not get involved with this case; the client is not threatening anyone. The client’s health care provider should be informed, but this is not a priority. Should the client refuse to allow the nurse to address the concerns, and continue the irate behavior, the nurse then should call Security. Overall, the nurse should resolve the issue.

The cry of the newborn is tearless because the lacrimal ducts are not usually functioning until the second month of life. Lacrimal ducts are naturally patent and not punctured (option 1). Neither silver nitrate nor antibiotics will reduce tear formation (option 2). Exposure to rubella is not known to cause stenosis of the lacrimal duct (option 3).

The nurse should consider pressing issues such as surgeries first. The client who is scheduled for surgery needs special preparation prior to the surgery. This is a priority that takes precedence over the urine specimen, documentation, and client education.

The nurse always should start with examination; a head-to-toe approach is the easiest way to remember what to check first. The nurse should start the examination with inspection of the head for injuries and neurologic damage. Examination of range of motion does not precede a head exam. Vital signs and oxygen saturation levels may be taken after the exam. The client might need an x-ray based on the findings from the exam, but it would be ordered by the physician.

The client with a potassium level of 2.8 mEq/L could go into a detrimental cardiac arrhythmia. The client’s potassium level is critically low. This client should receive the potassium immediately. The montelukast (Singulair) is a maintenance medication, and can wait until after the potassium rider is administered. The client with an oxygen saturation of 95% does not need two liters of oxygen. This client’s oxygen saturation level is within the therapeutic range. The client with a BP of 108/66 might not need 50 mg metoprolol (Toprol). This medication could decrease the blood pressure below 100/50, so this is not urgent to give in relation to other actions.

The nurse should check the postoperative client with the nasogastric tube and irrigate the tube to ensure it is functioning properly. The urinary catheter should be flushed next; while it is not an urgent matter, it otherwise could cause some discomfort. The nurse then should proceed to the client with the diabetic foot ulcer. Dressing changes often are ordered a few times per day. This is not a medical emergency, but is a scheduled treatment. And lastly, the 30-year-old client could have vitals checked by the nursing assistant; the nurse does not have to perform this task.

The client with a magnesium level of 0.8 mEq/L is in danger of having seizures and tetany if it falls further, so this client is a priority. It is important to keep this client safe and prevent seizure activity. A potassium level of 3.7 mEq/L is within the therapeutic range. The administration of potassium is not necessary. The client in option 2 is stable; the ABG results are normal. No intervention is warranted. Examination of the diabetic foot ulcer can wait until after the nurse has administered the magnesium. The examination of the foot ulcer is not a priority.

The geriatric client with dehydration and a low BP could go into multiple-organ failure due to fluid loss. The major organs might not receive adequate perfusion. This client is a priority over the other clients. The client in option 1 has a history of CHF; the stem does not indicate the client is actively in CHF. Most sickle-cell clients have low hemoglobin levels. The stem does not specify lab values. The middle-aged client with pneumonia is not in distress; the client with the low blood pressure is in physiologic distress and needs immediate intervention.

This is a diabetic client who has become diaphoretic, disoriented, and unsafe. These are classic symptoms of hypoglycemia. The nurse should check the client’s finger stick blood sugar first. Checking vital signs every hour is not warranted in this case. The nurse needs to check the client’s finger stick blood sugar prior to implementing any interventions. Chemical and wrist restraints should be a last option in any case, but neither is warranted in this case.

In this scenario, the nurse is using priorities based on medication therapy. This client is in respiratory distress, and requires medication immediately to prevent full heart failure and pulmonary congestion. Administering this medication is a priority at this time due to the client’s condition. Policies and procedures are not applicable to this scenario. Time is essential, but the question specifically is asking for a framework for determining priorities.

The staff nurse should respond by instructing the orientee to make a to-do list and prioritize to stay on track. Many experts in leadership and management recommend to-do lists to help organize tasks that must be accomplished throughout the day. Prioritizing the to-do list is a method to allow the nurse to focus on tasks that require immediate attention first, and then finish up with tasks that do not require immediate attention. The other options are examples of poor time management and barriers to time management.

The float nurse should get a quick orientation of the floor operation prior to receiving report. A quick orientation could alleviate tensions and fears the float nurse might have, and certainly could save time. Once report starts, the shift officially begins, and the float nurse might not get an opportunity to get an orientation. After report is given, the float nurse should make client assignments for the staff. The charge nurse could review orders written by health care providers as the orders are written. This is not an immediate task.

The tonic neck reflex, or the fencing position, refers to the position the newborn assumes when supine with the head turned to one side. The extremities on that side will extend, and the extremities on the opposite side will flex. The Moro reflex occurs when the newborn is startled and responds by abducting and extending arms with fingers fanning out and the arms forming a “C” (option 2). The cremasteric reflex refers to retraction of testes when chilled or when the inner thigh is stroked (option 3). The Babinski reflex refers to the flaring of the toes when the sole of the foot is stroked upward (option 4).

The nurse is in the process of collecting data on the client; the next action is to complete the data collection to determine if there are other aberrant findings. The health care provider should be called after the data collection has been completed, so the nurse can convey all aberrant findings. The health care provider might order an electrocardiogram after the nurse has communicated findings. The health care provider could direct an order for a phosphate level when the nurse calls with findings.

The nurse should replace the fluid with the correct fluid immediately to prevent the detrimental effects of receiving the wrong intravenous fluid. Once the bag of fluid has been replaced, the nurse should write an incident report and notify the physician of the error. The charge nurse and nurse manager should be alerted to the incident, but the first action is to replace the bag of intravenous fluid.

This client has classic heart failure symptoms. The client has an order for furosemide (Lasix); the nurse should administer the medication first to remove the extra fluid from the client’s circulating blood volume. The physician does not need to be informed at this time. The nurse needs to administer the medication and monitor the client’s response to the medication. Should the client’s symptoms persist, the nurse should call the health care provider. The charge nurse does not need to verify the findings in this case.

The nurse should administer morphine to the client in pain. This client is in an uncomfortable state of pain, 7 of 10. This should be addressed immediately. The administration of cardiac medications to the client with CHF should be addressed next, to prevent symptoms of CHF. The administration of bolus enteral feedings should be addressed next to meet the basic physiologic need of this client. The administration of enteral feedings comes after the nurse administers cardiac medications, which are important in preserving cardiac function. Vitamins typically are ordered daily. This is not an immediate priority.

In this case, the nurse must consider the physiologic needs of the clients. The client in bed 4 needs to have his or her physiologic needs met. Physiologic needs are addressed on the first level of Maslow’s hierarchy of needs. Moreover, the nurse must consider the ABCs of care; the client in bed 1 with the GI bleed could develop shock and renal failure, which speaks to the ABCs—circulation. Option 1 offers a solution that addresses the client who needs to go to the bathroom and the client with the GI bleed. Option 2 is appropriate, but it does not address the client who needs to go to the bathroom. Option 3 is not an immediate priority. The nurse first should check the client with a GI bleed due to the potential for severe blood loss. Option 4 does not address any of the pressing issues. ADLs can wait until physiologic needs have been addressed.

A client with a platelet count of 45,000/mm<sup>3</sup> has bleeding tendencies and abnormal bleeding, and when injured, the client will bleed for longer periods of time. The normal platelet range is 150,000–400,000/mm<sup>3</sup>. The goal for this client is to remain free of injuries, to prevent massive bleeding and hemorrhage. The scenario does not imply nutritional or cardiac problems. Tissue perfusion is not the pressing issue at this time.

This client has acute pain secondary to the fall and fracture. The client’s pain level is 8 out of 10, and should be treated immediately to increase the client’s comfort. Impaired comfort will be addressed when the pain is treated. The client came to the ED for acute pain related to a fall, not chronic pain related to osteoarthritis. Mobility is not a pressing issue at this time. Pain should be addressed first.

This client’s BP is within the normal range. However, adding a calcium channel blocker, beta-blocker, and diuretic could lower the client’s BP to extremely low levels, placing the client at risk for falls and possibly shock. The nurse should wait until hearing from the health care provider before administering these medications to the client. The nurse should document the findings and continue to monitor the client’s status.

This client’s phenytoin level is elevated. The normal is 10–20 mg/dL. The health care provider might not be aware of this lab result. The nurse should inform the health care provider of the client’s elevated phenytoin level. The health care provider might change the dose and/or frequency of the medication. The phenytoin level does not need to be redrawn; it is not critically elevated. The medication should not be administered until the nurse receives new orders from the health care provider. The nurse cannot make the decision to administer half the dose of phenytoin; a new order must come from the health care provider.

This client is allergic to a broad category of medications. The nurse should start with identifying specific drug allergies. This information can be gathered from the client and caregiver. Not all clients are allergic to all drugs in a general category of medications, and this client might not have a reaction to cephalexin. However, because this client has allergies to other cephalosporins, it is reasonable to anticipate that this client could have a reaction to this medication. Once the allergy data have been gathered, the nurse should inform the health care provider of the client’s current allergy status. This medication should not be administered until medication allergies are verified.

A full-term male infant will have both testes in his scrotum, with rugae present. Good muscle tone results in a more flexed posture when at rest (option 1) and inability to move his elbow past midline (option 4). Only a moderate amount of lanugo is present, usually on the shoulders and back (option 3).

This client has an elevated glucose level that leads to damage to the client’s vasculature. The insulin is rapid-acting, and will decrease the client’s glucose level more quickly than the oral medications. Actos is ordered once daily, and is not a priority, although it should be administered around the same time each day. Actos may be given in conjunction with Humalog, but the client must be able to produce insulin for Actos to work effectively. Starlix is ordered three times daily, and may be given in conjunction with insulin. However, it takes longer for this medication to work; the half-life is 1.5 hours. Starlix requires functioning pancreatic beta cells. Furthermore, Starlix should be administered on schedule, since it is ordered three times per day. Lipitor is given once daily, and is not a priority. In fact, Lipitor can be administered at night.

The nurse must initiate seizure precautions, because this client is at risk for seizure activity. The administration of one-half normal saline (option 2) is contraindicated, as this will pull more fluid from the vascular space into the cell, worsening cerebral edema. Repositioning the client is a comfort measure, not a priority. Antispasmodics may be administered, but this action is not a priority at this time. The nurse should make every effort to minimize harm should a seizure occur.

The nurse has initiated seizure precautions, and should now hang a bag of hypertonic IV solution as ordered to shift fluid back into the vascular space. The nurse then may administer antispasmodics as ordered and reposition the client in bed. After these measures have been instituted, the nurse should reexamine the client to determine the effectiveness of treatment and interventions.

A client with a platelet count of 58,000/mm<sup>3</sup> could bleed spontaneously, and should be kept safe. This client requires activity restrictions due to the lack of clotting ability. A low platelet count does not yield an elevated WBC. Aspirin is contraindicated, as it could decrease clotting time. The prothrombin time should be monitored, as it indicates the amount of time it takes for a platelet plug to form, but it is not an immediate priority.

This client is more likely to have an increase in clotting time due to the low platelet count, but spontaneous bleeding is unlikely at this level. However, the client should refrain from strenuous activity that might cause injuries. Blood in the urine and stool is an indication the client is actively bleeding and that her platelet count has decreased. In this case, the client should be seen immediately. This client’s platelet level should be monitored within 7–10 days.

This client’s blood glucose is elevated and should be treated prior to surgery for better surgical outcomes. The nurse should administer the 6 units of Humalog insulin immediately, to gain a tighter control on the client’s blood glucose. All other tasks may be handled after the nurse has administered the insulin. The nurse does not need to call the surgeon about the elevated glucose. The nurse should recheck the finger stick glucose 30 minutes to an hour after the insulin has been administered.

The client in this case is bleeding; the likely source is the incision. The first action by the nurse is to check the incision for drainage. Calling the health care provider is immature without first checking the client. Elevating the head of the bed on a client with a low blood pressure could decrease the blood pressure; the head of the bed should be lowered to prevent the blood pressure from dropping. A nurse needs an order from the health care provider to increase the rate of intravenous fluids.

There is an urgent situation in the next room, and the nurse should go check the client to determine the extent of the client’s change in status. After examining the client in the next room, the nurse should then call the charge nurse if extra help is necessary. The surgical client, while not technically stable, does not have any aberrant findings at this time, and therefore the nurse should check on the client who is presently having problems. The health care provider should be called after the data collection of the clammy client, with a detailed update of the client’s change in condition.

The nurse could instruct the CNA to obtain a set of vital signs on the postoperative client. This action allows the nurse to have ongoing data about the postoperative client, which could determine a change in the postoperative client’s status and need for medical attention. Checking on the postoperative client does not yield as much data as checking vital signs does. Checking on the client will yield information that can be gathered only by inspection. However, vital signs provide a better picture of the client’s physiologic status. The CNA should not stay with the clammy client; the nurse should check this client, take the client’s vitals, and check the client’s finger stick glucose.

The nurse must check on the client who has fallen; this client could have a head injury, hemorrhage, or some other grave complication from the fall. This client is a priority; the client could die if not given the proper and timely care that is needed to prevent complications from a fall. The exam on the client with pneumonia can wait. The nurse may ask the nursing assistant to check vital signs on the client who fell, but the nurse must still see the client first. The nursing assistant does not need to stay with the client who has pneumonia.

The first meconium stool should be passed within the first 24 hours after birth; if not, the abdominal girth should be measured to evaluate distention and the possibility of obstruction. The presence of anal fissures will not prevent the passage of a meconium stool (option 1). Notifying the physician will not provide more information (option 2). Increasing the amount of feedings will not provide more information, and if there is an obstruction, will complicate that problem (option 3).

The bed alarm system could alert the staff of the client’s large motor movements while in bed, which is an indicator that the client might attempt to get out of bed. The bed alarm system is a good device to notify the staff that a fall is likely. Monitoring the client every 10 minutes might be plausible, but if a bed alarm system is available, it should be used. Monitoring the client every 10 minutes, in many cases, is not enough to prevent the client from falling. While examining the etiology of the fall is warranted and needed, this is not an immediate priority. The immediate priority is to prevent the client from falling, and this can be done through the bed alarm system. The caregiver may sit with the client in an effort to prevent falls; however, the caregiver is not currently with the client. Something must be done now to alert the staff of major body movement.

Any client with a BNP of 800 pg/mL is in congestive heart failure, and should be seen first for respiratory and cardiac complications. This client also might need dialysis to remove additional fluid from circulation. A 90-year-old client with weakness and pneumonia does not take priority over the client with a BNP of 800 pg/mL. The hematocrit of this young individual is a little low but not life threatening. While the 72-year-old postoperative client is at risk for postoperative complications, this client can wait until the client in option 1 is seen. Respiratory and cardiac are first in priority.

A client with a BNP of 800 pg/mL has too much fluid in the circulating volume. The heart is unable to pump the additional volume effectively; thus it secretes the B-type natriuretic peptide to alert the body of this problem. This individual will have difficulty breathing; fluid backs up in the lungs, decreasing gas exchange and impairing respirations. The nurse first should administer this client’s diuretic to remove the additional fluid from the circulating volume. Oxygen is needed in most cases, and the actual order should be based on the client’s need for it. Most of these individuals need oxygen in excess of 2 liters per minute. Providing the client with oxygen does not improve heart failure. Ambulation is not a priority at this time, and could increase the oxygen demand of the heart, increasing the workload of the heart. Coughing, turning, and deep-breathing could help the client cough up pulmonary secretions, but does not address the heart failure.

The client with fluid overload is a priority in this case. Clients with airway impairments are the highest priority in most cases. With impaired gas exchange, the client is not able to exchange carbon dioxide for oxygen, leaving the client in air hunger. Depending on the situation, the nurse must decide whether to address pain or risk of injury. If the client’s pain level is high, the nurse should address this first if the client with the risk of injury is safe. If the client with the risk for injury is unsafe, the nurse must address that client first. Airway, breathing, circulation, safety, and pain are the order in which most cases should be prioritized; however, every nursing scenario is different. The client with impaired communication does not take precedence over the client with hypervolemia.

The nursing intervention that should be addressed first for the priority nursing diagnosis Impaired Gas Exchange is the administration of a diuretic. The cause of the impaired gas exchange is fluid in the pulmonary fields. Lasix is effective in removing additional fluid, thereby correcting the overload. While elevating the HOB is a good option, it is not a priority in this case; the client needs treatment that will remove the additional fluid. Lanoxin also is necessary, but the nurse should treat the cause of the impaired gas exchange first. Morphine sulfate is used to regulate respirations, but it does not correct the overload.

Monitoring for bleeding, monitoring the need for pain medications, and taking vital signs on an unstable client are all outside the scope of practice for the CNA. Recording intake and output is within the scope of practice.

Ambulating a confused client will not have any unexpected outcomes. Changing a postop dressing and assisting a client who has had a recent stroke with meals require nursing skills. The client with a new tracheostomy has the potential to be unstable.

This client is the most stable, as this behavior is expected in the manic client. All other clients are not stable in their current state, being at risk for possible violence (option 3) or suicide (options 1 and 4).

Option 4 is an expected state for a client with dementia, and the client therefore is stable. Option 1 requires teaching, while options 2 and 3 are unstable, and should be cared for by the registered nurse who has more experience.

Option 4 deals with the airway, which is a priority in care. The other options are not as high priorities as the airway. The client in pain would require attention second, the client with diarrhea and need for skin care third (however, this also could be delegated to another caregiver for faster attention), and the dressing change would be last.

The hard and soft palates are examined to feel for any openings, or clefts. The frenulum is a ridge of tissue found under the tongue and usually does not affect sucking (option 1). A thrush infection is usually visible as white patches adhering to the mucous membranes and does not need to be felt (option 3). Saliva is normally scant and can be observed (option 4).

Chest pressure or pain is potentially life threatening, making option 4 the priority. The other options are not as critical as option 4. The nurse next would examine the recent transfer from the ICU, the second-day postop client, and finally the client with mild dementia.

The client in option 2 could be experiencing pain. The other options are not as likely to be having an immediate crisis, and should be seen after client 2. The client who is receiving IV fluids likely would be second because of the risk of infiltration or a completed infusion, followed by the client who is blind (and therefore less able to function in a new environment), and finally the client who is immobile.

Clear fluid from the nose is a priority, indicating head injury. Option 1 is serious, but can be managed after the client with the head injury. Options 3 and 4 are relatively minor, as head wounds bleed profusely.

Femur fractures can precipitate a fat embolism, and so require immediate examination, such as a neurological exam. The pain level is important, but not as important as neurological function. Nutritional status and a medical history can be evaluated at a later time.

This is indicative of compartment syndrome, which is a condition that will cause ischemic injury and loss of limb within a few hours if a fasciotomy is not done to treat this, and is a priority in the care of clients. The nurse should examine the distal extremity for adverse circulatory changes, and then notify the physician. Elevating the head of the bed and administering pain medication will not address this potential loss of limb. Elevating the foot of the bed actually could worsen the situation by further reducing blood flow to the distal extremity.

This client is in danger of harming either himself or others, depending on what the thoughts are, and needs supervision. The nurse needs to protect the client and all others in the environment. The other options will not address this priority.

The client in option 4 is exhibiting danger signs. Depressed clients who suddenly begin to feel better are at risk for suicide. The other clients are exhibiting common signs of their illnesses.

Option 3 is a danger sign and requires immediate intervention. Frequent swallowing is an indicator of bleeding. The other options include common signs of those health problems.

Option 3 is a physiologic need and must be addressed first. Option 1 is important, but does not address the vital body systems that might be affected. Option 2 is not a priority at this time, and option 4 is beyond the scope of practice of the nurse.

Safety is the first priority for any client. The situation of an infant being left in the care of a school-aged child must be investigated. The other options are important, but do not come before safety. Option 3 suggests an acute illness that needs treatment, while options 1 and 4 imply that the client already is being treated for the failure to thrive, and as such are not emergencies.

Acrocyanosis is a bluish discoloration of the hands and feet and may be present in the first few hours after birth but resolves as circulation improves. Erythema appears as a rash on newborns, usually after 24 to 48 hours of life (option 2). Harlequin color results as a vasomotor disturbance, lasting 1 to 20 seconds, which is transient in nature and not of clinical consequence (option 3). Vernix caseosa is a cheeselike substance that protected the newborn’s skin while in utero (option 4).

A child with head lag at 10 months of age requires immediate intervention, as neurological aspects must be addressed. The clients in the other options represent normal developmental levels.

Option 4 is a life-threatening condition. Option 1 is strep throat, option 2 is chickenpox, and option 3 is scabies, all of which require intervention but are not as emergent.

This child is at risk for developing worsening respiratory distress. Remaining calm and administering cool mist might decrease the risk of respiratory distress, but preparing for intubation is priority. Options 3 and 4 are important, but not the priority.

Assessment is the first step in any situation, and the other options are all interventions which cannot be completed without first making an examination.

Option 3 is indicative of impending delivery. The clients in the other options present with situations that are expected or typical.

The client in option 4 could be experiencing compartment syndrome, which is a medical emergency. The other options are not emergent or life threatening; although all clients require attention once the client with the potential emergency is addressed.

The priority when caring for a client is handwashing. Opening the container of pills, raising the head of the bed, and getting the client a drink can be done after the handwashing.

Option 3 is critical for client safety. Options 1 and 2 are important, but not safety-related, and option 4 is inappropriate.

Option 3 is important so that potentially fatal reactions do not occur. Option 1 is important postop. Option 2 is important after checking the history, and option 4 is not appropriate.

Option 2 must be done in order for the client to progress through the stages of phobic disorders. Option 1 is not appropriate, and options 3 and 4 might cause more anxiety.

The first period of reactivity lasts up to 30 to 60 minutes after birth. The newborn is alert, and it is a good time for the newborn to interact with parents. The second period of reactivity begins when the newborn awakens from a deep sleep (option 1). The amount of respiratory mucus may still be noted during this period (option 2). Mothers may sleep and recover during the newborn’s sleep state (option 3).

Option 4 is important in this situation, as showering will obscure the evidence. This client also needs to be seen to address both the physiological and psychological trauma from the rape. The other options all are important but can be addressed afterward.

Manic individuals do not take time to stop and eat, so nutrition is priority. Stopping the walking and medicating her will not address the situation, and seclusion is inappropriate.

Data collection is the first step in any situation. Options 2 and 3 are important, but data collection comes first. Option 4 is inappropriate.

A high-pitched cry in a newborn is indicative of a neurologic problem. The findings in the other options all are normal.

Option 1 is the immediate priority in teaching, as this is needed to ensure that the child will become well. All of the other options are important, but not priorities.

A priority for a client postliver biopsy is bleeding, because the liver is a highly vascular organ. Positioning the client with the right side down can help to decrease the bleeding, because pressure is exerted both by the weight of the chest above and the mattress below. Increased fluids will not decrease bleeding; aspirin will increase bleeding; and a supine position will not decrease the bleeding.

Safety is a priority. Oxygen is flammable, so turning off the oxygen and removing the lighter are immediate interventions for the safety of everyone. Yelling for help and removing the clients will not stop the client from setting the room on fire. Pulling the alarm might be necessary if a fire starts, but not at this juncture. Removing the roommate does not address the client with the lighter.

Data collection is the first priority for all situations. In this case, the client could be experiencing autonomic hyperreflexia, which is triggered by a noxious stimulus below the level of the spinal lesion and leads to sudden and severe hypertension. The most common cause is a distended bladder, so the nurse should check that first. Next, the blood pressure should be measured, and the client might need to be removed from the day room if the source cannot be detected and corrected immediately. The client does not require pain medication for an episode of autonomic hyperreflexia, although an antihypertensive agent may be ordered.

A priority in the care of the client with skeletal traction is skin integrity, as skeletal traction requires the use of pins. Because the skin is broken by the traction pins, there is a risk of infection to the bone. Bowel sounds and nutritional status are important, but the risk of infection takes priority, and the knowledge level is not as important at this time.

A priority for the teaching that will occur in rehabilitation is the client’s willingness to learn. All of the other options can be important, but if the client is not willing, those answer options are not relevant.

Physiologic jaundice is best treated by more frequent feedings to increase stooling and the excretion of bilirubin. Switching to formula undermines the mother’s feeling of her ability to provide nutrition for the newborn and may result in too early weaning (option 1). Supplemental water may lead the infant to take less breast milk, delay the breast-milk supply, and cause the bilirubin level to increase (option 2). Withholding food from the newborn will provide inadequate nutrition and cause bilirubin levels to increase (option 4).

Turning the client to the left side is a priority in prenatal care to facilitate blood flow to the fetus. The other options are not necessary when option 1 is performed.

The priority for this client is visual acuity, as this client will be self-administering insulin. The other options are important, but safety is a priority.

Developmentally, this child is getting ready to start progressing to other stages. This is a safety issue for parents. The other options are not as high-priority at this age.

The priority in this situation is safety (to avoid risk of aspiration of tube feedings), and the critical issue is which method is most reliable in determining NG tube placement. Visualization of placement using x-ray is most reliable, followed by checking pH. Air should not be used as the sole method of checking placement because it is not as reliable. Instilling water is not a method used to check placement, although it would verify tube patency.

Low levels of oxygen can be harmful, and immediate application of oxygen is needed. The nurse should prepare to administer oxygen with a physician’s order. Checking other vital signs can be done after the oxygen issue is addressed, while options 3 and 4 are unnecessary.

Two degrees in 1 hour is a quick escalation of temperature, and this client needs monitoring by the nurse. The clients in the other options have important needs, but these can be addressed later. The client in pain should be monitored second, the child requiring a feeding third, and the child who is crying with boredom last. As an alternative, the nurse might delegate the feeding (which is a task) to another caregiver.

Adolescents are at risk for sunburn and skin damage, and this skin damage may not surface until later in life. Adolescents may minimize this risk. Options 2, 3, and 4 are safety measures more appropriate for adults and the elderly.

Toddlers are at risk for poisoning due to curiosity and the ability to climb. Childproofing the home by locking up toxic substances and medications can prevent poisoning. Options 1 and 3 are incorrect, as toddlers are not developmentally ready to learn rules of fire and traffic safety. Option 4 is also incorrect, as scissors are not a safe toy for toddlers.

Older adults are at risk for falls. Navigating in the bathroom and in the presence of throw rugs poses a threat for falls. Options 2–4 are good means of preventing falls.

Adults are at risk for injury in the workplace. Muscle pulls and strains are a common workplace injury. Option 1 is more appropriate for children and adolescents. Option 2 is more appropriate for the elderly. Option 4 is appropriate for adolescents through the elderly.

