Chap 30. Which of the following is an expected finding during assessment of the older adult?
Visual acuity often lessens with age. Facial hair is likely to become coarser, not finer. The sense of smell becomes less, rather than more, acute. The respiratory rate and rhythm is regular at rest. However, both may change quickly with activity and be slow to return to the resting level.
Chap 30. Which of the following assessments would the nurse expect to find during a well-baby visit for a 12-month-old infant?
Physical assessment of the infant requires a strong knowledge of child growth and development. It is expected that a 12-month-old infant will have a partially open anterior fontanel. It should be fully closed by 18 months of age. Infants can visually follow objects by the age of 4 weeks. The 12-month-old infant is expected to crawl and to show signs of interest/ability to stand and walk. The stepping reflex disappears by 6 months. Lanugo is a fine, downy hair that is present on premature infants. The femoral artery is a large artery and a strong bilaterally equal pulse is present. Weak femoral pulses may be a sign of a cardiac anomaly.
Chap 30. Which is the best place to assess for hydration in the older adult?
Hydration status in elders is best assessed over the sternum or clavicle due to normal loss of peripheral skin turgor.
Chap 30. Most health assessments are performed in a head-to-toe sequence. The nurse needs to be aware:
The nurse must be aware of physiological changes that occur with the aging process.
Chap 30. Nurses perform physical assessments for different reasons. One of those reasons is:
Nurses perform physical assessments for different reasons. One of those reasons is to obtain data about the client's functional abilities.
Chap 30. A client asks the nurse, "What is the purpose of a physical examination?" Which response by the nurse is not correct?
These are some of the purposes of the physical examination: To obtain baseline data about the client's functional abilities; To supplement, confirm, or refute data obtained in the nursing history; To obtain data that will help establish nursing diagnoses and plans of care; To evaluate the physiologic outcomes of health care and thus the progress of a client's health problem; To make clinical judgments about a client's health status; To identify areas for health promotion and disease prevention; The nurse collects data to supplement, confirm, or refute data obtained in the nursing history, during the physical exam. The nurse is not trying to determine if the client is being dishonest.
Chap 30. Students are taught to follow a head-to-toe assessment. This assists the student with:
Students are taught to follow a head-to-toe assessment. This assists the student with consistency in performing a systematic assessment.
Chap 30. Which of the following actions is correct for the nurse assessing a client who has just had a cast applied to the lower leg?
Nursing Assessments Addressing Selected Client Situations: 1. Client complains of abdominal pain: Inspect, auscultate, and palpate the abdomen; assess vital signs. 2. Client is admitted with a head injury: Assess level of consciousness using Glasgow Coma Scale (see Table 30-10 in the textbook); assess pupils for reaction to light and accommodation; assess vital signs. 3. The nurse prepares to administer a cardiotonic drug to a client: Assess apical pulse and compare with baseline data. 4. The client has just had a cast applied to the lower leg: Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able, and vital signs. 5. The client's fluid intake is minimal: Assess tissue turgor, fluid intake and output, and vital signs.
Chap 30. Some nurses will prioritize their sequence of performing a health exam according to:
Some nurses will prioritize their sequence of performing a health exam according to the disease process, beginning with the body system related to the client's primary concern.
Chap 30. What evidence would most likely indicate to the nurse that a client had a negative Romberg test? The client:
A negative Romberg test would be indicated when a client was able to maintain an upright posture and foot stance with minimal swaying. A positive Romberg would show a client who couldn't maintain foot stance, moved the feet apart to maintain stance, and exhibited increased swaying.
Chap 30. The nurse documented that a brown-skinned client has pallor. What is the specific observation for this client?
Pallor is most evident in body areas with the least pigmentation, such as the nail beds, oral mucus membranes, palms of the hand, and soles of the feet. Pallor in brown-skinned individuals appears as a yellow- brown tinge, and in black-skinned individuals it appears as ashen gray.
Chap 30. The nurse explains to the client that the client is in the hospital following a car accident. Several minutes later, the nurse asks the client, "Where are you now?" The nurse is assessing the client's:
The client is asked to identify where the client is, which assesses orientation to place.
Chap 30. Which examination technique is being used when the nurse touches the client's abdomen to examine the size of the liver?
Touching signifies palpation, inspection is looking, percussion is tapping, and auscultation is listening.
Chap 30. Auscultation is the:
Auscultation is the process of listening to sounds produced within the body. Inspection is the visual examination—that is, assessing by using the sense of sight. Palpation is the examination of the body using the sense of touch. Percussion is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt.
Chap 30. What are the methods used for physical examination?
Four primary techniques are used during the physical examination: inspection, palpation, percussion, and auscultation. Analysis is not a physical examination technique.
Chap 30. A nurse is evaluating a nursing student's understanding of cranial nerves. Which of the following statements demonstrates a need for further teaching? The assessment method for:
Cranial Nerve Functions and Assessment Methods Assessment of Cranial nerve II would be to ask the client to read a Snellen-type chart. Cranial nerve I would be to ask the client to close the eyes and identify different mild aromas, such as coffee, vanilla, peanut butter, orange/lemon, or chocolate. Cranial nerve VI would be to assess the client's directions of gaze. Cranial nerve VII would be to ask the client to smile, raise the eyebrows, frown, puff out the cheeks, and close the eyes tightly.
Chap 30. A nurse asks a client to close her eyes, and then places a paper clip in the client's palm. The client correctly identifies the object. What test did the nurse perform?
Stereognosis is the act of recognizing objects by touching and manipulating them. Extinction is failure to perceive touch on one side of the body when both sides are touched simultaneously. One- and two-point discrimination entail the ability to sense if one or two areas of the skin, respectively, are being stimulated by pressure. Paresthesia is an abnormal sensation, such as burning or pain.
Chap 30. In what sites should the nurse auscultate the heart?
The nurse should auscultate the heart in all four anatomic sites: aortic, pulmonic, tricuspid, and apical (mitral). Lateral, anterior, and posterior do not refer to auscultation sites. Carotid, aortic, jugular and coronary refer to arteries and veins near the heart. Apical and mitral refer to the same site. Sternal and costal refer to bony landmarks.
Chap 30. After auscultating the abdomen, the nurse should report which of the following to the primary care provider?
A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. In order for absence of bowel sounds to be considered abnormal, the bowels must be silent for 3 to 5 minutes. Continuous bowel sounds are normally heard over the ileocecal valve following meals. Bowel sounds are more commonly irregular than they are regular.
Chap 30. Which of the following indicates a normal finding on auscultation of the lungs?
Resonance is a normal sound over the lung. Tympany would be heard over the stomach (air filled); hyperresonance is never a normal finding; and dullness would be heard below (not above) the 10th intercostal space.
Chap 30. In a client with long-term emphysema, the nurse might expect to see which condition when inspecting the nails?
Clubbing is a condition where the nailbed is at least 180 degrees, often caused by lack of oxygen, such as in emphysema. Koilonychia is an abnormality where the nail curves upward from the nail bed, and is often seen in clients with iron-deficiency anemia. Paronychia is the technical term for "ingrown nail." A slow blanch test (greater than 2-3 seconds) may indicate circulatory problems.
Chap 34. Before obtaining a capillary blood specimen, in addition to assessing the client's understanding of the procedure and response to previous testing, what other factors need to be determined prior to the procedure?
The other factors that need to be determined prior to obtaining a capillary blood specimen include: medications that may prolong bleeding, status of client's skin, and circulatory status. It is not necessary to assess the client's complete blood count. Taking capillary blood samples does not precipitate an insulin reaction. Factors such as psychotropic medications, cognitive impairment, and the caregiver's response have no bearing on the capillary blood specimen collection. It is important to check the equipment prior to doing the procedure. Medication history is important, but the nurse needs to focus on specific drugs such as anticoagulants.
Chap 34. The nurse practitioner requests a laboratory blood test to determine how well a client has controlled the client's diabetes over the past three months. Which blood test will provide this information?
A glycosylated hemoglobin test would best determine diabetes control over the past three months. Fasting blood glucose and capillary blood specimen will provide information about the current blood glucose level. Glucose tolerance test is used to determine if a client has diabetes.
Chap 34. As a nurse obtains a capillary glucose reading, the nurse knows that the meter:
As a nurse obtains a capillary glucose reading, the nurse knows that the meter must be calibrated or it will give an inaccurate reading.
Chap 34. The client has a urinary health problem. Which of the following procedures is performed using indirect visualization?
KUB is an x-ray of the kidneys, ureters, and bladder. An IVP and retrograde pyelography use injections of contrast media. A cystoscopy uses a lighted instrument (cystoscope) inserted through the urethra resulting in direct visualization.
Chap 34. A client presents to the ER with shortness of breath and chest pain. The nurse knows that the following procedures may be used to determine a diagnosis:
Electrocardiography provides a graphic recording of the heart's electrical activity by using electrodes placed on the skin that transmit electrical impulses to a graphic recorder. Stress electrocardiography uses electrocardiograms to assess the client's response to an increased cardiac workload during exercise. Angiography is an invasive procedure using radiopaque dye that is injected into the vessels to be examined; this will help to diagnose a cardiac problem. In a lumbar puncture the cerebrospinal fluid is withdrawn to obtain a specimen to determine a diagnosis or to detect malignancy; this is not a test performed to diagnosis a person with shortness of breath or chest pain. A thoracentesis is performed to remove excess fluid or air to ease breathing; this would be done after diagnosis.
Chap 34. A client reports an iodine allergy. This information is most significant if the client is scheduled for which exam?
Iodine is present in the dye used in some imaging x-rays and scans including intravenous pyelogram. Iodine is not used in lung scan, computed tomography, or magnetic resonance imaging.
Chap 34. A primary care provider is going to perform a thoracentesis. The nurse's role will include which of the following?
Puncture site is usually on the posterior chest. Leaning forward separates the ribs, allowing for exposure of the site. The site would not be exposed when supine in the Trendelenburg position. Vital sign changes and pain are not commonly associated with this procedure. Administering a narcotic analgesic is normally not indicated with this procedure.
Chap 34. A nurse cares for a client following a liver biopsy. Which nursing care plan reflects proper care?
