QB 2

Question 1

Proparacaine HCl and client safety

Answer 1

Topical anesthetis used prior to ophthalmologic examinations. Once the medication is instilled, the nerve endings of the eye are blunted, reducing the ability of the eye to react to pain or pressure. The nurse knows that this places the client at higher risk for eye damage if the eye is touched or rubbed, an action that the client experiencing eye irritation may be more likely to do. The nurse prioritizes teaching the client about not touching the eye to minimize this safety hazard.

Question 2

Clients who are 50 years of age or older should have a colonoscopy every ______________ years

If fecal occult blood testing is selected as a screening for colorectal cancer, it should be done ______________

If a barium enema is selected as a screening for colorectal cancer, it should be done every _________–years.

Answer 2

10; annually; 5

Question 3

the term used for a group of diseases that result from unregulated growth of malignant cells. This affects the structure and function of healthy cells.

Answer 3

Cancer

Exposure to carcinogens, such as sun exposure, human papillomavirus, and tobacco products may initiate the development of cancer. Non-modifiable risk factors include age and genetic predisposition. Modifiable risk factors include a sedentary lifestyle, poor diet, excessive alcohol use, unprotected exposure to ultraviolet light, and smoking.

Question 4

This measure is considered the gold standard for the detection of colorectal cancer.

Answer 4

Colonoscopy

Preventive actions for this disease begin at the age of 50 at which time a colonoscopy is recommended and repeated every 10 years (if no precancerous condition exists). Other actions for early detection of this type of cancer include fecal occult blood testing and barium enemas; however, the rate of detection is not as sensitive as that achieved through a colonoscopy.

Question 5

S/S of hypocalcemia

CRAMPS

Answer 5

Nervous system becomes increasingly excitable . There are muscle cramps, paresthesias, hypotension, increased gastric motility

Confusion

Reflexes hyperactive

Arrhythmias (prolonged QT interval and ST interval) Note: definitely remember prolonged QT interval…another major test question

Muscle spasms in calves or feet, tetany, seizures

Positive Trousseau’s! You will see this before Chvostek’s sign or before tetany. This sign may be positive before other manifestations of hypocalcemia such as hyperactive reflexes.

Question 6

Role of calcium

Answer 6

plays a huge role in bone and teeth health along with muscle/nerve function, cell, and blood clotting. Calcium is absorbed in the GI system and stored in the bones and then excreted by the kidneys.

Question 7

S/S of hypercalcemia

The body is too WEAK

Answer 7

Weakness of muscles (profound)

EKG changes shortened QT interval (most common) and prolonged PR interval

Absent reflexes, absent minded (disorientated), abdominal distention from constipation

Kidney Stone formation

sedative effect on central & peripheral nervous system

nausea, constipation, decreased gastric motility

Question 8

Foods high in calcium

Mnemonic

“Young Sally’s calcium serum continues to randomly mess-up”

Answer 8

Yogurt

Sardines

Cheese

Spinach

Collard greens

Tofu

Rhubarb

Milk

Question 9

Calcium regulation is controlled by the parathyroid hormones,____________________ Feedback mechanisms regulate calcium levels and hormones increase or decrease calcium levels as needed. Bones rely on adequate absorption of calcium to maintain stores. Serum phosphate is _____________related to calcium. Calcium is also necessary for adequate cardiac output. Signs of hypocalcemia include ______________

Answer 9

calcitonin and calcitriol; inversely; muscle cramping or spasms, hyperactive deep tendon reflexes, irritability, and the Chvostek and Trousseau signs.

Question 10

For airborne precautions, wear an ____________—prior to room entry. Assign the client to a ____-person room equipped with special air-handling and ventilation. When possible, non-immune health care workers should not provide care to clients diagnosed with vaccine-preventable airborne diseases.

Answer 10

N95 mask or respirator; single

Question 11

Transmission-based precautions are infection control practices used in health care settings. These precautions are indicated when clients are known, or suspected, to be infected or colonized with infectious agents.

Transmission-based precautions are used in addition to _____________precautions. The three types of transmission-based precautions include ________________

Answer 11

standard; contact, droplet, and airborne.

Question 12

Airborne precautions - what diseases warrant this, what does airborne precautions entail

Answer 12

Airborne precautions are indicated for clients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei. Diseases requiring airborne precautions include, but are not limited to, measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), disseminated herpes zoster, and Mycobacterium tuberculosis. All health care workers, including unlicensed assistive personnel (UAP), must wear a fit-tested NIOSH-approved N95 respirator when providing care for clients who require airborne precautions. Transport and movement of the client outside the client’s room should be limited to medically necessary purposes only. The ideal room for airborne precautions should have 12 air changes per hour.

Question 13

What is hypophysectomy ?

Common complications

Answer 13

the surgical removal of the pituitary gland.

Postoperatively, frequently assess the client’s vision because there is a risk of a hematoma forming and subsequently compressing the optic nerve.

CSF leak and epistaxis are also complications.

The surgeon may place a petroleum jelly-coated ribbon of gauze or a balloon-tipped catheter in the sphenoid sinus. Check any clear drainage with a urine dipstick for glucose and protein. A persistent headache can indicate a CSF leak. Instruct the client to avoid vigorous coughing, sneezing, and straining to have a bowel movement.

Question 14

Cerebrospinal fluid has a high _________ content

What is the halo sign ?

If there is a CSF leak, what does the nurse anticipate doing ?

Answer 14

glucose

If a cerebrospinal fluid (CFS) leak is suspected, the nurse can simply test the drainage for sugar content (CSF has a high glucose content). The nurse should also conduct a thorough neurological assessment. The nurse may also assess for the “halo” sign of the suspected CSF leak. The halo sign is a classic image traditionally taught as a method for determining whether bloody discharge from the ears or nose contains CSF. If there is CSF leak, a “double-ring” appearance on the gauze used to dab the drainage is observed. The nurse anticipates sending the client with CSF leak for a CT of the head. The nurse understands that a CSF leak puts the client at risk for infection, a serious complication following surgery on the brain.

Question 15

Correct application of condom catheter

Answer 15

An elastic adhesive strip should be wrapped in a spiral pattern without overlapping on itself to ensure circulation to the penis is not impaired. The tape should be snug to hold the condom catheter in place, but not so tight that it causes discomfort.

One to two inches of space should be left between the end of the condom catheter and the tip of the glans penis. This space helps prevent irritation to the tip of the penis and allows for adequate urine flow.

Clipping the pubic hair is an appropriate action. The hair will adhere to the condom and become caught as the condom is applied or removed

Skin or circulatory compromise are risks associated with inappropriate application techniques. Applying an adhesive strip around the circumference of the penis in an overlapping pattern to secure a condom catheter can cause constriction and impair circulation to the penis. This poses a safety risk to the client and causes the nurse to intervene.

Question 16

Reasons for incontinence

and measures to address it

Answer 16

Incontinence may happen for various reasons. Urinalysis and urine culture should be obtained to rule out infection. A voiding history, intake and output, and bladder residual testing should be performed. Medications (diuretics, sedatives) can affect voiding and should be assessed. Causes of incontinence include weakness of pelvic floor muscles, increased abdominal pressure, infections, over-distention of the bladder, sphincter weakness, and cognitive impairments. Age-related changes in bladder size and sensory impairments can also cause urinary incontinence. Clients with incontinence or neurogenic bladder may require bladder training and scheduled toileting. Intermittent or indwelling urinary catheters and suprapubic catheters may be required.

Question 17

Clients receiving chemotherapy are at risk for ______________________

Answer 17

nausea, vomiting, malnutrition, electrolyte imbalances, hearing loss, alopecia, stomatitis, fatigue, and bone marrow suppression.