The top of the can and can opener should be washed with soap and water to remove microorganisms. The concentrate is mixed with an equal amount of water (option 2). Forcing an infant to finish a bottle after he or she seems satisfied may cause regurgitation and lead to infant obesity (option 3). Warming the bottle in the microwave can cause “hot spots” and burn the infant’s mouth (option 4).

The priority intervention is to protect the client and prevent injury. Do not leave the client. The application of oxygen with a mask may be appropriate as an additional measure once the head is protected, and the nurse should observe and document the seizure activity after the client has been stabilized.

A mitt restraint is appropriate for a client who is confused and picking at dressings and tubes. It allows the client to continue to move around freely. A belt, limb, or wrist restraint would not necessarily prevent picking at the dressing; instead, it would prevent movement of the client and may agitate a confused client.

It is imperative for the nurse to monitor and document the client’s behavior while the client is in restraints. The restraints must be removed as soon as the nurse feels there is no longer a safety risk to the client, staff, or family members. Options 1–3 can be documented, but they are not as critical as option 4. There must be documentation as to why the client has a continued need for restraints.

When a client is confused, a restraint may cause agitation. A restraint is only a last resort. A creative alternative such as moving the client to a room that nurses can easily observe is a better choice. Option 1 is incorrect because there is no PRN order for restraints. Options 2 and 3 (vest restraint and private duty nurse or companion) should not be the primary interventions.

The priority action is to restrict the spill so there is no danger to clients or staff. Each chemical spill is unique and will require a unique method to clean. Option 1 (MSDS form) must be done, but not until after the spill is cleaned. Options 2 and 4 are not the correct actions for every spill.

A heating pad is a dangerous intervention when used with a confused or elderly client. The client is at risk for burns resulting from improper use. Options 1, 2, and 3 are statements that reflect good safety measures for a confused elderly client.

A hospital bed in low position with a mattress on the floor is a good safety measure for preventing injuries that could result if the client falls from bed. Option 1 for restraint should not be the priority intervention. Bedside rails (option 2) may only agitate the client and increase the risk of injury if the client tries to climb over the rails. It is inappropriate to expect the family to stay with the client (option 4). Family members may assist with, but are not responsible for, client care and safety in the hospital.

To prevent medication errors, always ensure that you are administering medicine to the right client by checking an ID band. Option 2 is incorrect. In a long-term-care facility, clients are not in beds and may be confused. Do not ask, “Are you Mrs. Smith?” Options 3 and 4 are not correct. Follow the procedure of the medical facility for passing medication.

A major cause of adverse reactions during hospitalization is allergic response. Always inquire and document any history of allergic response to medications, foods, tape, or latex. Options 1, 3, and 4 should also be part of a health history interview, but they are not priorities for the prevention of adverse reactions.

Toddlers are at risk for poisoning due to their developmentally appropriate inquisitive behavior. Toddlers must be supervised at all times. Option 3 is a good answer, as toxic substances and medications should be stored in a locked cabinet; however, there are substances in the home, such as plants, that can be a hazard and yet are not locked. Options 1 and 2 are risks for poisoning for adolescents and adults.

Client/member freedom of choice cannot be taken away. However, HMOs require members to stay with doctors within the network unless they wish to pay all or a larger part of the cost of going outside the system. Options 2 and 3 would remove the client/member’s freedom of choice and option 4 would be incorrect.

Breastfed infants will have 6 to 10 small, loose, yellow stools per day during the first few months. Options 1 and 3 are incorrect in number and consistency of stool, and option 4 is incorrect with regard to color. Meconium may have a greenish color to it, but it is not a permanent color.

Never re-cap a used needle. If no sharps container is available, carefully use a one-handed scoop method to re-cap. Options 1, 2, and 3 are good safety tips for preventing a needle or sharps injury.

In case of a puncture wound from a needle or a sharp, the nurse should encourage bleeding and wash the area with soap and water. Options 1 and 2 are correct actions to take—the injury needs to be reported, and the client could be questioned about the incident—but these are not the priority actions. Option 3 (washing the area with saline for 5 to 10 minutes) is the action for exposure to membranes.

Toddlers need to be supervised at all times. Options 1 and 2 are good safety tips, but they are not the priority or the most effective means to prevent drowning. Option 4 is incorrect and is a personal decision for any parent.

Infants explore and learn by putting things in their mouths. Choking is a major risk in infants. Options 1, 3, and 4 are incorrect development milestones for an infant.

After a flood, insects may spread disease through contaminated or stagnant water. Options 2, 3, and 4 are psychological effects that may be caused by a disaster.

The purpose in planning care is to prioritize the order of care delivery. When caring for numerous clients, those with airway disorders will always be the first priority of care.

When delegating care to unlicensed assistive personnel (UAP) it is important to remember their scope of practice. It would not be appropriate to delegate care of clients requiring tracheostomy care, medication administration, or a client who is unstable, such as the client with congestive heart failure who has demonstrated a rapid weight gain. However, a UAP could appropriately babysit a client with Alzheimer’s and maintain a safe environment for him or her.

Option 4 is a victim with a possible head injury. This is the least stable victim and the victim in need of urgent professional nursing assessment. Options 1, 2, and 3 have injures that do not appear life threatening.

Ensuring an open or patent airway is the first step in a primary examination. Options 1, 3, and 4 are valid examinations, but they are not primary.

The primary intervention in an accident is to examine for injury and provide urgent care. Client safety is always first. Notify the doctor after the examination; gather data and fill out an incident report after the client is stable.

Breastfeeding the infant every 2 to 3 hours or on demand will stimulate hormone production which will, in turn, stimulate breast-milk production and the let-down reflex. Breastfeeding every 4 hours may result in a decreased or delayed milk production (option 1). Allowing the infant to breastfeed only 3 to 5 minutes does not allow enough time for the milk-ejection reflex to occur and may not allow for the let-down of the hindmilk, which contains a higher fat content (option 3). Supplementing with glucose water may cause nipple confusion in the infant and will decrease the infant’s demand for breast milk, thereby decreasing supply (option 4).

The purpose of seizure precautions is to protect the client. Always pad the bed rails and have suction available. Options 1 and 3 are incorrect. Do not use a nasal cannula for oxygen; have a mask available instead. Option 4 is also incorrect. Medications are not usually kept at the bedside, and a padded tongue blade is a matter of hospital policy. Many institutions will have an airway at the bedside.

There can be no PRN order for a restraint. A restraint order must include the reason for the restraint, type of restraint, and a time to use the restraint. Options 2, 3, and 4 are correct orders for a restraint.

The first step in determining an appropriate intervention is always data collection. The nurse must determine the client’s ability to ambulate before determining the appropriate fall precautions. Options 1, 2, and 3 are good interventions for reducing the risk of falls.

A third-grade student is approximately 9 years old. Any child under the age of 12 and shorter than 4 feet 9 inches should be in the rear of a car. A booster seat is needed if the lap/shoulder harness in the car does not properly fit the child. Options 1, 3, and 4 are incorrect according to car-restraint-system guidelines.

The school-aged child is capable of participating in a family fire escape plan. School-aged children are at risk for fire injuries due to an interest in matches, lighters, and fireworks. Option 1 is a good safety tip for toddlers. Option 2 is a good safety tip for families with firearms. Keep in mind that, if there are children in the home, firearms should be locked and ammunition kept in a separate locked location. Option 4 is a good safety tip for adolescents and adults.

In case of emergency, the primary action is to maintain safety for the clients on the unit. In case of disaster, there will be a protocol for strategies to follow to maintain client safety. Options 1, 2, and 3 are actions that need to be taken in a disaster; however, the disaster plan should designate a person in authority to conduct these steps. Practical nursing staff will not have responsibilities in these areas.

The number, extent, and location of the bruises and the mother’s vague explanations of the injuries indicate possible child abuse as does the mother’s statement that the child was unsupervised while playing. Children of this age should be supervised during play. No information is given about the level of maturity of the mother (option 2), but clearly it appears that the parenting is inadequate. While it is true that an 18-month-old is unsteady and will fall often (option 3), the nurse would not expect to see numerous large bruises of different stages confined to the back and hips. If tissue fragility was present in this child (option 4) it would not be limited to the back and buttocks.

The symptoms, client’s behavior, and daughter’s behavior would indicate possible abuse or neglect. The daughter may be the abuser, and it is necessary to first interview the client apart from the daughter to question for abuse. Most abusers of elders are family caretakers. If the daughter is an abuser, she will not give an accurate account of the client’s fall (option 1). Nutritional evaluation and teaching (option 2) may be appropriate later, but at this time the client’s safety is more important. Requesting a psychiatric evaluation (option 3) is premature at this time. Confusion alone is not a symptom of mental illness. Malnourishment and dehydration, both of which are treatable and reversible, may be responsible for the client’s confusion.

The child’s examination shows probable signs of sexual abuse, which must be reported. Nurses are mandated reporters of suspected child abuse. Further data gathering (options 1 and 4) and teaching (option 2) would be secondary priorities.

The client’s safety is of utmost importance. If returning to the violent environment, it is urgent for the client to have a safety plan. Instructing the client to leave the relationship (option 1) will not help if the client is not ready to do so. Additionally, the nurse should assist the client to make her own decision, rather than trying to impose personal views on the client. Providing information about legal assistance (option 2) and a list of services that are available (option 4) are appropriate, but are secondary to assisting the client to plan for personal safety.

The expected response for the sucking reflex is that the newborn will suck the object placed in his mouth, not lick it. Option 1 is the expected response for the grasp reflex. Option 3 is the expected response for the trunk incurvation (Galant) reflex. Option 4 is the expected response for the rooting reflex.

Education and money do <i>not</i> make persons immune from violence. It crosses all socioeconomic lines. Violence often begins in dating relationships (option 1). It is estimated that 30 to 40% of college students and 10 to 20% of high school students are in abusive relationships. As part of a predictable cycle of violence, abusers typically apologize and promise to stop (option 2). However, the reality is that the level of abuse generally intensifies with the passage of time. Abusers are often excessively jealous and possessive (option 3). They control the victim’s life and isolate the victim from outside family or social contacts.

The most dangerous time in an abusive relationship is when the victim leaves; having left, the victim is in greater danger. It often takes several times before victims are able to leave (option 2). For various complex reasons, emotional, social, and financial, many victims feel bound to the relationship. Victims often feel that the abuse is their fault (option 3). This area can be addressed once safety has been addressed. Abusers will make threats of removing children from the victim to intimidate and control the victim (option 4), which can also be addressed once safety has been addressed.

The child will be at risk for depression, both now and in the future. Among other frequent consequences are self-esteem disturbances, feelings of guilt, sexual acting out behaviors, posttraumatic stress disorders (PTSD), and self-mutilation behaviors. There are many long-term consequences of child abuse (option 1). Abuse is more devastating if the abuser is a person the child knew and trusted (option 2). It is true that many victims of child abuse do themselves become abusers in the future, but one cannot predict that this will happen in all cases (option 4). Many victims of child abuse are able to have normal, healthy, nonabusive parent-child relationships.

The client has been raped, and the nurse needs to respond to the client’s immediate concerns. Since the student describes occurrences that often lead to a situational crisis response, it is most important for the nurse to allow the student to ventilate feelings at the beginning of the interview. The nurse should listen patiently and supportively, understanding that compulsive retelling helps the victim gradually become desensitized to the rape. Pregnancy testing (option 1) and teaching (options 2 and 3) are secondary interventions that can be begun after the client has ventilated feelings about the rape.

It is vital that the client understand that the pregnancy may be in danger from the abuse. Among possible consequences of abdominal beating of a pregnant woman are miscarriage, placenta abruption, fetal loss, premature labor, and fetal or maternal fracture. The client will need resources (option 4), childbirth classes (option 3), and assertiveness training (option 2) in the future, but she must first understand the risk to the baby in order to provide safety for herself and the baby.

A delay in seeking treatment for serious injuries is an indication of abuse. Vague descriptions of the injuries with little detail are more likely to indicate abuse than a detailed description (option 2). Anxiety and concern on the parents’ part would be expected (option 3). Preventing the child from explaining the injuries, not encouraging explanation (option 4), would be an indication of abuse.

Initial observations of dehydration, unexplained bruises, and poor hygiene indicate possible abuse or neglect, the possibility of which should be determined immediately. It is premature for the nurse to report the suspected abuse before more data is gathered (option 2). Some of the necessary data will come from the history of the present illness and rehydration methods attempted at home (option 3) and medications the client has been taking at home (option 4).

The migraines may be the presenting problem (option 1), but the client is indicating a need to discuss the abuse (option 4). A nonjudgmental approach considering the client’s comfort level would be best to prevent the client from feeling guilt and shame. The nurse should acknowledge the client’s comment and explore what the client would like to share at this time. Obtaining the information in options 2 and 3 is secondary at this point. The client is indicating a readiness to express feelings, not provide data.

Sibling abuse is often unrecognized and can lead to serious injury if not addressed. The physical abuse described goes beyond sibling rivalry (option 1). The younger boy would not be able to stand up to someone older and larger than himself (option 2). The younger boy would not be mature enough or have the language skills needed to work things out with his sibling (option 3).

The respiratory distress and retinal bleeding are symptoms of shaken baby syndrome and represent a medical emergency. The child will continue to be at grave risk at least until cerebral and ocular bleeding subside. The events leading up to the distress are relevant but secondary at this time (option 1). Informing the mother that the greatest danger period has passed is inaccurate (option 3), as the child will continue to be at grave risk at least until cerebral and ocular bleeding subside. Reporting the incident to the children’s protective agency is important (option 4), but at this time is secondary to providing emergency care to the child.

Age-specific care is care that most closely meets the needs of the hospitalized child at any age. Although visitation of peers is important, open visitation is usually recommended only for family members. Mutual decision making is beneficial for the child and family. Depending on the status of the child’s illness and resources available, tutoring may be recommended.

The age-inappropriate behaviors combined with capacity to communicate verbally would indicate probable abuse or neglect. If mental retardation (option 1), autism (option 2), or pervasive developmental delay (option 3) were present, the child’s language skills would be affected.

Inappropriate self-blame and feelings that a child could have stopped an adult’s abuse indicate a low self-esteem. Options 1, 2, and 3 are possible concerns for adult survivors of abuse, but there is no evidence in the situation to support these diagnoses. More data would be needed.

Munchausen’s syndrome by proxy is characterized by a caregiver, usually a parent, fabricating or causing illness in another person in order to gain sympathy or attention for him or herself. The mother’s statement and the past history of repeated attempts to have the child hospitalized in the absence of diagnosed problems suggest that this rare somatoform disorder might be present. Somatoform disorders are considered anxiety-related disorders. While the mother is anxious, she is not in panic-level anxiety (option 1), since she is able to organize and verbalize her thoughts very clearly. There is no indication of more than one personality, or alter, being present in the mother, which would be the case if a dissociative identity disorder were present (option 2). There is no indication of Cluster A personality traits (option 4), which present as odd, eccentric, and suspicious behaviors.

Victims of rape and other sexual assaults often feel guilty and responsible for the assault. It is essential for the nurse to reassure the client that the rape was not her fault. Teaching and testing (options 3 and 4) are secondary interventions after the client is calmer. Gathering evidence (option 2) would proceed only after reassuring the client and obtaining permission to gather evidence.

The parents need to learn that 18-month-old children cry as a means of communication. The word <i>less</i> in option 1 makes it incorrect, since the child should not be spanked for crying. Attendance at parenting classes alone (option 2) does not indicate behavior change. Having unreasonably high expectations for children is a continued risk factor for abuse (option 3). Understanding normal growth and development will help the parents have more reasonable expectations of the child.

The sexual behavior, suicide attempt, and running away indicate possible sexual abuse. Examining for pregnancy (option 1), examining for physical abuse (option 2), and examining for sexually transmitted diseases (option 4) would be secondary examinations.

Option 1 is correct. The client is feeling powerless, and the nurse should empower her through mutual goal setting. Feeling powerless is common in victims of ongoing violence, as the emotional component of the violence instills terror and helplessness. The client is shamed and demoralized, criticized and controlled by the perpetrator, who makes numerous dire threats and convinces the victim that there is no hope of escaping. Option 2 is incorrect as teaching about further risk of violence is an appropriate intervention, but it will not be effective if the client feels powerless to act. Options 3 and 4 are incorrect because providing resources and/or mobilizing are appropriate interventions, but they will not be effective if the client feels powerless to act.

Option 3 is correct. Elder abuse is <i>not</i> easily identifiable because of the reluctance of the elders to report and lack of definitive physical findings. Additionally, many elderly persons have health problems that may result in significant changes in physical appearance or psychological functioning. Options 1, 2, and 4 are incorrect because no further teaching is needed, as these statements are true. Many elders have a strong fear of abandonment in general and see admission to a nursing home as the ultimate form of abandonment (option 1); while there are many motivators leading to child-to-parent violence, sometimes the abuser is retaliating for past actions/problems with the parent (option 2); and 60% of elder violence is carried out by spouses or partners.

Option 3 is correct. A 6-year-old who has begun exhibiting behaviors of a younger child is demonstrating regressed behavior, which can be an indicator of the child’s having been abused or violated. Option 1 is incorrect as oppositional defiant disorder is a medical diagnosis associated with negative, defiant, and hostile behavior such as defying rules, rather than a return to infantile behaviors. Option 2 is incorrect because attention deficit disorder is a medical diagnosis associated with lack of ability to concentrate on and attend to the environment, rather than a return to infantile behaviors. Option 4 is incorrect as developmental delay is a medical diagnosis indicating that the child is delayed in the normal achievement of developmental milestones.

Option 3 is correct. Children who are physically neglected will often steal and hoard food because of inadequate nutrition. Options 1 and 2 are incorrect as the child’s level of physical activity and response to discipline may be indicators of emotional or physical abuse. Option 4 is incorrect because a sudden onset of enuresis is one possible indication of sexual abuse.

Children crawl or pull their body along the floor by their arms by 8 to 10 months. This is a growth and developmental milestone during infancy. For a 15-month-old child, the inability to crawl is an abnormal finding, and it should be referred to the pediatrician for follow-up. It is a normal response for the infant to cry when left with others. Infants often become attached to security items, such as a blanket. Toddlers begin to display food preferences.

Option 1 is correct. Parents who have high expectations of their children and/or are extreme disciplinarians and believe in physical punishment are at risk for abuse. The nurse should recognize that being “tough” can have either physical or emotional components, or both. Option 2 is incorrect as the question is asking for risk factors for child abuse. Not having been beaten is not a risk factor, but a family history of violence is. Option 3 is incorrect because most abusive parents have <i>high</i>, not low, expectations of a child’s abilities and do not accept things about the child that are below the parental standard. Option 4 is incorrect as children who are wanted are less likely to be abused than children who were unplanned and/or unwanted.

Option 2 is correct. Intergenerational transmission violence, where children learn violence in their own homes by observing family members, is an example of social learning theory. In such situations, the child lacks positive role models who can assist with learning interaction and problem-solving skills. Option 1 is incorrect as, while it is certainly true that personality issues would motivate this parent to be abusive, the question is asking about social learning theory, not psychodynamic issues. Option 3 is incorrect because violence against family members does often result from impaired individual coping. Specifically, the perpetrator displacing his or her anger and frustrations, but this question is asking for a response about social learning theory. Option 4 is incorrect as dysfunctional family dynamics do exist when intrafamily violence is present, but this question is asking for a response about social learning theory, not family dynamics.

Option 4 is correct. The nurse should approach the client in a nonjudgmental manner to build a working relationship. The client will not be open to teaching or information sharing if the nurse is judgmental. The nurse should self-evaluate to determine if strong negative feelings are present. When they are, they can interfere with the objectivity of the nurse, and professional or peer supervision is recommended. Option 1 is incorrect because before the client is informed that the suspected abuse will be reported, the nurse should establish an effective working relationship with the client. Option 2 is incorrect as the nurse should plan to teach the client effective parenting skills, but not until after a working relationship is established. Option 3 is incorrect because determining if the client was abused as a child should be delayed until after a level of trust is established between the nurse and client.

Option 2 is correct. Experts on interfamilial violence agree that three common conditions for violence exist in almost every situation involving family violence: (1) A violence-prone individual, whose propensity for violence is related to childhood experiences and to personality issues related to low self-steem and general dissatisfaction with self and life; (2) A vulnerable person, who is someone in the family who lacks psychologic and/or physical power. Such persons include infants, children, pregnant women, and the elderly, especially if financially, physically or psychologically dependent on family members; (3) A crisis situation which puts stress on the family and taxes the coping skills of the abuse-prone individual. Option 1 is incorrect as the very young, as well as the old, can learn to modify their expressions of emotion. It is not the emotion of the victim that precipitates the violence. The causes arise from within the psyche of the perpetrator. Option 3 is incorrect because very young children and some elders may engage in ill thought out or careless behaviors. However, it is not the behavior of the recipient of the violence that precipitates the violence. Rather, the violence arises from unmet and unhealthy needs in the perpetrator. Perpetrators will say that the victim “asked for it,” but this is a rationalization of the perpetrator. Option 4 is incorrect as children and elders are vital parts of a family unit. If at times their behaviors are annoying, this is not a sufficient reason for violence against them. Perpetrators may try to justify their actions with an explanation of this sort, but the nurse should remember that causes of the violence arise from within the psyche of the perpetrator, not the recipient of the abuse.

Option 2 is correct. This client’s history was one of normalcy until very recently. The nurse should recall that adolescent victims of sexual violence are likely to have behavioral symptoms such as failing grades, seductive or promiscuous behaviors, running away from home, being arrested, and violent acting out behaviors. This is in contrast to child victims who tend to have obviously lowered self-esteem, a variety of somatic complaints, and depressive symptoms. Option 1 is incorrect since the client has done well in school until recently; the academic difficulties of this student could be symptomatic of significant difficulty in another aspect of the client’s life. Option 3 is incorrect because if this client had a diagnosed medical problem such as antisocial personality disorder, the behaviors that resulted in arrest would not have had a sudden onset. Antisocial and problematic behaviors would have been present very early in the client’s life. Option 4 is incorrect as this is an “it doesn’t compute” answer. Look carefully back at the stem of the item (the part that indicates what information is expected). Would indications of usual coping be something negative that would require further nursing examination? Eliminate this option without giving it serious consideration.

Options 2 and 4 are correct. The client is showing several possible signs of having been the victim of violence. Anxiety, a black eye, and various somatic complaints, when combined together, are suggestive of unacknowledged violence against the client. The client’s safety should be a priority. In situations where violence might have, or actually has occurred, many people feel so trapped and desperate that suicide (or homicide) may seem the only way out of a horrible and detrimental relationship and situation. Providing for the safety of the client includes monitoring for suicidal and/or homicidal potential. Options 1, 3, and 5 are incorrect as after examining for abuse and the risk of self- or others’ destructiveness, the nurse can examine for other physical causes, such as premenstrual syndrome, migraine headache and irritable bowel syndrome.

Hand hygiene is a core principle of standard precautions. Using gloves (option 2) is appropriate when there is a risk of exposure to blood, body fluids, secretions, and excretions, but gloves may not be needed for every care activity. If gloves are used, however, handwashing should be done after removal of the gloves. Not all clients require transmission-based precautions (option 3) or a private room (option 4).

Medical asepsis requires clean, not sterile, technique. Of the options listed, only collecting a stool specimen for ova and parasites (option 3) requires medical aseptic technique. Collecting a wound culture (option 1), suctioning a tracheostomy (option 2), and catheterizing the client (option 4) all require the nurse to use sterile asepsis.

Standard precautions are used with all clients, regardless of the medical diagnosis. Clients with either AIDS or <i>Pneumocystis carinii</i> pneumonia are not contagious and thus do not require transmission-based precautions.


Objects that can be grasped and banged together, such as blocks, are most appropriate for an 8-month-old child. Such play with blocks develops manipulation skills. Pleasure is experienced from the feel and sounds of these activities. A wagon or large-piece puzzle may be used by preschoolers and toddlers; rattles are recommended for infants (1 to 6 months).

Options 1 and 2 are core principles of medical asepsis. Option 3 violates principles of medical asepsis, and option 4 violates principles of surgical asepsis. Option 5 violates principles of transmission-based precautions for a client with tuberculosis. The nurse should wear an N-95 (fit-tested) mask instead of a simple surgical mask.

Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 microns in size. Wearing a surgical mask (option 1) will not protect the nurse from infection. The client will wear a surgical mask (not a particulate respirator mask as in option 2) when being transported within the hospital. Clean gloves rather than sterile ones (option 3) are needed to obtain a sputum specimen. The door to the client’s room should be kept closed (option 4) as part of transmission-based precautions for tuberculosis.

Sneezing and coughing are examples of modes of transmission, whereby droplet nuclei can transmit infection directly to a susceptible host. The items in options 1, 2, and 3 are examples of fomites, inanimate objects that could carry microorganisms if medical asepsis is not utilized.

A wound infection would be an indication for a nurse to utilize contact precautions, since contamination could occur when caring for the wound. Scarlet fever, pertussis, and rubella (options 1, 2, and 4, respectively) involve the spread of infection by respiratory particle droplets larger than 5 microns.


The employee should limit the amount of time in the client’s room to minimize exposure. In option 1, the employee is wearing the correct combination of personal protective equipment. In option 3, the employee has followed the correct procedure for exiting the client’s room. Equipment required for the care of the isolation client should remain in the client’s room (option 2) to limit exposure to other clients on the nursing unit.

If transportation to another hospital department is unavoidable, a client with tuberculosis must wear a particulate respirator mask. This is an element of airborne precautions necessary to limit the transmission of the microorganism. Tuberculosis is not transmitted by eating utensils (option 3) or urine (option 4). Removal and disposal of respiratory secretions (option 2) is important but does not require the client to wear gloves.

Equipment for client care is dedicated to the client on contact precautions and kept in the client’s room. It should not be stored in the utility room (option 2), because this could transmit infection. It is not realistic to be able to adequately cleanse the equipment after each use (option 3). Special action is needed with this equipment (option 4).

Methicillin-resistant <i>Staphylococcus aureus</i> is transmitted by direct contact. Options 1, 2, and 4 are not appropriate because the microorganism is not transmitted by airborne or particulate droplets. Gloves (option 3) are necessary when providing nursing care.

Transmission-based precautions are required for all these organisms; however, only penicillin-resistant <i>Streptococcus pneumoniae</i> is transmitted via respiratory droplets. The organisms specified in options 1, 3, and 4 are transmitted by direct contact.