Positioning the client in a right side-lying position with a pillow under the biopsy site reflects proper care. Positioning in a dorsal recumbent position, with one pillow under the head, does not permit the necessary pressure applied to the biopsy site. Bed rest is only required for several hours. There is no reason to do neurological checks.
Chap 34. During a bone marrow biopsy, the nurse needs to assess the client for:
Pallor, diaphoresis, and faintness due to bleeding or pain are to be observed during a bone marrow biopsy. During a thoracentesis, the nurse needs to observe for dyspnea, pallor, and coughing as signs of distress. Pallor, dyspnea, drop in blood pressure, abnormal pulse rate, skin color, and restlessness due to shock would be observations for a client during the abdominal paracentesis.
Chap 34. The nurse needs to collect a sputum specimen to identify the presence of TB. Which of the following is indicated for this type of specimen?
Sending the specimen immediately to the lab, offering mouth care before and after collection of the sputum specimen, and collecting a specimen for 3 consecutive days are all indicated. A sputum specimen is often collected in the morning. "Spit" is usually saliva-the client needs to cough up or expectorate mucus or sputum.
Chap 34. In collecting a sputum specimen, which of the following guidelines must be followed?
To collect a sputum specimen, the nurse follows these steps: Offer mouth care so that the specimen will not be contaminated with microorganisms from the mouth. Ask the client to breathe deeply and then cough up 1 to 2 tablespoons, or 15 to 30mL (4 to 8 fluid drams), of sputum. Wear gloves and personal protective equipment to avoid direct contact with the sputum. Follow special precautions if tuberculosis is suspected, obtaining the specimen in a room equipped with a special airflow system or ultraviolet light, or outdoors. If these options are not available, wear a mask capable of filtering droplet nuclei. Ask the client to expectorate (spit out) the sputum into the specimen container. Make sure the sputum does not contact the outside of the container (Figure 34-8). If the outside of the container does become contaminated, wash it with a disinfectant. Following sputum collection, offer mouthwash to remove any unpleasant taste. Label and transport the specimen to the laboratory. Ensure that the specimen label and the laboratory requisition contain the correct information. Arrange for the specimen to be sent to the laboratory immediately or refrigerated. Bacterial cultures must be started immediately before any contaminating organisms can grow, multiply, and produce false results. Document the collection of the sputum specimen on the client's chart. Include the amount, color, consistency (thick, tenacious, watery), presence of hemoptysis (blood in the sputum), odor of the sputum, any measures needed to obtain the specimen (e.g., postural drainage), and any discomfort experienced by the client.
Chap 34. The nurse needs to obtain a throat culture from a child client. Which of following techniques is NOT correct?
Sterile gloves are not necessary for obtaining a throat culture and is considered an unnecessary expense. To obtain a throat culture specimen, the nurse puts on clean gloves, then inserts the swab into the oropharynx and runs the swab along the tonsils and areas on the pharynx that are reddened or contain exudate. The gag reflex, active in some clients, may be decreased by having the client sit upright if health permits, open the mouth, extend the tongue, and say "ah," and by taking the specimen quickly.
Chap 34. A nurse is reading the lab report with the results of the blood specimens that were drawn this a.m. Which of the following is accurate?
As the nurse is reading diagnostic tests, he/she must be aware of the normal values of diagnostic tests and the implications of the test results.
Chap 34. The nurse is asked to obtain an arterial blood sample from a client. The nurse knows which of the following sites can be used to obtain the blood sample?
Arterial blood samples, drawn by a specialty nurse, can be obtained from femoral, radial, and brachial arteries.
Chap 34. While preparing the client for a colonoscopy, the nurse's responsibilities include:
The nurse is responsible for instructing the client about the bowel preparation prior to the test. Explaining the risks and benefits of the exam, instructing the client about medication that will be used to sedate the client, and explaining the results of the exam are the physician's responsibility.
Chap 34. A client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure?
The initial stream of urine contains bacteria from the distal urethra and urinary meatus, so it should be discarded as contaminated.
Chap 34. Which technique is NOT correct when collecting a urine specimen for culture and sensitivity by clean catch?
For a male client, using a circular motion to clean the urinary meatus is the correct technique. For a female client, the perineal area should be cleaned from front to back. Always explain to the client that a urine specimen is required, give the reason, and explain the method to be used to collect it. A nurse should always perform hand hygiene and observe other appropriate infection control procedures. The nurse must ensure that the specimen label is attached to the specimen cup, not the lid, and that the laboratory requisition provides the correct information.
Chap 34. A nurse is instructing a female client on the procedure to collect a clean-catch specimen. What specifically needs to be emphasized to decrease the risk of contamination?
To decrease the risk of contamination, the nurse explains to the client to clean the perineal area from front to back and use an antiseptic towelette to wipe the urinary meatus. Cleaning with just water and soap reduces the risk of contamination, but the urinary meatus also needs to be cleansed. Washing the perineal area from back to front is cleaning from the area of most contamination to the least. Using a wet face cloth does not decrease the risk of contamination.
Chap 34. A medical technician has just finished drawing blood for arterial gases. What is the most appropriate nursing action after the removal of the aspirating needle?
To prevent hemorrhaging, the nurse needs to apply pressure to the puncture site for 5-10 minutes after the removal of the needle. This is important because of the relatively great pressure of the blood in these arteries. It is not necessary to be monitoring for vital signs or intake and output after the collection of arterial blood gases. There is no incision site. Ice packs may decrease bleeding, but the application of pressure on the injection site is most appropriate.
Chap 34. The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. Which procedure will increase the blood flow to the area to ensure an adequate specimen?
Wrapping the finger in a warm cloth for 30-60 seconds will increase blood flow to the area. The hand is lowered to increase venous flow. The finger is pierced lateral to the middle of the pad perpendicular to the skin surface.
Chap 34. A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, which of the following measures is most important?
Communication of the test to all staff is likely to result in completing the collection. At the beginning of the test, instructing him to empty his bladder and saving this voiding to start the collection is incorrect because you want to discard the first voiding. A clean receptacle, not a sterile one, is used to collect the urine; the purpose of the test will determine if refrigeration is needed.
Chap 34. The nurse is preparing a client for an MRI. Which of the following would be a significant concern? The client:
Clients with implanted metal devices cannot undergo an MRI because of the strong magnetic field. Tattoo pigments may contain metal substances that create an electric current that can cause redness and swelling similar to a first-degree burn at the site of the tattoo.
Chap 34. Nuclear Imaging studies are:
Nuclear scans study the "physiology or function" of an organ system in contrast to other studies (e.g., CT, MRI, x-ray) which visualize "anatomic" structures.
Chap 34. Which procedure provides information regarding the physiology of an organ?
A nuclear scan demonstrates ability of tissue to absorb the chemical. All of the other answers provide anatomic information.
Chap 34. During an assessment, the nurse learns that the client has a history of liver disease. Which of the following diagnostic tests might be indicated for this client?
ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to liver. The liver contributes to the metabolism of protein which results in the production of ammonia. If the liver is damaged, the ammonia level will increase. Myoglobin, cholesterol, and BNP are relevant for heart disease.
Chap 34. The nurse would call the primary care provider immediately for which of the following lab results?
Hct = 22% for female client is very low and can lead to death. A Hgb = 16 g/dL for male client, WBC = 9 × 103/mL3, and Platelets = 300 × 103/mL3 are within normal range.
Chap 34. A female client has polycythemia. This indicates that the hemoglobin and hematocrit findings would be:
In polycythemia, the hemoglobin and hematocrit readings are increased. A decreased reading may indicate hemorrhage or anemia.
Chap 34. A client is admitted with gastrointestinal bleeding. One of the earliest and most important blood tests completed will be:
Since bleeding is the priority concern, lab values that provide information about the amount of blood loss will be the ones with the most value. Complete Blood Count is the important test to be completed. The electrolyte panel, arterial blood gases and the liver panel do not provide information related to the amount of blood loss.
Chap 34. The nurse doing the health teaching to a client for testing feces for occult blood informs the client that some items can produce false-positive results. Which of the following statements is consistent with what the nurse should emphasize?
Certain foods can produce inaccurate test results. False-positive results can occur if the client has recently ingested red meat or raw radishes and melons. Taking more than 250 mg of vitamin C from food or supplements may produce a false-negative result even if the client is bleeding. The presence of color is not what is being assessed with occult blood, so eating colored vegetables does not influence the test results unless they are raw turnips, radishes, or horseradish. Tea does not have any impact on occult blood results.
Chap 34. A client has a streptococcal throat infection. The white blood cell count is elevated. When looking at the differential, the nurse expects which type of white blood cell to be elevated?
When a client has a streptococcal infection, neutrophil count is elevated. Eosinophil count is elevated in allergic reactions. Monocyte count is elevated in chronic inflammatory disorders. Lymphocyte count is elevated in viral infections.
Chap 34. The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure?
Correct procedure includes collecting a sample from two different areas of the stool specimen; assessing for a blue color change; asking if the client has taken vitamin C in the past few days. The reagent is placed on the stool smear after it is applied to the card. A pink color would be considered negative and does not require verification.
Chap 34. The nurse is providing patient education about a fecal occult blood test. Which of the following statements is correct?
Taking the sample from the center of a formed stool to ensure a uniform sample is a correct technique for a fecal occult blood test. The nurse should state: "Avoid collecting specimens during your menstrual period and for 3 days afterward, and while you have bleeding hemorrhoids or blood in your urine." Either of these situations would give a false positive result to the fecal occult blood tests. Using a ballpoint pen to label the specimens with your name, address, age, and date of specimen is a correct technique for a fecal occult blood test. Avoiding contamination of the specimen with urine or toilet tissue is a correct technique for a fecal occult blood test.
Chap 34. The client is being tested for bleeding in the colon. The nurse knows that when performing a test for occult blood, three specimens are required. The specimens must be obtained:
The nurse must know that when performing a test for occult blood, three specimens are required. The specimens must be obtained from three separate, consecutive bowel movements.
Chap 38. A client's lifestyle affects the:
Lifestyle influences the quality and quantity of stimulation to which an individual is accustomed.