Question 18

Many medications can result in ototoxicity by damaging sensory cells in the middle ear. This results in ear damage, hearing loss, tinnitus, or balance issues.__________________________ are known to cause this effect.

When these drugs are administered in combination, the risk of developing ear damage increases. In some instances, ear damage is temporary; in many cases, it is permanent.

Answer 18

Aminoglycoside antibiotics, platinum chemotherapy agents, aspirin, non-steroidal anti-inflammatories (NSAIDs), quinine, and loop diuretics

Question 19

The UAP can provide direct client care to stable clients with _______________

Answer 19

standard, unchanging procedures

Any activity that requires an element of the nursing process cannot be assigned to an UAP.

The UAP does not have knowledge, skills, and abilities for unpredictable situations

Question 20

Increased intracranial pressure (ICP) occurs when there is an abnormal accumulation of ______________________in the brain causing cerebral edema. This cerebral edema may be caused by lesions, head/brain injury, cerebral infections, vascular insult, or encephalopathies. Increased ICP is a very serious diagnosis.

Answer 20

cerebrospinal fluid

Question 21

Cephalexin is a ______________-antibiotic. Before administering cephalexin, ensure the client is not allergic to ______________, as cross-reactivity can occur.

Answer 21

cephalosporin; penicillin

Question 22

The nurse has four new admissions. Each client has a prescription for an IV to be started. It is most important for the nurse to start the IV for which client?

1. A client reporting abdominal pain.
2. A client experiencing a sickle cell crisis.
3. A client exhibiting poor skin turgor.
4. A client scheduled for surgery.

Answer 22

2. CORRECT— Hydration is important during a painful sickling crisis. Increasing the fluid volume dramatically reduces pain, increases perfusion, and decreases complications such as acute chest syndrome. IV access is also essential for proper pain management.

Sickle cell crisis is a severe, painful, acute exacerbation of RBC sickling, causing a vasoactive crisis. As blood flow is impaired by sickled cells, vasospasm occurs, further restricting blood flow. One of the care priorities is managing the severe pain, possibly by parenteral analgesics; therefore, the urgent need for an IV line.

Sickle cell disease (SCD) is a severe hereditary form of anemia in which a mutated form of hemoglobin distorts the red blood cells into a crescent shape at low oxygen levels. Multiple organ damage can result from a sickle cell crisis. The client is at risk for impaired gas exchange and ineffective tissue perfusion (stroke can occur). The nurse should promote optimal oxygenation, adequate rest periods, hydration (dehydration promotes a crisis), adequate nutrition, and adequate pain management. Patient-controlled analgesia (PCA) may be required.

Question 23

The nurse knows that the ________________method is the best way to ensure client understanding.

Answer 23

teach-back

Seeing the client perform a skill ensures that the client is able to complete the skill safely. It is important for the nurse to validate that the client can perform self-care at the time of discharge. The best opportunity is for the nurse to watch the client perform the task and provide feedback as needed.

Question 24

Irrigation of the indwelling catheter is within the scope of practice of the UAP.

TRUE OR FALSE

Answer 24

FALSE; IT IS NOT WITHIN THE SCOPE OF PRACTICE OF THE UAP

Question 25

_______________-encompasses the values, faith, convictions, and behaviors of an individual related to the purpose and meaning of life. Spiritual support is part of holistic care.

Answer 25

Spirituality

Assess the client’s sense of emotional and spiritual distress. Assess the influence of the client’s spiritual beliefs on health and illness. Be sensitive to the client’s spiritual dimensions and needs. Provide emotional support and offer referrals to chaplains, clergy, or spiritual support personnel. Remain objective and nonjudgmental. Employ active listening and therapeutic communication. Incorporate spiritual beliefs when providing care.

Question 26

Assessment of Duodenal Ulcers

and Assessment of Gastric Ulcers

Answer 26

Duodenal Ulcers -

Burning pain in the mid-epigastric area 1.5 to 3 hours after a meal and during the night (often awakens the client)

melena is more common than hematemesis

pain is often relieved by the ingestion of food

Gastric Ulcers

Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30-60 minutes after a meal (food ingestion accentuates the pain)

hematemesis is more common than melena

Question 27

_______________________________are key symptoms of a perforated duodenal ulcer.

Answer 27

Sudden, sharp discomfort that begins in the midepigastric area, along with a boardlike abdomen,

Question 28

A disease caused by the erosion of the mucosa of the gastrointestinal (GI) tract by hydrochloric acid (HCL) and pepsin.

Answer 28

Peptic Ulcer Disease

Peptic ulcers can develop in any segment of the gastrointestinal tract exposed to HCL and pepsin. Gastric ulcers occur in the stomach whereas duodenal ulcers occur in the duodenum segment of the small intestine. They are categorized as acute or chronic. Erosion of the mucosa may be deeper with prolonged, chronic PUD.

When erosion of the mucosa occurs, the client is at risk for hemorrhage (blood in stool, dizziness, and hypovolemic shock), perforation (severe abdominal pain that radiates, rigid abdomen, and fever), and gastric outlet obstruction (epigastric fullness, nausea, and vomiting). They are all emergent situations requiring rapid assessment and treatment.

Question 29

In the presence of an ulceration that perforates, there will be ______________________-

Answer 29

bleeding and severe pain.

Question 30

What is milieu therapy ?

Answer 30

The purpose of milieu therapy is primarily for client benefit, with the goal of providing an environment in which new patterns of behavior can be developed.

In milieu therapy, all aspects of the environment are utilized as instruments of growth for the client’s benefit. Clients are encouraged to take responsibility for various tasks and to participate in activities that allow them to develop healthy social behaviors. Milieu therapy is primarily intended to treat behavior and personality disorders.

Safety is the most important priority in managing the milieu, and all encounters with the client have the goal of being therapeutic. Milieu refers to the safe physical and social environment in which an individual is receiving treatment

The focus of milieu therapy is to empower the client through involvement in setting his or her own goals and to develop purposeful relationships with the staff to assist in meeting these goals.

Question 31

Women may not experience the typical signs of an MI and instead experience jaw pain, fatigue, and nausea.

TRUE OR FALSE

Answer 31

TRUE

Question 32

Classic signs of a myocardial infarction (MI) include severe angina that may be described as _______________________. The pain is not relieved by changing positions, resting, or administering nitrate medication. However, angina associated with MI may also be experienced as chest tightness, pressure, or discomfort. Among women, atypical signs and symptoms of MI are more likely. For example, women may experience shortness of breath, sharp chest pain, abdominal pain, nausea, neck or jaw pain, and/or vomiting. Symptoms of MI also may include fever and cool, clammy skin. Clients diagnosed with diabetes may be __________________when experiencing an MI

Answer 32

crushing, burning, constricting, or otherwise excruciating; asymptomatic

Question 33

The client has the right to the following:

Answer 33

to receive care that is respectful and considerate, privacy, information about treatment, and prognosis, as well as the right to refuse treatment.

Question 34

The EMTALA (Emergency Medical Treatment and Active Labor Act) requires that hospitals must

Answer 34

perform a medical screening examination on any person who comes to the hospital and requests care, and that clients should be stabilized before transfer to another facility.

Question 35

Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency Medical Treatment and Active Labor Act)? (Select all that apply.)

1. Client is not provided with advance directives information.
2. Client who reports dental pain is denied a medical screening.
3. Client’s protected health information is shared with those not participating in client’s care.
4. Client prepares to sell kidney to the highest bidder.
5. Client is transferred to another facility before attempts are made to stabilize client.