The use of dolls may decrease a child’s anxiety and fear if the nurse uses such aids to explain what is expected. Brochures and videotapes are useful with explanations to adolescents. A visit from the surgeon is informative primarily with the parents.

Transmission-based airborne precautions require everyone entering the client’s room to wear a mask at all times. It is not acceptable to remove a mask to kiss the client goodbye. The actions in options 1, 3, and 4 are correct.

The ability of the client to manage effectively the therapeutic regimen requires the nurse to collaborate with the physician, social services, and community health agencies to achieve the best outcome for the client. Medications to treat the infection require a physician order. The nurse monitors the client’s response to medications and provides feedback to the physician, alerts social services regarding client concerns about the cost of medications, and makes referrals to home health agencies. Social services can assist the client in obtaining financial aid to cover the cost of medications, if necessary. The public health department must be notified of the client’s infection and will follow the client once discharged. Home health agencies and directly observed therapy (DOT) programs can assist with medication compliance. Options 1 and 4 are managed with independent nursing interventions, such as pacing nursing care to promote rest and minimize client fatigue; providing small, frequent meals; and teaching the client about the rationale for, dosing schedule of, side effects of, and importance of taking prescribed medications. Option 2 (nutrition) may involve the physician and dietitian, but not the entire health care team.

Varicella is a contagious viral infection spread through airborne droplets smaller than 5 microns in size. Airborne precautions (option 2) should be instituted to limit the transmission of this infection. Varicella would not be adequately controlled using contact or droplet precautions, or with reverse isolation (options 1, 3, and 4, respectively).

Gloves are removed first, as they would be the most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed next, followed by hand washing.

Clients with rubella are placed in droplet precautions, as the causative agent is transmitted by particle droplets larger than 5 microns. Rubella is not transmitted by the airborne route (option 1), contaminated food (option 2), or direct contact (option 4).

Signs of tuberculosis include low-grade fever, increased sputum production, purulent or blood-streaked sputum, increased shortness of breath or difficulty breathing, decreased activity tolerance, decreased appetite, weight loss, and night sweats. Option 2 indicates the client is getting better, while options 1, 3, and 4 indicate the client is having a relapse.

Infertility is often a very stressful situation, and the nurse’s monitoring of the couple’s coping mechanisms is important. The other options would not be appropriate for the clients at this time.

These are common side effects of clomiphene citrate (Clomid) which usually disappear in a few days or weeks. Intervention is directed toward relief of the symptoms, which do not represent an allergic response or pregnancy, nor do they require immediate assessment by a physician.

Motility is the swimming ability of sperm. Morphology is the shape, and sperm count is the number of sperm. Ejaculation is not dependent on the age of sperm.

During ovulation, cervical mucous is more abundant and thinner, and becomes stretchy. These changes facilitate sperm transport toward the ovum.

There are many reasons why a child would be uncooperative, including fatigue, illness, and fear. In order to get accurate results, the test should be rescheduled for another day, and the child should not be forced to undergo testing that day. The child’s behavior does not indicate developmental delay, and there is no evidence at this time that the child needs a specialist.

Anovulatory menstrual cycles are those in which ovulation does not take place. Medications such as clomiphene citrate (Clomid) or Pergonal, a menotrophin, are given to stimulate the ovaries to mature and release an ovum. Multifetal pregnancies are sometimes a side effect of these medications, not a desired outcome.

Delegated assignments must be according to the legal practices of each state and the abilities of those being delegated to. A medical assistant could provide supplies to the client, but the remaining options require a nurse’s intervention.

Varicoceles raise the scrotal temperature, thus decreasing the number of sperm and the number with normal morphology. Repairing the varicocele does not affect the ability to have or maintain an erection.

In vitro fertilization occurs in a laboratory, thus bypassing the fallopian tubes.

Self-esteem can be threatened by the inability to conceive a child. Care must be taken to avoid placing blame on the person whose body is not functioning as expected. The client’s amount of formal education does not affect fertility or treatments for infertility. Information should be given when appropriate and never withheld. Relaxing vacations to conceive are a myth that can become very expensive. Fertility testing takes a long time and therefore results are not instantaneous.

The scrotal portion of the vas deferens is surgically incised or cauterized. Sperm are still produced, but they can no longer be squeezed from the storage site (epididymis) into the urethra for ejaculation. The epididymis and prostate gland are not excised during this procedure. Severing the urethra would prevent passage of urine from the bladder as well as semen and would not be considered.

Either partner may experience feelings of guilt when faced with infertility. If the problem is with one partner, that partner’s feelings of guilt are often more intense. Option 2 relates to client history, not the plan of care. Option 3 is nontherapeutic. Option 4 is not the role of the nurse.

Iodine-based dye is instilled into the uterus and watched on X-ray to detect uterine anomalies or lack of tubal patency. An allergy to iodine or to shellfish, which is high in iodine content, should alert the nurse to a potential allergic response to the iodine-based dye.

Ova retrieval and GIFT are outpatient procedures. The client will not be hospitalized overnight. The other statements are correct and do not require any follow-up by the nurse.

The identity of sperm donors is confidential information. Donors are assigned random numbers to identify their sperm, and the listing of donors and numbers is kept locked.

Children must have the physical and developmental capabilities to begin toilet training. They should be able to stand and walk well, pull pants up and down, recognize the urge to urinate or defecate, and be able to wait until they reach the potty chair.

To maximize the chances of conception through achieving the greatest number of motile sperm, couples must abstain for 2 to 3 days prior to expected ovulation, and then have intercourse on the day of ovulation or the date of artificial insemination or in vitro fertilization. Because of this, the client's husband must be a willing participant in the infertility regime.

A complete bicornuate uterus is two complete and separate unicornuate uteri. Because of the shape of the uteri being long and narrow (instead of pear-shaped), the maximum uterine volume is often less than a normally shaped uterus. Risks of bicornuate uterus include multiple pregnancy losses, preterm labor, and breech presentation. Becoming pregnant is not an issue; carrying the pregnancy to term is the problem.

Severe abdominal pain during a cycle of induced ovulation may indicate hyperstimulation of the ovaries. The ovaries could potentially rupture, leading to death. The risk of this complication takes precedence over the routine care required by the other clients in the question.

Bilateral tubal blockage requires surgical intervention. The client will not become pregnant until the tubes are cleared surgically; a pregnancy cannot occur and "unblock" the tube. This statement indicates that the client does not understand her situation and requires further education. The other options contain statements that indicate understanding of the condition or its treatment.

Fourteen percent body fat is considered adequate to have regular menses and regular ovulation. A client with less than 10% body fat will ovulate and menstruate very irregularly if at all.

Pregnancy is characterized by a 0.5 to 1.0°F persistent increase in BBT. The incorrect responses do not follow this trend.

An ovulatory cycle is biphasic. The basal body temperature drops slightly then raises 0.5–1.0°F 24 to 48 hours after ovulation. Progesterone is thermogenic (heat producing), thereby maintaining the temperature increase during the second half of the menstrual cycle.

Chlamydial PID causes scarring of the fallopian tubes, thus increasing the incidence of ectopic pregnancy. All other options do not reflect the true possible consequence of chlamydial PID.

A vas deferens blockage will prevent the sperm from being ejaculated, resulting in a deficiency of sperm in the seminal fluid (oligospermia). The other options do not correctly explain the effects of the blockage.

Options 1, 2, and 3 all increase the likelihood of conception by timing intercourse around the expected time of ovulation. Option 4 decreases the likelihood of becoming pregnant and indicates a need for further teaching.

Imitative behaviors teach the toddler new skills. Toddlers enjoy such toys as a play telephone. Manipulation of toys develops both gross and fine motor abilities in this period. Paint-by-number sets and complex puzzles are recommended for school-aged children. Musical mobiles are appropriate for infants.

Inadequate number or motility of sperm and tubal anomaly or blockage are the most common causes of infertility. Semen analysis will provide information on number of and motility of sperm, and hysterosalpingogram will detect uterine or tubal anomalies or blockage. The other tests do not diagnosis infertility problems.

Infertile couples must deal with guilt, shame, and other psychosocial issues. The nurse's role is to be supportive, facilitate sharing of feelings between the couple, and provide guidance through the infertility and treatment process. There is no indication that the couple needs family therapy or that there should be anyone to blame for the infertility problem.

Tubal blockage will prohibit sperm from traveling through the fallopian tubes to reach an ovum and fertilize it. In vitro fertilization involves harvesting ova and placing them with sperm in a Petri dish. The resultant embryos are then returned to the uterus. The other options would not result in pregnancy.

Hysterosalpingograms are performed in the follicular phase of the cycle to avoid interrupting an early pregnancy, so the nurse needs to establish the client's phase of the menstrual cycle. The other options do not address this point.

Three to four embryos are implanted in the uterus or fallopian tube following in vitro fertilization to maximize the chance of achieving pregnancy while minimizing the risk of multifetal pregnancy. The information contained in the other client statements is correct and therefore does not require any follow-up on the part of the nurse.

Antisperm antibodies can develop in the vaginal and cervical secretions. Inserting the sperm directly into the uterus via intrauterine insemination bypasses the secretions so that the sperm are not destroyed.

The basal body temperature usually drops just before ovulation occurs, then rises and remains elevated for several days. This client likely ovulated on day 14 with the fertile period occurring days 14-17.

The woman’s shortest and longest cycles must be determined to calculate the number of days per month to abstain from sex. The woman is unlikely to ovulate during menses. The woman must abstain from sex for the 5 days that the sperm are viable as well as the time the ovum is viable.

Since the condom must be correctly applied to the penis at the time of sex, use can affect spontaneity and sensation. The cost of male condoms remains relatively low.

This client has not yet decided on a method of fertility; she is in the decision phase. Fear, pain, and grieving are not even mentioned in the question.

In team nursing, RNs, LPNs/LVNs, and CNAs work together to care for a group of clients, with each care provider working to his or her scope of practice. Working as a team means no client is any nurse’s sole reponsibility. Option 2 doesn’t provide any helpful information, and option 3 doesn’t explain that each team member is expected to work within their scope of practice.

Play is not recommended at bedtime. A quiet and calm environment will promote sleep. Play is a very effective teaching intervention. It is often used before surgery and diagnostic tests to enhance understanding of these events. Play is therapeutic to help the child express feelings during stressful times.

Abnormal spotting or bleeding may be experienced with the use of an intrauterine device. Weakness or numbness, headache, and chest pain are typically signs of complications associated with oral contraceptives.

A spermicide must be used with the diaphragm to achieve a high level of effectiveness. No more than 4 hours should elapse between insertion of the diaphragm and intercourse. The diaphragm should not be removed for 6 hours after intercourse. The diaphragm is a good contraceptive choice for nursing mothers.

If the pill is forgotten for more than 12 hours, the pill should be taken and a backup method of contraception used for the rest of the cycle for extra protection. Extra pills are not typically prescribed. There is no evidence that the client is pregnant; counseling regarding pregnancy options at this time is unwarranted. If the menses is missed, this may be appropriate.

Hypertension is an absolute contraindication to oral contraceptives. While epilepsy is not an absolute contraindication, clients affected by it require extra monitoring. History of toxic shock syndrome and pelvic inflammatory disease are not factors in oral contraceptive use.

Emergency contraception must be initiated within 72 hours of unprotected intercourse, rape, or method failure. Oral contraceptives may be taken up to 12 hours late and cervical caps may be left in up to 48 hours without compromising safety. Depo-Provera is given every 80 to 90 days; this client is not within this time period and emergency contraceptive protection is indicated.

The cervical cap and diaphragm both require use associated with intercourse. The client does not give any indication that she is willing to abstain from intercourse. Depo-Provera injections meet all of the client's requirements.

Option 1 is part of determining the client's knowledge and should be performed before the teaching session. Printed materials may not be appropriate to the client's reading ability. Visual cues are provided by demonstration of the procedure. Practice sessions provide the nurse with an opportunity to give positive and corrective feedback integrating visual, auditory, and tactile senses.

Leaving space at the end of the condom to collect the semen can prevent breakage or spillage after ejaculation. The male condom is placed when the penis is erect, and then rolled down. Water-based lubricants can be used to provide additional comfort, if needed. Oil-based lubricants are contraindicated.

The cervical cap increases the risk of toxic shock syndrome because it may be left in place for up to 48 hours. The other methods identified pose no additional risk to this client based on her history and could be considered for contraception.

Ethical and legal considerations dictate that clients are knowledgeable of the benefits and risks of the contraceptive method. This empowers the client in making an informed decision. Not all contraceptive methods are invasive or require a surgical procedure. Informed consent is not related to the effectiveness of a method.

Toddlers chew well but may have difficulty swallowing large pieces of food. Young children cannot discard pits (such as from cherries). Firm foods such as peanuts and hard candies are easily aspirated, while softer ones, such as cereal or raisins, are better tolerated.

Specific information about the type of IUD inserted is not provided; Progestasert needs to be replaced annually and the Copper T380A can be left in place for 10 years. The string should be checked once a week for the first month, then after the menses thereafter. Contraceptive effectiveness begins when the IUD is inserted. Although douching is sometimes used to treat vaginal infections, it is not a recommended practice to prevent infection.

A spermicidal cream or jelly is applied to the rim and dome of the diaphragm before inserting the device to increase the contraceptive effectiveness of the device. Options 2, 3, and 4 are statements reflecting correct client behavior for effective diaphragm use.

Shortness of breath and chest pain can indicate a serious complication associated with the use of oral contraceptives and require immediate evaluation. Waiting for a return telephone call could delay evaluation and treatment, jeopardizing the client's health. Changing the contraceptive method or food intake pattern does not reduce the immediate health risk to the client.

Spermicide should be applied to the inside of the cervical cap. The device may be left in place up to 48 hours after sexual activity. Reapplication of spermicide with repeated acts of intercourse is not needed.

Every pill contains a low dose of hormone and should be taken daily; consistency in taking the pills ensures a constant serum level of the hormone to maximize effectiveness. The pills are absorbed with or without the presence of calcium. If a pill is missed, it should be taken immediately, and an additional method of contraception should be utilized through the remainder of that cycle.

This client has a need for information about the various contraceptive methods available to her and their risks and benefits. No information is provided to determine if the client fears pregnancy or is engaging in unprotected sexual intercourse. If the client does not know what contraceptive methods are available, it is unlikely she knows or fears potential complications from using a method of contraception.

Family planning can help the client make decisions about avoidance of pregnancy, determining the number of children to conceive and the spacing of those children, and voluntary termination of pregnancy.

Contraceptive counseling is best done in private, determining the client's needs, desires, and risk factors. This will result in a contraceptive method that best suits the needs and health of the client.

Condoms, used with or without a spermicide, are mechanical methods of contraception. While abstinence is a natural method, since the woman is sexually active, it will increase compliance if she only needs to be abstinent during fertile periods. Therefore, using the basal body temperature method permits her to be sexually active at certain times.

Oil-based lubricants can break down latex condoms. The condom should be unrolled onto the penis, starting at the tip of the penis. Holding the rim keeps the condom from slipping off and leaking semen into the vagina. Small amounts of semen are released before ejaculation and can result in pregnancy.

Nutrition is the greatest influence on growth and development because diet supplies the nutrients needed to sustain physiological needs and for bodily growth, which then influences overall development. Other factors such an income and exposure to secondary smoke indirectly affect health, while ethnic background has significant influence on culturally based habits but not necessarily on biological growth and development.

Female condoms can be applied up to 8 hours before intercourse, are not made of latex, and do not require that the client be measured for proper fit. Both partners are protected for STD during intercourse.

Cleaning agents other than soap and water and oil-based lubricants can damage the rubber of the diaphragm. The chemical barrier (spermicidal cream or jelly) supplements the mechanical barrier (diaphragm) to increase the effectiveness of this contraceptive method. It takes at least 6 hours for the spermicidal cream or jelly at the rim to destroy sperm deposited in the vagina. Use during the menses increases the risk of toxic shock syndrome and should be avoided.

Oral contraceptives place the client at decreased risk for iron-deficiency anemia, ovarian cancer, and fibrocystic breast disease. Oral contraceptives can decrease the effectiveness of insulin.

Because of alteration of hormone levels, irregular bleeding and thickened cervical mucous can result. Norplant does not cause incomplete emptying of the bladder, increased production of thin cervical or vaginal mucous, or increase the risk for pelvic inflammatory disease.

The procedure, usually performed in a clinic under local anesthesia, is not effective for 4 to 6 weeks. The client should rest with minimal activity for 48 hours following the procedure.

The pregnancy rate following tubal ligation is 1 to 4 per 1,000 women. Reversal of the procedure, not effectiveness, is affected by the method used for the procedure. The effectiveness of the method is not related to client behavior.

The woman has linea nigra, a line of darker pigmentation from the umbilicus to the pubis. It is normal, caused by hormonal changes in pregnancy, and will fade after delivery. Chloasma affects the face, and striae gravidarum are reddish stretch marks on the abdomen, breasts, thighs, or buttocks.

The addition of a new baby causes many changes in family roles, emotions, and money management. If these changes are not anticipated, family dysfunction can result.

A rapid increase in fundal height could indicate a problem such as multiple gestation, hydatidiform mole, or polyhydramnios. The other answers are all normal findings and not a cause for concern.

Lower back pain results from increased hormone levels that cause the joints to relax and curvature of the lumbosacral vertebrae as the uterus enlarges. Pelvic tilt exercises help restore proper body alignment and can decrease discomfort. The other answers are not therapeutic but blame the client rather than helping to intervene to decrease the discomfort.

Adolescents often think no harm can come to them, which places them at high risk for injury or disease from dangerous behaviors. The adolescent’s immune system is well developed. Urinary tract infections do not cause sexually transmitted infections. Not all adolescents lack parental supervision.

Flat nipples are caused by adhesions around the nipple that prevent it from becoming erect. Hoffman's Exercises break the adhesions. Nipple shields are effective in breaking the adhesions, but they should be worn in the last 3 to 4 months of pregnancy and only a few hours at a time. Flat nipples do not preclude breastfeeding.

Although the fetal risk from alcohol appears to be proportionate to the amount of intake, no safe level of drinking has been established. Therefore, it is recommended that pregnant women not consume alcohol. The risks related to tobacco use are present throughout pregnancy. No teratogenic effects of marijuana use during pregnancy have been documented, but caffeine has been found to interfere with absorption of iron.

Protein and iron intake in pregnancy must increase to meet the needs of the growing fetus. Calcium requirements increase at the same rate as phosphorus. Caloric needs increase, but only by about 300 calories per day. Iodine requirements increase during pregnancy.

Anemia in pregnancy is often caused by inadequate iron intake. Lean meat and enriched bread are good sources of iron.

Conveniently located prenatal services that are open at convenient hours ease access for poor and working women. Support for prenatal care from the public and legislature increases access for poor women.

The child should be included in planning for the new baby. Children may feel threatened by a new sibling and so may need extra time and attention. Parents should avoid putting too much responsibility on the child. Option 1 is not therapeutic but places shame on the child. Staying with the grandparents may be felt as further rejection from the parents.

If the maternal level of alpha-fetoprotein is elevated, it could indicate that fetal alpha-fetoprotein from a fetal neural tube defect has leaked into the maternal serum. The test is most sensitive between 16 to 18 weeks' gestation. It is not definitive enough to make a diagnosis and is best used as a screening tool.

In singleton births with fetal growth within normal limits, fundal height in centimeters multiplied by 8 and divided by 7 should correlate with gestational age in weeks. Eliminate options that do not address this finding.

Childbirth education should be geared to the time in pregnancy. In the third trimester, the pregnant woman begins to focus on labor, delivery, and newborn care.

The first number, gravida, represents the total number of pregnancies including the current one. In this case that equals 4. Para is represented by using the TPAL system. T represents the number of term births, 1; P represents the number of preterm births, 1; A represents the number of therapeutic or spontaneous abortions, 1; and L represents the number of living children, 4. Multiple births do not affect the parity in the T, P, or A categories; they are counted in the L category.

Nurses are credible sources of information, support, and encouragement that can help adolescents cope with challenges. To develop trust, honest and accurate information must be given to the client. The adolescent should be given the choice to have his or her parents present because of the nature of the health problem, but treatment for STIs can be given without parental consent. The client should not smoke during discussions with the nurse for general health reasons.

Palpation of fetal movement is considered to be a completely objective sign of pregnancy that cannot have any other cause. The other signs listed here could have another etiology.

The husband can take on a variety of roles during labor and delivery, including coach, teammate, and observer. Exploring both partners' expectations may help to clarify reasons for the husband's hesitancy in participating in the birth. This could result in improved communication and family coping.

Increased pigmentation during pregnancy is a response to increased estrogen levels. It can be worsened by the sun, is harmless, and generally fades after the pregnancy ends.

Heartburn is usually caused by gastric reflux. Remaining in an upright position, not overeating, and use of low-sodium antacids all help to relieve the problem.

Nausea and vomiting, probably related to hormonal changes, usually disappear by the 12th week of pregnancy. Small, frequent meals; carbonated beverages; and crackers or toast sometimes relieve the symptoms.

While some ambivalence is common during pregnancy, the client should also have some feelings of happiness, tolerance of physical discomforts, and a feeling that she can deal with the changes and problems related to the pregnancy.

Maternal diabetes places both the mother and infant at risk during pregnancy and would require further follow-up. The other answers present no further untoward risk.

The risk for the mother and fetus increases as the pregnancy progresses. Therefore, clients are seen more frequently as pregnancy nears term. Visits every 4 weeks for low-risk clients are appropriate until 28 weeks of gestation.

A positive at-home pregnancy test indicates the presence of growing trophoblastic tissue and not necessarily a uterine pregnancy. It could even indicate a potential ectopic pregnancy.

Using Nägele's Rule, the estimated date of birth is calculated by subtracting 3 months from the first day of the last menstrual period and then adding 7 days to that date.

The infant at 6 months should have head control and is working on sitting without support. Pulling the child to a sitting position allows the neck muscles to support the head. Propping the child in a sitting position helps to develop self-righting behaviors. It is too early to worry about standing. Talking to the child promotes language development. Handling a rattle is fine-motor behavior.

Counting the current pregnancy, the client has been pregnant a total of four times for gravida 4. Para is the number of pregnancies that have reached viability, in this case two.

The fluid leaking from her breasts is colostrum. It normally leaks from the breasts during the last trimester. The client should wear a supportive bra.

Dizziness and blurred vision can be symptoms of pregnancy-induced hypertension, a complication that requires further intervention and medical management. The other answers are not danger signs of pregnancy.

The client has expressed a realistic concern. The nurse needs to help her explore what support systems are available for her and her child.

Topics should be timed to present information that the woman needs at that specific stage of pregnancy. The items identified in the other options can be covered later in the pregnancy.

For women of normal pre-pregnant weight, the recommended pattern of weight gain during pregnancy is 3 to 5 pounds during the first trimester and 1 pound per week thereafter. Nutritional counseling is an appropriate action for the nurse or the nurse should make a referral for the client to meet with the nutritionist. Salt intake during normal pregnancy should be moderate but not restricted.

Multiparous women in the transition phase of the first stage of labor with strong regular contractions will progress to the second stage and delivery very quickly. The health care provider should be notified prior to this time to ensure his or her presence for delivery. Analgesia is inappropriate this late in labor because it may cause fetal sedation and respiratory depression. Most women prefer to lie down during transition.

Upright positioning and walking facilitates the progress of labor. Staying in bed continuously may slow labor progress. Blood pressure is usually taken every 4 hours during the first stage of labor. The nurse should encourage the partner's involvement as the couple desires.

The second stage extends from complete cervical dilatation to delivery of the newborn. Any position of comfort may be selected by the woman. Ice chips and clear fluids prevent dehydration and are normally allowed. Analgesics are administered in the first stage of labor, usually during the active phase, to prevent fetal sedation and respiratory depression at birth. An Apgar evaluation would be conducted after delivery of the newborn during the third stage of labor.

Knowing what culture the client comes from, and how traditional she is with her cultural beliefs and practices, is important to understand, as it may dictate labor and birthing practices that the client will want to follow, as well as the client's response to pain. The expectations of the experience are important in order to try to integrate realistic ones into the labor plan or help to establish realistic ones that can be explored. FHR measurement is not part of the psychosocial evaluation. Plans to name the child are not relevant at this time.

It is recommended that the child’s height be measured with a stadiometer. The correct procedure is to have the child remove his or her shoes and stand erect facing the examiner, holding the head erect. Shoulders, buttocks, and heels should touch the back of the wall.

During the second stage of labor, fetal heart tones are measured every 5 minutes or after each contraction when continuous fetal monitoring is not in use. Blood pressure is measured every 5 to 15 minutes, not after every contraction. Maternal position can change according to the woman's comfort and desire and the health care provider's preference. Urine testing is not undertaken during the second stage because of the likelihood of contamination of the sample by amniotic fluid, blood, or feces.

Most women have a gynecoid pelvis which is rounded and most conducive to vaginal delivery. Android pelvic shapes are more common in men. Anthropoid and platypelloid shapes tend to slow the labor and birthing process, and are not favorable for a vaginal birth.

The largest diameter of the fetal presenting part must reach or pass the pelvic inlet in order for engagement to occur. This can be detected with a vaginal examination with the fetal head being deep enough into the pelvis so that gentle upward pressure on the presenting part does not cause it to float away from the fingers.

Contraction frequency is determined from the onset of one contraction, through the length of that contraction, including the rest period between contractions, and up to the start of the next contraction.

The pain felt during advanced labor is primarily caused by the stretching of the lower uterine segment and dilatation of the cervix. It is normally felt posteriorly in the lower back or anteriorly at the symphysis pubis. The other answers are incorrect descriptions of pain during this stage.

Fetal position is described by first giving the presenting part, then relating the presenting part to the maternal pelvis. In this example, the occiput, or back of the fetal head, is closest to the posterior aspect of the maternal pelvis. This position, LOP, is represented in option 4.

The cardinal movements (position changes) of the fetus occur in the order of engagement, descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. These movements represent the normal adaptation of the fetus in a cephalic presentation to the maternal pelvis and facilitate vaginal birth.

Analgesia and anesthesia methods are used for pain relief during labor as indicated by the client's response to pain, what phase and stage of labor the woman is in, how fast labor is progressing, and the fetal response to contractions. Parity alone does not determine what analgesia or anesthesia is indicated. The other responses are all accurate.