Chap 38. In what way does culture affect sensory functioning?
Culture determines the amount of sensory stimulation that a person considers usual or normal, and also affects the amount of stimulation an individual desires and believes to be meaningful. Physiological changes related to sensation are usually due to developmental changes. Culture does not determine the levels of stress; however, it does affect how one deals with the stress. The occurrence of illnesses related to sensory functioning does not depend upon the culture of the individual.
Chap 38. It is important for the nurse to be sensitive to stimulation that is culturally acceptable to a client. The lack of culturally assistive or supportive acts is called:
Nurses should encourage clients who want to have culturally related symbols present and to follow practices with which they are comfortable, provided that these practices do not endanger health.
Chap 38. A nurse planning a seminar on delirium and dementia plans to explain the characteristics differentiating the two. Which of the following describes an alertness that fluctuates—that is, the client may be alert and oriented during the day but become confused and disoriented at night?
Delirium alertness fluctuates. The client may be alert and oriented during the day but become confused and disoriented at night. The dementia client's level of alertness is generally normal.
Chap 38. A client has been oriented to person, time, and place but becomes disoriented within 24 hours of admission to the hospital. What is the most probable reason for this?
Confusion can be caused by physiologic disturbances such as chronic medical problems (e.g., dementia, chronic obstructive pulmonary disease, hypertension, stroke) that place them at risk. Chronic depression does not cause an acute change in orientation. Lack of sensory stimulation generally does not cause disorientation. Failure to orient the client would not cause disorientation to person and place.
Chap 38. Which statement by a hospitalized client indicates a need for further orientation to time, place, person, or situation?
The client's statement "I'm tired of sitting in this train station" indicates disorientation. Listen to clients carefully to pick up signs of disorientation and not confuse them with other causes. Comparing a hospital to a busy train station is an appropriate analogy for an oriented person in the hospital. A client's statement about not remembering things well is not uncommon. Not remembering a staff member may reflect impaired memory related to organic causes, multiple caregivers, medication, or stress; yet the client asks an appropriate question to clear the memory lapse.
Chap 38. An 85-year-old client has impaired hearing. When creating the care plan, which of the following should have the highest priority?
The amplified telephone helps with hearing and provides a means for communicating with others. "Teaching the importance of changing his position" refers to a tactile impairment. "Providing reading material with large print" relates to a visual impairment, and "Checking expiration dates on food packages" is an olfactory impairment.
Chap 38. Nurses have a role in promoting healthy sensory function. Which of the following guidelines is applicable to provide appropriate sensory input to children?
Healthy sensory function can be promoted by providing appropriate sensory input to children by stimulating as many senses as possible and using a variety of stimuli. Consistency is not necessary in the provision of stimuli. Regular visual screening is necessary but does not ensure appropriateness of sensory input. Blocking stimuli is necessary to prevent sensory overload, and overload is not present in this situation.
Chap 38. A client has impaired vision. An intervention to best adapt the environment to this loss includes:
Keeping the room pathways free of clutter is the best intervention to adapt the environment for the client with impaired vision. Interventions will focus on compensating for the loss of vision in order to optimize client independence. Initially, the nurse may need to assist the client with ambulation. Later, the nurse will need to evaluate whether this is still necessary. Clients unfamiliar with side rails may find them confusing and actually fall trying to climb over them. Regular schedules help clients orient to time, but are less likely to benefit those with vision loss.
Chap 38. A client who had a stroke is unable to distinguish written words and symbols. Which of the following is the most appropriate nursing diagnosis for this client?
Disturbed Sensory Perception is the condition where an individual has a change in the amount of incoming stimuli accompanied by an impaired response to these stimuli. The inability to recognize written words and symbols is a disturbance in the interpretation of the stimuli. Impaired Memory means that a person has inability to remember or recall information or behaviors. Acute Disorientation refers to the person not being aware of time, space, or place. Ineffective cognition is a very vague term and is not a nursing diagnosis.
Chap 38. The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who:
Because of the paraplegia (paralysis of lower body), the client is unable to feel discomfort. The client will be taught to lift self using chair arms every 10 minutes if possible. "Cut foot by stepping on broken glass." is an actual problem versus a potential problem. In "Wears glasses because of poor vision.", the client wears glasses that help correct the poor vision. "Is legally blind and smokes in bed." is more of a Risk for Injury diagnosis.
Chap 38. Sensory perceptual deficts can be the etiology for other nursing diagnoses. An example of such a diagnosis is:
The nurse determines what effects the sensory defict will have on the client. Swallowing is not a sensory/perceptual deficit. Fluid overload is related to excess intake relative to output, or organ failure such as heart failure, not sensory deficit. Sensory perceptual deficts would not relate to a person's overeating.
Chap 38. The nurse is assessing for sensory function. Match the assessment tool in column 1 to the specific sense it will be testing in column 2.
External stimuli are visual (sight - the snellen chart is a vision test), auditory (hearing - the tuning fork is a tool used to assess hearing), olfactory (smell - identifying aroma), tactile (touch - stereognosis), and gustatory (taste).
Chap 38. While performing a history, which of the following sensory perceptions does the nurse assess?
Mental status is assessed while performing a history. Kinesthetic perception, deep tendon reflexes, and cranial nerves are assessed during the physical exam, not the history.
Chap 38. A client admitted to the intensive care unit complains of excessive fatigue and racing thoughts and is moderately anxious. In addition, the client is unable to follow instructions. This client has clinical signs of:
Sensory overload is characterized by fatigue or sleeplessness, racing thoughts, anxiety, irritability, and reduced task performance. A sensory deficit is impaired perception, reception, or both of one or more of the senses. Examples are deafness and blindness. In sensory deprivation, clients experience decreased attention span, drowsiness, excessive sleeping, and apathy. Sensory reception is the process of receiving stimuli or data.
Chap 38. A 16-year-old client has just had emergency surgery for a fractured femur after being involved in a motor vehicle crash. The client was unconscious upon admission and the parents signed for client to have the surgery. Client is in own room after surgery, feeling drowsy, and unaware of surroundings. Client does know parents, but does not understand all the noise of the oxygen machine, the IV, and the monitors. This is a sign of:
Sedation is a state of calm, restfulness. This client has sensory overload which generally occurs when a person is unable to process or manage the amount or intensity of sensory stimuli.
Chap 38. A client is at risk for sensory deprivation. Which of the following clinical signs are most likely to contribute?
Decreased attention span, excessive sleeping, crying and depression are clinical signs of sensory deprivation. Sleeplessness and irritability are clinical signs of sensory overload.
Chap 38. Which client is most likely to experience sensory deprivation?
Sensory stimulation comes from our senses, environment, and presence of meaningful data. The deaf client with +4 edema who lives in an upstairs apartment does not have easy access to sensory stimulation and has limited potential for socialization. Although the 93-year old client has no sight and is unable to get out of bed, she is still capable and likely to receive sensory stimulation. She may converse with staff and other residents, feel the touch of bathing, and taste a variety of foods. There is a potential for sensory deprivation related to abandonment and the presence of anomalies. Since the child is being cared for in a special needs foster home, and attends preschool, one can reasonably assume that the child receives some stimulation. Premature infants in neonatal intensive care units often suffer from sensory overload.
Chap 38. The nurse is providing care to an unconscious client. Which of the following actions by the nurse is correct?
The nurse should also provide mouth care, perform range-of-motion exercises, and provide aromatic stimuli. Nose care is not an appropriate action. Too much environmental stimuli can be very distressing to a client. The nurse should inform the client beforehand of the care to be provided, not during the care.
Chap 38. A client, who is unconscious for a long period of time, needs 24-hour care. The nurse understands the need to:
The nurse should introduce him/herself to the client and explain procedures.
Chap 38. When a client is unconscious, the health care staff is responsible for providing:
Coma stimulation consists of providing sensory stimulation to promote brain recovery by waking the reticular activating system (RAS).
Chap 38. Which statement by a client with decreased hearing indicates a need for a sensory aid in the home?
A sensory aid will help the client compensate for hearing loss. "My eyesight is good if I wear my glasses" and "I tripped over that throw rug again" are unrelated to hearing deficit. "I can hear the radio if I turn it up high" is an example of compensation.
Chap 38. During discharge planning, the nurse is teaching the client how to prevent sensory disturbances. Which of the following actions is correct?
The nurse should teach the client the following: Wear protective eye goggles when using power tools, riding motorcycles, spraying chemicals, and so on. Wear ear protectors when working in an environment with high noise levels or brief loud impulse noises (e.g., blasting). Wear dark glasses with UV protection to avoid damage from ultraviolet rays and never look directly into the sun. Have regular health examinations.
Chap 38. Which client is at greatest risk for experiencing sensory overload?
A sudden, unexpected admission for surgery may involve many experiences (e.g., lab work, x-rays, signing of forms) while the client is in pain or some form of discomfort. The time for orientation will thus be lessened. After surgery, the client may be in pain and possibly in a critical care setting. "A 40-year-old client in isolation with no family" and "A 28-year-old quadriplegic client in a private room" reflect a greater risk for sensory deprivation, and "A 16-year-old listening to loud music" is a normal activity for a teenager.
Chap 38. Stereognosis is:
Stereognosis is the ability to perceive and understand an object through touch by its size, shape, and texture. Sensory reception is the process of receiving stimuli or data. Sensory perception involves the conscious organization and translation of the data or stimuli into meaningful information. Sensoristasis is the term used to describe when a person is in optimal arousal.
Chap 38. A client needs to have which of the following components to experience a sensory experience:
The sensory process involves two components: reception and perception.
Chap 38. Clients admitted into the emergency department may experience behavior changes due to:
Sensory overload generally occurs when a person is unable to process or manage the amount of time or intensity or sensory stimuli. Clients may be experiencing more quantity or quality of internal stimuli such as pain, syspnea, or anxiety as well as external stimuli such as noise, intrusive diagnostic studies, and contact with many strangers. Sensoristasis is time of optimum arousal, not too much or too little. Sensory reception is the process of receiving internal and external data.. Stereognosis is the awareness of an object's size, shape, and texture.