Answer 35

1) INCORRECT - The lack of information regarding advanced directives violates the Patient Self-Determination Act (PSDA).
2) CORRECT – Refusing to provide care violates EMTALA. All clients should receive medical screening examinations to determine whether emergency medical conditions exist.
3) INCORRECT - Sharing client’s information violates the Health Insurance Portability and Accountability Act (HIPAA).
4) INCORRECT - Private selling of organs violates the National Organ Transplant Act.
5) CORRECT– A client should not be transferred prior to stabilization or until the transferring hospital has provided medical treatments within its capability.

Question 36

TRUE OR FALSE LABOR

contractions are felt in the lower back and fetal movement will decrease

Answer 36

TRUE LABOR

Question 37

The client may also experience a rupture of membranes and bloody show.

TRUE OR FALSE LABOR

Answer 37

TRUE LABOR

Question 38

True labor starts when

Answer 38

the cervix begins to dilate and efface due to contractions that become regular and increase in intensity and frequency. Contractions initially begin in the back and radiate to the abdomen.

Question 39

Appropriate actions when providing care to a client in labor include

Answer 39

Assess labor onset and contraction pattern.

Assess cervical effacement and dilation.

Assess for bloody show or rupture of membranes.

Assess fetal station and presenting part.

Assess fetal response to uterine contractions.

Monitor vital signs.

Remind client to empty bladder often to assist in the progression of labor.

Assist with positioning during labor.

Prepare client for delivery of fetus.

Notify health care provider of transition phase and imminent delivery.

Question 40

TRUE LABOR CHARACTERISTICS

Answer 40

Regular uterine contractions that are increasing in frequency, intensity and duration

Rupture of membranes

bloody show

discomfort radiates from back around the abdomen

contactions do not decrease with rest

cervix progressively effaced and dilated

Question 41

FALSE LABOR CHARACTERISTICS

Answer 41

cervical changes do not occur

contractions that are irregular with no change in frequency, duration or intensity

discomfort is usually abdominal

contractions may lessen with activity or rest

Question 42

Movement usually decreases with the onset of labor.

TRUE OR FALSE

Answer 42

TRUE

Question 43

Breastfeeding: Placing ____________-to nipples can reduce discomfort, and _________can be used for dry or cracked nipples. The mother needs to ensure nipples stay dry. If leaking of milk occurs, apply pressure to nipples or use nursing pad (not plastic ones though because they retain moisture and can increase the risk for yeast infection)

Answer 43

ice; lanolin

Question 44

Breastfeeding Principles TRUE OR FALSE

Soap on nipples during bathing and washing is okay

Answer 44

FALSE

Soap causes drying and removes protective oils. Apply breast milk to nipples after feedings because breast milk has healing properties.

Question 45

Breastfeeding Principles:

TRUE OR FALSE

Warm compresses help milk to flow more quickly.

Answer 45

TRUE

TRUE

Question 46

Normal WBC count is ______________________/mm3

Answer 46

4,500 to 11,000

Question 47

What to remember about electroconvulsive therapy (ECT) or electroshock therapy - what important side effect is there to remember?

Answer 47

A client who undergoes electroshock therapy (ECT) may suffer from retrograde amnesia. The client may report difficulty recalling events immediately before ECT, in the weeks or months before treatment, or in the previous years before treatment (rare). The nurse can reassure the client that these memory problems usually improve within a couple of months after treatment ends. The nurse should also keep in mind that on the days of an ECT treatment, some clients may experience headaches, jaw pain, muscle aches, or nausea.

Electroconvulsive therapy (ECT), or electroshock therapy, is performed for major depressive disorder or mania, as well as for some clients with Parkinson disease to improve motor function. Scalp electrodes are placed and a seizure is induced using low-voltage alternating current to the brain. ECT involves several treatments over a period of 4 to 6 weeks. Informed consent should be obtained before the procedure. Ensure that NPO status has been maintained for the past 8 to 10 hours, since the procedure is done under general anesthesia. Once the seizure is over, obtain vital signs and level of consciousness. Monitor client during the postictal phase of recovery.

Question 48

What is Hantavirus pulmonary syndrome ?

Answer 48

a disorder caused by exposure to rodents who carry the virus and results in severe cardiopulmonary illness. Those at risk for developing this disorder include individuals who live in rural areas and are exposed to rodents and their droppings. Signs and symptoms include fever, aching muscles, nausea, and shortness of breath. Complications associated with HPS include thrombocytopenia, hemoconcentration, and cardiopulmonary compromise.

The nurse caring for a client infected with Hantavirus pulmonary syndrome (HPS) knows that the this virus primarily attacks the circulatory and pulmonary systems. HPS can cause hemorrhagic fever, which causes the client to bleed from access sites and mucous membranes. This client should be thoroughly assessed for any signs of bleeding from the gums, intravenous insertion sites, and gastrointestinal and urinary tracts. If the client experiences hemorrhagic fever, the client may develop renal failure secondary to shock. However, the risk of bleeding poses a more acute risk of harm to the client.

Hemorrhagic fever: Any of a group of infectious diseases that interfere with the blood’s ability to clot.

Question 49

In a primigravida, the progress of labor is ____________________________________The normal progression of labor is at ___________cm cervical dilation per hour for a primigravida.

Answer 49

cervical effacement, followed by descent and dilation; 1 to 1.2

Question 50

A newborn should have_______________-wet diapers per day

Answer 50

six to eight

Adequate fluid balance is determined by the number of saturated diapers per day.

Question 51

Breastfeeding Principles: Encourage the mother to feed the infant on demand, at least every ____________-hours for a newborn

Answer 51

3

Question 52

Breastfeeding Principles: Proper latch-on can be assessed by listening for ________________-during feeding.

Answer 52

swallowing

Developmentally, the infant who is able to swallow without difficulty when being breastfed is most likely receiving adequate nutritional intake.

Swallowing is also indicative of the presence of milk; if the infant sucks without swallowing, the infant should be moved to the other breast or breastfeeding session is stopped.

Question 53

The client recovering from gastric surgery is at risk for developing ___________________-, which occurs when ingested carbohydrates move too rapidly into the small intestines.

Answer 53

dumping syndrome

Reclining after eating is recommended to delay the gastric emptying process

Question 54

Gastric surgery - ______________is the most common reason for this procedure. Other gastric surgeries are for resection for ulcers, gastric bypass surgery (Roux-Y) or for congenital reasons, such as pyloric stenosis. Surgery performed to remove the entire stomach is called a ____________, but a partial gastrectomy also may be performed.

Answer 54

Cancer; gastrectomy

Question 55

Medication administration includes the following:

Answer 55

Prepare medication, correctly calculating dose as needed.

Check for medication incompatibilities and interactions.

Verify the rights of medication administration, which minimally include right client, right medication, right time, right dose, right route, right site, and right documentation.

Check allergies and identify the client following institutional policy.

Inform the client about the medication, the reason for its administration, and how and when effectiveness will be determined.

Assist client with positioning.

Document the medication administration according to institutional policy.

Assess for expected outcomes for the administered medication.

Question 56

With an allergic reaction, a client may report __________________ A client may also exhibit skin dryness, redness, or rash, conjunctivitis, and hives.

. The nurse needs to educate the client about the need to avoid exposure to known antigens and to take prescribed medications to help reduce the allergic response.

Answer 56

itching, burning, and hay fever-like symptoms (itchy, watery eyes, sneezing)

Question 57

Amputation

Answer 57

Depending upon the height of the amputation, the client may be immediately considered for a prosthesis or fitting may be delayed. Regardless of the timing, the residual limb must be cared for to support the future prosthetic device. This includes ensuring proper wound healing, preventing infection, and molding of the stump for correct fitting of the prosthesis. Psychologically, the nurse understands that the client is dealing with a loss and will experience grief over loss of function and changes in physical appearance. The nurse will utilize therapeutic communication and the art of caring to meet the client’s psychological needs.

