QB 2 Flashcards

Question

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-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 1

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.

Answer 2

**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**

Answer 3

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

Answer 4

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.

Answer 5

bleeding and severe pain.

Answer 6

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.**

Answer 7

crushing, burning, constricting, or otherwise excruciating; asymptomatic

Answer 8

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

Answer 9

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.**

Answer 10

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.

Answer 11

TRUE LABOR

Answer 12

TRUE LABOR

Answer 13

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.

Answer 14

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.

Answer 15

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

Answer 16

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

Answer 17

ice; lanolin

Answer 18

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

Answer 19

4,500 to 11,000

Answer 20

**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 i**nvolves 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.

Answer 21

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 t**his 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.

Answer 22

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

Answer 23

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

Answer 24

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.

Answer 25

dumping syndrome Reclining after eating is recommended to delay the gastric emptying process

Answer 26

Cancer; gastrectomy

Answer 27

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.

Answer 28

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

Answer 29

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.

Answer 30

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.

Answer 31

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.

Answer 32

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

Answer 33

**promote health and prevent illness**

Answer 34

Myasthenia Gravis

Answer 35

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

Answer 36

**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.

Answer 37

***a diet low in salt and fat with limited protein.***

Answer 38

Diet high in protein, iron and vitamins

Answer 39

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

Answer 40

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

Answer 41

**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.

Answer 42

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

Answer 43

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.

Answer 44

**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.**

Answer 45

kidney; cardiac; **creatinine**

Answer 46

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**.

Answer 47

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.**

Answer 48

When working with an interpreter, the nurse must remember that the content will be translate*d. **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

Answer 49

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**

Answer 50

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

Answer 51

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

Answer 52

**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.

Answer 53

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.**

Answer 54

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.***

Answer 55

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.

Answer 56

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.**

Answer 57

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.

Answer 58

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

Answer 59

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

Answer 60

**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.**

Answer 61

3000; 2000; 500

Answer 62

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

Answer 63

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.

Answer 64

hyperlipidemia and cardiovascular disease

Answer 65

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

Answer 66

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.

Answer 67

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).

Answer 68

hyperlipidemia; 2 to 8

Answer 69

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.

Answer 70

30 minutes daily, 5 days per week

Answer 71

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.

Answer 72

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.**

Answer 73

Open; feelings

Answer 74

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.

Answer 75

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

Answer 76

cephalosporin ## Footnote ***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.***

Answer 77

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

Answer 78

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

Answer 79

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.

Answer 80

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).

Answer 81

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.

Answer 82

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.

Answer 83

**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.**

Answer 84

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

Answer 85

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.**

Answer 86

shallow; lack

Answer 87

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.

Answer 88

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.

Answer 89

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.**

Answer 90

Injury, causation, duty, breach of duty Causation (nurse conduct causes injury) Duty (legal relationship between nurse and client)

Answer 91

**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.

Answer 92

**meat and dairy**

Answer 93

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.

Answer 94

**dairy and meat products** during the same meal.

Answer 95

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

Answer 96

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.***

Answer 97

Nausea, vomiting, abdominal cramping.

Answer 98

**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. A**dminister 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.

Answer 99

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.

Answer 100

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.

Answer 101

carbamazepine, phenytoin, amoxicillin, ampicillin, doxycycline, metronidazole, penicillin, tetracycline, and benzodiazepines. acetaminophen, ascorbic acid, and fluconazole.

Answer 102

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.

Answer 103

**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.

Answer 104

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.