Chap 42. When a person is approached with a stressful situation, and responds by trying to improve the situation by making changes or taking action, it is described as:
Problem-focused coping focuses on efforts to improve a situation by making changes or taking some action.
Chap 42. A nurse feels vulnerable after a child dies following a lengthy resuscitation effort. A positive coping strategy for the nurse is to:
Nurses must learn positive coping strategies to deal with stress and prevent burnout. The nurse needs to tune into feelings rather than suppress and numb them with sedatives. A child's death is always extraordinary. It is important for the nurse to deal with the grief. The nurse should not make the assumption that a mistake caused the child's death, rather than recognizing that people do the best they can in desperate circumstances and that even children cannot always be resuscitated. However, reviewing resuscitations can be useful if done to improve overall care.
Chap 42. After the death of several long-term clients, which of the following actions indicates the nurse is demonstrating ineffective coping?
Taking on additional work would only serve as an additional stressor. In addition, a nurse who has not begun resolution of feelings is unlikely to be able to meet clients' emotional needs. Effective coping may include verbalizing feelings (one-on-one or in groups) or initiating distractions. Of course, the nurse may not disclose confidential information to a friend or others who would not already have this information.
Chap 42. Which of the following is an example of the defense mechanism of displacement?
Displacement is the transferring or discharging of emotional reactions from one object or person to another object or person. An example would be when a husband and wife are fighting, and the husband becomes so angry he hits a door instead of his wife. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. An example would be a woman who, though told her father has metastatic cancer, continues to plan a family reunion 18 months in advance. Projection is a process in which blame is attached to others or the environment for unacceptable desires, thoughts, shortcomings, and mistakes. An example would be a mother who is told that her child must repeat a grade in school, and she blames this on the teacher's poor instruction. Substitution is the replacement of a highly valued, unacceptable, or unavailable object by a less valuable, acceptable, or available object. An example would be a woman who wants to marry a man exactly like her dead father and settles for someone who looks a little bit like him.
Chap 42. A client who was raised in an abusive family resented the mother for not being protective. Since the death of the father, the client has been taking care of the mother and devoting time to counseling abused women. What defense mechanism is this client using?
Reaction formation causes persons to act exactly the opposite from the way they feel. Sublimation is the displacement of energy associated with primitive drives into more acceptable outlets. Undoing is acting in a way to relieve guilt or unacceptable thoughts by reparation. Identification is the attempt to manage anxiety by imitating the behaviors of someone feared or respected.
Chap 42. When discussing their father's behavior during a family counseling session, a brother says to his sister, "Sure, Dad was rough, but not as bad as Grandma. Don't you remember Grandma? She was much worse. If it weren't for her, he would have been OK." The defense mechanism the brother is using is:
The brother is projecting the behavior being discussed to his grandmother. He is not rationalizing or justifying his father's behaviors by faulty logic or ascribing motives. He is not minimizing by not acknowledging his father's behavior. He is not compensating by emphasizing a more desirable trait of his father.
Chap 42. The spouse of a client is discussing the difference between anxiety and fear. Which of the following statements indicates a need for further teaching?
The source of anxiety may not be identifiable; the source of fear is identifiable. Anxiety is related to the future, that is, to an anticipated event. Fear is related to the present. Anxiety is vague, whereas fear is definite. Anxiety is the result of psychologic or emotional conflict; fear is the result of a discrete physical or psychologic entity.
Chap 42. The nurse has recently changed jobs to work with young adults and recognizes that sources of stress common to that population include which of the following?
Common stressors among young adults include marriage, starting a new job, and leaving the parental home. Stressors from aging parents are more common among middle-aged adults; decreased physical abilities is a stressor in elders; and changing body structure serves as a stressor in both children and older adults.
Chap 42. Which physiological response describes the ability of a person to perform a far more strenuous physical activity than normal when faced with a stressor?
Increased blood clotting is the physiological response to epinephrine. The sympathetic system, not the parasympathetic, is stimulated in response to stressors. Bronchial dilation allows for increased oxygen intake. Adrenal hormonal effects allow the person faced with a stressor to do more strenuous activities than normal.
Chap 42. A young adult comes to the clinic complaining of chest pain. Upon further assessment, the nurse knows that which of the following stressor(s) could be contributing to the client's physical pain?
There are many sources of stress. Developmental stressors occur at predictable times throughout an individual's life. The stressors that are associated with the young adult developmental stage may include: getting married, leaving home, managing a home, starting a career, continuing education, and/or rearing children.
Chap 42. Two people have been in a motor vehicle crash and have similar injuries. According to the transaction-based model, their degree of stress from the crash would be:
In the transaction model, stress is a very personal experience and varies widely among individuals. "Extremely similar since they had the same stimulus" represents the stimulus model, and "The identical physiologic alarm reaction" represents the response model of stress. In "Different depending on their external resources and support levels," external resources and support are factors in determining stress levels, but omit the key aspects of internal/personal influences.
Chap 42. Which of the following clients is most likely to be experiencing a negative situational stress response?
An 18-year-old beginning college in a new state is experiencing a situational stress response. The other answers are examples of developmental stressors.
Chap 42. A middle-aged male client is experiencing job-related stress associated with the fear of layoff, resulting in his accepting projects that require a great deal of travel. Which of the following would be the most important health promotion strategy for this client?
All of the four areas of health promotion strategies may be important, but for this client, sleep is likely to be the most adversely affected by travel, in which changing time zones and unfamiliar sleeping quarters are common. It is easier for clients to adapt to modifying exercise, nutrition, and time management during travel than it is to control sleep. Thus, it becomes the most important area requiring intervention to avoid worsening the existing stress.
Chap 42. A nurse is planning a seminar on minimizing stress and anxiety. Which of the following statements is NOT correct?
To minimize stress and anxiety, the nurse should communicate in short, clear sentences; provide an atmosphere of warmth and trust; convey a sense of caring and empathy; listen attentively; try to understand the client's perspective on the situation; and control the environment to minimize additional stressors, such as by reducing noise, limiting the number of persons in the room, and providing care by the same nurse as much as possible.
Chap 42. _____________ is a short-term helping process of assisting clients to work through a crisis to resolution and restore their precrisis level of functioning.
The goal of crisis intervention is to provide immediate relief for the client. Crisis intervention goes beyond kindness. It involves deliberate acts to benefit the client. Emergency management, goal clarification, and trauma interventions are not interventions that are implemented during a crisis.
Chap 42. A client is having difficulty exploring and using resources available to deal with the stress of raising a child. Which of the following is the most appropriate nursing diagnosis?
Ineffective Coping is the inability to form a valid appraisal of stressors, inadequate choices of responses, and inability to use available resources. Post-Trauma Syndrome is a sustained maladaptive response to a traumatic event. Decisional Conflict is uncertainty about the course of action among competing actions that involve loss or challenge to life values. Defensive Coping is repeated projection of falsely positive self-evaluation to defend against a perceived threat to self-esteem.
Chap 42. The client is informed of a cancer diagnosis but claims to be fine. Which of the following is the most indicative physical evidence to the nurse of the client's stress?
With stress, respirations increase, pupils dilate, peripheral blood vessels constrict, and the heart rate increases.
Chap 42. Immediately after the parents of a hospitalized child are informed that the child has leukemia, the father responds by continuing his usual work schedule, rarely visiting, and asking when the child can return to school. Of the following, which is the least likely to be an appropriate nursing diagnosis at this time?
It is too soon for Caregiver Role Strain to be an appropriate nursing diagnosis—especially since the child is not at home. Ineffective Denial and Fear are common reactions to this type of threat. The father demonstrates Compromised Family Coping by his difficulty in being supportive.
Chap 42. Selye's description of general adaptation syndrome includes a physical response to the body. The body system most affected by the stress response is:
Parts of the body particularly affected by stress are the gastrointestinal tract, the adrenal glands, and the lymphatic structures.
Chap 42. A client's husband died suddenly this week. She has two young children and is staying strong for them emotionally. It has been 4 days and the funeral is over and family has gone. Which of the following stages of the general adaptation syndrome is the client in?
The stage of resistance is when the body's adaptation takes place. In other words, the body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it.
Chap 42. According to Selye, what is the body's reaction when a client receives disturbing or happy news?
The initial reaction of the body is the alarm reaction, which alerts the body's defenses.
Chap 42. While performing discharge planning for a client recovering from a stroke, the nurse may use which of the following factors as an indication of the client's potential for effective coping?
How the client and family understand stressors, and the family's ability to provide a supportive environment, are important factors for the nurse to consider. Effective coping is not dependent upon one's education level. Confidence is an important element of coping, but may not be based on the reality of the client's current condition. Insurance may help the client afford community resources not covered by Medicare, but this alone does not indicate a client's or family's ability to cope.
Chap 42. The nurse helps a 50-year-old diabetic client who is to begin giving insulin injections identify previously successful coping strategies that may be useful in the current situation. Which of the following stressors is closely related to the new stressor?
Wearing glasses is another example of beginning a new strategy to assist with what will be a lifelong health need even though it is not necessarily a desired change. Interviewing for a job is a very short-lived situational stressor. Coping strategies effective while a teenager may not be relevant at age 50. Experiencing the stress of a divorce is a social/role stressor quite unlike that of a health problem.
Chap 42. Which of the following is an appropriate strategy for the nurse when dealing with a client's anger?
Try to understand the meaning of the client's anger. Let clients talk about their anger. After the interaction is completed, take time to process your feelings and your responses to the client with your colleagues. Listen to the client, and act as calmly as possible.
Chap 42. A client comes into the clinic with vocal tremors and pitch changes. The client is also experiencing facial twitches, shakiness, and slightly elevated respiratory and heart rates. At the end of the assessment the client tells the nurse, "I feel like I have butterflies in my stomach." Which level of anxiety is this client experiencing?