When caring for a client with an amputation, the nurse should administer pain medications and evaluate effectiveness, especially before and after moving client or carrying out procedures. Teach about relaxation, visualization, and deep breathing to reduce anxiety and pain. Splint and support the affected area, elevating to reduce edema, and specific positioning to maintain limb function. Turn and reposition frequently and provide range of motion exercises. Provide nutritional support for healing. Assess wound during dressing changes and report excess bleeding or sign of infection; use aseptic technique. Compression dressings are used to reduce edema and facilitate use of a prosthetic device. Teach client/family to care for skin, use elastic wraps, and massage site after wound heals. Use active listening to help client/family grief loss.

Question 58

The nurse in a community clinic evaluates a client diagnosed with type 1 diabetes mellitus. Which observation indicates to the nurse that the client is not rotating insulin injection sites?

1. Wheal present at an injection site.
2. Discomfort at an injection site.
3. Glucose levels rise temporarily.
4. Increased muscle mass at an injection site.

Answer 58

1) INCORRECT — A wheal (a red, swollen mark) at an injection site indicates an allergic reaction to the insulin.
2) INCORRECT — Repeated injections into the same site become less painful rather than more uncomfortable.

3) CORRECT — Failure to rotate sites results in poor absorption of the insulin, which increases the blood glucose level.

4) INCORRECT — Increased muscle mass is not a complication of repeated insulin injections in the same site. Lipodystrophy, or an increase or decrease in fatty tissue, may occur.

Question 59

Insulin Injection - what to teach client ?

Answer 59

Clients diagnosed with diabetes mellitus are often required to perform self-injection of prescribed insulin. The nurse teaches the client to use sites on the front of the body. The abdomen absorbs insulin the fastest, followed by the arms, thighs, and buttocks. The client is reminded to keep a record of which injection sites are used and to rotate appropriately so that absorption is not negatively affected. It is best to use the teach-back method to verify the client understands what was taught.

Content Refresher

Assess the client’s knowledge of acceptable subcutaneous insulin injection sites (upper arms, abdomen, thighs, and buttocks). Instruct the client to think of the abdomen as a checkerboard, with each 0.5 to 1 inch (1.27 to 2.5 cm) square representing an injection site. Instruct the client to rotate injections systematically across the “checkerboard” and to use the shortest needle desired and insert the needle at a 45- to 90-degree angle. Additionally, teach the client about the different types of insulin prescribed, including onset, peak, and duration. Teach the client symptoms of hypoglycemia, such as trembling, weakness, and fatigue, and the time frame in which these manifestations most likely will occur.

Question 60

A skin lesion that is a different ___________________-could indicate skin cancer. The characteristics of malignant melanoma include an________________________

Answer 60

color, texture, and size; irregular surface and have various colors

Question 61

Primary prevention includes activities that _________________, such as giving immunizations

Answer 61

promote health and prevent illness

Question 62

A disease that affects the neuromuscular junction, interrupting the communication between nerve and muscle, causing weakness. Clients may have difficulty breathing, moving their eyes, speaking clearly, swallowing, and walking, depending on the severity and distribution of weakness.

Answer 62

Myasthenia Gravis

Question 63

What is schizoprenia ?

Answer 63

A thought disorder that affects a person’s thinking, language, emotions, behavior and ability to accurately perceive reality

Assessmnet: Withdrawal from relationships and the world

flat affect

inappropriate display of feelings

inability to meet basic needs

poor reality testing

hallucinations

delusions

Question 64

How should the nurse respond to a client’s hallucinations?

Answer 64

Express empathy- it must be difficult for you

Validate reality - I don’t see or hear them though

Do not challenge client’s beliefs or assertions

They are very “real” to clients who experience them, and there’s little point in arguing with them about their delusions or false beliefs. Instead, move the conversation along to areas or topics upon which both the nurse and the client agree.

Question 65

Recommended diet for hypertension

Answer 65

a diet low in salt and fat with limited protein.

Question 66

Recommended diet for client with anemia

Answer 66

Diet high in protein, iron and vitamins

Question 67

Liver disease diet recommendations

Answer 67

a diet of increased carbohydrates, low protein, and low sodium is recommended.

Question 68

Recommended diet for those with kidney disease

Answer 68

a diet with limited protein and restricted potassium, sodium, and phosphorus is recommended

Question 69

When providing care for a client with iron deficiency anemia, the nurse should:

Answer 69

Administer iron supplements as ordered with vitamin C.

Maintain the client’s safety if dizzy, weak, and lightheaded.

Monitor for constipation when giving iron supplements, and teach the client to eat a diet high in fiber and roughage.

Educate the client about foods rich in iron, such as red meats and poultry, beans, dark green leafy vegetables, and fortified cereals.

Question 70

A neonate born to a woman with diabetes mellitus (DM) is at risk for ____________________ due to in utero exposure of high glucose levels. As a result, many newborns experience a period of _________________ after birth as maternal glucose is withdrawn and excessive insulin remains. Signs of hypoglycemia in a newborn include___________________________. Treatment of hypoglycemia is critical as low blood glucose levels can lead to seizures and serious injury to the brain

Answer 70

hyperinsulinemia; hypoglycemia; tremors, poor muscle tone, lethargy, hypothermia, and difficulty feeding

Question 71

How does a mother’s diabetes affect a fetus ?

Answer 71

While in utero, the fetus becomes accustomed to a higher blood glucose level, and the fetus’ pancreas reacts accordingly. Upon delivery, the amount of glucose being provided through the umbilical cord ceases. The newborn’s insulin production needs to adjust to the lower blood glucose level. Prior to a decrease in insulin production by the newborn, the nurse will carefully monitor for the symptoms of hypoglycemia (Blood glucose value of less than 30 mg/dL in a neonate.)

- Tremors, poor muscle tone, lethargy, hypothermia, and difficulty feeding.

Large birth weight (macrosomia) is expected in an neonate born to a client diagnosed with DM. Fetal hyperglycemia stimulates production of insulin to metabolize carbohydrates, which results in excess nutrients being transported to the fetus.

Question 72

What is a 24 hour urine test and creatinine clearance test ?

Answer 72

24-hour urine protein measures the amount of protein released in urine over a 24-hour period.

How the Test is Performed

A 24-hour urine sample is needed:

On day 1, urinate into the toilet when you get up in the morning.

Afterward, collect all urine in a special container for the next 24 hours.

On day 2, urinate into the container when you get up in the morning.

Cap the container. Keep it in the refrigerator or a cool place during the collection period.

Label the container with your name, the date, the time of completion, and return it as instructed.

Almost all creatinine in the blood is excreted by the kidneys. The creatinine clearance is the most accurate indicator of kidney function. Blood will be drawn for the creatinine clearance test.

Creatinine is a waste product of muscle breakdown. A client should not engage in strenuous exercise during, or just before, the test.

It is appropriate to drink during the test so that urine is being produced.

For this test after discarding the first voiding, the time is noted and all urine is saved for 24 hours in the special container.

Question 73

Assessment of urine output is performed routinely. It is a measurement of ____________-function as well as ____________-function. The color, amount, and consistency should be assessed. Urine output is also used as a diagnostic test for electrolytes, glucose, protein, and infections. A comparison between _______________levels in urine and serum can indicate kidney function.

Answer 73

kidney; cardiac; creatinine

Question 74

Naegeles Rule

Answer 74

Subtract 3 months from the date of the first day of the last normal menstrual period (October 11 - 3 months = July 11th), add 7 days (July 11th + 7 days = July 18th), and then correct the year.