Moderate ecchymosis and edema are a normal response to the trauma of childbirth, as well as to the presence of sutures. Sutures should be closely aligned without gaps and there should be no puslike drainage, indicating infection. Edema severe enough to cause the tissue to look shiny or taut is abnormal.

Frequent inspection for redness, swelling, tenderness, and hematoma is essential to fourth-stage nursing care. Pain relief begins with immediate application of ice. Ice packs should be applied for 20 to 30 minutes and removed for at least 20 minutes. If ice is applied for more than 30 minutes, vasodilation and edema may occur. Clients are usually advised to wait until bleeding stops and stitches heal (about 3 weeks) before resuming sexual activity, but this teaching would be part of the client's discharge instructions, and is not appropriate during the fourth stage of labor.

The 13-month-old will suffer from toddler hospitalization reaction, which is primarily related to separation from the parents. The 2-month-old has not recognized object permanence and will not suffer from the hospitalization as long as his or her needs are met in a consistent fashion. The 8-year-old and the 14-year-old are accustomed to separation from parents and working with new adults.

The goal of childbirth education classes is to teach pregnant women and their support person(s) the birth process, strategies to cope with the pain of labor and to facilitate an easier labor, what to expect during childbirth, an understanding of operative delivery (use of forceps, vacuum extraction, and cesarean birth), and common procedures that may be performed throughout the birthing process. Many pregnant families get the information they need about the childbearing process by reading or from friends and extended family members. Childbirth preparation cannot prevent complications and thus cannot ensure vaginal deliveries for all clients.


An android pelvic structure is narrow in both the anterior–posterior diameter and the lateral diameter, and can cause prolonged labor with a large fetus or a malpositioned fetus.

Frank breech position is when the sacrum of the baby is presenting, the hips are flexed, and the feet are extended upward toward the fetal head. Option 1 describes a complete breech, option 2 is characteristic of a kneeling breech, and option 4 represents a double footling breech.



The presenting part is given first when describing fetal position. The second half of the fetal position description refers to the maternal pelvis. In this example, it is the sacrum presenting, and the fetal sacrum is toward the maternal anterior pelvis.

A change in the cervix is the only indicator of true labor. The other factors do not correlate as closely as the cervical changes.

The fetal heart rate response to contractions is a physiologic finding that indicates the presence or absence of fetal well-being. The other options are appropriate for the laboring client, but safety of the fetus is the first priority of the options presented.

As labor progresses, contractions will become more intense, occur more frequently (shorter resting phase between contractions), and have an increasing duration. Less frequent or shorter contractions can impede labor progress.

Excessive milk consumption should be discouraged, especially more than 1 liter/day (32 oz), since it is a poor source of iron. Fat-soluble vitamins will not increase absorption or utilization of iron. Although grains and legumes are good sources of nutrients, they are not especially high in iron. Foods high in protein should be encouraged, and especially food proteins of animal origin and organ meats, such as liver.

Apgar scores are based on 0, 1, or 2 points in each of the five categories: respiratory effort, color, muscle tone, heart rate, and reflexes. This neonate would score 2 points in each category except color, where the presence of acrocyanosis would warrant a score of 1 point.

As the uterus contracts and the placenta begins to shear off the uterine wall and be expelled, you will see a small gush of blood resulting from the uterine contractions emptying the uterus. In addition, the cord will lengthen as the placenta is released from the uterine wall and moves toward the cervix prior to expulsion.

Anxiety commonly increases the perception of pain, and childbearing is no exception to this. Decreasing anxiety through education and support will facilitate the birthing process.

An increase in fetal heart rate baseline can be an indication of fetal distress, as well as maternal fever. Narcotics may decrease the short-term variability but do not affect the baseline. Fetal movement will create an acceleration of the fetal heart rate. Utero-placental insufficiency causes late decelerations.

Effacement is the thinning of the cervix from 0 to 100%. The opening of the cervix from 0 to 10 centimeters is called dilatation. In primigravidas effacement usually precedes dilatation, while in multigravidas these processes usually occur concurrently.

The first stage of labor is from the onset of labor to complete dilatation, and is divided into latent (0 to 3 centimeters), active (4 to 7 centimeters), and transition (8 to 10 centimeters) phases. The second stage of labor has no phases and is from complete dilatation until delivery of the newborn. The third stage has no phases and extends from delivery of the newborn to delivery of the placenta.

The fundus should remain firm after delivery to decrease the risk of postpartum hemorrhage and decrease 1 centimeter below the umbilicus each day. All nursing interventions presented are appropriate, but massaging the fundus until firm is the most important to prevent hemorrhage.

Afterpains are anticipated in the postpartum client and are effectively treated with analgesics.

This client should be encouraged to verbalize her disappointment as the first step in resolving her negative feelings. The other responses are incorrect. This is not a normal response, nor is it one that requires a psychiatric referral.

Having sexual intercourse before the episiotomy is healed or the lochia has stopped increases the risk of infection. Water-soluble lubricants can be used, if necessary. An IUD is contraindicated during the early postpartum period.

Object permanence is the knowledge that an object or person continues to exist when not seen, heard, or felt. The baby will not attach to a single person, even the mother, until he or she is aware of the mother’s existence. Options 1, 2, and 3 do not address this phenomenon.

Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help suppress lactation. Milk supply is stimulated by expressing milk and applying heat to the breasts. Medications to suppress lactation are not recommended.

Temperature elevation immediately after delivery is often caused by dehydration during labor. Increasing the client's fluid intake will usually decrease the temperature to within normal limits. There is no indication for analgesia or antibiotics at this time. If the fever persists beyond 24 hours or the client has clinical signs of infection, then further investigation and perhaps treatment is warranted.

Clients are at risk for orthostatic hypotension, especially right after delivery. The nurse should stay with the client the first time she ambulates after delivery to promote safety. Early ambulation prevents circulatory stasis in the lower extremities and should be encouraged. The perineum should be patted (not wiped) dry from front to back to avoid trauma, discomfort, and contamination with bacteria from the anal region.

A client with a hemoglobin of 7.2 grams/dL would most likely have significant signs and symptoms of anemia, and this could be life threatening. It would be important to determine if the client had a large estimated blood loss during delivery or if she is currently bleeding excessively. The hematocrit is within normal limits, and mild proteinuria or leukocytosis up to 30,000/mm<sup>3</sup> is common in early postpartum.

An adult client should have a minimum urinary output of 30 cc/hr and this client is below that minimum. In a postpartum client, this is most likely related to urinary retention secondary to perineal edema and trauma from delivery. It is important that postpartal clients are able to empty their bladder without assistance prior to discharge.

If a postpartum client is experiencing pain, she will be less likely to ambulate, less receptive to teaching, and more likely to experience constipation because of the fear of pain with a bowel movement. By treating her pain first, interventions for the other nursing diagnoses will be more successful.

Clients who have had a cesarean delivery are at risk for complications of surgery, including thrombophlebitis. Early ambulation can significantly decrease the risk of blood clots and other postoperative complications.

This client has signs of an incisional infection. The physician needs to be notified first so that treatment can be started as soon as possible. Betadine has not yet been ordered. Documentation should follow reporting. Continued observation would be an ongoing intervention.

A third- or fourth-degree perineal laceration involves the rectal sphincter, therefore suppositories, enemas, and rectal exams are contraindicated until the rectum heals. Increased fiber and fluids or use of stool softeners are appropriate to promote bowel elimination in all postpartum clients.

Breast milk production is based on supply and demand. The more the breasts are stimulated to produce milk, by nursing the baby or pumping the breasts, the more milk will be produced.

The goal of time management is not finding more time, but using time more wisely by setting a reasonable amount of time to spend on individual tasks. It takes practice and doesn’t occur on the first day of the new job. One aspect of time management is setting priorities.

Flotation devices are not a substitute for supervision by an adult. Young children should never be left unattended in a swimming pool. Options 1, 3, and 4 all describe appropriate parental behaviors to support safety in the area of swimming pools.

Immediately after expulsion of the placenta, the uterus is firmly contracted, about the size of a grapefruit. The fundus is located in the midline of the abdomen and halfway between the symphysis pubis and umbilicus. Within 6–12 hours after delivery, the fundus rises to a level of the umbilicus. The top of the fundus then descends the width of a fingerbreadth each day until it descends into the pelvis by about 2 weeks, when it is no longer palpable.

This client's fundus is already firm, so it is not appropriate to massage the fundus. It is also higher in the abdomen than expected, and it is displaced to the right, which is probably caused by a distended bladder. Having the client void may return the uterus to the expected position; palpating the fundus after voiding will confirm this finding. A pad count would be appropriate if bleeding is increasing; no information given implies that this action is indicated.

The rubella vaccine is a live virus. If a client becomes pregnant within the first 3 months after administration, her fetus is at risk for congenital anomalies related to the virus. Women who are not rubella immune should be vaccinated postpartum, prior to discharge. Teaching should include an effective method of birth control and the importance of avoiding pregnancy for the next 3 months.

The vital signs are not normal. An elevation in body temperature greater than 100.4°F after the first 24 hours postpartum could indicate maternal infection. An elevated temperature within the first 24 hours is usually related to dehydration, although the possibility of infection still exists. Rising pulse and falling blood pressure rather than rising temperature is an indicator of hypovolemic shock.

Even when perfect sterile technique is used when doing a vaginal exam, organisms present on the perineum are transported into the vagina and close to the cervix. By limiting the number of vaginal exams, the risk is decreased. Option 1 is incorrect because clean technique, not sterile technique, is used when palpating the fundus. Options 2 and 4 are correct answers, but not the earliest intervention a nurse could perform.

A potential side effect of Methergine is hypertension. If a client's blood pressure is elevated, the nurse should hold the scheduled dose and notify the physician. An apical heart rate of 56 is within normal limits postpartum. Blood type, Rh factor, and chosen feeding method are not related to the use of Methergine.

All of the answers could occur in an anemic client and should be included in the teaching plan. However, the one most likely to risk the client’s safety is that she may feel lightheaded or dizzy. Because this could cause the client potential injury, it is the most important information to include.

3+ proteinuria is significant and could indicate the presence of preeclampsia within the first 48 to 72 hours postpartum. The other laboratory values are within normal limits for a client in the first postpartum day, and reflect expected physiologic changes related to labor and delivery.

Postpartum clients are at risk for urinary tract infections related to urinary retention after delivery. The risk is increased if the client has been catheterized during labor, delivery, or postpartum. Signs of a urinary tract infection include urgency, burning, and frequency of urination. The other answers are normal and do not require immediate attention.

New fathers may feel overwhelmed with caring for a newborn, especially if they have not had many opportunities to interact with babies. By encouraging him to discuss his feelings, the nurse may be able to help him explore his new role as a father and feel more comfortable asking questions related to infant care. The nurse may also be able to identify cultural expectations of the father's role and avoid misinterpreting the father's behavior.

Toddlers should be transported in a high-top crib with siderails up to ensure safety. The sedated toddler is at risk for falls. A wagon, wheelchair, or gurney will not eliminate the risk of fall injury to a sedated toddler.

Chinese clients may perceive an imbalance in the hot and cold forces in the body after delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if warmed) to regain a sense of balance between these extremes. A client's culture plays a very important part in who they are, and nurses should respect their wishes as long as it will not result in harm to the client or others. Showing a videotape will not change the client's cultural beliefs and is not appropriate. The other answers do not show evidence of acceptance of another's culture.

Because this mother is single and this is her first baby, it is important to determine her support system. The other answers are incorrect; there is no indication that the client is in pain or is uncomfortable with her parenting skills. Reporting the behavior to the physician isn't necessary.


Although this client is not demonstrating positive signs of bonding at this time, it is important to look at her history before concluding that she is not bonding well with her infant. This client just experienced a long labor and the influence of fatigue on the attachment process should be considered. It is important to continue to determine infant bonding with this client throughout her hospitalization to reach a nursing judgment based on evidence over time.

The nurse is responsible for delegating tasks appropriately and is responsible for the actions of unlicensed employees. Ambulating a postoperative client and obtaining supplies for a urine specimen are the only tasks that the nurse could delegate from those listed. The other tasks require higher level knowledge and critical thinking skills.

The en face position, which facilitates parent-infant attachment, is assumed when the mother arranges the newborn in order to have direct face-to-face and eye-to-eye contact in the same plane. There is intense interest in having the infant's eyes open, and when they are, the mother typically talks to the newborn in a soft, high-pitched tone of voice.

This finding is normal. No further action is required.

A Babinski reflex is elicited by stroking the lateral aspect of the sole of the heel upward and across the ball of the foot. A positive test (in newborns) of fanning the toes and dorsiflexing the big toe is an indicator of fetal well-being. Touching the corner of the mouth or cheeks (option 1) elicits the rooting reflex. Changing the newborn's equilibrium (option 2) elicits the Moro reflex. Placing a finger in the palm of the newborn's hand (option 3) elicits the palmar grasp reflex.

Cephalhematoma is a collection of blood between the skull bone and its covering (periosteum). Caput succedaneum is swelling of the tissue over the presenting part of the fetal head caused by pressure during labor. Molding refers to the overlapping of cranial bones or shaping of the fetal head to accommodate and conform to the bony and soft parts of the mother's birth canal during labor. Subdural hematoma refers to bleeding between the dural and arachnoid membranes of the brain.

The normal range is 120–160 beats/min. The rate varies with activity, increasing to 160 while crying and decreasing to 120 while in deep sleep. Bradycardia, rates below 120 (included in options 1 and 2), and tachycardia, rates above 160 (included in options 2 and 4), are not normal and require further evaluation and intervention.

A history of an allergic reaction to baker’s yeast would be a contraindication to receiving this series of immunizations. Aminoglycoside antibiotics, mold, and egg yolks do not pose any risk to the client for allergy to the vaccine.

After 12 hours, the edema of tissues present in most newborns begin to resolve and creases appear; these creases do not have the same predictive value as those found before resolution of newborn edema (option 3). All of the criteria in options 1, 2, and 4 remain predictive beyond the first 12 hours after birth.

These symptoms reflect cold stress and require the temperature to be taken immediately (option 2). These symptoms are not associated with bleeding from the umbilical stump (option 1), congenital abnormalities (option 3), or respiratory distress (option 4).

Periodic breathing with no color or heart rate changes is normal in the newborn adapting to extrauterine life. Option 4 provides verbal reassurance and also physical reassurance by the presence of the nurse. Option 2 doesn't reassure the mother and option 3 confirms the mother's fears. Option 1 provides information but doesn't address the mother's subjective sense of fear.

Keeping the infant close with head elevated is an optimal position for bottle-feeding. Keeping the nipple full of formula prevents the infant from sucking air. Options 2 and 4 can cause aspiration of formula and option 3 could cause the infant to gag and vomit.

Discomfort while breastfeeding is almost always caused by improper latch-on. Removing the infant from the breast and repositioning with proper position can reduce the discomfort. Having the mother pump and give the breast milk from a bottle can interfere with the breastfeeding process and may cause nipple confusion. Giving the mother a nipple shield to wear and having the mother breastfeed from the uninjured nipple will not solve the poor latch-on, and feeding from one breast will cause engorgement in the other breast.

Breast milk will not protect the baby from all illnesses. Lactoferrin (a whey protein in human milk) inhibits the growth of iron-dependent bacteria in the GI tract together with secretory IgA (another whey protein in human milk), which protects against respiratory and GI bacteria, viral organisms, and allergies. Breast milk does have other enzymes and proteins that protect the infant from illness.

The foramen ovale is an opening between the right and left atria that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. Options 1, 3, and 4 are incorrect as they do not connect the right and left atria.

One of the nursing goals of newborn care during the first few hours after birth is to identify actual and potential problems that might require immediate attention. Options 1, 2, and 4 are all considered to be continuing care goals. All of these should be carried out after the initial goals are met.

The usual position of the infant is partially flexed and all movements should be symmetrical. Any weak, absent, asymmetrical, or fine jumping movements suggest nervous system disorders and indicate the need for further evaluation. Common reflexes found in the normal newborn include the Babinski or plantar, fanning, and hyperextension of the toes when the sole is stroked upward from the heel toward the ball of the foot; the grasping, stimulating the newborn to grasp on an object by touching the palm of the hand; and the stepping, placing one foot in front of the other as though walking in response to one foot touching a flat surface.

Uric acid crystals in the urine may produce the reddish "brick dust" stain on the diaper. Mucous and urate do not produce a stain. Bilirubin and iron are from hepatic adaptation.

It is normal for the solution in the vial to appear cloudy. The nurse should gently shake the vaccine and then draw it up for administration. It is unnecessary to discard it or to notify the manufacturer. Warming the solution will not affect the cloudiness.

The newborn cannot limit the invading organism at the port of entry. Options 1, 2, and 4 are true adaptations in other body systems.

The flexed position of the term infant decreases the surface area exposed to the environment, thereby reducing heat loss (option 1). Blood vessels are closer to the skin than in an adult and constrict when exposed to cooler temperatures (option 2). Limited subcutaneous fat will increase a newborn's heat loss (option 3). Larger body surface than an adult increases the newborn's heat loss (option 4).

Small amounts of regurgitation of formula are common, often caused by "overfeeding" or an immature cardiac sphincter (option 2). Regurgitation of formula is not necessarily a sign of infection, or a reason to take a temperature (option 1), or discontinue a feeding (option 3). Vomiting or forceful or persistent expulsion of formula should be further investigated (option 4).

Mothers are encouraged to offer both breasts to the infant in the beginning for simultaneous stimulation, but it is not imperative nor harmful if the infant does not feed off of one breast at a session. Giving supplemental feedings can upset the natural supply and demand and can shorten the breastfeeding experience (option 1). Prolonged exposure to plastic liners or wet nursing pads may result in skin breakdown (option 2). Time limits should not be imposed on breastfeeding infants as they each have different styles of suckling (option 3).

Opened cans of formula must be used within a 24-hour period (option 4). There are no nutrients in whole milk that can enhance formula, and the Academy of Pediatrics strongly recommends that infants only take mother's milk or formula for the first 12 months of life to decrease the chance of allergies (option 1). Tap water is not always safe (option 2). Any formula not taken by the infant should be disposed of, as bacteria from the infant's mouth can enter the bottle and contaminate the remaining formula (option 3).

Audible swallowing during a feeding produces sounds heard as a soft "ka" or "ah." Burping is related to how much air the infant swallows during feedings (option 1). Newborns usually spend 15 to 20 minutes at the breast in the first few weeks. Some older infants may be able to finish a feeding in 3 to 5 minutes (option 2). Because breast milk is more digestible than formula, and a newborn's stomach is small, feeding is usually needed more frequently than every 4 hours. Frequent feedings are important in the early days to establish lactation (option 4).

Clearing the airway is best done by suctioning the airway. Slapping on the back may cause aspiration (option 1). Starting CPR and calling the code team are not necessary (options 2 and 4) at this time.

Abduction is limited in the affected leg. The nurse would also find asymmetrical gluteal folds and an absent femoral pulse when the affected leg is abducted.

Initial responses are triggered by physical, sensory, and chemical factors. The chemical factors include a decreased oxygen level, increased carbon dioxide level, and a decrease in the pH as a result of the transitory asphyxia that occurs during delivery. Oxygen is not increased in the blood (option 1). Rapid respirations and nasal flaring indicate a poor adaptation (option 2). The newborn's respiratory rate is not hyperresponsive to stimuli (option 3).

Infants undergoing phototherapy will need additional fluids to compensate for the increased fluid loss through the skin and loose stools. Decreasing the time in phototherapy needs a physician's order (option 1). Losing excess fluid can cause dehydration leading to a life-threatening event (option 2). Instituting enteric isolation is not necessary as there is no risk of infection from the stools (option 4).

The vial should be discarded according to agency policy. Administering the vaccine does not protect the safety of the client, and it is unnecessary to report this particular incident to the state Board of Public Health.

Most infants, whether breastfed or formula-fed, average a weight gain of 4-7 ounces per week during the first 6 months. An infant's weight triples by 1 year (option 1). A pound a month for 6 months is an insufficient weight gain (option 3). One pound per week for the first 6 months represents an excessive weight gain (option 4).

The respirations are within normal limits and periodic breathing with short periods of apnea may be expected at this age. The nurse should continue the routine examination. Even though heart rate is at the upper end of the normal range, the infant is pink with no central cyanosis. Cyanosis on the soles of the feet is to be expected (option 1). The infant is not displaying signs of cold stress (option 2) or the need for oxygen (option 3). The clinician need not be called at this time (option 4).

Maternal conditions such as pregnancy-induced hypertension (PIH), diabetes mellitus, and medications the mother received during labor may affect certain gestational age components. Data collection criteria do not have to correlate with the composite score (option 1), nor do they always correlate with the weeks of pregnancy (option 3). Data collection criteria are equally useful is determining postmaturity and prematurity (option 4).

Conduction is the transfer of body heat to a cooler surface, the infant seat. Convection is the heat loss to a cooler air current (option 2). Evaporation is the heat loss through conversion of a liquid to a vapor (option 3). Radiation is heat loss to a cooler solid object not in contact with the infant (option 4).

After lactation is well established between 3 to 4 weeks after the birth, the father can give a relief bottle of pumped milk. Giving supplemental bottles of formula daily can prevent the let-down reflex from being established and may result in engorgement. Husbands can participate in other ways the first few weeks through diapering, burping, bathing, and infant massage.

The football, or clutch, position provides the mother with more control of the newborn's head and full view of the face. The lying-down position is usually done in bed (option 1). The cradle position often causes the newborn's head to wobble around on the mother's arm (option 2). Options 1, 2, and 4 do not allow a full view of the infant's face.

These are classic symptoms of menopause. The first approach to management is implementing lifestyle changes, including following dietary and exercise plans. Reducing caffeine, salt, and sugar helps to reduce stimulation and water retention. With increased activity, more calories are burned, raising levels of endorphins for feelings of well-being and improving the glucose tolerance curve. Smaller meals are helpful so the client feels satisfied without overeating. This is not a psychiatric issue but a physiological adaptation to changing hormone levels; drugs for sedation or hypnotics are not necessary. Asking the family to talk about the problem could help, but exercise is necessary to help overcome other symptoms. Resting too much only frustrates the client by leading to additional weight gain and/or decreased feelings of self-worth.

Women in the middle-adult range often have a decreased intake of iron products, in addition to a gradual loss of red blood cells from menstruation. Therefore, at this age anemia is more common in women than men. After women reach menopause, the statistics change, and levels of coronary artery disease and hyperlipidemia increase to match those of men at this age. Osteoarthritis is not a gender-based disorder but rather one of wear and tear on joints caused by lifestyle.

Older clients develop a slower metabolic rate and often decrease their activity at the same time. By reducing intake of refined carbohydrates, the calorie count meets the needs of the body. In addition, the other options are recommended to minimize complications of atherosclerosis and constipation.

Younger adults as a group are at risk for improper eating habits, and if exercise is inadequate, this could lead to obesity. Obesity increases the risk of diseases such as atherosclerosis, hypertension, and heart disease. Hypoglycemia (option 2) is not a common disorder among young adults. Cancer (option 4) and heart disease (option 1) occur with greater frequency with increasing age.

The dose should be delayed for 1 month following any type of immunosuppressive therapy, such as prednisone. The other actions do not protect the client or uphold safe administration procedures for immunizations.

With economical changes in society and possible financial and childcare issues, there is an increased incidence of children (and grandchildren) who are returning home to live with their parents (or grandparents). For some, this may be the result of financial struggles and divorces or broken relationships. In addition, the cost of long-term care has forced many adults to be the primary caregivers for their own aging parents. The trend is that the “sandwich” generation is now caring for both ends of the spectrum in addition to trying to subsist in a slowing economy.

The client is experiencing symptoms of heat exhaustion. The first action is to remove the client from the heat (the outdoors). Moving the client to a cooler environment and letting him rest with a single cool cloth behind his neck will allow the body to return to normal temperature without any major complications. Excessively low temperatures or too many fluids can do more harm than good by lowering the body temperature too quickly, causing a circulatory collapse. With the current symptoms, the client’s reaction to heat does not include complete heat stroke or heat cramps. This is not necessarily a major medical emergency that demonstrates a need to call EMS or 911.

Constipation in the older adult results from decreased fiber intake and decreased activity, which are compounded by a decreased peristalsis from declining basal metabolic rate. Although roughage may be an issue (option 1), the actual problem is the decreased acidity and digestive juices along with the slowed peristalsis that causes the food to move more slowly through the intestines. Decreased muscle mass and decreased strength of the abdominal muscles also reduce the effectiveness of stool evacuation. Refined starches can exacerbate constipation but do not directly cause bloating (option 3). Salt and sugar do not delay digestive juices; rather, digestive juices are slowed as part of normal aging (option 4).

Anticoagulant therapy with Coumadin needs to be monitored in relation to dietary habits as well as understanding of medical administration. If the drug is taken as directed, the only other influencer is the dietary changes that impact the Coumadin. Green, leafy vegetables and liver contain Vitamin K, and when eaten too much will decrease the effectiveness of Coumadin as an anticoagulant. Therefore, these foods change the effectiveness of Coumadin and modify the lab results. The statements in options 1 and 3 reflect practices that enhance client safety.

The nurse’s primary role is to protect the client and maintain dignity within a safe environment. By first speaking with the client to determine his or her perception of the problem, the nurse can plan care around the client’s problem. Talking to the family or telling the client what to do without addressing the client’s feelings takes away client independence. Speaking very loudly and writing messages are not helpful in approaching the problem long term, and often these suggestions will further increase the client’s anxiety. The client may also perceive hearing loss as a personal failure in the process of growing old.

When hearing loss is present, the best method of communicating with the client is to face the client, get his or her attention, and speak in a deeper tone at a regular speed. The older adult loses the higher pitch tones first; therefore, yelling and raising your voice only changes the tone without clarifying the words. Talking loudly directly into the ear does not allow the client to see the speaker’s facial expressions or nonverbal cues. Exaggerated speech and slow enunciation of words also will not assist the client with his or her understanding. Pointing or using a communication board is not helpful in maintaining the adult client’s dignity.

Constipation can come in many forms. One of the most common in the elderly is the perception that they are constipated because they don’t have a stool every day. Therefore, asking about perceptions will clarify whether this is an actual or perceived problem for the client.

Increasing isolation from others is not a healthy adaptation, although it is common when one spouse dies that the other needs to adjust to leisure time spent as an individual rather than as part of a couple. Bladder and sphincter weakness are normal with the aging process. Decreased tolerance of spicy foods also results from decreased acidity and motility of the digestive processes that are common in the aging process. Circulatory instability can occur when getting up too quickly, since the vasoconstriction process of the legs can be slower as one ages. Also, dehydration can lead to a feeling of slight dizziness when moving about.