The client is experiencing moderate anxiety as evidenced by voice tremors and pitch changes, facial twitches, shakiness, and slightly elevated respiratory and heart rates, and states, "I feel like I have butterflies in my stomach." Mild anxiety would be characterized by mild restlessness, sleeplessness, increased verbalization, feelings of increased arousal and alertness, and no changes in respiratory and heart rates. Severe anxiety is characterized by communication difficulties; increased motor activity; inability to relax, focus, and concentrate; ease of distractibility; tachycardia; and hyperventilation. Panic anxiety is characterized by increased motor activity, agitation, unpredictable responses, distorted or exaggerated perception, dyspnea, palpitations, choking, chest pain, and a feeling of impending doom.
Chap 42. An individual complains of difficulty concentrating and a headache. The nurse observes that the client has a fearful facial expression and is easily distracted. What level of anxiety is the individual manifesting?
A severely anxious person would have concentration difficulties, distractibility, headache or dizziness, and fearful facial expression. In the mild level, individuals are alert. In the moderate level, there is narrowed focus of attention and selective inattention is present. Mild gastric symptoms may be present in the moderate level. In panic, perception is distorted and the person is unable to function. The individual experiences feelings of impending doom.
Chap 42. A bystander at an automobile crash is excited and alarmed. The bystander also feels nauseated and dizzy, has difficulty focusing, and has an elevated pulse. What level of anxiety is the bystander feeling?
Severe anxiety symptoms include nausea and dizziness, difficulty focusing, and elevated pulse. Mild anxiety symptoms include increased arousal, few if any gastric symptoms, and minor if any respiratory or circulatory changes. Moderate anxiety symptoms include a narrowed focus of attention, selective inattentiveness, slightly increased heart and respiratory rate, and "butterflies in the stomach." Panic symptoms include agitation, unpredictable responses, distorted perception, dyspnea, palpitations, and feelings of impending doom.
Chap 43. A nurse is evaluating a client who has just lost a spouse and the client states, "He used to like this time of year when he could plant his tomatoes in the garden." The nurse knows the client is experiencing which of the following stages of grieving?
The nurse assesses the grieving client or family members following a loss to determine the phase or stage of grieving. During resolving the loss, the person thinks over and talks about memories of the lost object.
Chap 43. At which age do children begin to accept that they will someday die?
Until children are about 5 years old, they believe that death is reversible. Between ages 5 and 9, children know death is irreversible, but believe it can be avoided. Between 9 and 12 years of age, children recognize that they, too, will someday die. At 12 to 18 years old, children build on previous beliefs and may fear death, but often pretend not to care about it.
Chap 43. The ability of an individual to cope with death is dependent upon a number of factors. Which person is likely to have the most difficulty coping with a death?
Many factors affect the grieving experience. These include age, significance of the loss, culture, spiritual beliefs, gender, socioeconomic status, social support systems, and the cause of the death. In our culture, the death of an older person is accepted more easily than that of a younger person. The death is more easily accepted if it is anticipated, and if the person who died did not contribute to the death. Usually, the closer the individual is to the person who died, the more difficult it is to cope with the death.
Chap 43. A nurse's client just passed away. The nurse understands that rigor mortis is the stiffening of the body that occurs about _____ hours after death.
Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death. It results from a lack of adenosine triphosphate (ATP), which causes the muscles to contract, which in turn immobilizes the joints. Rigor mortis starts in the involuntary muscles (heart, bladder, etc.), then progresses to the head, neck, and trunk, and finally reaches the extremities. All other times are incorrect.
Chap 43. Proper handling of the body following death is an important intervention for the client, family, and nurse. Which of the following interventions reflects an important principle of postmortem care?
The body is to be handled with dignity at all times. After the body is cleaned and the linen freshened, the sheet is pulled to cover the patient's shoulders. Laws and policies differ regarding the nurse's ability to declare death.
Chap 43. Which of the following actions is NOT appropriate for the nurse providing postmortem care?
Nursing personnel may be responsible for care of a body after death. Normally, the body is placed in a supine position with the arms either at the sides (palms down) or across the abdomen. Dentures are usually inserted to help give the face a natural appearance. The mouth is then closed. One pillow is placed under the head and shoulders to prevent blood from settling into the face and discoloring it. The eyelids are closed and held in place for a few seconds so that they remain closed. All jewelry is removed, except a wedding band in some instances, which is taped to the finger.
Chap 43. A nursing student has a client who just lost her brother to suicide. The client accepts the situation intellectually but denies it emotionally. Which of Engel's stages of grieving is the client experiencing?
During the shock and disbelief stage, the client refuses to accept loss, has stunned feelings, and accepts the situation intellectually but denies it emotionally. During the developing awareness stage, reality of loss begins to penetrate consciousness, and anger may be directed at the agency, nurses, or others. During the restitution stage, the client conducts rituals of mourning (e.g., funeral). During the stage of resolving the loss, the client attempts to deal with the painful void, is still unable to accept a new love object to replace the lost person or object, may accept a more dependent relationship with a support person, and thinks over and talks about memories of the lost person or object.
Chap 43. The client has been diagnosed with an illness and given a prognosis of less than a month to live, yet the client continues to make plans for speaking engagements for 6 months in the future. This is an example of which of Elizabeth Kübler-Ross's stages of grieving?
Kübler-Ross defined 5 stages of grieving, including: denial, bargaining, depression, acceptance, and anger. This client demonstrates the stage of denial and demonstrates the behavioral response of refusing to believe that loss is happening.
Chap 43. A nurse must tell a family of a client's death. The nurse knows the family will go through the Kübler-Ross stages of grieving, which include which of the following?
One of the most well-known descriptions of the stages or phases of grieving is the one by Kübler-Ross. It describes five stages of grief: denial, anger, bargaining, depression, and acceptance.
Chap 43. What is a therapeutic strategy for communicating with a client who is dying?
It is therapeutic to acknowledge that clients who are dying may be having some struggles or concerns. Encouraging silence is denying the client the chance to speak about concerns. Talking about pleasant events is ignoring the fact that clients may have some issues with which to deal. Reassurance is appropriate unless it is false reassurance, but sympathy is nontherapeutic. Clients who are dying do not need pity.
Chap 43. When a nurse is taking care of a client who knows that death is imminent, the nurse must be aware that the client:
The Dying Person's Bill of Rights assists the client in maintaining dignity at the time of death.
Chap 43. A nurse is planning a seminar on the Dying Person's Bill of Rights. Which of the following statements is NOT part of the Dying Person's Bill of Rights?
The Dying Person's Bill of Rights includes: I have the right not to die alone. I have the right to express my feelings and emotions about my approaching death in my own way. I have the right to expect continuing medical and nursing attention even though cure goals must be changed to comfort goals. I have the right to be free from pain.
Chap 43. When asked to sign the permission form for surgical removal of a large but noncancerous lesion on the face, the client begins to cry. Which of the following is the most appropriate response?
The nurse needs to assess and explore the meaning of the client's crying. "You must be very glad to be having this lesion removed" and "Isn't it wonderful that the lesion is not cancer?" leap to assumptions about the meaning of the tears and ignore the possibility of the client's distress. "I cry when I am happy or relieved sometimes, too" suggests that the client has the same feelings as the nurse, which may not be correct.
Chap 43. A client from another country has died in the United States, which is where the body will be buried. The nurse needs to:
Explore and respect the client's and family's ethnic, cultural, religious, and personal values in their expression of grief.
Chap 43. A client whose child died from a motor vehicle crash states, "I know I should grieve, but I just don't have the time. My other children need me and I can't be crying." The nurse's most therapeutic response is:
The most therapeutic response is empathetic and nonjudgmental. Making the suggestion that working through one's grief is important because bereavement may have potentially devastating effects on health is part of the necessary teaching. The other responses give advice ("have to take time," "need to look at") and judge the client ("you should be grieving").
Chap 43. The shift changed while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate?
The statement, "I'm very sorry for your loss" acknowledges the family's grief simply. Avoid statements that may be interpreted as overly impersonal, false support, or harsh. Other responses may also be correct as the meeting progresses.
Chap 43. While talking to adult children of a dying client, the nurse finds them tearful, with ambivalent feelings toward the client. The client often expresses beliefs of a wasted life. The children say that the client was a parent who often showed love but followed it with criticism, anger, damaging accusations, and emotional abuse. The nurse suggests an intervention that may be helpful to the client and the client's children. The intervention most likely to be helpful is:
Making a videotape of loving memories helps both the client and family to focus on the positive. Relaxation tapes help with stress reduction, but do not help resolve problems experienced by the client and children. Staffing needs do not permit a nurse to be with one client continually, and families require privacy as well. Assurance that the past no longer matters is an assurance lacking concrete properties.
Chap 43. What is the best route for administering pain medication to a dying client?
Analgesics need to be administered by intravenous infusion because of decreased blood circulation. Due to poor absorption of the GI tract and possible nausea, the oral route is not the best choice. Because of decreased blood circulation, the subcutaneous and intramuscular routes are not the best routes.
Chap 43. If a client loses a spouse after 50 years and begins giving away possessions, this is a clue to the nurse that the client is experiencing:
Complicated grieving may be characterized by extended time of denial, depression, severe physiologic symptoms, or suicidal thoughts. Giving away one's possessions can be a warning sign of the potential for suicide.
Chap 43. If a client experiences the death of an aging pet, the client will go through a grieving process. This process is called:
Losses that occur in the process of normal development are called developmental losses.
Chap 43. A nurse is evaluating a nursing student who is caring for a dying client's physiological needs. Which of the following actions demonstrates a need for further teaching?
An unconscious client experiencing airway clearance problems would be placed in a lateral position. A conscious client with an airway clearance problem would be placed in a Fowler's position. If the client is diaphoretic, the nursing student would give the client frequent baths, change the linen, and regularly change the client's position. The nursing student would provide skin care to the client in response to incontinence of urine or feces.
Chap 43. After a nurse questions a client about relationship abuse, the client claims to be ready to leave the abusive relationship, although past attempts were not successful due to fear, lack of support, lack of confidence, and financial considerations. The client asks the nurse for help. Which of the following examples of perceived loss may the client be experiencing?
Perceived loss is experienced by one person but cannot be directly verified by others. Loss of partner, residence, and lifestyle can be seen and acknowledged by others, even if they are not favorable. Dreams are something of which only the client is aware. She may have dreamed of a happier relationship that she finally acknowledged was not forthcoming, or the dream may be of a different origin. Only the client knows.