The Naegele rule gives the nurse a reliable indicator of the client ’s due date. However, the nurse teaches the client that this is an estimate. More accurate dates are obtained during the pregnancy via ultrasound measurements of fetal growth, which take into account bone length and estimated weight. The actual birth date depends on multiple maternal, fetal, and placental factors. Additionally, the baby can be born within a window of 3 to 4 weeks around that due date and still be considered a full-term, “on time ” newborn.

Question 75

In addition to the Naegele rule, methods used to calculate the estimated date of delivery (EDD) include ___________________________.

Answer 75

ultrasonography and fundal height measurement.

Ultrasonography provides an estimate of fetal age based on head measurements. To measure fundal height, a flexible, non-stretchable tape measure is used to estimate the distance between the fundus and the top of the pubic bone. When gestational age is between 12 and 14 weeks, the fundus is typically palpable just above the level of pubis symphysis. By 20 weeks gestation, the fundus usually reaches the level of the umbilicus (approximately 20 cm). Fundal height rises about 1 cm per week until 36 weeks, after which it varies.

Question 76

What to do when a nurse has a non-English speaking client and must work with an interpreter

Answer 76

When working with an interpreter, the nurse must remember that the content will be translated. The best way to ensure that the context of the conversation is correct is to use short sentences or simple phrases, avoid jargon since this can be misinterpreted, and ask one question at a time to limit confusion.

Phrase questions so that there is only one answer at a time (i.e. “Are you having any nausea?” instead of “Are you having any nausea, vomiting or stomach pain?”).

It may take longer to directly say or explain something in non-English. This may occur when the word and/or concept has no equivalent in the other culture, when the topic is seen by the other culture as embarrassing or taboo, or when there are dialect differences.

The nurse should look directly at the client. This reinforces the nurse’s interest in client, ensures communication flow between the nurse and the client, and allows for observation of nonverbal behaviors

Question 77

For full-term infants, energy requirements are _____________calories/kg/day.

Answer 77

120

Question 78

Introduction of solid foods to infants - basic principles

Answer 78

When introducing solid foods (starting at 4 to 6 months of age), introduce only one solid food at a time for each 2-week period and evaluate for tolerance and allergies.

The least allergenic foods are given in the first 6 months of life. More allergenic foods (e.g. eggs) are offered in the second half of first year.

The usual order of food introduction is: cereal, fruit, vegetables, potatoes, meat, egg, and orange juice. No honey should be given during the first year due to the high risk of botulism

Question 79

Fruit juice offers no nutritional benefit to infants younger than 6 months of age. Infants younger than 6 months of age should only receive breast milk or infant formula.

TRUE OR FALSE

Answer 79

TRUE

Question 80

Early symptoms of gastric cancer tend to be vague, such as pain relieved by antacids. As the tumor grows, a client may experience ________________________-.

Since gastric cancers are usually adenocarcinomas, which arise from the inner layer of the stomach, the cancer often spreads to the lymph nodes and metastasizes to the liver, pancreas, esophagus, and duodenum. Treatment may include endoscopic removal of the tumor, subtotal or total gastrectomy, radiation, and chemotherapy.

Answer 80

a loss of appetite, indigestion, nausea and vomiting, a bloated feeling, weight loss, and pain just above the umbilicus

Question 81

Stage 1 of labor is

Answer 81

beginning to complete cervical dilation

there are 3 phases

Phase 1 (latent): 0-3 cm; contractions 10-30 sec long, 5-30 min apart; mild to moderate.

Phase 2 (active): 4-7 cm; contrations 45-90 sec long, 3-5 min apart; moderate to strong. client becomes doubtful of the ability to control pain

Phase 3 (transition): 8-10 cm; contractions 45-90 sec long, 1.5-2 min apart; strong. copious amount of bloody show

Question 82

True labor starts when

Answer 82

the cervix begins to dilate and efface due to contractions that become regular and increase in intensity and frequency. Contractions initially begin in the back and radiate to the abdomen

Assess labor onset, contraction pattern, and cervical effacement and dilation. Observe for bloody show or rupture of membranes. Assess fetal station, presenting part, and fetal response to uterine contractions. Monitor vital signs. Remind the client to empty the bladder often to assist in the progression of labor. Assist with positioning during labor. Prepare the client for delivery of the fetus. Notify the health care provider of the transition phase and imminent delivery.

Question 83

The nurse is aware that active labor routinely lasts ________________-hours, or more. _________________contractions (e.g. in abdomen and groin), which the client may have experienced throughout pregnancy, may become ___________and more _____________-as impending labor begins. In true labor, contractions are felt in the ____________–.

Answer 83

4-8; Braxton Hicks; stronger; frequent; lower back

During labor, the nurse is expected to keep the client informed of progress, keeping in mind that every labor is unique. The nurse should be able to distinguish between true and false labor, understanding that contractions become longer, stronger, and closer together in true labor. True labor also involves increased effacement and dilation.

Question 84

Rule for conducting infant assessment

Answer 84

Conducting a physical assessment on an infant can be challenging because of the client’s size and activity. Before beginning, the nurse should categorize assessment activities into those that cause the least amount, and the most amount, of disruption to the client.

The ones that cause the least amount of disruption should be completed first. These may include listening to heart, lung, and bowel sounds. As the assessment progresses, the nurse should conclude with those activities that are the most disruptive such as assessing the eyes, ears, and mouth.

Question 85

Wounds heal by ____________ or ______________intention.

Answer 85

primary or secondary

Primary intention involves suturing or stapling the incision and healing occurs by connective tissue growth.

Secondary intention involves the formation of granulation tissue at the base of the wound, allowing the wound to heal from the inside without surgical closure. The wound bed should be pink or red and moist without evidence of necrosis, tunneling, or undermining.

Question 86

________ technique is another term for clean technique.

Answer 86

Aseptic

Preparation for changing this type of dressing is to perform hand hygiene to remove microorganisms from the surface of the hands. Sterile gloves are not used when performing a dressing change using aseptic technique. The wound does not need to be covered at all times. The client should use the prescribed medications on the wound.

Question 87

Cushing syndrome occurs when the body makes or is exposed to excess ___________, which is a hormone that helps the body respond to ____________. Cortisol alters how the body uses ____________________. Excess cortisol contributes to osteoporosis, causes increased blood pressure and cholesterol, and may cause obesity and diabetes mellitus.

Answer 87

cortisol, stress; carbohydrates, lipids, and proteins

For the client diagnosed with Cushing syndrome, poorly managed symptoms place the client at serious risk of heart disease. Diet and exercise are essential to management and prevention of complications such as myocardial infarction and peripheral vascular disease.

Question 88

Signs & Symptoms of Cushing’s

Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS hormone CORTISOL)

Answer 88

Skin fragile

Truncal obesity with small arms

Rounded face (appears like moon), Reproductive issues amennorhea and ED in male(due to adrenal cortex’s role in secreting sex hormones)

Ecchymosis, Elevated blood pressure

Striae on the extremities and abdomen (Purplish)

Sugar extremely high (hyperglycemia)

Excessive body hair especially in women…and Hirsutism (women starting to have male characteristics), Electrolytes imbalance: hypokalemia

Dorsocervical fat pad (Buffalo hump), Depression

Question 89

What kind of diet should someone with Cushing’s Syndrome be on ?

Answer 89

Low Carbohydrate, Low Calorie, High Protein, Low Sodium, High Potassium

Question 90

Cushing syndrome affects most body systems and results from chronic exposure to corticosteroids. The most common features of Cushing syndrome include

Answer 90

weight gain and accumulation of adipose tissue in the trunk (centripetal obesity), the face ( “moon face ”), and the cervical region ( “buffalo hump ”). Additional features of Cushing syndrome include hyperglycemia, hypervolemia, hypertension, weakness, muscle wasting, back pain, osteoporosis, weak or thin skin that bruises easily, petechial hemorrhages, purple striae on the abdomen, facial redness, acne, hirsutism, hyperpigmentation, poor wound healing, glycosuria ,hypercalciuria (which may lead to kidney stones), insomnia, anxiety, and depression.