When trying to get all of the information possible, an open-ended question could be answered in a variety of ways. By first restricting the focus of the conversation, the nurse is trying to determine what daily activities are present in the client’s life. Withholding food, pleasure, and activities can be identified or eliminated as problems when gathering the background data on care provided for the client.

Vision and hearing commonly deteriorate as part of the normal aging process. Although options 2, 3, and 4 represent changes that take place in the neurological system, none of the causes are directly related to the aging process. A disease process would change the others. Nerve damage can occur with diabetes or decreased blood flow from atherosclerosis. Dysuria and incontinence are related to relaxed muscle tone or sphincter damage. Peripheral neuropathy is a disease process that changes the sensations and motor function, such as diabetes mellitus.

The immunizations should be administered as scheduled. They would be withheld for clients who are immunosuppressed or have moderate to severe febrile illnesses. The presence of a runny nose and low-grade fever is not a contraindication according to the literature.

A healthy 30-year-old has the greatest risks related to lifestyle behaviors, such as multiple sexual partners, “on-the-edge” lifestyle (thrill seeking), haphazard dietary intake, speeding, and not sleeping enough. Cancers of the breast, uterus, lung, or prostate are not the greatest risks for a 30-year-old; rather, these are of greater concern for the older adult. Bone density testing for osteoporosis is often not recommended for the female in her thirties. Most women will test for this near menopause.

When the nurse provides neutral information, the middle-aged adult can learn of risks without feeling personally attacked. A referral also allows the client to choose the timing of the follow-through. One cannot refer <i>all</i> clients that drink to detoxification units. Not all accept their own diagnosis and are ready to begin the needed rehabilitation process. Limiting your counseling to only those clients who admit abuse will cause you to miss the high proportion of the population that is ETOH-dependent. By avoiding talking to the client and by going to the family/significant others first, you do not address the issue directly with the client.

Muscle mass and strength decline with age, and demineralization of the bones may occur because of hormonal changes and dietary losses. Demineralization of the bones allows them to be easily fractured. Spinal curve changes also reflect the collapsing of bone in the spine, leading to kyphosis and shortened stature. Arthritis and inflammation of the joints do not lead to fractures since an overgrowth of scar tissue occurs. Some bone-on-bone changes can occur, but generally hip fractures do not fall into this category.

Taking control over aspects of an adult’s life when it is unnecessary does not respect or recognize the client’s value or worth. Alternatively, to allow clients to do whatever they want to do may not be safe and could lead to harm, despite saving some self-esteem. Financial issues are the most worrisome issues that must be dealt with, and taking them over also removes the independence of the client. A plan of care needs to be clarified when the adult has clear thought processes and can delegate or make an advanced directive.

Nighttime vision is impaired in the “old-old” adult years. Of the options presented, this is the only one that allows dignity and safety within some guidelines. Warming up the interior of the car is nice but does not make the client a safer driver. Driving the speed that matches the flow of traffic might be dangerous, since in most areas the flow is well above the restricted guidelines. In addition, the reaction time is decreased among people in this age group, and staying with the flow might not give them time to react safely. Using the hearing aid is helpful, but vision is a greater risk than hearing. Yearly eye exams would be of greater benefit, so the client can more clearly see what is on the road.

Polypharmacy is using multiple doctors and multiple pharmacies to get the health care needed, often from a variety of specialists. Although taking over-the-counter medications on one’s own in combination with prescription meds can lead to problems, polypharmacy is a greater issue. Sharing medications may be an issue for some adults who want to assist another by providing medications that helped in their own cases. Financial issues may come into play, but this is also a less-dangerous issue than polypharmacy. Taking medications as ordered will not increase the risk of complications; it should reduce that risk.

Some children might have missed earlier doses due to illness or missed health care visits. Children at any age can be started on the immunization schedule. Immunizations would not be repeated in this case. Having the child go to the lab to draw titers for all of the immunizations would be inappropriate. All children need to be immunized.

A tetanus-diphtheria booster is recommended every 10 years. This situation does not warrant an MMR booster. The immunization history and/or a titer needs to be done before administration of this immunization.

Common side effects of vaccines include redness, soreness at the injection site, and fever. These are NOT symptoms of anaphylaxis or an allergic reaction. The nurse should reassure the mother but offer a route to share future concerns if they arise.

The first dose of the MMR is recommended at 12–15 months of age. The other immunizations may be started earlier in life, according to the current immunization schedules.

A contraindication to MMR vaccine is a history of allergic reaction to neomycin or gelatin. Minor illnesses and history of local reaction to a previous dose are not contraindications. Weight loss is irrelevant to the question.

Because of the high fever (which could lead to seizures in very young children), the nurse needs to consult with the health care provider. The reaction might need to be assessed further, and the provider needs to determine how to proceed with the immunization schedule to protect the child from adverse effects.

A mild fever is an expected side effect of immunizations, and can be treated safely and effectively with acetaminophen (Tylenol). The immunizations are not given together (option 2), the physician does not need to be called unless the fever is high (option 3), and a rash is of concern because it could indicate hypersensitivity, and needs to be addressed rather than treated at home (option 5).

A laboratory test called a titer can be used to detect whether the child has an adequate level of circulating antibodies against the varicella virus responsible for chickenpox. The statements in the other options are incorrect.

The response in option 1 is honest and provides full information to the mother. It is true that vaccines have some adverse effects, but the benefits in terms of disease prevention do outweigh the risks. The statements in the other options either are falsely worded or do not provide the mother with adequate information.

Immunizations are considered to be a prevention strategy during infant, toddler, and school-aged years. Most parents do not follow through with the elective boosters or vaccines, since they are not required. The student will be exposed to many new people, and might be in a different living environment, so there are immunizations to protect her. If the student has any health problems, or needs birth control or nutrition education, this would have been determined in questioning by the school nurse.

Children younger than 10 years of age who are internationally adopted are not required to have proof of immunizations prior to entry into the United States. Adoptive parents are responsible for immunization decisions. Titers can be drawn to check immunity status. Immunizations should be initiated as soon as possible, to reduce the risk of contracting and spreading infectious diseases.

Vaccine risks and benefits always should be discussed with parents for informed decision making. Misconceptions are common. An informed consent form always should be documented. The nurse should not give personal opinions. Objective information is vital to the decision-making process.

The nurse should provide the current Vaccine Information Statement (VIS) to parents for each vaccine the child will receive, as required by the National Vaccine Injury Act of 1986 and 1993. Aspirin is contraindicated due to the risk of Reye’s syndrome. Immunizations should not be delayed if the child is healthy.

Age-appropriate choices and forms of distraction are needed to promote coping strategies when performing painful procedures. EMLA cream must be applied at least 1 hour before injections to be effective. Due to anxiety, needle size should not be discussed with the child. “Sticking” the child without warning will create a fearful situation.

When reconstituting vaccines, it is important to use the solution provided, and to follow the manufacturer’s directions. The pharmacist, pediatric nurse, and pediatrician are less reliable sources because it is possible that they might be incorrect in their advice.

The nurse would inquire about the nature of the exposure and the client’s immune status. Chicken pox can be fatal in immunocompromised children, such as those who are undergoing steroid therapy, chemotherapy, and those who have other illnesses. If warranted, the varicella zoster immune globulin can be given up to 4 days after exposure to those with no history of chicken pox or prior exposure. Exposure to rubella (a different disease), height and weight of the child, and the person to whom the child was exposed are irrelevant as priority items in protecting the health of the child.

Immunizations may be given if the child has a mild illness, with or without fever. Anaphylaxis is a life-threatening reaction to an allergen or antigen, and can occur again if the patient is exposed to the offending allergen or antigen. Redness and soreness are common reactions, not contraindications, to immunizations. One month is too long a time period for febrile convulsions to be related to vaccine administration.

The child’s temperature will help the nurse decide if the child has a mild illness or a severe one. Postponing the immunization might result in a missed opportunity if the parent does not keep the appointment. Missing school is not a contraindication for immunizations. The nurse should ask about previous reactions to immunizations, but this is not related to withholding the immunization because the child is not feeling well.

The risk of encephalopathy from complications of measles and varicella is much greater than the risk of encephalopathy from being immunized. Wheals and urticaria are local, non-life-threatening allergic reactions that can occur within minutes of any immunization. A mild fever is a common reaction 24–48 hours after administration of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine. A rash can occur 7–10 days after the administration of measles, mumps, and rubella (MMR) vaccine.

This child’s reaction describes angioedema, laryngeal edema, and respiratory distress, indicating impending anaphylactic shock. All other answer choices are possible reactions to immunizations, but are non-life-threatening.

<i>Haemophilus influenzae</i> type B (HIB) vaccine is given at 2, 4, 6, and 12–15 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 12–15 months and 4–6 years of age (two doses). Varicella (Var) is given at 12–18 months or anytime up to 12 years (one dose), and to children 13 years and older (two doses, 4–8 weeks apart).

Fifth disease manifests first with a flulike illness, followed by a red “slapped-cheek” sign. Then a lacy, maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chickenpox) and rubella (German measles) are unlikely if the child had all recommended immunizations. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants, and begins abruptly with a high fever, followed by a pale, pink rash starting on the trunk and spreading to the face, neck, and extremities.

Open-ended questions encourage the client to speak freely and to elaborate and clarify answers as needed. Restrictive questions that only require “yes” or “no” answers do not encourage free exchange of information; nor does frequent rephrasing of the client’s answer. Leading questions tend to elicit the answer that the nurse anticipated.

Validation of the effectiveness of the interventions to achieve the client specific goals encompasses input from the health care team members and knowledge of hospital standards of care. Medical documentation and written orders are components of the client care but not the focus of the nursing plan of care.

Renal failure results in the inability of the kidneys to excrete potassium and that leads to hyperkalemia. Nausea, vomiting and excessive laxative use, and loop diuretic will cause hypokalemia.

Arterial blood gas findings of PO<sub>2</sub> 90 mm Hg (80 to 100 mm Hg normal) and pH 7.40 (7.35 to 7.45 normal) would be within the normal range for an adult. All the other choices are abnormal findings.

Contraindications to varicella virus vaccine include allergy to neomycin or gelatin, immunosuppression, or administration of immune serum globulin or blood products in the last 3 to 11 months. A history of spleen removal and allergies to penicillin or milk are irrelevant to safe use of this vaccine.

A low serum potassium level enhances the action of digitalis and predisposes the client receiving digitalis to develop toxicity. The other lab values do not contribute to digitalis toxicity.

The client will be required to have an empty stomach for the procedure to allow visualization of the gallbladder and adjacent structures to accurately rule out tumors, structural abnormalities, or the presence of stones. Since the lower GI tract is not visualized during this procedure, there is no need for the bowel to be empty. Also, ultrasound does not require the use of radioactive isotopes to be used.

The administration of a local anesthetic is possible during the procedure to decrease the gag reflex and increase comfort. The nurse should check for the return of the gag reflex to prevent the potential for aspiration. The position of the side rails, availability of the call light, and the ability to ambulate without assistance are safety concerns but not related to the specific client request.

An oxygen saturation of less than 80% with observable signs of shortness of breath indicates respiratory distress, which requires immediate intervention. A full respiratory examination should be performed and the physician should be advised of the findings immediately. Symptomatic respiratory distress should not be ignored. The repositioning of the client and the receiving of a physician’s order to increase the oxygen being delivered would be helpful. The client should be continually monitored, but a 15 L/min flow rate of oxygen may be excessive.

Diagnosing is a specific step of the nursing process that utilizes the information collected during the client-specific database collection. Once nursing diagnoses are determined, the next step would be planning care. Client teaching is a nursing intervention based on plans made for care. Team collaboration is important in the intervention and evaluation phases of the nursing process. The utilization of a previously developed clinical pathway includes components of all steps of the nursing process.

Assisting the client to use the incentive spirometer puts the client’s plan of care into action to maintain optimal oxygenation status. Auscultation of the carotid bruits would be a part of the data collection process from which a care need may be identified. Prioritization of care issues is part of the planning stage of the nursing process from which nursing interventions are determined. Consultation with other care providers is used in evaluating the effectiveness of the planning of care and gathering of information for possible revision.

Discharge planning should begin on admission to the unit and should be an ongoing process. As a rule, clients are not ready to discuss discharge plans on the day of admission; however, planning for appropriate follow-up and coordination of care cannot frequently be achieved the morning of discharge.

The evaluation step of the client’s plan of care includes the determination of their accomplishments toward a previously identified desired outcome. The desired outcome would have been the result of the gathering of the client’s health history, identifying of a nursing diagnosis, goal formation, and implementing the assigned plan of care such as ambulation.

In liver failure, an excess of serum ammonia results from the liver’s inability to convert ammonia to urea for excretion. Because of the liver’s inability to perform its normal functions, glucose, albumin, and the client's platelet count will be decreased rather than increased.

MRI testing involves the use of a magnetic field and radio frequency waves. Any object that contains metal of any kind will be attracted to the magnetic field, which will affect the diagnostic ability of the test and can potentially harm the client. Foam, plastic, and the urinary catheter are not attracted to the magnetic field.

Negligence is the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not do in the same or similar circumstances. Options 3 and 4 do not fit the description of the event, and option 1 is the opposite of option 2.

Shortness of breath is always first priority. The client who had a stress test requires careful monitoring for potential complications. Client C needs to be repositioned to prevent further skin breakdown. While Client A’s emotional concerns are important, they are of lower priority than the other three clients.

When there is accidental exposure and inadequate vaccination, passive immunity with tetanus immune globulin is indicated for immediate protection from the bacterial spores in the nail. Options 1 and 4 provide active immunity and option 3 (broad-spectrum antibiotic) is inadequate.

LDH<sup>1</sup> and LDH<sup>2</sup> are the primary isoenzymes for cardiac muscle and are utilized to diagnose an acute MI. LDH<sup>3</sup> is the primary pulmonary isoenzyme and LDH<sup>4</sup> and LDH<sup>5</sup> are indicators of hepatic dysfunction.

Normal ABG pH is 7.35-7.45 and a normal bicarbonate level is 24-28 mEq/L. A low pH would indicate a client is in an acidotic state and the low bicarbonate would indicate a metabolic cause for the acidosis. The pCO<sub>2</sub> level is an indicator of the respiratory component of the client’s acid-base balance.

Creatinine levels are more sensitive and specific for renal disease. Although the BUN level is used to monitor renal function, it can be affected by diet and fluid status. The potassium level can be affected by many factors as well. Specific gravity is not a blood test, but rather is performed on the urine itself.

A colonoscopy is the insertion of a flexible tube into the lower GI tract for evaluation and treatment of conditions of the bowel. An evaluation of the esophagus and stomach would require an approach from the upper GI tract such as an esophagogastroduodenoscopy (EGD). The presence of blood in the abdominal cavity would require an abdominal ultrasound or other x-ray procedure.

DKA produces an excess release of hydrogen ions into the serum that cannot be buffered by the already depleted bicarbonate level due to an osmotic diuresis that occurs. Therefore the client is in metabolic acidosis. There is no essential respiratory cause for this metabolic condition and the results will not be within normal limits due to the pathophysiology of the disease process.

The first nursing data collection technique utilized to gather data is inspection of the area. Palpation of any of the area would be attempted after the inspection. Obtaining the client history is not a component of the physical examination.

A nurse must focus on using good communication skills, which will enhance the interview. In addition, the ability to interpret nonverbal communication is paramount in achieving the goals of history taking. The history should be done at a comfortable pace and should not be rushed. The nurse must document carefully, but it is subjective data, not objective, that is recorded using the client's own words. The client can have family in the room if they do not distract the client or nurse in the interview; in many instances family members are helpful in the process.

Before palpating the abdomen, the nurse should first listen to all four quadrants for bowel sounds. Palpating and percussing the abdomen first can alter bowel sounds, making the results less reliable. It is unnecessary to use sterile gloves unless there is an open wound or lesion. The client should be in a supine position if tolerated by the medical condition.

The nurse seeks to obtain data from the client using a holistic approach. The nurse focuses on physical, psychosocial, and spiritual concerns. Information regarding a client's personal finances should not be alluded to in the interview. Reactions to past hospitalizations and goals for future health care are encompassed in the psychosocial aspect of the history.

Subjective data are only apparent to the person affected and can be described or verified only by that person. Itching, pain, and feelings of worry are examples. In addition, the client's sensations, feelings, values, beliefs, and attitudes are regarded as subjective. Objective data are detectable by an observer or can be measured against accepted standards. They can be seen, heard, felt, or smelled during physical examination.

The IPV, DTaP, Hib, and PCV vaccines are all scheduled to be given at 2 months of age. The MMR is given at 12 to 15 months, and again at 4 to 6 years. The varicella zoster vaccine is given at 12 to 18 months.

A comfortable environment puts the client at ease and increases the likelihood that the nurse will be able to obtain necessary data. The family may be able to provide additional data through the nursing process (option 3). As the nurse proceeds with the more intimate components of the examination, the family may be asked to leave. Inform the client immediately prior to examining each system (rather than before the examination) about what is entailed to facilitate understanding (option 2). Using lay terms for medical equipment (e.g., blood pressure cuff vs. sphygmomanometer) is appropriate (option 4).

Auscultation uses the sense of hearing to identify sounds that are normal and abnormal. A bruit is an abnormal sound of the venous/arterial system that is only detectable by listening with a stethoscope.

Evaluation of ocular motility provides information about the extraocular muscles, the orbit, cranial nerves III, IV, and VI, their brain stem connections, and the cerebral cortex.

The Romberg test is performed to test motor function. The client is asked to stand with feet together, arms resting at the sides, and then to close the eyes. The nurse watches for the presence of swaying, which is considered normal if it is only slight. However, if the client cannot maintain foot stance, it is documented as a positive Romberg's sign.

Using the principles of the ABCs (airway, breathing, and circulation), an alteration in respiration is always a primary concern. A disturbance in normal ventilation is occurring secondary to the medical diagnosis of myocardial infarction. The blood pressure remains in acceptable range, and the temperature elevation is likely related to the overall inflammatory response of the body. Infrequent abnormalities of cardiac rhythm are common and should be of concern when appearing regularly or with longer duration.

The thyroid should be midline, smooth, and free of nodules. The parathyroid glands are too small to be manually palpated. Any other findings are considered an abnormality.

In order to gain as much insight and information from the client as possible, the nurse should establish a level of trust or rapport with the client. The client will be best able to relax and answer questions if he or she is asked in a nonthreatening manner. Offering the client food and drink is not appropriate. The nurse should not ask the client about health insurance or finances, as other personnel determine this. The client does not need to wear an examining gown to answer questions.

During inspection, the nurse scrutinizes and evaluates by sight any clues of pathology that may be present. By first performing the other examination techniques (percussion, palpation, and auscultation), the nurse could alter the findings.

The health history is an important tool that assists the health care team to learn about the client’s overall state of health using data from the past and present. After the health history is complete, the health care team can assist the client to identify ways to improve the lifestyle. The health care team should display concern for the client during all phases of care.

The chief complaint offers the nurse an indication of what the problem is and how health care should proceed. The nurse can continue to probe during the interview to identify contributing factors to the client's chief complaint. The client's statements must be documented using his or her own phrases and terminology.

The solution used for Hib vaccine is clear and colorless. MMR and varicella vaccines are a clear yellow in color. No vaccines are pale pink or brown, although some are cloudy.

The cremasteric reflex is tested in men only. The nurse uses a cotton-tipped applicator or other smooth object to stimulate the inner thigh. The normal reaction is contraction of the cremaster muscle and elevation of the testicle on the side stimulated.

To examine for jugular venous distention (which indicates fluid volume overload), the client should be lying supine with the head elevated to 30 degrees. The nurse examines the highest point of distention of the internal jugular vein in centimeters in relation to the sternal angle, the point at which the clavicles meet. The other positions listed would not aid in this physical examination technique.

During physical examination, the nurse inspects the client’s legs for hair distribution. The most common reason for shiny skin and a complete absence of hair is poor circulation related to peripheral vascular disease (PVD). The other nursing diagnoses should not affect hair distribution.

If the nurse begins with deep palpation and there are sensitive areas, the client may be too uncomfortable for light palpation, which is important to allow detection of masses, distention, and the position of the abdominal organs. Deep palpation involves depressing the abdominal wall approximately 4 to 6 cm. Palpation should be completed despite absence of bowel sounds. The nurse uses the distal palmar surface and fingers of the hands for this examination.

The Bartholin glands are part of the female anatomy located on the posterior aspect of the vaginal orifice. Therefore, if the medical condition allows, having the client in a lithotomy position (on her back, knees flexed, legs apart with feet supported on a surface or in stirrups) will provide the best opportunity for examination. The other responses are incorrect.

In order to facilitate visualization of the ear canal and tympanic membrane, the pinna should be pulled up and back for an adult client. If earrings are attached to the lobe, there should not be a safety issue; however, they may be removed if they are large in size or are causing the client discomfort during the examination. The nurse should not remove cerumen with an applicator because of the risk of pushing it further into the canal or rupturing the tympanic membrane. Generally, the ear and eye physical examination are performed with the client sitting upright.

To inspect a client means that the nurse is scrutinizing and evaluating by sight any clues of pathology that may be present. The order of physical examination of the heart and lungs is inspection, palpation, percussion, and finally auscultation.

Clients must be assured the right of privacy because they disclose sensitive and personal information. Beneficence promotes the health professional to do good for the client. Disclosure of information is restricted to authorized personnel only. Anonymity is not possible for permanent, legal health care records because the client’s name, social security number, and other identifying data must be included.

Monitoring a client’s answers for truthfulness can be a difficult task for the nurse. When doing so, the nurse can ask very clear and pointed questions regarding the illness. Subjective facts can be compared with objective findings to determine the validity of the statements.

It is not easy to ask clients about sensitive items, but the answers may impact the health and the findings of the exam. Therefore, the nurse must ask these questions with sensitivity, which can be conveyed with a calm yet direct manner.

The parents should be taught to expect pain and redness at the site as possible local reactions. Fever, irritability, and decreased appetite are common side effects of the heptavalent pneumococcal conjugate vaccine (PCV).

A nonthreatening and nonjudgmental attitude is most likely to put the client at ease. It is normal for a client to feel some anxiety during the interview; however, panic is not expected. The nurse should not rush the interview, since doing so will heighten the client’s anxiety level. Music may or may not be a helpful distraction.

The family history can offer certain clues about hereditary diseases, such as hypertension, coronary artery disease, diabetes, and breast cancer. The other options would not directly affect the client's health status.

The nurse should approach the initial physical exam holistically and it serves as the baseline of the client's functional ability. The nursing diagnoses and evaluation of client goals would require more in-depth contact with the client.

Inspection of the mucosa of the nares for color, moisture, presence of polyps, exudate, and inflammation is performed with the aid of the nasal speculum. The otoscope can be used as a light source (as can a penlight).

The bell is placed lightly in contact with the skin to hear low-pitched sounds, such as murmurs and bruits. The diaphragm detects sounds of higher pitch. The length of the stethoscope tubing is standard; a Doppler is not necessary.

Under normal circumstances, no sound should be heard while auscultating the carotid artery. The presence of a sound is termed a bruit, and it indicates turbulent flow, often caused by atherosclerosis and subsequent narrowing of the blood vessel.

Pulling feet to mouth begins at about 4 months, smiling at self begins at about 5 months, and rolling over begins at about 6 months of age. An infant of 7 months just begins to transfer objects from one hand to the other.

The Snellen eye chart measures visual acuity by measuring from a set distance how well a child can see. An ophthalmoscope looks at the internal parts of the eye, the cover-uncover test measures eye muscle coordination, and the Weber test measures hearing.

By age 7, most children are able to clearly, and in chronological order, describe symptoms. Their vocabulary is extensive enough to have words to describe what they are feeling, time of onset, changes from the norm, and so on.

It is important for the nurse to know the immunization record and status for any child. If a child is not up to date with immunizations, it is up to the nurse to plan a schedule with the family to get necessary immunizations. Hospitalizations, coping mechanisms, and accidents are important for the nurse, but immunizations are uniquely important for pediatric clients.

Before administering a dose of IPV, the nurse should assess for allergy to neomycin, streptomycin, or polymixin B. The solution should be kept in the refrigerator and should be clear and colorless. The dose is administered by the subcutaneous route.

Females are indicated by circles and males by squares. The child is indicated, so the individual will be one generation up on the mother’s side. The mother is indicated as number 30. Therefore, the uncle of the child is number 28.

The normal range for most children falls somewhere between the 10th and 90th percentile. The other ranges do not accommodate as many variations in height and weight that are considered normal.

Save the painful area for last to avoid abdominal guarding and to gain the child’s trust. Always tell the child before touching a tender area. Light palpation, not deep palpation, would be used when examining a painful or tender area.

The Denver II is used to screen children for possible developmental delays in the areas of gross motor skills, language, fine motor skills, and personal-social development. The Denver II does not measure intelligence, cognitive difficulties, or speech difficulties.

Auscultation is always easiest in a sleeping or quiet baby. Checking the eyes is considered invasive and should be saved for the end of the examination. Examination should proceed in an orderly fashion from head to foot.

Children do not need detailed explanations, nor do they need to be told to act older than they are. Most children at this age are willing to remove clothing.

The ear canal in infants and young children is shorter, wider, and more horizontally positioned than in older children. To adequately examine the tympanic membrane in young children, the pinna must be pulled back and down.

Children younger than 2 or 3 should be measured lying down, preferably on a horizontal measuring board, to get an accurate measurement of height. A tape measure would be used to measure head circumference. An arm-span measure is not an appropriate estimation of adult height.

The school-age years are the first time a child is able to reliably cooperate with the examiner and not squirm, talk, or otherwise interrupt the exam. In younger children, it is essential to begin with the chest and thorax because the child needs to be quiet and at rest.

The nursing process is used to identify and solve problems and to plan client care. A nursing diagnosis is a statement of an actual or potential problem that can be resolved or changed by nursing interventions. It involves the use of common labels established by NANDA. Nursing diagnoses are based on data collected by the nurse, but are not related to disease etiology or judgments of the overall health status of a client.

The first dose of IPV is given at 2 months, with subsequent doses at 4 months, 12 to 18 months, and 4 to 6 years, for a total of four doses. The other options do not match the acceptable timeline for administration of this vaccine.