Chap 43. In assessing a client who will be undergoing a lung resection, the nurse understands the significance of losing a body part. Which of the following questions is most appropriate to ask during the assessment?
It is important to ask the client about what changes the surgery will cause in order to find the meaning of this current loss of a body part. Asking what the client will do after the surgery is appropriate to assess the client's current grieving reaction. Questioning about what the nurse can do to help is too general and is not an appropriate assessment question. Asking about losses in the past assesses previous experiences.
Chap 43. Which of the following may be considered normal or "healthy" types of grief?
Healthy/normal types of grief include abbreviated grief (normal grief that is briefly experienced), anticipatory grief (experienced before the loss/death but appropriate), and disenfranchised grief (the emotions are felt privately, but not expressed in public). Unhealthy/abnormal types of grief include complicated grief in several different forms: unresolved grief, which is extended in length and severity; and inhibited grief, in which symptoms are suppressed and other effects, including somatic, are experienced instead.
Chap 43. When caring for a dying client, the nurse observes for which of the following signs of impending clinical death? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Nursing care and support for the dying client and family include making an accurate assessment of the physiologic signs of approaching death. In addition to signs related to the client's specific disease, certain other physical signs are indicative of impending death. The four main characteristic changes are loss of muscle tone which makes it difficult for the client to speak, slowing of the circulation, changes in respiration, and sensory impairment.
Chap 43. The nurse is providing care to an unconscious client who is dying. Which of the following is not a clinical manifestation of impending clinical death?
Clinical manifestations of impending clinical death include: Slower and weaker pulse. Difficulty swallowing and gradual loss of the gag reflex. Mottling and cyanosis of the extremities. Rapid, shallow, irregular, or abnormally slow respirations.
Chap 43. While the nurse is discussing a client's likely death with family members, one of the client's children says, "We plan on taking turns being here for now, but we all want to be here at the time of death. Is there any way we can tell when that time is close?" The nurse's best response is:
As death nears, muscles relax with decreased activity. Muscle rigidity is not a usual pattern. The gag reflex is lost, and mucus accumulates in the back of the throat. Vision is blurred. A lucid moment is not a pattern in death. It is difficult to pinpoint the exact time when death will occur, but the imminence of clinical death can be detected.
Chap 48. Which of the following factors affect voiding?
Some foods and fluids can change the color of urine. For example, beets can cause urine to appear red. Antinflammatory medication to not interfere with the normal urination process. The client living alone or being physically active do not affect voiding.
Chap 48. The nurse recognizes that urinary elimination changes may occur even in healthy elders because:
The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained. Elders do not ignore the urge to void and may have difficulty in getting to the toilet in time. The kidney becomes less able to concentrate urine with age.
Chap 48. Which of the following types of medication affect the client's voiding?
Antihypertensive medication may cause urine retention. Antibiotics, blood thinners, and stool softeners do not affect a client's voiding.
Chap 48. Urine production is a result of the process of which of the following areas of the urinary tract system?
The functional units of the kidneys, the nephrons, filter the blood and remove metabolic wastes.
Chap 48. Micturition is another word for:
Other words to use for urination are micturition and voiding.
Chap 48. The process of urination is stimulated by which of the following?
The stretch receptors transmit impulses to the spinal cord, specifically to the voiding reflex center located at the level of the 2nd and 4th sacral vertebrae, causing the internal sphincter to relax and stimulating the urge to void.
Chap 48. Which of the following is an abnormal color or clarity of urine?
The normal color or clarity of urine is straw, amber, or transparent. Abnormal color or clarity of urine is dark amber, dark orange, red, dark brown, cloudy, mucous plugs, viscid, or thick.
Chap 48. Medications can affect the urinary process. The type of drug that increases urine output is:
Diuretics increase urine formation by preventing reabsorption of water and electrolytes from the tubules of the kidney into the bloodstream.
Chap 48. The normal adolescent should void approximately how much urine in a 24-hour period?
The average adolescent from 14 years through adulthood should have an average of 1500 mL of urine output in a 24-hour period.
Chap 48. The client with the NANDA diagnosis of Stress Urinary Incontinence has:
The client with stress incontinence has sudden leakage of urine occurring with activities that increase abdominal pressure. The client with functional urinary incontinence has an inability to reach toilet in time to avoid unintentional loss of urine. The client with reflex urinary incontinence has an involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. The client with total urinary incontinence has continuous and unpredictable passage of urine.
Chap 48. Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes?
It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced by performing slow, deep breathing and pelvic muscle exercises . Some clients may need diapers; however, this is not the best indicator of a successful program. Citrus juices may irritate the bladder. Carbonated beverages increase diuresis, increasing the risk of incontinence.
Chap 48. The nurse is counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle exercises to strengthen her bladder muscles. What action would the nurse recommend to this client in order to perform this activity correctly?
Stopping the flow of urination midstream focuses on the muscle used to control this activity. The remaining answers do not affect this muscle in the same manner.
Chap 48. Oliguria is:
Oliguria is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. Polyuria (or diuresis) refers to the production of abnormally large amounts of urine by the kidneys, often several liters more than the client's usual daily output. Polydipsia is excessive fluid intake. Anuria refers to a lack of urine production.
Chap 48. The client with a neurogenic bladder:
The client with a neurogenic bladder does not perceive bladder fullness. The client with urgency has a sudden strong desire to void. The client with urinary frequency is voiding at frequent intervals, more than 4-6 times a day. The client with dysuria has painful or difficult voiding.
Chap 48. A client comes to the primary care provider's office with the complaints of urinating all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. A urine specimen has been sent for analysis. Based on the signs and symptoms expressed by the client, which of the following health problems would be anticipated?
The noted signs and symptoms help to identify the problem of urinary tract infection. The signs and symptoms noted are not common with the other diseases listed.
Chap 48. Which of the following assessments should be ongoing for clients with urinary retention catheters?
Gravity drainage should be checked and maintained, so the receptacle should be below the client's bladder. Observation of the flow, color, odor, and abnormal constituents needs to be done every 2 to 3 hours. Drainage system should be well-sealed or closed and should have no leaks. Tubing should be fastened to the client's bedclothes, not the bed sheet.
Chap 48. A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Which type of client would benefit from this type of procedure?
A client with an injury to their bladder would need a diversion to route the urine to the outside of the body by a different route than via the bladder. A renal failure client and a client with kidney stones have problems at the kidney level where urine is produced. This is not a problem with the route the urine takes once it leave the kidney. Infections would not be treated with a urinary diversion. The bladder and urethra still function.
Chap 48. Which of the following statements indicates a need for further teaching of the home care client with a long-term indwelling catheter?
Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage. Intake of cranberry juice creates an environment not conducive to infection. Clean technique is appropriate for touching the exterior portions of the system.
Chap 48. The nurse is teaching a young female client how to reduce the number of urinary tract infections. Which of the following client behaviors needs to be altered?
Clients should avoid bubble baths, since this can be irritating to the urethra and encourage inflammation and bacterial infection. If the client drinks 8, eight oz glasses of fluid per day, wipes her perineal area from front to back following urination, and wears cotton underwear she is following the proper guidelines to prevent a recurrence of a UTI.
Chap 48. During discharge planning, the nurse is teaching the client ways to prevent a recurrence of a UTI. Which of the following actions is correct?
Ways to prevent a recurrence of a UTI include: Avoid tight-fitting pants or other clothing that create irritation to the urethra and prevents ventilation of the perineal area. Drink eight, 8-ounce glasses of water per day to flush bacteria out of the urinary system. Wear cotton rather than nylon underclothes. Girls and women should always wipe the perineal area from front to back following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra.
Chap 48. The nurse is requested to perform teaching to a client in the emergency department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes which of the following?
Tight-fitting clothing creates irritation to the urethra and prevents ventilation of the perineal area. It is recommended that eight glasses of water be drunk to flush out the urinary system. Avoid harsh soaps, bubble bath, powders, and sprays in the perineal area, because they can have an irritating effect on the urethra, encouraging inflammation and a bacterial infection. Practice frequent voiding (q 2—3 hours) to flush bacteria out of the urethra and prevent organisms from ascending into the bladder.
Chap 48. Which nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate?
Dietary guides related to fiber and fluid balance are given to clients with this problem. The remaining actions are noted in the assessment guide and are appropriate measures to use with clients.
Chap 48. During assessment of the client with urinary incontinence, the nurse is most likely to assess which of the following?
The perineum may become irritated by the frequent contact with urine. Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage. Urinary tract infections can contribute to incontinence. Antihistamines can cause urinary retention rather than incontinence.
Chap 48. A nurse is testing urine for specific gravity. Which of the following would be considered a normal result range?
Normal results for a urine specific gravity should be in the range of 1.010 to 1.025. All other results not in this range are considered abnormal.
Chap 49. The mother of a 6-year-old reported that the child goes to the bathroom frequently. After measuring the urine for 24 hours, she reported that it totaled 2000 mL. This is an example of:
Polyuria is the production of an abnormally large amount of urine. A 6-year-old usually has a normal urinary output of 700-100 mL daily. Anuria refers to a lack of urine production; nocturia is voiding two to three times during the night; oliguria is the production of low urine output, usually less than 500 mL a day for adults.
Chap 49. Which of the following statements provides evidence that an older adult who is prone to constipation is in need of further teaching?
The standard of practice in assisting elders to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition, a normal stool pattern for an elder may not be daily elimination.
Chap 49. At the local wellness fair, the nurse is asked to share information on having healthy bowel life. Included in this area is the topic of having a healthy defecation. The nurse should include which of the following information as an appropriate action to follow?
When peristaltic waves move the feces into the sigmoid colon and the rectum, the sensory nerves in the rectum are stimulated and the individual becomes aware of the need to defecate. The number of times a person defecates a day would be important information to have about bowel habits, but it is not related to the actual process of defecation.
Chap 49. The nurse is presenting information at the community health fair about normal defecation patterns across the lifespan. Which of the following factors would NOT be part of the discussion?
There is no relationship noted between gender and defecation pattern. Diet, fluids, and medications all can affect the amount, consistency, or pattern of defecation.