Question 91

The American Heart Association recommends a sodium intake of less than _____________mg per day

Clients on sodium restriction are generally limited to __________-mg per day. The minimum needed intake is _________mg per day.

Answer 91

3000; 2000; 500

Question 92

The nurse should inform the client that food sources low in sodium include

Answer 92

rice, dried beans, peas and lentils, light turkey, avocado, raw broccoli, potatoes, apples and bananas.

Question 93

Side effects of Antiretroviral therapy

Answer 93

Antiretroviral therapy (ART) has saved many lives, but it is not without its drawbacks. Adherence to the medication regimens is difficult due to significant and unpleasant side effects and the price of the medication.

ART also leads to negative metabolic effects. For example, hypertriglyceridemia, dyslipidemia, and insulin resistance are common adverse affects of this therapy, resulting in an increased risk of myocardial infarction. With advances in ART, HIV and AIDS are now chronic illnesses, allowing the client time to develop significant cardiac disease as a comorbidity.

Content Refresher

No effective cure currently exists for HIV, but it can be controlled and treated with antiretroviral therapy (ART). Adherence to the prescribed ART regimen can dramatically prolong the lives of many people infected with HIV, keep them healthy, and greatly lower their chance of infecting others. ART is used to keep the viral load low and the CD4 count high. Adherence to the medication regimen is challenging for many clients due to the various side effects and the cost.

Question 94

Long-term ART leads to _____________________–, possibly due to chronic stress

Answer 94

hyperlipidemia and cardiovascular disease

Question 95

a low potassium level can cause life-threatening _____________________.

Answer 95

cardiac dysrhythmias

Because of this, the client should be immediately placed on continuous cardiac monitoring before administering the prescribed potassium replacement.

Question 96

Hypokalemia is caused by

what should the nurse assess for ?

Answer 96

decreased dietary intake, increased loss or a shift into the cells that can occur with alkalotic conditions, and the use of loop and thiazide diuretics. Gastrointestinal losses such as vomiting or diarrhea, nasogastric suctioning, potassium excreting diuretics, corticosteroids (drugs that retain sodium and therefore decrease potassium), malnutrition, or dietary lack of foods high in potassium. When caring for a client with hypokalemia, the nurse should assess for muscle weakness or paresthesias. Assess electrocardiographic changes such as U-wave or rhythm changes. Ask patient about symptoms such as palpitations. Treatment depends on severity of level and symptoms present. Supplemental potassium (oral or intravenous) is administered. Client should be taught about foods high in potassium, and if daily supplemental oral medications are needed, education about the medications should be included.

Question 97

When evaluating the effectiveness of a medication for a blood clot, the nurse looks for the reversal or absence of blood clot symptoms. A deep vein thrombosis (DVT) causes _____________________-Evidence of ______________restoration is a positive sign that the prescribed thrombolytic is working.

Answer 97

absent pulses distal to the clot, edema, erythema, and pain or absence of sensation; circulation

A deep vein thrombus causes an obstruction in a blood vessel, which results in decreased perfusion to extremities. Following treatment, the client should demonstrate increased signs of perfusion to extremities (e.g., warmth, pink color, and stronger pulses).

Question 98

If the child has a sibling with a history of stroke, screening for _________________is recommended in children ages ____________years.

Answer 98

hyperlipidemia; 2 to 8

Question 99

The younger a person is when diagnosed with a chronic health problem, the ___________-the predisposition for other family members to develop the disease process.

Answer 99

stronger

Question 100

Hypercholesterolemia

Answer 100

Hypercholesterolemia or hyperlipidemia is defined as an excess amount of cholesterol in the blood. Normal cholesterol levels should not exceed 200 mg/dL (5.18 mmol/L). Risk factors for the development of hypercholesterolemia include a family history, a diet high in fat, and a sedentary lifestyle. High cholesterol is diagnosed by a blood level of greater than 200 mg/dL (5.18 mmol/L). It is also important to have high density lipoproteins (HDL), low density lipoproteins (LDL), and triglycerides drawn. The HDL levels should be greater than 40 mg/dL (1.04 mmol/L) for males and 50 mg/dL (1.29 mmol/L) for females. The LDL levels should be less than 100 mg/dL (2.59 mmol/L) or 70 mg/dL (1.81 mmol/L) for very high risk clients. Triglyceride levels should be less than 150 mg/dL (1.69 mmol/L). Treatment of high cholesterol includes dietary management, weight reduction, and physical activity. Lipid lowering medications may also be prescribed.

Question 101

Excessive sodium intake (greater than 2 grams daily) _______________the risk for hypertension.

Answer 101

increases

Question 102

The American Heart Association recommends moderate activity for at least _________________________–.

Answer 102

30 minutes daily, 5 days per week

Question 103

Coffee use is a recognized risk factor for hypertension and should be limited

Answer 103

FALSE

Although caffeine may cause a spike (not a sustained increase) in the blood pressure of some people, coffee use is not a recognized risk factor for hypertension.

Question 104

Risk factors for hypertension

who is more likely to develop it ?

Answer 104

Risk factors for the development of hypertension include excessive sodium intake, a sedentary lifestyle, use of tobacco products, and excessive alcohol intake. Sodium increases the amount of body fluid, which can cause a subsequent increase in blood pressure. A sedentary lifestyle encourages hemo-stagnation in the extremities, which weakens blood vessels. Tobacco and nicotine directly effect the blood vessels, causing constriction. Alcohol alters fluid balance, which affects all body systems.

Content Refresher

Risk factors for hypertension include smoking, obesity, heavy alcohol consumption, sedentary lifestyle, increased cholesterol and triglycerides, stress, family history of hypertension, increased dietary sodium intake, and decreased dietary intake of potassium, magnesium, or calcium. In general, blood pressure typically increases with aging. However, hypertension is more common among men than women until 55 years of age; after age 55, this disorder is more common among women. Black men and women are more likely to develop hypertension than are individuals of other racial backgrounds.

Question 105

_________-ended, therapeutic communication techniques focusing on the client’s ____________encourages further verbalization.

Answer 105

Open; feelings

Question 106

Characteristics of therapeutic relationship

Answer 106

In addition to asking open-ended questions, the nurse also may use active listening to enhance communication. Active listening improves mutual understanding between the nurse and client.

A therapeutic relationship is one in which the relationship between the client and the caregiver is to promote and/or restore health. The relationship is based on caring, respect, and mutual trust. Failure to establish a therapeutic relationship could result in stress, poor communication, and an inability to achieve positive client outcomes. Be empathetic when listening and responding. Be respectful, genuine, concrete, and specific. Clarify misconceptions with a client. Consider family relationships and a client’s values. Maximize a client’s abilities to participate in decision making and treatments.

Question 107

The nurse may delegate components of client care but does not delegate the _________________-itself. The five rights of delegation include _______________________.

Answer 107

nursing process; right task, right circumstances, right person, right communication, and right supervision

Question 108

True or false

The UAP can transport specimens to the laboratory.

Answer 108

TRUE

Question 109

Amoxicillin is a penicillin antibiotic. Determine if the client is allergic to ________________–antibiotics because cross-reactivity can occur.

Answer 109

cephalosporin

Stress the importance of taking the medication as prescribed and finishing the entire course of antibiotic therapy, even after the client starts to feel better.