Strabismus is detected with the cover-uncover test that can first be reliably administered to children over the age of 2. It is important to detect the problem early to prevent amblyopia. By school age, vision loss would have occurred.

A positive Babinski in infants is a fanning of the toes when a stimulus is applied to the foot along the lateral edge and across the ball. The response is normal and disappears by about age 2.

The Denver Developmental Screening Test II evaluates 4 areas: Personal/Social, Fine motor/adaptive, Language, and Gross motor. The Denver II does not include measurement of physical maturity.

Indirect percussion can be used to evaluate borders and sizes of abdominal organs and masses. Percussion produces sounds of varying loudness and pitch, and these sounds help to identify the density of organs and tissues. The nurse examines the liver with palpation and percussion, but not for placement. Inflammation is examined with inspection, and tenderness is examined with palpation.

Infants and young children use the diaphragm and abdominal muscles for respiration, so the nurse would watch the rise and fall of the abdomen to count respirations. Use of accessory or intercostal muscles may be observed in respiratory distress.

The posterior fontanel closes by 3 months of age. The anterior fontanel closes by 18 months.

The grasp reflex usually disappears from the hands and feet by 3 months of age. This is an abnormal finding that should be reported to the physician. The other options do not correctly interpret the significance of this finding.

The Denver II is a screening test, not a diagnostic test; therefore children who score a failure should be retested. The child is considered at-risk until other diagnostic indicators can determine a specific problem.

While difficult to examine directly in infants and young children, visual acuity does not approach that of adults until school age or about 6 years.

The major reason for low hemoglobin and hematocrit in infants and children is deficiency of iron intake in the diet. Iron-fortified rice cereal is the first solid food recommended for infants beginning about 4 months of age as fetal iron stores are depleted. Children need iron daily in their diets. Hemodilution and blood loss are uncommon causes of low hemoglobin and hematocrit in children.

Although mild to moderate fever, drowsiness, and decreased appetite are some of the side effects of PCV, the most important one to report to the health care provider is rash with hives. This likely indicates an allergic reaction, which could progress to anaphylaxis if left untreated.

The easiest way for a nurse to observe a child's gait is to unobtrusively observe the child move about the examining room. If that is not possible, the nurse can ask the child to walk across the room at the conclusion of the physical exam. Barlow's maneuver is performed to examine for congenital hip dislocation in infants. Stretching is not part of the examination and parent report is part of the history.

Tonsils enlarge throughout childhood and gradually begin to shrink with puberty. Exudate should not be present on tonsils.

The history deals with subjective data, that which is reported by parents, for example. Option 3 is vague and should not be included as stated. Option 4 would be obtained by physical exam.

Objective data is that which the nurse obtains through physical examination or diagnostic studies. The presence of a scar is objective data. Other selections listed are part of the health history and therefore are subjective data.

The typical toddler has lordosis and a protruding belly. The head still appears somewhat large in proportion to the rest of the body. Because these are normal findings, there is no need to be concerned about developmental delays, malnutrition, or neurological problems.

Inspection, or observation, is always done before proceeding with other techniques of physical examination. It is the least intrusive method of examination.

Genetic screening can identify markers for several types of cancer. One method of reminding men to perform self-checks for cancer is for them to mark on a calendar to do a monthly check for changes. Self-exams as well as medical tests and exams uncover tumors. After a total mastectomy, women do not need mammograms. Colonoscopy is generally recommended once a client reaches age 50.

Tanning from ultraviolet light, even in new tanning beds, is not safer than tanning from sun rays. The statements in the other options are true. Skin damage is more likely to occur when a client is in direct sunlight. Sunscreens are recommended in tanning beds, and proper cleaning of tanning beds will help prevent the spread of infection.

A client with diabetes should follow the prescribed dietary plan, which usually includes three meals and one or more prescribed snacks. This meal plan will help to maintain a blood glucose level within normal limits (with the addition of exercise and perhaps oral antidiabetic medication or insulin). Eating six meals per day is likely to lead to excessive calorie intake and hyperglycemia. Drinking orange juice (option 1) and eating an apple and cheese before bedtime (option 2) are acceptable and require no follow-up by the nurse. Buying canned fruit (option 3) should trigger the nurse to question whether it is packed in water, juice, or syrup, but this is the second concern after questioning about the number of meals eaten.

Because the client has had all molars removed and the designated time frame is the third postoperative day, the client should be able to eat a mechanical soft diet, which includes gelatin and applesauce. A soft diet that requires no chewing will be necessary until molars are replaced, and it is especially necessary to use caution until the gumlines have healed. Foods that require more chewing or are rougher in nature, such as toast, bacon, fresh fruit, and cold cereal, should be avoided until further healing has occurred.

High-risk populations are found in specific states, all of which are west of the Mississippi River. Native American and Native Alaskan clients are the cultural populations at highest risk.

A client who is a vegetarian of the vegan type does not eat meat, milk, or egg products. The most appropriate diet, therefore, is the green salad and walnuts, which contains only vegetables and nuts. Option 2 contains meat (sausage), while option 3 contains milk. Option 1 contains canned vegetables and noodles, which may be acceptable in the diet but are also high in sodium. Thus, the fresh salad would be a better choice.

Discharge teaching for clients with diabetes mellitus should include a review of diet and nutrition information (option 1), exercise (option 2), and the need for follow-up medical appointments (option 4). The client with type 1 diabetes will need to take insulin rather than oral agents (option 3) and may be near normal weight or possibly underweight based on disease pathophysiology (option 5).

Cancer, particularly breast and skin cancer, may be linked to DNA tissue type. Clotting disorders such as Factor VIII hemophilia are genetically linked. While pregnancy for women past age 35 or in other at-risk situations warrants genetic screening, all routine pregnancies do not. Hypertension is a prevalent health problem but does not warrant genetic screening and counseling.

Males and females over age 50 should have a baseline colonoscopy, but not annually. If at risk for osteoporosis, or if symptoms present, a bone density test can be done for a baseline, but it is not indicated as a routine annual exam. A prostate screening is recommended annually because of the incidence of prostate enlargement or cancer. Testicular self-exams are performed monthly, not annually, although testicular cancer has higher frequency in late teens and in young adult males.

Bone or joint pain can be serious for the 75-year-old who suffers from osteoarthritis or osteoporosis, as fractures can occur spontaneously. Nodes can indicate infection or cancer. Loneliness after loss of a spouse is normal, but may need the attention of a physician or practitioner if it affects daily living habits (i.e., eating, sleeping, socialization), as depression in the elderly can lead to further physical problems. Dark pigments on forearms are likely normal for this client, as part of the skin changes that occur with aging. Slight fatigue at the end of the day is also expected.

Comments that indicate increased risk of behaviors associated with risk (unprotected sex in option 2 and risk of drug experimentation in option 4) require follow-up teaching by the nurse. Comments that indicate decreased health risks to adolescents, such as those made in option 3 (regarding sex) and option 5 (regarding alcohol), do not pose concerns to the nurse. Neither does the comment in option 1 regarding learning to drive a truck.

The blood testing for screening is likely a complete blood cell count, which identifies the normal cells. Screening is not done to detect all types of hepatitis (option 1), underlying infection (option 3), and diabetes (option 4). These would be tested for according to specific risk.

A routine health screening for a child who is 4 years old would include routine determination of growth and development and would screen for developmental delays, such as with the Denver II screening exam. It may also include a routine urinalysis, but cranial nerve testing is unnecessary.

The most important data collection needed next is what else the client may be taking, as a combination of herbs can cause cardiac dysrhythmias, and she may have mixed prescription medicines with herbs. The family history is important, but not as urgent to explore further. Venous blood would be deoxygenated; the oxygen saturation is an intervention, and the question is focused on data collection.

Yoga, acupuncture, and chiropractic practices are not used in hospital settings, since physicians usually direct the orders for treatments. The client with cancer who has pain may benefit from progressive relaxation, guided imagery, and hypnosis, but any treatment that may stimulate cells, create nausea, or increase vital signs is usually contraindicated during cancer treatments.

The influenza vaccine is administered annually in the autumn, especially during October, November, and into December. The other months do not correlate with administration times that would prevent development of influenza during the winter months.

Meditation is a complementary therapy that is noninvasive and does not require an order. Also, it will not interfere with other physiologically based treatments such as chemotherapy, and it will not exacerbate symptoms such as nausea.

Music and hypnosis can assist with decreasing awareness of unwanted side effects, and may promote healing and circulation. Aromatherapy will likely stimulate nausea and is therefore not recommended. While light massage could relax a client, therapeutic massage will stimulate lymph flow, which may increase cancer cell proliferation. Acupressure also is generally not used, in keeping with the principles that apply to therapeutic massage.

Genetic screening involves obtaining blood samples of parents and children to analyze genetic makeup. Counseling is provided at a follow-up appointment. It is unnecessary to record intake or take prescribed medications. The client does not need to keep a diary during the week that the screening is conducted.

The elderly lose tissue elasticity in the hand, so accurate determination of turgor and hydration cannot occur in this area. Better areas for examination include the skin of the forehead, chest, and abdomen. The other actions are unnecessary (options 1 and 2) or not yet timely (option 4).

Laxatives can alter fluid-and-electrolyte balance. Dry skin is normal with aging. Occasional dribbling of urine is not a normal finding, but is not likely to cause a fluid-and-electrolyte imbalance. Drinking adequate fluids, as in option 4, will aid in maintaining normal fluid balance.

Daily weight-bearing activities reduce reabsorption of calcium from the bones. The other choices do not affect bone structure.

Extra time is needed for teaching and reinforcement of content when an elderly client has sensory deficits, especially visual and hearing deficits. The other care activities described would be carried out as needed by any client.

A Hemovac drain removes fluid from the wound through closed suction. The drain must be compressed and closed to create suction as it slowly reexpands. No treatment change is needed specifically because the client is elderly.

Tetanus strains do not usually change from year to year. As humans age, there is a decline in natural antibodies, a decreased response to antigens, and a reduction in antibody response time. The vaccination will act as a booster to the one administered 5 years ago.

Herpes zoster, or shingles, is an infection that is seen in later life from residual virus retained in the dorsal root ganglia of sensory nerves after a client has had varicella or chickenpox. Usually, shingles occurs whenever the client is immunocompromised. The elderly easily can become immunocompromised. Shingles is not transmitted from a person with chickenpox.

Meningococcal vaccine is indicated for children older than 2 years with asplenia. The vaccine duration is 5 years if the client is older than 4 years at the time of immunization. If the client is younger than 4 at the time of initial immunization, it should be repeated after 1 year.

The client is the only one who can tell you if he is in pain. Confusion and being asleep do not mean that the client is not in pain, or that he shouldn’t receive pain medications. Being medicated three hours earlier does not mean he is pain-free, or that he shouldn’t receive pain medication.

Elderly clients do not present with typical manifestations of infection. Confusion or behavioral changes from hypoxia might be the first signs of pneumonia in the elderly. Sputum rarely is seen unless a sample is obtained through suctioning, as coughing is diminished in the elderly. Tenting of the back of the hand is normal aging, and does not indicate dehydration.

A diminished inflammatory response and muscle age cause the clinical manifestations of fever and cough to be absent in elderly clients with pneumonia. Atypical presentations are the norm.

Elderly clients might have presbycusis, and might not hear sounds like “sw,” “th,” or “m” well. Validation confirms appropriate understanding. Speaking to elderly clients with presbycusis in a low-pitched tone also assists hearing.

Maintenance of independence in all clients is a foundation of nursing practice. Strategies within the environment and adaptive devices can help the elderly maintain their independence if disorders occur.

Gastrointestinal absorption of digoxin is uneven. Many medications interfere with absorption. Digoxin should not be taken if the pulse rate is below 60 beats per minute. Aspirin may be taken with digoxin; however, aspirin should not be combined with anticoagulants.

Most over-the-counter cold remedies contain sympathomimetic medications within the preparation, which will increase blood pressure.

Falls can be one of the first signs of infection in the elderly, and should be investigated to rule out infection, as well as cardiac, neurological, or musculoskeletal disorders. A temperature of 36.5° Celsius is normal in an elderly person. If other signs/symptoms of infection exist, and temperature is normal, this should still be investigated, as the elderly might not present with elevated temperature. Ingestion of aspirin every 2 hours or 8,000 mg of Vitamin C is not safe.

Integrity (instead of despair) is being demonstrated in the statement in option 1. According to Erickson, adults who do not achieve the tasks of middle adulthood will focus on themselves, becoming overly concerned about their own needs. Peck expands on this theory too.

These are physiologic symptoms of aging heart muscles and potential cardiac disease. No chest pain is acceptable. Chest pain should always be 0 out of 10 on a pain rating scale.

Remembering the ABCs, the first priority is always breathing. Once oxygen has been applied, testing blood sugar, summoning help, and having someone call the physician would all be appropriate care measures.

Epinephrine is the priority medication to have on hand if a client should experience hypersensitivity reaction/anaphylaxis following a dose of an immunization. Lidocaine is given for cardiac dysrhythmias, while acetaminophen and ibuprofen are peripheral CNS analgesics.

More data are needed. Nurses collect information and don’t “pass the buck,” as choice 4 allows. Nurses do not diagnose disease but rather the human responses to disease. Clients with Alzheimer’s disease experience patterns of forgetfulness and progressive confusion, and cannot perform daily activities. A client would do more than forget where he or she placed the keys, such as not know what keys are for.

Elderly clients often are confused by new surroundings, and require orientation to units. Not all infections require isolation, and not all elderly clients are incontinent or malnourished. These are individualized responses to disease, not general rules of aging.

Options 1, 2, and 4 correspond to fluid intake. Answer 3 corresponds to fluid volume changes related to sodium and osmosis of fluid from higher to lower concentrations. Option 5 (that older adults dislike water) is not necessarily true.

Both REM and non-REM sleep are critical to physiological and psychological rest. Five to seven hours per night is recommended. The other behaviors are healthy behaviors.

Hand grip strength correlates with strength of other muscles, and therefore is a good indicator of overall strength. The other examinations require additional time or do not correlate well with overall muscle strength.

Ultraviolet light, injury, and viral infections increase the incidence of cataract development. The nurse recommends the use of sunglasses, eye protection, and safety throughout the life span. Vitamin A and eyestrain do not increase the risk of cataract development.

This is the only appropriate choice. Aging eyes require additional light and time to adapt to light to see effectively. Use of the call bell will provide assistance so that falls are prevented. Four side rails are considered a form of restraint, as is chemical sedation.

Older adults need increased fiber, calcium, and Vitamins C and A. They also need to decrease the number of calories taken in. Margarine contains transfatty acids, which have been linked to heart disease and cancer. Canned foods and prepared package foods contain large amounts of sodium, which could adversely affect the cardiovascular, fluid-balance, and elimination systems.

Most elderly clients have a slower rate of drug metabolism and excretion, resulting in more frequent drug toxicities at normal and higher doses. Many prescribed medications are effective at lower dosage levels.

Data collection is the first step in planning care with the client. Data collection will guide how blood glucose monitoring will be done, and by whom. Independence should be fostered; dependence will have a negative effect.

Diphtheria, Tetanus and acellular pertussis (DTaP), <i>Haemophilus influenzae</i> type b (Hib), inactivated polio vaccine (IPV), and the pneumococcal conjugate vaccine (PCV) are the routine immunizations scheduled for the 2-month well-child visit. The MMR is given first at 12 to 15 months, and the varicella can be given at 12 months or anytime thereafter.

Following cataract surgery, the client should not do anything that will increase intraocular pressure. Bending at the waist will increase the pressure; sleeping on the opposite side of surgery and nonvigorous care of nasal congestion will not. The physician should be notified of increased pain and fever, as intervention might be required.

Appropriate use of our health care system allows needs to be met. Many clients might require direct care, or reinforcement of learning and application, in the home environment. Keeping clients in the hospital when home care is available is not an appropriate use of resources; neither is asking the pharmacist to call the client at home to take medicine. Asking daughters, sons, or significant others to rearrange their lives might not be the first choice if home care is available and chosen by the client.

Risk factors for osteoporosis include being female; being amenorrheal with a BMI under 24; being postmenopausal; being older; a diet low in calcium and Vitamin D; excessive alcohol intake; being sedentary; smoking cigarettes; being obese or too thin; and using medications such as steroids, anticonvulsants, or loop diuretics on a long-term basis.

Asking the client to describe feelings seeks additional information and indicates to the client that the nurse is attentive. Asking “why” questions may force the client to defend himself or herself by indicating there must be a reason for these feelings. Stating the client looks nervous may be interpreted as nonsupportive. Providing a back rub does not allow the client to express feelings.

Asking what has been done before focuses the client on solving his or her own problems and helps the nurse determine the client’s coping mechanisms. The other options, although empathetic, may block the communication process.

During the introductory phase of communication the nurse and client identify goals and objectives. Nurses should not offer advice when establishing a therapeutic relationship with a client. Preparing for a client interview is the preinterview phase of communication.

Clients are more likely to successfully complete a new procedure if they can actively demonstrate the procedure immediately after instructions have been given with the nurse present the first several times. A video or written literature does not allow for active participation; however, they can be used as supplementary learning aids.

Learning is more likely to take place when the client’s perceived needs are met. The nursing data collection identifies areas for client teaching and the client’s ability to learn. The amount of time needed to implement a teaching plan is not associated with establishing priorities.

Description of the client’s self-care abilities provides data to the referral nurse about information needed to continue the client’s care. Vital sign information is only one parameter and does not provide enough information about the client’s overall status. Medication last administered does not identify all of the medications the client is currently taking. The surgical report does not have direct relevance to the client’s home care needs.

All information in the client’s record is confidential and access to the record is restricted unless the client has given permission for release. The other responses do not directly advocate for the client’s right to confidentiality.

Subcutaneous emphysema or crepitus is caused by pneumothorax. This condition consists of air introduced into the tissue from another condition, such as pneumothorax. Pneumocystis pneumonia is an opportunistic infection often experienced by individuals who are HIV-positive; hemothorax refers to blood in the chest, and hemodilution is associated with fluid overload of the vascular system.

A client who has not urinated following catheter removal would require nursing intervention, specifically an examination of the client for abdominal distention, reviewing intake and output records, and possibly calling the physician for an order to do a straight catheterization. The second priority would be the client who has incisional pain; however, since the client is 3 days postoperative, this is not as urgent a problem as option 1. The information contained in options 2 and 4 poses no threats to the health status of those clients.

Answers 1, 2, and 3 are judgmental and have no information to support the conclusions reached by the nurse documenting these notes. Only option 4 supports the statement made.

Recording the time of the entry, the time of the data collection, and the missing data is an acceptable documentation practice. Inserting information in the client record is not an appropriate documentation action. Clients’ records should not be recopied. Verbally reporting the omission solely is not acceptable.

The nurse should validate his or her perceptions with the client to ensure the correct interpretation of the client’s nonverbal behavior. Option 3 is inaccurate. The nurse should not make false assumptions (option 1) and should not ignore the client’s behavior (option 4).

Exploring the client’s feelings indicates that the client’s feelings are important to the nurse. Providing reassurance to the client may dismiss the client’s feelings as unimportant. Providing information to a client at this time is inappropriate because it may not be assimilated because of anxiety. Relating a personal experience focuses the attention on the nurse, rather than the client.

For a client who is hearing impaired, speaking slowly in a low-pitched voice and facing the client will promote understanding of the message sent. Option 4 will not provide enough information to effectively care for the client. Options 1 and 2 may be appropriate if the client cannot hear at all.

Documentation needs to be accurate and complete and should not express the opinions or judgment of the nurse. The other options are unclear, judgmental, and/or represent the nurse’s interpretation of data.

Before a client is able to learn a new skill he or she must be able to perform the skill. In this case if the client doesn’t have the dexterity to palpate a pulse or ability to see a clock’s second hand, the client will need assistance with the skill. Options 1 and 2 are unnecessary for the nurse prior to implementing the teaching plan. Motivation to learn is also important, but the nurse must first evaluate the client’s ability to perform the skill.

Having the client actively demonstrate the procedure is the best way for the nurse to evaluate the client’s level of skill. The other options are less effective ways for the nurse to evaluate the client’s learning of the new skill.

Learning in the cognitive domain involves the acquisition and use of knowledge mentally or intellectually. Option 3 involves learning in the affective domain, which involves changing feelings and values toward a positive health behavior. Options 2 and 4 involve learning in the psychomotor domain.

The correct abbreviation for pupils that are equal, round, and responsive to light and accommodation is PERRLA. The other options represent incorrect abbreviations. It is important for nurses to document using agency-approved abbreviations to avoid misinterpretations and to enhance communication among caregivers.

The Kardex should supply the information to provide nursing care to the clients assigned. The other options are not good indicators of client care needs.

Physical data and client response to care are pieces of information that are most important in ensuring that the client’s health care needs are being met. The other options are useful to a nurse assuming care of a client, but are more limited in the scope of information they provide (options 3 and 4) or are not as relevant to the client’s status in real time (option 2).

Charting by exception is a form of documentation where notations are made if there is an exception to the rule. All other options are normal and are therefore not necessary to include in documentation using this format.

When teaching a skill to a client, the means of evaluation is observing the client perform the skill to determine if the teaching/learning goal has been reached. This action represents the evaluation phase of the nursing process.

Return demonstrating is an activity that actively involves the client and increases learner retention. The other options involve visual (options 1 and 2) and auditory (option 3) learning, but do not engage the client as fully as when the client participates.

The client is more likely to accept a plan consistent with the client’s value system. If not, the plan may be more difficult for a client to accept, and the nurse may need to modify it later based on the data.

Learning in the affective domain involves emotions, feelings, and attitudes. Learning in the cognitive domain (option 2) involves processing information by listening or reading facts. Learning in the psychomotor domain (option 3) involves learning by doing. Option 4 is a prior condition needed for the most effective learning to take place.

The client will be less anxious about his/her intimate space being invaded if the client knows the reason why and how it relates to health care. Ignoring the client’s discomfort sends the message that the client’s feelings are not important. Acknowledging the client’s discomfort may be beneficial but is not the best option. Deferring the examination is not appropriate nursing practice.

Providing positive reinforcement is likely to increase the client's continued use of positive health behaviors. Option 2 is vaguer than option 1. Options 3 and 4 do not promote the client's healthy behavior.

Nonverbal behavior should be consistent with verbal communication to ensure the message sent is the message received. The other options are not components of the communication process.

The Romberg test is done when the nurse asks the client to stand with eyes closed and feet together. There should be minimal swaying for up to 20 seconds. A positive Babinski test in adults indicates upper motor neuron disease of the pyramidal tract. The Glasgow coma scale checks the client’s level of consciousness. The abdominal reflex, if absent, may indicate a disease of the upper and lower motor neurons.

Documentation is the means to communicate clients’ health care needs to all members of the health care team, and is the most important to ensure continuity of care. Reporting to another nurse (including list of activities still to be done) also needs to be done. Telling clients he or she is leaving is appropriate, but it is not the most important item to ensure continuity of care. Not all clients may require side rails.

The proper way to correct an error is to draw a line through the information, write the word “error,” and initial above it. All other ways listed are incorrect because they violate guidelines for legally defensible charting.

Abbreviations used in documentation need to be consistent with facility policies for documentation. The client’s record is a permanent document that must be consistent with professional and legal standards, which include agency/facility policy.

Many Native Americans have been taught to live in the present and not be concerned with the future. Because they tend to be present-oriented, they might not adhere to laboratory monitoring and follow-up appointments for medication therapy. While it would also be important for the nurse to explore the individual’s financial resources and dietary intake practices, these factors would not be as critical as evaluating whether the client would adhere to follow-up appointments. Because warfarin requires ongoing monitoring to prevent excessive bleeding, the highest priority would be for the nurse to verify that laboratory follow-up appointments would occur. If the client is unable or unwilling to adhere to the monitoring schedule, the nurse should contact the physician for alternative anticoagulant therapy.

Chinese-Americans can be erroneously perceived as being extremely shy or withdrawn. Chinese-Americans might view tasks associated with increased eye contact as impolite and offensive. The nurse should provide explanations when performing tasks, while understanding that Chinese-Americans might feel uncomfortable with face-to-face arrangements.

Collaborating with the client and family to reinforce the importance of keeping the scheduled appointment offers the most realistic intervention for promoting timely arrival for appointments. Unless the lateness is associated with forgetfulness (and this information is not in the question), it is unlikely that providing a client with a reminder call or an appointment card will facilitate timely arrival. Providing the client with a block of time in which to arrive might be convenient for the client; however, it is unlikely that the health care provider’s schedule can accommodate such flexibility.

When providing culturally competent care, it is essential as a first step for the nurse to be aware of personal biases. While appreciation of, sensitivity toward, and acceptance of diverse cultures is desired, these will not be accomplished until the nurse first considers his or her own biases.

Involving the client in the establishment of dosage times is an appropriate nursing intervention. By initiating the client’s desired administration schedule during hospitalization, the client will be able to maintain the same schedule upon discharge. While the client can alter the medication schedule following discharge, the nurse should attempt to integrate the desired time parameters during the inpatient stay as well.

By collaborating with the client and family, the nurse can best identify the expectations of nursing services. While performing a literature search and consulting with an individual of Chinese heritage may be helpful, such interventions might not promote the timely meeting of the client’s needs. Recommending the reassignment of the client to another nurse is not necessary, particularly for the nurse who is interested in learning more about the client’s unique cultural background. Further, it is essential for the nurse to understand that as much diversity exists within cultural groups as exists between cultural groups.

Cancer is a disease associated with excessive yin forces. Diseases with yin forces are treated with foods with yang qualities. Yin is associated with cold, while yang is associated with warmth. Yang foods, such as fried foods and spicy foods, are associated with warmth, whereas green vegetables and cold foods are associated with cold.

A weak, thready pulse is one that is difficult to palpate and easily diminished by slight pressure. A 2+ pulse indicates one that is easily palpable and normal. A forceful pulse and a pulsation felt with pressure from the index finger may be labeled as “full” or “bounding.”

Select Asian cultures believe in reincarnation. According to these cultural beliefs, an autopsy cannot be performed, as it is necessary to keep the body intact for its next life. While many cultures associate health status as being a gift from God, this premise is not necessarily associated with declining an autopsy. The risk of disfigurement and the potential for disease release are not associated with Asian cultures.