Chap 49. Which of the following is a very important part of the movement process of defecation?
When peristaltic waves move the feces into the sigmoid colon and the rectum, the sensory nerves in the rectum are stimulated and the individual becomes aware of the need to defecate. The number of times a person defecates a day would be important information to have about bowel habits, but it is not related to the actual process of defecation.
Chap 49. A client has complained of diarrhea for the last 3 days. The client is passing mucus, but no stool. This indicates to the nurse that the part of the anatomy that is affected is:
The colon serves a protective function in that it secretes mucus. This mucus contains large amounts of bicarbonate ions. The mucus secretion is stimulated by excitation of parasympathetic nerves. During extreme stimulation—for example, as a result of emotions—large amounts of mucus are secreted with little or no feces.
Chap 49. After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include which of the following?
Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies available for clients to help control odor that may be incurred because of the ostomy. Although ostomy supplies require a prescription, they can be ordered from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling.
Chap 49. The nurse is most likely to report which of the following findings to the primary care provider for a client who has an established colostomy?
An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.
Chap 49. Which of the following is the correct order for the physical examination of the abdomen?
Physical examination of the abdomen in relation to fecal elimination problems includes inspection, auscultation, percussion, and palpation with specific reference to the intestinal tract. Auscultation precedes palpation because palpation can alter peristalsis. Examination of the rectum and anus includes inspection and palpation.
Chap 49. Because a client is scheduled for a colonoscopy, the nurse will instruct the client to perform which of the following?
Small-volume enemas along with other preparations are used to prepare the client for a colonoscopy. An oil retention enema is used to soften hard stool. Return flow enemas help expel flatus. Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used.
Chap 49. The nurse assesses the intestinal tract function by:
Administering pain medications is not part of assessment. Food preferences may be related to many factors and may not provide the nurse with enough information about the client's intestinal tract function. A pain diary does not give the nurse direct information about the client's intestinal tract function. Completing a history, inspecting the client's stool, and auscultating the abdomen are appropriate ways of assessing the intestinal tract function. Reviewing serum (blood) lab values is not the most accurate method of assessing the client's intestinal tract function.
Chap 49. During discharge planning, the nurse is teaching the client how to manage diarrhea. Which of the following actions is NOT correct?
Limit foods containing insoluble fiber, such as high-fiber whole wheat breads, whole grain breads and cereals, and raw fruits and vegetables. Drink at least eight glasses of water per day to prevent dehydration. Eat foods with sodium and potassium. Limit fatty foods. Increase foods containing soluble fiber, such as rice, oatmeal, and skinless fruits and potatoes.
Chap 49. Which of the following guidelines should the nurse follow when administering enemas?
Tap water enemas should not be repeated because of the danger of circulatory overload when the water moves from the interstitial space to the circulatory system. Air instilled into the rectum can cause unnecessary distention. The client should be in the left lateral position to facilitate the flow of the solution into the sigmoid and descending colon which are on the left side. Enema solution should be administered slowly to avoid cramps and spasm.
Chap 49. Which of the following guidelines should be followed when administering an enema to children?
Enemas should be 200-300 mL in children 18 months to 5 years. Insert the tube 5 to 7.5 cm in children and 2.5 to 2.75 cm in infants. Enema temperature should be 37.7°C, which is slightly higher than normal body temperature. The enema solution should be isotonic, as hypertonic solutions can lead to hypovolemia. Enemas should be 200-300 mL in children 18 months to 5 years.
Chap 49. Which of the following interventions is appropriate for a client with flatulence?
Limit carbonated fluids and the use of straws and chewing gum to avoid ingestion of air. Cauliflower and onions are gas producing and should be avoided. Excessively hot or cold fluids stimulate peristalsis and should be avoided by clients with diarrhea. Increasing daily fluid intake is recommended for clients with constipation.
Chap 49. Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?
Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result—if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool. The ability to ignore the urge indicates a strong voluntary sphincter, not a weak one, that could result in incontinence. Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool.
Chap 49. A client has a transverse colostomy. What kind of fecal drainage is to be expected?
A transverse colostomy produces a malodorous, mushy, uncontrolled drainage. A descending colostomy produces increasingly solid fecal drainage that can be controlled. Malodorous, liquid fecal drainage is produced by an ascending colostomy, while an ileostomy produces constant liquid fecal drainage.
Chap 49. A student nurse questions the nurse about the difference between constipation and fecal impaction. Which of the following statements is most accurate?
Constipation is fewer than three bowel movements per week with the passage of hard, dry stool or no stool. It is defined in relation to the person's regular elimination patterns. Fecal impaction is the collection of hardened feces in the folds of the rectum, not the anus.
Chap 49. A nurse is evaluating a client's understanding of healthy defecation. Which of the following statements indicates a need for further teaching?
Maintaining fluid intake of 2000 to 3000 mL a day promotes healthy defecation. Other client teachings for healthy defecation are: Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet; allow time to defecate, preferably at the same time each day; avoid over-the-counter medications to treat constipation and diarrhea.
Chap 49. The nurse is promoting regular defecation for a client in the nurse's care. Which of the following actions by the nurse is NOT correct?
Although the squatting position best facilitates defecation, on a toilet seat, the best position for most people seems to be leaning forward. A client should be encouraged to defecate when the urge is recognized. Regular exercise helps clients develop a regular defecation pattern. For clients who have difficulty sitting down and getting up from the toilet, an elevated toilet seat can be attached to a regular toilet.
Chap 49. The elderly population is known to use laxatives with regularity. In advising an older adult practicing this habit, the nurse would NOT identify which of the following?
Laxatives decrease the absorption of vitamins. The remaining answer choices are true.
Chap 49. A nurse is evaluating a nursing student's understanding of the actions of enema solutions. Which of the following statements demonstrates a need for further teaching?
Oil solutions lubricate the feces and the colonic mucosa. Isotonic solutions distend the colon, stimulate peristalsis, and soften feces. Hypertonic solutions draw water into the colon. Hypotonic solutions distend the colon, stimulate peristalsis, and soften feces. Soapsuds solutions irritate the mucosa and distend the colon.
Chap 49. The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
A return flow enema provides relief of postoperative flatus by stimulating bowel motility. Soapsuds enemas, retention enemas, and oil retention enemas manage constipation and do not provide flatus relief.
Chap 49. A client is being prepped for intestinal surgery. The nurse has an order to administer an enema. Before getting a clarification order as to the type of enema to administer, the nurse is aware of the following types
An enema is a solution introduced into the rectum and large intestine. The action of an enema is to distend the intestine and sometimes to irritate the intestinal mucosa, thereby increasing peristalsis and the excretion of feces and flatus. Enemas are classified as cleansing, carminative, retention, and return flow.
Chap 49. The most appropriate goal for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection is which of the following?
Once the cause of diarrhea has been identified and corrected, interventions should focus on getting clients to return to their previous elimination patterns. This is not an example of an allergy to the antibiotic, but a common consequence of overgrowth of bowel organisms not killed by the drug. Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock. Increasing intake of soluble fiber, such as oatmeal or potatoes, may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not.
Chap 49. An 80-year-old client is in the emergency department. The client complains of diarrhea and vomiting for the past 2 days. In assessing the client, it is noted that the client has lost 8 lb, is itchy, and has dry skin that can be tented. Which NANDA diagnosis would be most appropriate to use with this client in making a plan of care?
This client is showing signs of dehydration. Risk for Deficient Fluid Volume related to prolonged diarrhea and vomiting is the only appropriate answer.
Chap 49. Which of the following actions is NOT appropriate for the nurse removing a fecal impaction?
Ask the client to assume a left side-lying position, with the knees flexed and the back toward the nurse. Place a bedpad under the client's buttocks and a bedpan nearby to receive stool. Drape the client for comfort and to avoid unnecessary exposure of the body. Gently insert the index finger into the rectum and move the finger along the length of the rectum.
Chap 49. Which of the following is most likely to validate that a client is experiencing intestinal bleeding?
Bleeding into the upper GI tract is black and tarry. Large quantities of fat mixed with pale yellow liquid stool can be a sign of malabsorption in an infant. Brown, formed stools are normal stools. Narrow, pencil-shaped stools are characteristic of an obstructive condition of the rectum.
Chap 49. A client has the flu with gastrointestinal symptoms and has been incontinent. This is not uncommon if the client has:
Diarrhea refers to the passage of liquid feces and an increased frequency of defecation. Rapid passage of chyme reduces the time available for the large intestine to reabsorb water and electrolytes. The person with diarrhea finds it difficult or impossible to control the urge to defecate for very long. It is a threat of incontinence.
Chap 49. A primary care provider orders an examination of stool for signs of intestinal infection. What color stool would the nurse expect to see?
The normal color of stool is brown. An intestinal infection would result in green or orange stool. Red stool would indicate bleeding from the lower gastrointestinal tract (e.g., rectum); some foods, such as beets, may also cause red stool. Black or tarry stool indicates bleeding from the upper gastrointestinal tract (e.g., stomach, small intestine); a diet high in red meat and dark green vegetables (e.g., spinach) may also cause black, tarry school. White or clay-colored stool is due to absence of bile pigment (bile obstruction), or the result of a diagnostic study using barium.
Chap 52. The results of an arterial blood gas are as follows: pH: 7.5, PaCO2: 40, PaO2: 88, HCO3: 28. Evaluate the acid-base imbalance.
Arterial blood gases are performed to evaluate the client's acid-base balance and oxygenation. pH is the measure of relative acidity or alkalinity. PaCO2 is the partial pressure of carbon dioxide in arterial plasma. PaO2 is the pressure exerted by oxygen dissolved in the plasma, HCO3 is the measure of the metabolic component of acid-base balance. Base excess is a calculated value of bicarbonate levels.
Chap 52. A client is complaining of a bounding pulse, dyspnea, and confusion. Upon further assessment, the nurse notices distended neck veins and hears moist crackles. These are clinical manifestations of:
The manifestations of fluid volume excess are full bounding pulse, dyspnea, moist crackles, confusion, and distended neck veins. In fluid volume deficit, the pulse rate is rapid and weak, neck veins are flat, and there are no evidences of confusion or moist crackles in the lungs. The signs of hyponatremia are confusion, lethargy, muscle twitching, abdominal cramps, headache, and seizures. In hypercalcemia, the client is weak and lethargic, has polyuria, and dysrhythmia.