Question 110

Heparin is an anticoagulant. Herbal supplements such as ___________________________ may increase the client’s risk for _______________. Monitor the client’s partial thromboplastin time (PTT) to evaluate the effects of heparin. Assess the client for bruising and bleeding

Answer 110

garlic, ginger, ginkgo, ginseng, and licorice; bleeding

Question 111

The scope of practice for unlicensed assistive personnel (UAP) includes completing __________________________

Answer 111

standard, unchanging tasks and providing basic care for stable clients.

Question 112

The nurse knows that in the older adult client, ______________–is a common cause of elevated serum BUN

Answer 112

dehydration

Blood pressure assessment is most helpful when evaluating the client’s fluid volume status. Elevated serum BUN may also occur due to renal dysfunction, in which case the client would require evaluation with additional laboratory and diagnostic tests.

Question 113

Causes of dehydration -

what are some symptoms

Answer 113

Causes of dehydration include inadequate fluid intake, diarrhea, vomiting, and disorders that result in fluid losses (e.g. diabetes mellitus, diabetes insipidus, fluid shifts, burns, and hemorrhage). Certain medications, such as diuretics, may cause dehydration. Signs and symptoms of dehydration include thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy. Treatment includes oral and/or IV fluids and electrolyte replacement. Evaluate the client’s response to fluid therapy by monitoring urine output, lung sounds, blood pressure and pulse, and laboratory values (e.g. blood and urine chemistry, urine specific gravity, complete blood count, and serum osmolality).

Question 114

Vaginitis

Answer 114

An inflammation of the vagina that results from a bacterial, fungal, or parasitic infection. Low estrogen and sexual activity may also cause vaginitis. Normal acidic urine can cause burning if labial tissues are inflamed because of a vaginal infection or injury.

Clients with vaginitis typically complain of unusual vaginal discharge, itching, burning, and sometimes pain.

Assessment should include past history of sexual activity, recent antibiotic use, and determining if client is experiencing fever, chills, or pelvic pain. Painful urination may also be present. It is important to determine if the client is pregnant. A pelvic exam may be required to examine the vagina for inflammation and abnormal discharge. Samples of discharge are taken for identification of infective pathogen.

Question 115

Therapeutic Communication Techniques

Answer 115

The nurse needs to use therapeutic communication when caring for this client. Therapeutic communication includes the following communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad open statements, 6) asking about thoughts/feelings, 7) restating and reframing, 8) reflecting, 9) presenting reality, 10) sharing observations, and 11) clarifying meaning.

The nurse needs to avoid non-therapeutic communication techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial.

Question 116

A client scheduled for a CT scan says to the nurse, “The health care provider had me sign that form for the scan. I thought I understood what was said, but now I ’m not so sure. ” Which is the best response by the nurse?

1. “What is it that you are not sure you understand? ”
2. “I ’ll contact the health care provider so that you can get your questions answered. ”
3. “Maybe I can help you. ”
4. “There is nothing to this test. ”

View Explanation

Answer 116

1) CORRECT— This response specifically addresses the client ’s concerns so they can best be addressed. The nurse can clarify questions after the HCP has explained benefits and risks of the procedure to the client.

2) INCORRECT - This is not appropriate because the nurse should identify the client ’s concerns and try to address them.
3) INCORRECT - This is not the best response because the tone is tentative and does not directly elicit the client ’s specific concerns.
4) INCORRECT - This is a nontherapeutic response, and is dismissive of the client ’s feelings and concerns.

Think Like A Nurse: Clinical Decision Making

The nurse understands that having a diagnostic test can be overwhelming to a client. Even though the health care provider reviewed the procedure and obtained informed consent, the client may still need clarification about what is going to occur. The nurse should consider the client’s anxiety level and ask the client to explain what exactly the client would like to know. The nurse is able to review the procedure and preparations needed for a successful test and answer any questions the client may have. The need for in-depth information may require input from the health care provider. The nurse should not attempt to provide information beyond the nurse’s scope of practice or understanding.

Question 117

Pneumonia Symptoms

Answer 117

When diagnosed with pneumonia, the client may exhibit tachypnea, crackles in lung fields, use of accessory muscles, pallor, confusion, cyanosis, and diaphoresis. The client may also exhibit restlessness, orthopnea, diaphoresis, and nasal flaring. In addition, the client may report generalized weakness, lack of energy, and inability to perform activities of daily living. Other symptoms may include shortness of breath, chest pain (especially on breathing in deeply), fever, and cough. Diagnostic testing may include auscultation of lungs with stethoscope, chest X-ray, or computed tomography

Question 118

Certain health problems ______________the risk of developing pneumonia.

Answer 118

increase;

The client with cystic fibrosis is at risk because the disease causes a chronic lung disorder. Pain of a fractured rib would be exacerbated by deep breathing and coughing. Shallow breathing with this disorder increases the risk for the development of pneumonia.

Being in musculoskeletal traction reduces lung expansion and promotes stasis of pulmonary secretions, increasing the risk for pneumonia.

Question 119

The pain of a fractured rib causes ___________breathing and easily leads to pneumonia due to ___________of lung expansion.

Answer 119

shallow; lack

Question 120

Why do we give bronchodilators before corticosteroids?

Answer 120

Albuterol is a bronchodilator that opens the passageways so the steroid medication, beclomethasone, can get into the bronchioles

Steroids will not be able to penetrate unless the bronchioles are opened by the bronchodilator first

The medication that dilates the bronchioles (albuterol) should be used first, so that the second medication, the corticosteroid, will have the maximum effectiveness to reduce inflammation.

The nurse educates the client to wait 1 to 2 minutes between administering each dose of the bronchodilator inhaler to allow the subsequent dose to reach deeper into the lungs.

Question 121

What can be done to prevent varicose veins ?

Answer 121

Varicose veins are common during pregnancy

The client should not cross legs at the thighs

wear support hose or elastic stockings and apply them before getting out of bed each morning.Don’t wear constrictive clothing or tight fitting socks

Elevation of the legs higher than 3 to 6 inches above heart level prevents varicose vein formation.

Frequent position changes prevents varicose veins.

Strategies to prevent or reduce varicose veins include avoiding high heels, elevating the legs, avoiding standing for long periods, increasing fiber and reducing sodium in the diet, and avoiding tight socks or stockings.

Question 122

Transdermal medication patch principles

Answer 122

The nurse should use clean water to cleanse the skin. The nurse should not use soaps, lotions, oils, or alcohol, as these substances may cause irritation or prevent adhesion.

Heat application should be avoided with transdermal medication administration. Heat causes vasodilation of skin blood vessels, which increases the absorption of medication and can lead to toxicity.

The nurse folds the old patch in half with sticky sides together.

Transdermal patches retain enough medication to be hazardous to pets and children. Folding in this manner ensures that the medication is sealed inside before disposal.

Medication patches deliver doses transdermally, or across and through the dermal surface into circulation. They must be placed in an area that will have rich circulation. Bony prominences like shoulder blades should be avoided. Patches can be irritating, so sites are rotated, patches are dated and initialed when applied, and placement is documented. Disposing of a medication patch depends on facility policy, but it should not be left open because this increases the risk that someone will touch it and absorb the medication.

Question 123

What are the four elements of malpractice ?

Answer 123

Injury, causation, duty, breach of duty

Causation (nurse conduct causes injury)

Duty (legal relationship between nurse and client)

Question 124

When does malpractice occurs ?

Answer 124

Injury, causation, duty, breach of duty are the four elements of malpractice

Causation (nurse conduct causes injury)

Duty (legal relationship between nurse and client)

Malpractice occurs when a nurse fails to act as a competent nurse normally would act in the same situation and this results in client injury. Failing to enact immediate steps in response to an emergency, using equipment incorrectly, and administering medication without following prescribed parameters or protocols are all instances of potential malpractice. Examples of negligence in nursing might include failing to call for the code team in response to a client who demonstrates agonal respirations or administering digoxin to a client whose heart rate is 48 beats per minute.