<i>Empacho</i> is a culture-bound syndrome associated with Latino culture. <i>Empacho</i> occurs when food forms into a ball and clings to the stomach or intestines, resulting in pain or cramping. Hysteria is a Greek culture-bound syndrome associated with the belief that the uterus has left the pelvis for another part of the body. <i>Mal ojo</i>, or the evil eye, is a Latino culture-bound syndrome believed to be caused by an individual excessively admiring a child. Bulimia is a white culture-bound syndrome associated with overeating followed by vomiting.

When bathing a client, it is essential for the nurse to remember that the washcloth removes some of the outermost skin layer. Sloughed skin will appear on the washcloth, with the color depending on the ethnic group of the client being bathed. Therefore, such findings do not suggest improper bathing technique, neglect, infection, or incontinence.

Pregnancy is considered a hot state, with the delivery of an infant resulting in a loss of heat. Thus, the postpartum phase focuses on the restoration of warmth. Cold packs and sitz baths are likely to be avoided. Heat packs and warming blankets are more appropriate for the restoration of warmth in this client population.

Fallen fontanel, a Mexican-American culture-bound syndrome, is associated with options 1, 2, and 4, but is not associated with slow removal of the nipple after feeding. Rather, it is associated with abrupt removal of the nipple during feeding.

Following exposure to salicylates or other potentially injurious agents, the plasma membranes of erythrocytes become damaged, leading to hemolytic anemia. Chronic renal failure would not be a clinical manifestation of G6PD deficiency. Hemophilia A is caused by a deficiency of factor VII. Thalassemias are inherited autosomal recessive disorders that lead to an impaired rate of synthesizing of the alpha or beta chains of adult hemoglobin.

<i>Susto</i> is thought to be the result of a frightening experience or event that leads to the temporary loss of the spirit from one’s body. <i>Susto</i> is thought to be associated with childhood epilepsy. <i>Brujos</i> or <i>brujas</i> (witches) are not associated with the presenting symptoms. <i>Mal ojo</i>, the evil eye, is thought to be the result of someone excessively admiring a child. <i>Caida de la mollera</i>, fallen fontanel, does not present with the identified symptoms.

Because succinylcholine is a muscle relaxant, the absence of the enzyme that inactivates the medication can lead to an exaggerated or prolonged response to the medication. Therefore, monitoring the client for prolonged muscle paralysis would be a priority for the nurse. While an allergic reaction is possible, it is not associated with Asian clients. Because the response might exceed the desired effect, it is not likely that the medication will fail to induce muscle relaxation. Seizure-like activity also is not associated with Asian clients’ receiving the medication.

Keloids are more common in African-Americans than in other racial groups. Presenting as ropelike scars, keloids represent an exaggeration of the healing process.

During the 28-day period of Ramadan, Islamic adults refrain from food and drink from dawn until sunset. Regardless of their content, meals are not accepted during the daylight. Total parenteral nutrition would not be indicated for all clients who are fasting. While the physician should be made aware that oral medications may not be taken until night hours, it would not be correct to identify the client as having no oral intake.

The nurse seeks to identify the intensity of the pain by asking the client to rate the pain on a scale of 1 to 10, with 1 indicating a slight nagging pain and 10 indicating an excruciating pain. Some of the other components of the examination would include the location (option 1), duration (option 4), and methods that the client has used to control the pain (also called alleviating factors, option 3).

Hypertensive African-American clients tend to respond best to single-agent therapy rather than combination therapy. Beta blockers and ACE inhibitors tend to be less effective, while calcium antagonists and alpha blockers are considered to be the most optimal agents. It has been suggested that thiazide diuretics place the African-American client at risk for signs and symptoms of depression.

Vitiligo is a condition in which melanocytes become nonfunctional. The skin presents with unpigmented patches. The other options do not reflect correct information.

Smiling and nodding one’s head does not necessarily indicate that the Chinese-American client is agreeing with the nurse’s statements. This form of nonverbal communication is culturally acceptable behavior.

Ethnocentrism is the belief that one’s traditions or culture is superior to that of another cultural group. Identifying another cultural group as a minority has been suggested as an ethnocentric statement in itself. Cultural imposition is the process of imposing one’s cultural beliefs on another individual. Acculturation is the process of integrating into the mainstream culture. Culture-universal nursing care refers to commonly shared values and lifestyles that are similarly held among cultures.

Mexican-American culture is associated with placing a high value on extended family relationships. In addition, Mexican-American culture is associated with being patriarchal (machismo), as well as having respect for authority. Mexican-American culture does not value independence and autonomy. Rather, interdependence is valued.

Cupping occurs when a vacuum is created inside a cup by igniting cotton soaked in alcohol sitting within the cup. When the flame is extinguished, the cup is placed onto the skin at the painful site. The cup remains in place until the suction is released. The symmetrical burns would not be associated with abuse or cigarette burns. Coining occurs when the edge of a coin is rubbed over a painful area.

Anorexia nervosa is associated with Western culture, where food is prevalent. Trance dissociation, <i>susto</i>, and the evil eye are not associated with Western culture.

Beef, eggs, and fried foods are considered warm foods, and as such, would be a treatment for yin (cold) conditions. Honey and broccoli are considered cold foods, and would not be consumed with a cold condition.

Anglo-American culture values materialism (such as money), youth, and beauty. Competition is valued over harmony. Independence is valued over interdependence.

Chinese-American clients might elect to be stoic in pain management, and might not readily accept pain medication. However, it is necessary for the nurse to continue to monitor the pain status of the client, as well as offer pain medication as needed. Biological differences or the potential for dependency would not be factors in the monitoring for or treatment of pain. By waiting for the client to ring for pain medication, the nurse might miss valuable information on the client’s pain status.

The Rinne test involves the examiner using a tuning fork to compare air conduction to bone conduction related to transmission of sound. Mobility, thought processes, and swallowing are not tested with this examination.

Kawasaki disease is observed primarily in children of Japanese descent. The other cultural groups identified are incorrect.

The dominant value orientation of the United States promotes independence and hard work. Youth and beauty also are valued, as well as planning for a more productive, fulfilling future.

African-American culture typically values extended family, religion, and interdependence. Long-term goals and seclusion are not typically associated with African-American culture.

Since the client has experienced both injury and surgery to the body, changes in body image should be anticipated (option 3). Having experienced an accident, this client is now in a situation (acute illness and hospitalization) that is expected to limit the client’s personal autonomy (option 4). There is inadequate information to suggest that changes in verbal communication ability (option 1), cognitive patterns (option 2), or family relationships (option 5) may occur.

The client shows a personal commitment to health and health-seeking behaviors and a willingness to participate actively in the treatment plan. This reflects a strong internal locus of control. The other options reflect an external locus of control. In option 1, the client is blaming others. In options 3 and 4, the client expects that efforts of others will restore wellness.

Many people with cardiovascular disease show Type A personality behaviors, consisting of anger, hostility, a sense of urgency, becoming easily frustrated, and having workaholic-type behaviors. These characteristics may play a significant part in the etiology of cardiovascular problems, and when present, they can complicate treatment and recovery. Option 1 is incorrect because it is more common for people with Type A personalities and/or cardiovascular disease to be controlling of others. Option 3 is incorrect because the nature of social encounters, rather than the frequency, is more significant in determining the individual’s behavior. Option 4 is incorrect because feelings of urgency and frustration will not necessarily decline when the person is alone.

The behaviors described in this situation are characteristic of clients with dementia, which is a possible late consequence of AIDS. The nurse should understand that the occurrence of symptoms indicates progression of the AIDS illness and that care should be planned accordingly. Option 1 is incorrect because an individual can live with dementia for some time before death occurs, either from AIDS or another cause. Option 2 is incorrect because the situation describes behaviors that are characteristic of the chronic progressive decline that is seen in persons with dementia. Option 4 is incorrect because the particular pattern of behaviors that is described is not particularly associated with the side effect profile of drugs used to control AIDS.

Anger is included in the stages of mourning, as clients grieve for what has been lost. Although clients may experience multiple emotional feelings in response to the diagnosis of a life-changing medical illness, anger is one of the most common ones because of the sudden and often dramatic change in lifestyle. Anorexia (option 2) and apathy (option 3) might occur but are not considered stages of grief and mourning. Euphoria (option 4) is not a common manifestation of grieving, but if it is seen, it is probable that the loss precipitated a period of elevated affect associated with bipolar disorder.

Since a developmental task of adolescence is dealing with one’s emerging social and sexual urges and needs, the appearance of the body assumes great importance. When the body is unattractive to the self and/or others (as in situations of debilitating medical illness or significant changes in body weight), issues surrounding sexuality and identity are common. It is common for adolescents to have relationship difficulties with parents (option 1), but this is considered a normal part of adolescence. In this client’s situation, present (option 3) and future (option 4) educational plans and activities are not as likely to be directly impacted as is sexuality.

This client is at risk for developing a crisis response (options 1 and 2). If balancing factors (social support and using familiar coping techniques) are present, a crisis will not be as likely to occur. If the individual can cope using socially appropriate rituals (option 4), a crisis response will not be as likely to occur. Persons of all socioeconomic and educational levels can be overwhelmed with life situations and develop a crisis response (option 3). No one is exempt from the possibility of developing a crisis response. The client’s response to a situation is not always parallel with the severity of the actual problem (option 5). Instead, it is parallel with the client’s perception of the problem.

As the nurse performs the health examination and focuses on various systems, time can be spent reinforcing education for the client about achieving and maintaining wellness. The nurse should have a professional, caring approach and avoid in-depth focus on pathology. The focus of routine examinations is not to explore client–family relationships.

Eating disorders are a manifestation of problems in living and difficulty dealing with emotions and stress. Eating disorders are not about eating per se, but rather about making unhealthy attempts to control emotions and manage stress. The nurse should avoid focusing on food and food-related topics with this client (option 1). If this client has bulimia, food is being used to express underlying issues and conflicts. Clients with eating disorders do not typically have declines in academic performance (option 2). In fact, many of them are compulsive overachievers who may be seen as model students. Clients with bulimia may not lose weight and may even be at or near ideal body weight (option 4).

It is likely that increased social connectivity (option 1) would result in increased social support, since the other persons in the group would also be dealing with grief issues. The work of grieving is best accomplished in a compassionate and supportive emotional environment. Grief support groups are aimed at helping a person to recognize, express, and cope with strong emotions (option 3), not eliminate them (option 2). It is normal for a grieving person to feel intense emotions. Feelings of loss are normal in grief responses (option 4). Grief groups acknowledge this and support healthy expression of these feelings, which must be fully expressed and dealt with so the person can progress healthily through all stages of grieving. Grief counseling does not focus on the deceased (option 5), but rather on the survivor and the survivor’s coping.

Option 1, adaptive, indicates that the client is able to mobilize internal/external resources to cope with the chronic illness and its effects. Maladaptive (option 2) relates to a response that is negative in nature. This client’s response will reduce the stress response, not increase it (option 3). This client’s response shows realism and adaptation to the stress being experienced, not hopelessness (option 4).

The client understands the disruption of the accident and that feeling down might be expected, but the client is able to differentiate between mild and more severe depressive symptoms, such as anhedonia and having trouble sleeping and eating. The client does not understand that depression may be experienced somatically (options 2 and 3). The client does not recognize that being inactive and remaining in bed (option 4) could be a symptom of depression, nor does the client recognize that physical inactivity may increase the intensity of depression.

The client has verbalized that there is a relationship between the disease and stress and is learning how to deal with the stress. Options 1 and 3 indicate no understanding of the relationship between stress and gastrointestinal symptoms being experienced. Option 4 indicates blaming, rather than awareness of the relationship between stress and gastrointestinal symptoms.

Option 4 is correct because it indicates interest and concern about the client and facilitates open communication. Options 1, 2, and 3 indicate that the nurse wants distance from the client.

Option 3 is correct because it indicates knowledge related to how personality types impact cardiac illness. Options 1 and 2 do not have anything to do with understanding stress and cardiac disease. Option 4 is not a beneficial way to decrease tension.

Persons with debilitating illness are at high risk for suicide. When suicidal ideation is present, the nurse should gather other data, including whether there is a specific plan for suicide and a means for carrying out the suicidal act. The areas in options 2, 3, and 4 should be determined, but they do not have priority over determining if a suicide plan has been developed and the level of lethality. These last two factors would represent the most severe and dangerous response to physical illness and disability.

Option 2 describes the normal response that a person engages in when threatened in any way, such as with pain. Options 3 and 4 are inappropriate responses of coping with pain. Option 1 is not an option related to the psychological nature of pain.

Option 4 indicates that the client is a part of his or her own care and supports interdependence. Option 1 does not promote feelings of independence. Option 2 could lead to client isolation, while option 3 would place undue pressure on the client to feel that he or she should be doing things by him- or herself.

The information extrapolated from the health history should be documented in the client’s medical record in a timely manner. If the nurse does not write the information down, the data could be forgotten or omitted from the record. The nurse should not wait until the client has left the area to document information unless there is an emergency. Standard abbreviations should be used in the chart. Asking the client to review the documentation is not required.

If the client is not receiving adequate sleep or nutrition, heightened symptoms of illness and psychological distress will occur. Sleep and nutrition are basic physiologic needs (options 1 and 2). If the client’s anxiety level is significantly elevated, the client will not be able to focus on important information about the plan of care. Additionally, heightened anxiety will create physiologic stress responses that can intensify prior existing medical illness and complicate recovery (option 3). The nurse does not typically evaluate the financial status of clients, as this is the responsibility of the social worker (option 4). Talking about aftercare plans is not appropriate when the nurse is establishing an initial plan of care (option 5). This discussion should take place later.

Option 3 conveys the information that the ill person and the family all share responsibility for decision making. It further suggests that each person, including the client, should have an awareness of his or her capacities and limitations and ask for assistance as necessary. Option 1 conveys useful information, but the information relates to preventing caregiver role strain, rather than promoting interdependence. Option 2 conveys useful information and indicates that the family should be a team, but it does not suggest a specific route to productive interdependence for the family. Option 4 suggests restricting the client’s independence and removing the client from the family team.

The existence of comorbidities is more prevalent in individuals in lower socioeconomic levels. Research indicates that a lower socioeconomic level does lead to a higher number of illnesses in these clients. No research indicates a specific correlation between socioeconomic level and increased grief (option 1), increased pain (option 2), or use of defense mechanisms (options 3).

The exact role of psychologic factors in inflammatory bowel disease is unclear, but stressful life events, such as separations, failures, and disappointments seem to interact with autoimmune factors and infections to bring about symptoms. There was a time that much emphasis was given to compulsive personality traits as a causative factor, but recent research suggests that dependent personality traits and problems in living may be more significant. Option 1 is incorrect as inflammatory bowel disease is not thought to be caused from dietary indiscretions. Although, when inflammatory lesions are present, the physical or chemical properties of certain foods may be further irritating to the bowel. Option 3 is incorrect because impatience and competitiveness are sometimes seen in persons with inflammatory bowel disease, but recent research suggests that dependent personality traits and problems in living may be more significant. Option 4 is incorrect as projection of emotions is not present in inflammatory bowel disease. It is possible, though, that the client is using the defense mechanisms of interjection and/or conversion.

Pessimism is a trait that can create an increased likelihood of medical illness. It indicates the deficiencies or the absence of self-efficacy, hardiness, resilience, and resourcefulness, all of which are considered to be positive traits that will lead to improved health and coping. Pessimism is a trait that diminishes an individual’s capacity for self-healing. Option 2 is incorrect as the capacity for self-healing has a positive impact on outcome of illness. Option 3 is incorrect because humor can have a positive impact on the outcomes of illness. It can enhance the therapeutic effect of a variety of treatments from the traditional medical model. Option 4 is incorrect as energetic actions are useful in promoting relaxation, fitness, and improved coping. Pessimism leads to apathy, uninvolvement, and diminished energy.

Option 4 is correct. It indicates that the client is attempting to cope or deal with the situation by making lifestyle changes. Option 1 is incorrect as the statement indicates that the client is coping with anxiety, but that the anxiety level is escalating. Options 2 and 3 are incorrect because these behaviors are not demonstrated in the scenario. However, the client’s changing of preexisting behaviors could lead to reduced anxiety and anger, as well as increased hopefulness.

Option 3 is correct because the client described stressful circumstances that existed prior to the accident. Options 1, 2, and 4 are incorrect because as this situation is described, there is no data to support these options.

Option 1 indicates that the client is feeling overwhelmed by the enormity of the diagnosis and does not know how to manage this clear and obvious threat. As in other crisis responses, the client is expected to be able to reestablish equilibrium, but during the crisis the priority of the nurse is to provide safety and assist with coping responses. Option 2 is incorrect as dissociative coping responses occur when the individual is facing an intensely stressful situation and parts of the personality split apart from other segments of the personality, which may lead to experiences as depersonalization, dissociative amnesia, or multiple personalities. Option 3 is incorrect because when individuals are self-destructive, their level of anxiety is very high and can be the precipitant that causes them to carry out a self-destructive act. However, nothing in the situation directly describes anxiety. Option 4 is incorrect as nothing in the situation describes dependent personality traits, which are characterized by feeling helpless and having difficulty making everyday decisions.

Option 4 is correct. Sleep disruptions can take a number of forms, including hypersomnolence and impaired sleep efficiency. Options 1 and 2 are incorrect because in order to reach the conclusion that the client has physical or emotional problems, the nurse would require more data. Option 3 is incorrect as this is a nonsensical answer. Don’t give it a second glance.

Support systems can provide emotional sustenance that can help reduce stress, diminish feelings of isolation, and positively influence the ability to cope and adapt. Self-efficacy is the belief that personal abilities and efforts affect the events in our lives. Having a sense of control allows an individual to believe that personal behavior can make a difference. Accordingly, this client is most likely to take action and cope more effectively. Option 2 is incorrect as a specific anatomical understanding is not necessarily imperative for the person to adapt to the diagnosis. Options 3 and 4 are incorrect because, while these options might contribute to the response, options 1 and 5 clearly have an impact on a person’s ability to cope with situations.

Infants should always be put to sleep on the back. Options 1, 3, and 4 are correct statements related to infant care and therefore pose no risk to the infant and no concern to the nurse.

Inspection of a client can offer many clues about the overall state of health and can include all data gathered through the senses. The nurse should compare each side of the body for symmetry prior to inspecting the next system (option 2). Equipment such as a tongue blade, otoscope, or tape measure can be used during inspection but does not necessarily need to be prepared ahead of time (option 3). The time required depends on the client’s condition and the nurse’s skill level (option 4).

The symptoms are indicative of a possible anxiety-related response. Other indicators could be tremulous voice, jerky body movements, and dilated pupils. Options 1 and 4 are incorrect as it is premature to take such definitive action without collecting more data. Option 3 is incorrect because further monitoring is needed, and the client’s safety needs should be attended, but a basic determination of anxiety level is more appropriate at this time.

Hypertension has a strong psychophysiologic component and is highly correlated with increased stress levels. Options 1, 2, and 4 are incorrect as these options address psychodynamic factors that may have an impact on emotions, which affects biochemical functioning such as blood pressure. However, there is a stronger and more direct link between hypertension and poorly managed stress.

Most clients diagnosed with HIV/AIDS experience anxiety disorders at some time during the course of their illness. Confirmation of the diagnosis can be catastrophic for the individual and will elicit a cascade of emotional and social reactions including feelings of isolation and stigmatization. These feelings are usually heightened as there is the sense of anxiety about how people will respond to the person and the new diagnosis. Options 1, 3, and 4 are incorrect because, although they may be concerns of the client, they are not usually the ones of primary concern at the time immediately following diagnosis.

This option is measurable, and the others are not. Statements of client outcomes should be written in specific measurable terms so that any nurse could determine outcome achievement or lack of achievement. This option indicates that a specific numerical comparison can be made. Options 1, 3, and 4 are incorrect. Each of them indicates the nurse’s intention to bring about a change in the client’s status, but not one of them is measurable. How does one measure “more” or “increase” without a standard of comparison?

At age 5, children do not understand the finality of death, but rather consider it a temporary state. Options 1 and 2 are incorrect as these responses would be those of older children. Option 3 is incorrect because 5-year-olds do not understand the irrevocability of death.

Erickson’s theory places emphasis on peers and the culture and environment. Emphasis is given to attempts of the adolescent to incorporate beliefs and values of the culture. Option 1 is incorrect as adolescents struggle and strive to become independent of the family. Option 2 is incorrect because Erickson’s theory places emphasis on peers and the culture and environment, with the family being a sociocultural unit in the environment. Option 4 is incorrect as the adolescent is in Erickson’s stage of identity versus role confusion.

Displacement is the transfer of emotional reactions from one object or person to another object or person. Like other defense mechanisms of the ego, displacement is an unconsciously determined behavior that attempts to reduce anxiety. Reaction formation is a mechanism that causes a person to act exactly opposite to the way he or she feels. Projection is a process in which blame is attached to others or the environment. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them.

It is average and expected for a 7-year-old to be anxious and fearful when admitted to a hospital. One of the ways that the client can reduce the anxiety is to use unconsciously motivated defense mechanisms of the ego. Reaction formation is a mechanism that causes a person to act exactly opposite to the way he or she feels. Regression is resorting to an earlier, more comfortable level of function. Repression is the unconscious mechanism by which threatening thoughts, feelings, and desires are kept from becoming conscious. Rationalization is the justification of certain behaviors by faulty logic and ascription of motives that are socially acceptable.

A client who is receiving Ritalin is at risk for delayed growth and development. This is one of the most adverse effects that may occur if Ritalin (or most other stimulants) is administered to children over a long period of time. The child should be weighed 2-3 times per week, and weight loss should be reported promptly to the doctor or other prescribing health care team member. Dental care, although important for child health, is nonspecific to therapy with Ritalin. Drying of membranes is a bothersome, but manageable, side effect of Ritalin. Like other children, children taking Ritalin have specific physiologic needs for milk. However, there is no reason to decrease or increase milk intake in clients taking Ritalin. Instead, intake of caffeine should be restricted.

According to Erikson’s stages of development, a 10-year-old is experiencing industry versus inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other developmental levels.

Percussion is a method of touching and tapping that the nurse uses to determine areas of density. The notes of percussion differ in various regions of the body. The thorax and abdomen are usually examined. Percussion can detect numbness, pain, or abnormal masses.

Children and adolescents with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD, which are part of the spectrum disorders of childhood. The adolescent client with bipolar disorder is likely to experience multiple and extreme mood swings in the course of a day. The adolescent client with bipolar disorder does have inflated self-esteem, but this is not as evident as in the adult with bipolar disorder. Instead, the adolescent client is much more likely to be irritable and socially aggressive and to experience multiple mood swings in the course of the day. The adolescent client with bipolar disorder does tend to manage money poorly, but this is not as evident as in the adult with bipolar disorder.

This child is demonstrating inability to think abstractly. Rather than being alarmed by this, the nurse should recognize it as normal growth and development. Eight-year-olds cannot be expected to think abstractly. In Piaget’s theory, abstract thinking develops during the formal operational phase (12 years to adult). Children between 7 and 12 are in Piaget’s concrete operational phase and cannot think abstractly, although they can pretend. Option 1 is incorrect because, while Piaget’s theory does focus on cognitive styles, and this option contains the term “cognition,” Piaget’s theory does not address impaired cognition. Impaired cognition is abnormal. Piaget’s theory deals with normal growth and development. Option 3 is incorrect as this client is not able to think abstractly. In Piaget’s theory, ability to reason abstractly is a function of formal operational thinking that begins at approximately 12 years of age and extends into adulthood. Option 4 is incorrect because Piaget’s theory does not use the term “illogical thought processes” to describe any period of normal growth and development.

Children at 10 years of age are egocentric and concerned with themselves. Focusing on behavioral symptoms could lead to an adversarial relationship. Children often are uncomfortable talking about friends and family until they get to know a person better. Most children are unconcerned about past medical problems; they are focused on the here and now.

In Piaget’s concept of preoperational thinking, the child can use symbols to represent objects and has the ability to pretend. The child does not think logically. Sullivan describes dynamisms (option 1) as habits that highlight personality traits. Freud’s theory regarding defense mechanisms of the ego (option 3) is that they are unconsciously motivated ways of dealing with anxiety. According to Erickson’s theory (option 4), these developmental tasks are appropriate to middle childhood (6-11 years).

Children with autistic disorders are highly indifferent to shows of affection by anyone and do not relate well with others. Autistic children’s play is generally ritualistic and repetitive, rather than creative and imaginative (option 1) and involves inanimate objects rather than people. Rather than having early speech development, many autistic children have delayed development of language and mental retardation (option 2). Children with autistic disorders are not overly affectionate (option 4). They instead are remote and uninvolved emotionally, usually resisting shows of affection by the parents.

The primary focus of treating anxiety disorders in children is to decrease fear and anxiety. The most useful techniques for reducing phobias and the anxiety and fear associated with them are desensitization, reciprocal inhibition, and cognitive restructuring. These techniques can be used with any age group. Having the child face his or her fear (option 1) is often unrealistic because of the developmental level of the child. Children are easily overwhelmed when forced to face fears directly. The primary focus of treating anxiety disorders in children is to decrease fear and anxiety. Decreasing the fear, not protecting from fear, is the aim of treatment (option 3). Allowing the child to express his or her fears may be useful (option 4) but does not necessarily lead to decreased anxiety or fears.

The correct ranking is 1) Accidents, 2) AIDS, 3) Homicides, 4) Suicide. For people 15–24 years of age, suicide is the third leading cause of deaths, behind accidents and homicide. More U.S. teenagers and young adults die from suicide each year than from heart disease, cancer, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease <i>combined</i>. Because of their lack of maturation and the developmental issues they face, many adolescents have a fatalistic perspective of the future and view suicide as the only option to manage their pain or problems.

Anorexia nervosa occurs more often in young girls who perceive themselves to be grossly overweight. Anorexia nervosa and other eating disorders are considered to be manifestations of underlying psychological issues, such as control, power, and denied sexuality. If untreated or inadequately treated, complications of anorexia nervosa can lead to death. Anorexia occurs most often in young girls, but increasing numbers of boys and adult women and men are affected as well (option 1). Depression often coexists with anorexia, and antidepressants are often given to the client who is anorexic. Anorexia nervosa occurs more often in girls whose families are perfectionistic and rigid (option 3). If they develop an eating disorder, girls whose families are more chaotic and impulsive tend to have bulimia nervosa. Anorexia nervosa is not seen exclusively in young boys and girls (option 4). Increasing numbers of adult males and females are developing this problem.