Chap 52. The following are normal values of arterial blood gases except:
The normal values of arterial blood gases are: pH7.35 to 7.45; PaO280 to 100 mm Hg; PaCO235 to 45 mm Hg; HCO3-22 to 26 mEq/L;Base excess-2 to +2 mEq/L; O2 saturation95 to 98%
Chap 52. The average adult should drink about __________ mL of fluid per day if they exercise moderately and it is a moderate temperature.
During periods of moderate activity at moderate temperature, the average adult drinks about 1,500 mL per day but needs 2,500 mL per day, an additional 1,000 mL.
Chap 52. Insensible fluid loss via exhaled air measures 300 to 400 mL per day. True or False
Insensible loss occurs from the water in exhaled air. In an adult, this is normally 300 to 400 mL per day.
Chap 52. Which of the following is a route of fluid output?
Fluid losses from the body counterbalance the adult's 2,500 mL average daily intake of fluid. There are four routes of fluid output: urine, insensible loss through the skin as perspiration and through the lungs as water vapor in the expired air, noticeable loss through the skin, and loss through the intestines in feces.
Chap 52. Which of the following events occurs when a person hyperventilates?
When a person hyperventilates, more carbon dioxide than normal is exhaled, carbonic acid levels fall, and the pH rises to greater than 7.45.
Chap 52. Edema that forms in clients with kidney disease is due to:
The edema is due to low levels of plasma proteins that exist with this disease, altering the oncotic pressure that helps regulate fluid movement in the vascular space moving into interstitial area. Increased capillary hydrostatic pressure is the cause. Capillaries have increased permeability when edema formation is possible. Obstructed lymph flow impairs the movement of fluid from interstitial tissues back into the vascular compartment, resulting in edema.
Chap 52. The client's arterial blood gas results are: pH 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid-base imbalance?
Because of CO2 retention the PaCO2 is elevated. C02 is involved in production of acid which will result in a decreased pH. HCO3 will vary. Metabolic acidosis involves a loss of bicarbonate but no retention of CO2. Metabolic alkalosis involves a loss of acid or retention of HCO3, but no retention of CO2. Respiratory alkalosis involves a loss of CO2 resulting in an increased pH.
Chap 52. Which of the following statements about the functions of the body's fluids is most accurate?
Extracellular fluid carries nutrients to and waste products from the cells. Plasma carries oxygen from the lungs to the capillaries of the vascular system. Intracellular fluid contains solutes and provides a medium for the metabolic processes to take place; it is not a transport system. The extracellular fluid is the transport system that carries nutrients to and waste products from the cells.
Chap 52. Which of the following information about osmosis is NOT correct?
Diffusion is the continual intermingling of molecules in liquids, gases, or solids brought about by the random movement of the molecules. Osmosis is the movement of water across cell membranes, from the less concentrated solution to the more concentrated solution. Osmosis occurs when the concentration of solutes on one side of a selectively permeable membrane, such as the capillary membrane, is higher than on the other side. Osmosis is an important mechanism for maintaining homeostasis and fluid balance. Osmolality is determined by the total solute concentration within a fluid compartment and is measured as parts of solute per kilogram of water.
Chap 52. A nurse is evaluating a nursing student's understanding of body water. Which of the following statements indicates a need for further teaching?
Women have a lower percentage of body water than men. Approximately 60% of the average healthy adult's weight is water, the primary body fluid. In good health this volume remains relatively constant and the person's weight varies by less than 0.2 kg (0.5 lb) in 24 hours, regardless of the amount of fluid ingested. Infants have the highest proportion of water, accounting for 70% to 80% of their body weight. Water makes up a greater percentage of a lean person's body weight than an obese person's.
Chap 52. When a client is on a fluid restriction, it means the client cannot:
The restriction of fluids can be difficult for some clients, particularly if they are experiencing thirst. Provide frequent mouth care and rinses to reduce the thirst sensation. Periodically offer the client ice chips as an alternative to water because ice chips when melted are approximately half of the frozen volume.
Chap 52. An elderly client was hydrated with lactated Ringer's solution in the emergency department for the last hour. During the most recent evaluation of the client the nurse noted a rapid bounding pulse and shortness of breath. Reporting this episode to the primary care provider, the nurse suspects that the client now shows signs of:
Isotonic solutions have the same osmolality as body fluids. Isotonic solutions, such as normal saline and Ringer's lactate initially remain in the vascular compartment, expanding vascular volume. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions, and serum osmolality remains constant.
Chap 52. Which of the following IV solutions are isotonic?
Isotonic solutions are often used to restore vascular volume. 0.9% NaCl and 5% dextrose in water are isotonic. 0.45% NaCl is hypotonic. 5% dextrose in normal saline and 5% dextrose in 0.45% NaCl are hypertonic
Chap 52. Which individual would least likely have a disturbance in fluid volume, electrolyte, or acid-base balance?
The proportion of body water decreases with aging. Tissue trauma, such as burns, causes fluids and electrolytes to be lost from the damaged cells, and the breakdown in the continuity of the tissue. In type I pressure ulcer, the skin remains intact, and any shifting of fluids is due to the inflammatory process and internally maintained within the body. Vomiting and diarrhea can cause significant fluid losses. Age, sex, and body fat affect total body water. Infants have the highest proportion of water; it accounts for 70 to 80% of their body weight. Decreased blood flow to the kidneys as caused by impaired cardiac function stimulates the renin-angiotensin-aldosterone system, causing sodium and water retention. Clients who are confused or unable to communicate are at risk for inadequate fluid intake. Age does not play a significant factor here.
Chap 52. The response of the body to stress as it relates to fluid volume is to:
Stress can increase cellular metabolism, blood glucose concentration, and catecholamne levels. In addition, stress can increase production of ADH, which in turn decreases urine production. The overall response of the body to stress is to increase the blood volume.
Chap 52. How does the normal aging process affect fluid balance?
Although in the elderly the ADH or antidiuretic hormone levels remain normal or may be elevated, the nephrons are less able to conserve water in response to the antidiuretic hormone. This is part of the normal aging process. Multiple medications and the presence of many chronic illnesses are not part of the normal aging process. Thirst response is usually blunted in the elderly and could lead to decreased fluid intake.
Chap 52. The nurse is admitting a new client, 80 years old, with congestive heart failure into your home health agency. The following assessment findings have been determined after meeting the client: overweight but no gain since the client left the hospital two days ago; VS: T 99.0, HR 100, R 22, BP 130/86. Foods eaten include canned soup at each meal, ham, and cheese. When completing the care plan for this client the nurse should include which of the following nursing diagnoses:
Sodium is found in high quantities in the foods noted that the client has consumed. When sodium levels increase in the body, water is retained, adding to the volume of fluid in circulation and making it harder for the body to move circulate fluids. Therefore, the excess fluid may in time impair gas exchange if levels eventually act on the lungs. Fluid volume is increasing, not decreasing, in this situation and Impaired Skin Integrity has no involvement with platelets.
Chap 52. A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority?
The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity.
Chap 52. A client with hypokalemia complains of an irregular heart rate. What are the most appropriate initial nursing interventions?
Cardiac dysrhythmias can be a result of hypokalemia and if it occurs it is an emergency situation. While notifying the primary care provider, monitor closely the heart rate and rhythm as well as the blood pressure. It is important to monitor the cardiovascular status, but encouraging fluids and starting an IV infusion are not appropriate immediate interventions. Trendelenberg's position is useful for clients in shock, not for dysrhythmias.
Chap 52. A client is diagnosed with a GI bleed. The nurse has an order to administer two units of packed red blood cells (PRBCs). What is the purpose of this order?
Intravenous fluids can be effective in restoring intravascular (blood) volume; however, they do not affect the oxygen-carrying capacity of the blood. A blood transfusion is the introduction of whole blood or blood components into the venous circulation. When red and white blood cells, platelets, or blood proteins are lost because of hemorrhage or disease, it may be necessary to replace these components to restore the blood's ability to transport oxygen and carbon dioxide, to clot, to fight infection, and to keep extracellular fluid within the intravascular compartment.
Chap 52. The nurse administers an IV solution of D5 1/2 NS to a postoperative client. This is classified as a __________ intravenous solution.
Hypertonic Solutions: 5% dextrose in 0.45% NaCl (D5 1/2NS) Hypertonic solutions draw fluid out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume. Do not administer to clients with kidney or heart disease or clients who are dehydrated. Watch for signs of hypervolemia.
Chap 52. Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period is that blood:
Hanging for longer than four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less time. The remaining items are not likely to happen.
Chap 52. A nurse is planning a seminar on wellness care and promoting fluid and electrolyte balance. Which of the following statements is correct?
The following pertain to wellness care and promoting fluid and electrolyte balance: Consume six to eight glasses of water daily; avoid excess amounts of foods or fluids high in salt, sugar, and caffeine; limit alcohol intake because it has a diuretic effect; increase fluid intake before, during, and after strenuous exercise, particularly when the environmental temperature is high; and replace lost electrolytes from excessive perspiration as needed with commercial electrolyte solutions.
Chap 52. The nurse has been invited to discuss "the importance of promoting a good fluid and electrolyte balance in children" for a group of parents at the local school parents meeting. Of the following actions, which is not representative of this topic?
Salt causes the body to retain fluids due to an increase in the concentration of sodium and the release of ADH. Caffeine acts as a diuretic in individuals and may lead to loss of excess fluids in the body. The remaining identified measures are all appropriate.
Chap 52. A client taking lasix (furosemide) for congestive heart failure is seeing the primary care provider for a potassium value of 3.0. An order for oral potassium taken daily is written and discussed with the client. In addition, potassium-rich foods should be eaten. The nurse educator meets with this client and has the client identify all of the following foods as potassium-rich except:
White bread is known to help meet fiber needs for the body. Potassium is found in many fruits, vegetables, meat, and fish.