Content Refresher

Acts of negligence include carelessness, delivery of substandard client care, or failure to adhere to standards of care. When an individual commits negligence while serving in a professional capacity, the negligent act may constitute professional malpractice. If the nurse is uncertain about a specific protocol or procedure, reviewing the agency ’s written policy is essential. If the nurse lacks knowledge about a specific client intervention, necessary preparation includes seeking out appropriate resources prior to implementing an intervention. The nurse must maintain knowledge of current clinical guidelines and recommendations related to quality and safety improvements.

Question 125

the nurse needs to know that the client who adheres to strict Judaism dietary laws will not consume __________________products in the same meal.

Answer 125

meat and dairy

Question 126

Principles of Cultural Competency

Answer 126

The nurse should determine the client’s food intake, food preferences, recent weight changes, and health history and medications, as well as activity level and religious/cultural practices. Cultural diversity defines groups of individuals (religious, racial, ethnic, and/or social groups) with different values, beliefs, traditions, customs, behaviors, and/or language.

Assess client/family attitudes, beliefs, and values about food including cultural values and beliefs. The nurse will complete a cultural assessment. This includes an ethnohistory (cultural orientation and background), family structure, education, communication patterns (e.g. eye contact), and nutritional practices along with spiritual and religious beliefs. The nurse should incorporate cultural practices when providing care.

Question 127

For clients practicing Judaism, dietary laws based on biblical and rabbinical regulations forbid the consumption of these products during the same meal?

Answer 127

dairy and meat products during the same meal.

Question 128

Torticollis

Answer 128

A rare condition in which the neck muscles contract, causing the head to twist to one side.

Question 129

Symptoms of PCP use

Answer 129

The symptoms of blank stare, rigid muscles, ataxia, and nystagmus that are both vertical and horizontal indicate probable PCP intoxication. Aggression in all forms is another symptom that manifests with PCP use. This can take the form of assault, belligerence, impulsiveness, or suicidality, and it is very often bizarre in nature. It often occurs in unpredictable outbursts. PCP use causes increases in blood pressure, temperature, and pulse. An overdose could even lead to a hypertensive crisis. Hyperthermia can also occur. Torticollis also.

Phencyclidine (PCP) is known by a variety of street names, including angel dust, wack, and ozone. Medical management of PCP intoxication is primarily supportive, and the nurse should provide treatment for agitated behavior, hyperthermia, and seizures. The nurse should closely monitor the client’s vital signs, including temperature. Deep sedation and endotracheal intubation may be needed if the client’s delirium is severe and compromises safety to self or staff. If PCP ingestion is recent (less than 60 minutes), gastrointestinal decontamination may be warranted. If the client is symptomatic, the health care provider may prescribe activated charcoal (1 g/kg), and the activated charcoal may be repeated every 4 hours for several doses.

Question 130

Symptoms of Opiate withdrawal

Answer 130

Nausea, vomiting, abdominal cramping.

Question 131

What to remember about flail chest

Answer 131

Flail chest results from fracture of multiple adjacent ribs, thus causing the chest wall to become unstable. Paradoxical movement occurs during breathing (i.e. the affected side goes in with inspiration and out during expiration) and ventilations become inadequate. Administer supplemental oxygen. Administer prescribed analgesia to help promote adequate respiration. Endotracheal intubation and mechanical ventilation may be necessary. With time, the lung parenchyma and fractured ribs heal, but surgery may be necessary to repair traumatic injuries.

Nursing care for the client diagnosed with flail chest is complex. Aggressive pain management is essential to decrease the discomfort associated with chest movement and allow for effective ventilation. An inability to effectively cough due to pain causes impaired airway clearance, which leads to retention of pulmonary secretions and atelectasis. Oropharyngeal suctioning may be needed and deep breathing is essential. Hypoventilation causes retention of carbon dioxide which, in turn, leads to respiratory acidosis. Endotracheal intubation and mechanical ventilation may be necessary. Metabolic acidosis also may develop due to inadequate tissue perfusion. Prioritize airway, breathing, and circulation. Monitor the client ’s oxygenation status, including physical assessment findings, pulse oximetry readings, and arterial blood gas measurements. Careful monitoring of urine output and electrolyte balance is also required.

Question 132

Education for caregivers and parents on how to modify the environment to prevent injury and promote safety is an important goal for health care providers. For the home with an infant and toddler, appropriate information may include:

Answer 132

Safe use of car seats.

Storage of all potentially hazardous materials (including household cleaners and medications) in locked areas.

Hazards associated with swallowing and choking as solid foods are introduced.

Fall risk due to walking and climbing.

The use of child-proof locks and electrical plug covers.

First aid for injuries and the need for follow-up x-rays if fractures are suspected.

Question 133

Risk factors associated with hormonal contraceptives include an

Complications of using hormonal contraceptives include

Answer 133

increased risk of cervical and breast cancers, increased risk of heart attack and stroke, migraines, higher blood pressure, gallbladder disease, infertility, and benign liver tumors.

blood clots, breast tenderness, decreased libido, headaches, intermenstrual spotting, missed periods, mood changes, nausea, and weight gain.

Question 134

The nurse may inform the client of medications that can decrease the effectiveness of combined hormone contraception. These include ___________________________Medications that may increase the combined hormone contraception pill action include ________________________ Birth control pills can increase clotting factors and decrease the effectiveness of anticoagulants.

Answer 134

carbamazepine, phenytoin, amoxicillin, ampicillin, doxycycline, metronidazole, penicillin, tetracycline, and benzodiazepines.

acetaminophen, ascorbic acid, and fluconazole.

Question 135

Non-hormonal intrauterine devices (IUDs)

Answer 135

use copper to prevent pregnancy. The copper ions are toxic to sperm and also induce a thickening of cervical mucus, making sperm motility more difficult.

Question 136

Circumcision of the male client is defined as the removal of the foreskin of the penis. There are several medical benefits to male circumcision, including

Answer 136

a decreased risk for urinary tract infection, a decreased risk for penile cancer, a reduction in risk for penile problems (e.g., inflammation of the glans), a decreased risk for sexually transmitted infections (e.g., chancroid, HIV, HPV, herpes simplex virus type 2, and trichomonas), and ease of hygiene.

Adverse effects include amputation of the glans penis, infection requiring antibiotics, and meatal ulcer.

Question 137

The nurse reviews circumcision site care with the parents of a newborn client. The newborn was circumcised with a clamp. Which statement by the parent to the nurse indicates that teaching is successful?

1. “I will wipe off any discharge that appears using warm water and a gentle circular motion.”
2. “I will put petroleum jelly on a gauze pad and put that over the penis before I diaper him.”
3. “I will be sure the diaper fits snugly, but not too tightly, and that it is changed when wet.”
4. “I understand that it is normal for the first few days for the penis to look red or swollen.”

Answer 137

1) INCORRECT – Yellowish-white exudate appears on the second day. This is part of the granulation process. Do not remove or disrupt during cleaning of the area.
2) CORRECT – A small gauze pad with either petroleum jelly or medicated ointment is placed on the circumcision site as a dressing. This prevents the wound from adhering to the dressing or diaper. Dressing changes continue for 3 days after the procedure.
3) INCORRECT – The diaper should be loosely fastened to prevent friction, rubbing, or pressure against the tender penis, but it should be changed when wet.
4) INCORRECT – These are signs of infection. Penile edema can cause urinary obstruction. This is reported to the health care provider immediately.