Binging (excessive overeating) and purging (intentionally ridding one’s body of food ingested) are characteristics of bulimia nervosa. These behaviors represent unhealthy attempts to cope and increase in frequency as anxiety increases. At the beginning of a bingeing episode, the client loses all self-control and ingests enormous quantities of food in a short period of time. The purging activity temporarily—and falsely—restores the sense of control. Rigid control of what one eats is characteristic of anorexia nervosa (option 1). The person with bulimia actually loses all self-control when beginning a bingeing episode and subsequently ingests enormous quantities of food. When the client has bulimia nervosa, overeating does occur, but it is followed by purging, which is used as a relief behavior (option 3). Overeating in the absence of purging is not considered to be a typical behavior associated with bulimia nervosa. Since the client with an eating disorder is using food-related behaviors as an unhealthy means of coping with stress, the client is also likely to use other unhealthy coping methods, such as excessive alcohol intake (option 4). However, bulimia nervosa is characterized by both bingeing and purging involving food, not alcoholic beverages.

Depression in adolescents is often masked by aggressive and/or behavioral problems. Symptoms are usually different from adults in that adolescents often exhibit intense mood swings, academic difficulties, antisocial behavior, and hypersomnia. While the DSM-IV-TR criteria for depression are the same for adults, children, and adolescents, the clinical presentation may be different in the different age groups (option 1). Depression in adolescents can have the same consequences as in adults and should be treated seriously (option 3). Family dysfunction may or may not be present when the adolescent client is depressed (option 4). As with adults who are depressed, there is evidence that depression in adolescence is highly associated with psychobiologic changes, especially in neuroendocrine functioning.

The nurse is employing the communication technique of clarifying in order to fully understand the client’s subjective complaint. After understanding the client’s perception of this side effect, the other questions would be appropriate.

Option 1 indicates that the client is experiencing amenorrhea. DSM-IV-TR criteria for anorexia nervosa include the absence of at least 3 menstrual cycles when there is not another medical reason for this, including pregnancy. Option 2 indicates that the client has disturbed body image and an unrealistic perception of her own body appearance. A client suffering from anorexia nervosa has a weight loss of 15% or greater of normal body weight because of self-imposed dietary restrictions and/or excessive exercise regimes. Even when dangerously underweight and in physiologic peril, the anorexic client will continue to believe that more weight should be lost. Option 3 indicates a serious interest in food, but not in eating it. Persons with anorexia are indeed often preoccupied with food, but they refuse to allow it into their bodies. It is not uncommon for them to prepare food for others but not partake of it. Option 4 indicates a severe revulsion to food, which is common to persons who have anorexia nervosa. It does not suggest that the client will self-stimulate nausea, as would the bulimic individual. Option 5 is not a correct statement. In addition to denying the reality of their extreme thinness, clients with anorexia deny that they have an eating problem.

Set this up as a ratio and proportion problem. Step 1 (Basic ratio) 84 pounds: 70% = x :100%; Step 2 (Cross-multiply) .70 x = 84 pounds; Step 3 (Divide by .70) x = 120 pounds

It is important for the nurse to answer this question in an accurate and factual way that the adolescent can understand. The nurse should know that fluoxetine (Prozac) is classified as a selective serotonin reuptake inhibitor (SSRI) and that it is one of the antidepressants fully approved for treating children and adolescents. In option 1, the nurse is not responding to what the client has asked. This is a nonanswer answer, and the adolescent is likely to feel demeaned and belittled by it, feeling that the nurse is treating the client like a child. Unlike tricyclic antidepressants, it is not associated with changes in norepinephrine levels (option 3) and is not known to have a direct effect on blood glucose and dopamine levels (option 4).

It is important for the client with an eating disorder to be able to connect emotion to the relief-seeking behavior: bulimia, anorexia, or bingeing without purging. Completing such a diary in an honest manner will assist the client to recognize that the eating behavior is an unhealthy attempt to deal with uncomfortable feelings. Individuals with eating disorders are often preoccupied with food and its nutritional content, although they do not eat normally. The client’s remaining focus of attention in this area does not suggest that therapeutic progress is being made (option 1). Persons with bulimia generally isolate themselves from others before, during, and after eating. They eat in secret, ingest unusually large quantities of food while alone, and purge themselves as soon as possible after the meal (options 3 and 4). One of the means of discouraging purging is to have the individual remain in the presence of others for at least an hour after eating. Also, the client is an adolescent and should continue to function as a member of the family, even if family discord is present (which is often the case in families with bulimic members.)

Conduct problems are considered manifestations of acting-out behaviors. Inconsistent limit setting with very harsh discipline is often characteristic of families with children suffering from conduct disorders. Imposing high expectations on the child may cause the child to be anxious, but this parental behavior is not generally thought to be directly related to conduct disorders (option 1). Being excessively involved in the child’s life (option 3) may indeed make the child anxious, but it is not directly related to conduct disorders. Conduct disorders occur in one-child and multichild families (option 4).

The child with ADHD has difficulty concentrating and maintaining a focus. Behavior that is seen as resistant may actually result from the child’s not having properly understood what has been said. If the child repeats what was heard, the parent will be able to know if the intended message was actually received. If not, the message can be sent again in simple, concrete language. It is also helpful for the parent to know that giving only one instruction at a time is likely to be more effective than giving a complex set of instructions at the same time. Options 1, 2, and 3 are useful techniques to employ when the child has ADHD, but they address an area of functioning that is not shown in the parent’s statement.

Behavior modification is an effective strategy with children and adolescents. The child is told exactly what behaviors are expected, what is not acceptable, and the consequences for specific undesirable behaviors. These strategies use limit setting and require consistency for correct implementation. Open communication is effective, but a flexible approach to acceptable behavior may be confusing to the child (option 2). Open expression of feelings and assertiveness training (options 3 and 4) are useful techniques; however, they are more effective within a controlled environment and will not necessarily address impulsive and aggressive behavior.

Separation anxiety disorder may develop at any age, although it is most common in children, with the peak onset between 7 and 9 years old. When it does occur, the child generally has performance and attendance difficulties in school. Obsessive-compulsive disorder (option 1) is not common in children, although obsessive compulsive personality traits may be present in children this age. While the incidence of depression in children is increasing (option 2), it is not as common a problem in this age group as is separation anxiety. Posttraumatic stress disorder (option 4) can occur in persons of any age, but it is not as common as separation anxiety. As with adults, PTSD in children occurs following some intensely emotionally painful event, which is not an average occurrence for children. However, separation anxiety is considered more common.

Behavior modification is quite effective with young children and adolescents. The child is told what is expected, what is not acceptable, and what the consequences will be for undesirable behavior. The child is rewarded for changes in behavior. Reminiscence therapy (option 1) is indicated for clients who have memory deficits. It is often used with the geriatric population, particularly individuals with dementia. Emotive therapy (option 2) is more effective in older children. The young child with oppositional defiant behavior is often very emotive, but in an inappropriate way. While cognitive reframing (option 4) can be used with young children, the first approach should be to modify the behavior. Once the child is behaving more acceptably, other interventions such as cognitive reframing can be used.

Central nervous system stimulants such as methylphenidate (Ritalin) and amphetamine and dextroamphetamine (Adderall) are the most frequently used medications for ADHD. These medications increase the ability to focus attention by blocking out irrelevant thoughts and impulses. Antidepressants (options 1 and 2) are not typically prescribed for the treatment of ADHD. When they are used for depression, venlafaxine (Effexor) and fluoxetine (Prozac) seem to be the most effective. Haloperidol (Haldol) in option 4 is an antipsychotic drug that is useful in treating children and adolescents with Tourette’s syndrome. It is not commonly prescribed for clients with ADHD. When it is, the nurse must be particularly observant for the occurrence of extrapyramidal side effects (EPS).

The client may have restrictions based on a medical condition (e.g., low-sodium for heart disease), food allergies (e.g., shellfish), or religious convictions (e.g., abstaining from pork if Jewish). The nurse must note these restrictions and communicate with the nursing and dietary staff in order to avoid a potentially harmful occurrence. The other questions are pertinent for a dietary history but would not lead to a physiologic alteration if changed while hospitalized.

Play therapy is especially useful for children under 12 because their developmental level makes them less able to verbalize thoughts and feelings. Learning to talk openly about themselves (option 2), learning how to give and receive feedback (option 3), and learning problem-solving skills (option 4) are not the intended goals of play therapy. Options 2, 3, and 4 require more structured group and individual activities than 6-year-olds are able to master. Play therapy provides an opportunity for children to express their feelings through play, without the need for advanced verbal or social skill sets.

Recall that children with ODD are disruptive, argumentative, hostile, and irritable. These children also have social problems with peers and adults and have impaired academic functioning. Stealing (option 2), along with cruelty (option 1) and arson (option 5), are included in the antisocial behaviors seen in children with CD.

Childhood disorders that appear to be genetically transmitted include enuresis, autism, mental retardation, some language disorders, Tourette’s syndrome, and attention-deficit/hyperactivity disorder (ADHD). Of these, autism is the more pervasive disorder. Anxiety (option 1), sleepwalking (option 2), and oppositional defiance disorder (ODD) (option 4) do not appear to be genetically transmitted.

This will allow for collection of baseline data that can be used for developing a weight control/loss program. Option 1 is incorrect as weighing daily can be discouraging, as within the course of a week, several normal fluctuations in weight might occur. Additionally, reporting to the clinic daily (if the client has not already been doing so) is unnecessary and would add to both expense and stress levels of the client. Options 2 and 4 are also incorrect. It is premature to enroll in a formal weight management program or see a nutritionist at this time. The nurse should assist the client to establish baseline data before seeing other professionals.

Redirecting the client in a calm, firm, nondefensive manner is the most appropriate action to begin de-escalation. This client will be distractible but irritable, so it is important that the nurse’s approach is one of quiet, matter-of-fact calmness. Options 1, 2, and 3 are incorrect. Turning on the television is not an appropriate approach because it is not likely to distract the client. The nurse should personally gain the client’s attention and attempt to verbally redirect the client. If the client with bipolar disorder is in a locked unit, prn orders should already be in place. At this time, the client’s behavior requires the nurse’s personal attention and intervention, not medication. In fact, if medication is given before other, less restrictive interventions are used, it is illegal. Medication is considered a form of chemical restraint. In option 4, the client’s behavior is not sufficiently out of control to warrant the use of seclusion. In addition, the nurse should be aware that before seclusion can be legally justified, all other less restrictive techniques should be attempted. Redirection is an appropriate initial less restrictive technique.

The nurse should recognize that this client is describing feelings which could result in suicide. Even though the client has not directly described feeling self-destructive, the nurse should recognize that there is a strong likelihood that these feelings are present but unacknowledged. The nurse should directly and kindly inquire whether such thoughts are present and provide safety measures as appropriate to the client’s response. Having a suicidal plan and the means to carry out the plan increases the potential lethality of any situation with a client in suicidal crisis. Option 1 is incorrect because, while the client is describing disturbance in physiologic functioning that is consistent with the mood state of depression, the nurse should know that examining for self-destructive intent is of higher priority than examining basic physical needs. Option 3 is incorrect as completing the Beck’s Depression Scale is not an urgent priority. Information gained from the test will contribute to planning appropriate care, but the test can be delayed. The priority action of the nurse should be to determine if the client is suicidal. Option 4 is incorrect because putting the client in a quiet room is contra indicated because the client needs to be in the staff’s eyesight until suicidal ideation is confirmed or eliminated. Additionally, the client has begun to express feelings of depression and appears ready to discuss it. The nurse must be responsive to the client’s emotional state.

Helping the client to avoid large amounts of caffeine could help improve his or her sleep. Side effects of caffeine, particularly large doses or doses taken after noon, include insomnia, irritability, and anxiety. Option 1 is incorrect as fluoxetine (Prozac) should not be given at bedtime because it impairs sleep. Option 3 is incorrect because decreasing the amount of time with friends (unless the time spent is unreasonably long) would not be therapeutic for the client, since the client is being treated for depression. Withdrawal from social contacts is one of the symptoms of depression, so if the client is experiencing satisfaction from being with friends, this indicates improvement. Option 4 is incorrect as for most people, napping late in the day interferes with successful nighttime sleeping. Avoiding this is a part of good sleep hygiene for all persons.

This client is within the therapeutic blood level for clients newly begin on Lithium (0.8 mg/% to 1.4 mg/%) and is displaying two of the commonly expected side effects of Lithium. This client in option 1 is not showing signs of possible Lithium toxicity, but rather is displaying normal side effects while in the therapeutic blood level range. While renal impairment is a possible untoward effect of Lithium (option 2), nothing in the question suggests that renal problems are being experienced. Do not be misled by the client’s frequent drinking of water. The client is not manifesting early return of symptoms of elevated affect (option 3), which would include increased grandiosity, flight of ideas and irritability. The client is experiencing normal side effects of Lithium. Full control of symptoms of mania may not occur for one to two weeks.

The family needs the nurse to listen to and support them. Reinforcing signs and symptoms of relapse will help the family members decrease their anxiety, knowing they have a clear role in the recovery and ongoing care of the client without being totally responsible for the client. In option 1, the family needs to express their concerns, not be asked to identify what will make them feel better. Option 2 does not address the family concerns and attempts to give them false reassurance. Option 4 is an unreasonable recommendation that would place undue pressure on the family. The family and the client should be assisted to formulate safety plans that will allow all to carry out usual responsibilities.

The client should be NPO before the procedure in order to be given anesthesia for the procedure. In option 1, the client, not the spouse, should sign the consent form. The client should be wearing loose-fitting clothing that would not restrict movements of breathing (option 2). In option 4, the client should be NPO before the procedure in order to be given anesthesia.

How a client spends income, even on an unhealthy habit, is not necessary for the nurse to know in order to provide effective care. Option 1 would be considered appropriate in an initial interview as a means for the nurse to provide acknowledgment and positive reinforcement for a lifestyle change that resulted in a potentially improved health status. Options 2 and 3 would be common questions used to inquire about a client’s behavior.

Option 3 is incorrect as dysthymia is not a psychotic condition, and antipsychotic medications are not generally given to these clients. Option 4 is incorrect because it describes behaviors associated with dissociative identity disorder (DID), not dysthymic disorder.

The client’s level of risk for self-harm is a major concern. While the mood is elevated, the client may injure self from restless hyperactivity or poor judgment. Additionally, the client may experience unpredictable mood swings and act on accompanying suicidal urges. Options 1, 2, and 4 each describe a common client presentation in states of elevated affect. However, none of them are as important in regard to safety as is the likelihood of rapid mood swings.

This is a respectful response of the nurse. It shows that the nurse recognizes that during this initial phase of the group process, the client may be (1) being observant in order to decide whether he or she feels safe in the group or (2) remaining silent because of feelings of inadequacy. Options 2, 3, and 4 are not appropriate early in the process of therapy. If offered in a supportive manner, they could possibly be employed much later.

The nurse should recognize that this client is experiencing psychomotor retardation, which, in addition to slowing voluntary motor activities, will also slow other bodily processes. The anticholinergic effects of the client’s medication will decrease motility of the GI tract, specifically the stomach and bowel. The nurse should remember that the client’s low level of physical activity increases the risk for constipation. If the client’s constipation is not managed adequately, other serious problems of fecal impaction and bowel obstruction may occur. There is nothing to indicate that the client is at high risk for vomiting (option 2), although the other GI symptoms noted in options 1 and 3 are likely. The nurse should recognize that this client not at risk for diarrhea (option 4), but is actually at high risk for constipation. Most experts consider weight gain (a common side effect of antipsychotics) to be an anticholinergic side effect (option 5).

The client is demonstrating a pattern of behavior that should be investigated. The nurse should take the time to determine the client’s feelings, thoughts, and actions. The client may just be tired and have a need to rest, but the nurse needs to be sure that the client is safe and not upset. The nurse should not make assumptions about what the client is feeling (option 2). Before ascribing a meaning to the client’s behavior, the nurse should first talk to the client to determine what feelings she is experiencing. Additionally, the nurse is using a closed-ended question that can be answered with a “yes” or “no.” This is not the correct therapeutic technique to use when interviewing a client. The response in option 3 does acknowledge the client’s change in attitude but does not indicate that the nurse has any concern for the client. The response in option 4 changes the focus from the client to food in addition to prematurely and inappropriately presuming to understand the meaning of the client’s behavior.

Salami is a cured meat and must be avoided by clients taking tranylcypromine, a monoamine oxidase inhibitor (MAOI). Foods rich in tyramine or tryptophan, such as cured foods, may induce a hypertensive episode in clients taking MAOI medication. Other foods to be avoided include those that have been aged, pickled, fermented, or smoked. Clients taking monoamine oxidase inhibitors (MAOIs) can eat potatoes (option 1), baked chicken (option 3), and cottage cheese in reasonable amounts (option 4).

Providing safety for the nurse and the client is the primary concern immediately after admission when the client is in a manic state. This is because the client is likely to be labile, hostile, and uncooperative. The information given in this question suggests that the client’s elevated and angry mood poses potential safety hazards for the client and the nurse. While obtaining the intake data is important (option 1), this activity can be delayed until safety issues have been addressed. When the client demonstrates an elevated angry mood, it poses a potential safety risk for the client and the nurse. It is this risk that requires the nurse’s immediate focus, not nutritional imbalance (option 2), even though this is often a nursing concern for a client in a manic episode. There is nothing in the question that indicates that the client’s behavior is so extreme that medications must be given (option 4). The nurse should remember that prn neuroleptic medication is considered to be a chemical form of restraint. Other less restrictive measures, such as environmental manipulation, must always be used before the nurse administers prn medication.

Option 2 acknowledges independent and positive actions by the client. Information is reported in a matter-of-fact manner to the client, and no evaluative words are used. While option 1 is probably intended to convey encouragement, it is very much overstated. Depressed clients do not accept praise easily. The appropriate feedback for the nurse to provide is a matter-of-fact observation that does not include evaluative terms like “wonderful.” Options 3 and 4 use the technique of exploring. The question that is being asked concerns feedback. Feedback involves the giving of information to the client, rather than getting information from the client. Questions are not asked when feedback is given.

Providing nursing care to clients with elevated mood (mania) can be particularly challenging for the nurse. The client will generally be excited, physically hyperactive, labile, and unpredictable. Clients in manic states tend to exhibit behaviors that are controlling, competitive, irritable, aggressive, and domineering in social situations. They are often socially intrusive and inappropriate. When their demands are not met, they can easily become aggressive in ways that are dangerous to self or others. Because of this, the nurse should always consider the person in a manic state to be at risk for injury to self or others especially. Persons experiencing manic states will resist being alone and act as if they feel compelled to interact with others at all times (option 2). Persons in a manic state have unrealistically elevated self-esteem, often feeling that they are the most knowledgeable person in the world (option 5). They will therefore not hesitate to make decisions, but the decisions are made impulsively and without regard for consequences.

Psychomotor agitation is recognized when a person’s behavior involves increased physical activity, restlessness, and/or aggression. The behavioral manifestations will be accompanied by strong affects, such as anxiety, and speeding of physiologic processes. When psychomotor agitation is present, the client and others are at risk for injury. Psychomotor retardation (option 1) is a term that refers to slowing of physical activities and bodily processes. It is the opposite of what is described in this situation. Anxiety is a feeling, not a behavior (option 2). This question calls for the nurse to identify a behavior. The behavior of the client may indeed be related to anxiety, but there are other possible reasons for the behavior. Depression is a mood state, not a behavior (option 4). The behavior of the client may indeed be related to depressed mood, but there are other possible reasons for the behavior.

Wernicke’s aphasia is the inability to understand verbal or written words. Impairment is located in the posterior speech cortex in the temporal and parietal lobes. Based on the information provided, the client should be able to speak, spell, and eat with this type of neurological deficit.

The client is describing symptoms that are consistent with those of a mood disorder, probably dysthymic disorder. The client’s life is not well managed, nor does the client experience pleasure. There is nothing in the client’s statement to indicate an immediate risk for violence (option 2). The client is dispirited and dissatisfied, but does not indicate that this is overwhelming enough to cause self-destructive ideas or urges. The client’s statement does not suggest inability to tolerate physical activity (option 3), but rather fatigue and disinterest. Activity intolerance is much more intense and specific than fatigue. Nothing in the client’s statement suggests that acute anxiety is present (option 4). Anxiety is a common human emotion, but in order for it to be a nursing concern, there should be clear evidence that the anxiety level is elevated beyond normal.

The nurse should know that carbamazepine (Tegretol) frequently causes changes in liver enzymes. These changes can result in dangerous or fatal problems for the client. Therefore, baseline laboratory results must be available before the first dose of the drug is administered. Subsequent results are then compared to this set of baseline data as the prescriber makes decisions about future doses. Changes in blood glucose (option 1) are not commonly associated with carbamazepine. Instead, there is a strong relationship to blood glucose changes and certain second-generation antipsychotics, such as olanzapine (Zyprexa). While it is true that bleeding problems can be associated with carbamazepine (option 3), baseline bleed/clotting times are not required before the drug is administered. If the client were being given lithium (option 4), baseline information about thyroid functioning would be required.

The client has indicated that environmental noise and activity are preventing sleep. The nurse should first attempt to minimize environmental stimuli. Simply closing the client’s door is a noninvasive, nonstimulating strategy that may work, assuming that it will not pose a safety hazard for the client. Before administering a prn sedative (option 1), the nurse should attempt other nonpharmacological options. It is not necessary to move the client (option 2) when closing the door can produce a noninvasive strategy. However, the door should not be closed if this would pose a risk for the client’s safety. Turning on the television (option 4) will increase the amount of noise in the environment and could further stimulate the client and/or others.

The client receiving a series of ECTs can be expected to have “patchy” memories of events occurring during the days or weeks of the treatment period (option 2). This may or may not resolve as time passes. While modifications in the ECT procedure have increased the level of safety for the client, amnesia and possibly temporary confusion still remain as side effects of the procedure (option 5). The client is likely to have amnesia for recent events, especially for events that occurred just before the treatment was administered (option 1), so the client will not remember that the treatment has been administered. The memory loss that may occur as a side effect to ECT is not selective. Both positive and negative life events may be forgotten (option 3). Memory deficits are common in the client receiving ECT. When they do occur, the client and significant others generally feel alarmed. However, the nurse should recognize this as an expected and nonurgent side effect (option 4).

The nurse should recognize that the client is experiencing side effects that are normal at this time. That information should be conveyed to the client, as well as information about what to expect in the future. It is important that the client continue to take the medication as prescribed. Serum lithium levels should be monitored frequently in order to determine therapeutic blood levels and prevent lithium toxicity. Minor hand tremors do not indicate lithium toxicity, but they can interfere with writing and other motor skills. Helping the client understand that the tremors can subside or disappear after 1 or 2 weeks is reassuring. Option 2 fails to give the client important information about side effects of Lithium. It also fails to respond to the client’s concern that something is wrong. Fine hand tremors are expected side effects at this time in the client’s treatment (option 3). However, the presence of coarse tremors, coupled with such symptoms as gait changes, would suggest possible toxicity, which would require a totally different response from the nurse. In option 4, the nurse is probably trying to be reassuring, but the client will likely feel demeaned. This response also deprives the client of the opportunity to receive important teaching.

The nurse should understand that in order for a client to be diagnosed with major depression, DSM-IV-TR specifies that symptoms consistent with at least 5 of 9 criteria must have been present for at least 2 weeks. Suicidal ideations and plans are included in one criterion (option 1). The nurse should keep in mind that the presence of suicidal ideations alone would not support the diagnosis of major depression. Another criterion for major depression involves markedly diminished interest or pleasure in all, or almost all, activities (option 4). Option 2 is incorrect because major depressive symptoms represent a more recent change in functioning, not a single episode within 2 years. While persons with major depression often have changes in weight and appetite (option 3), the relevant DSM-IV-TR criterion for major depression does not involve a 3-day period. It also allows for either increases or decreases in appetite to have occurred. Hallucinations (option 5) may occur in psychotic levels of major depression, but they are not part of the diagnostic criteria in DSM-IV-TR.

The manic client has poor judgment and is impulsive and at risk for injury. The nurse should attend to the safety needs of this client before taking other actions. It is possible that the client will not be able to contract for safety. (At this point, the first part of the contract would be for the client to remain in the hospital.) If the client could not do this, the nurse’s next action is to explain the terms of the client’s admission status. Because the client is being treated on a formal voluntary basis, the nurse cannot comply with the client’s demand to be discharged. It is not appropriate to involve the police (option 1). While informing the spouse might be an appropriate later action, at this time the nurse should focus attention on the client. It is appropriate for the nurse to report the client’s request to the nursing supervisor, but the first response to the client’s request should be made to the client (option 4). Meeting the client’s safety needs is of higher priority than informing the supervisor.

The nurse should know that one of the common side effects of sertraline (Zoloft) is insomnia. Therefore, most clients are given sertraline (Zoloft) early in the day. Sexual side effects to sertraline (Zoloft) and other SSRIs are common. One way to decrease the likelihood of noncompliance is to inform the client that prompt reporting of such side effects can lead to corrective treatment measures. It is important for the nurse to know that diarrhea is a much more common side effect to sertraline (Zoloft) than is constipation (option 2). It is vital for the nurse to know that all persons taking sertraline (Zoloft) or other SSRIs should be taught to recognize early symptoms of possible central serotonin syndrome (option 3). Such symptoms include sudden onset fever, sweating, and extrapyramidal side effects (EPS). The development of central serotonin syndrome is a rare medical emergency, but the client will need intensive medical treatment because the mortality rate is very high. The nurse should teach the client that while some reduction in symptoms may occur in a relatively short period of time, it may be several weeks before full therapeutic effects are realized (option 4). Without this knowledge, clients often become discouraged and think that the medication is ineffective.

The clinical presentation of depressed mood is similar to that of medically diagnosed depression. There is a high incidence of depressed mood and depression among hospitalized clients. Usually the more severe the illness, the more pronounced the symptoms. Clinical depression in the recovery period is relatively common among cardiovascular surgical clients. There is nothing in the client’s complaint that suggests body image concerns (option 1), although most postsurgical clients have this concern to some degree. The statements of this client instead suggest that the client is experiencing depressed mood, which is similar to the medical diagnosis of depression. Nothing the client has said indicates that the client is intolerant of activity (option 2). Feeling tired is a much more moderate problem than being intolerant of activity. There is no data in the stem of this question to suggest that the client’s recovery is delayed (option 4).

1 comment:

Dr.sandy said...
