Decerebrate posturing, characterized by abnormal extension in response to painful stimuli,
indicates damage to the midbrain.
abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied.
this indicates damage to the diencephalon or cortex
A decreased acetylcholine level
has been implicated as a cause of cognitive changes in healthy geriatric clients and in the severity of dementia.
Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis,
has been found to be deficient in clients with dementia.
Norepinephrine is associated with
aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.
Taking it on arising in the morning or taking it with or after a meal wouldn't minimize adverse effects.
taking it at bedtime does
Respiratory acidosis is associated with
hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should realize that the client has respiratory depression, and she should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine sample for drug screening.
Lower brain stem dysfunction alters
bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.
which results form damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.
Symptoms: Kussmaul respirations (rapid/deep breathing), nausea/vomiting (ketone body action on CTZ), abdominal pain, psychosis/delirium (due to cerebral edema due to increased plasma osmolality), dehydration, fruity breath odor. At risk of mucormycosis, rhizopus fungal infection (organism contains keto-oxidase and can use ketone bodies), arrhythmias (due to hyperkalemia), heart failure
pain and diminished pulse volume
are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity
Absent bowel sounds, involuntary guarding and rebound tenderness of the abdomen
a hard, rigid abdomen and an elevated WBC count this is a medical emergency
Which statement by a client with sickle cell disease indicates further teaching is needed to reinforce the therapeutic regimen?
"I should take one baby aspirin daily to help prevent sickle cell crisis."
Aspirin inhibits platelet aggregation and won't help prevent sickle cell crisis. Hydroxyurea is prescribed for some people to help prevent sickle cell crisis. High altitudes increase oxygen demand and therefore can also precipitate a crisis. Tobacco, alcohol, and dehydration can precipitate a sickle cell crisis and should be avoided.
Which action must a nurse take first before drawing a blood sample for human immunodeficiency virus (HIV) testing?
Make sure that an informed consent form has been signed.
Before obtaining a sample for HIV testing, the nurse should make sure that an informed consent form has been signed. The nurse should explain why she is obtaining the sample — in this case, for HIV testing, not for routine testing. Gloves are necessary to obtain the sample. Eye protection should also be worn if splashing is likely. The client should be informed of the test results whether they are positive or negative.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Risk for injury
In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Dysfunctional grieving may be relevant in AIDS, these diagnoses don't take precedence for a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective tissue perfusion: cerebral isn't
A 20-year-old male seeks care at a local emergency care center after spraining his ankle while playing football with his friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician?
Select all that apply:
1. ^ Initially apply cold.
2. ^ Instruct the client to elevate the ankle for 48 to 72 hours.
3. ^ Provide crutch gait training.
4. X Tell the client that pain typically worsens 24 hours after the injury.
5. ^ If needed, apply an elastic bandage from the toes to midcalf.
rationale for previous question about sprang
Pain caused by an injury is best treated initially with cold applications. Cold reduces localized swelling and decreases vasodilation. Decreasing vasodilation prevents pain-producing chemicals from being carried into the circulation. The client should be instructed to call the physician if pain worsens or persists. Additional X-rays may be necessary to detect a fracture that might have originally been missed. The client should also be instructed to elevate the joint for 48 to 72 hours after the injury. If an elastic bandage is needed, the nurse should wrap the bandage from the toes to the midcalf, forming a figure eight, and teach the client how to reapply it. The nurse should ensure that the client also receives crutch gait training.
A diagnostic technique that uses tapping on the body to differentiate air, solids, and fluids
inspection, auscultation, percussion, then palpatation
The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation.
To evaluate a client's posterior tibial pulse, where should the nurse palpate?
1. Medially in the antecubital space
2. Midway between the superior iliac spine and symphysis pubis
3. ^ On the inner aspect of the ankle, below the medial malleolus
4. Along the top of the foot, over the instep
To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluate the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral pulse; and along the top of the foot, over the instep, to evaluate the dorsalis pedis pulse.
google posterior tibial pulse images
The nurse is to administer an I.M. injection into a client's left vastus lateralis muscle. How should the nurse position the client?
1. ^ Lying supine
2. Lying on the stomach
3. Lying on the left side
4. Lying on the right side
To administer an I.M. injection into the vastus lateralis muscle, the nurse should position the client lying flat on the back (supine) or sitting upright to allow access to the muscle in the thigh. Lying on the stomach would allow access to the ventrogluteal or dorsogluteal site. Lying on the left or right side would allow access to the ventrogluteal site.
Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance?
1. Administer sleeping medication before bedtime.
2. Ask the client each morning to describe the quality of sleep during the previous night.
3. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.
4. ^ Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques.
When checking the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?
3. ^ Lag
At the end of the lag phase, the fibrin network dries out and forms a scab. The fibrinoplastic phase concludes with a scar, and the contraction phase is demonstrated by sloughing and shrinking of the scar. Inflammation is the first stage of wound healing and includes hemostasis, edema, and drawing of leukocytes to the wound area.
A client with chronic pain asks for assistance with pain relief techniques. Which technique doesn't need to be included in the teaching?
1. Relaxation techniques that aid in reducing pain by releasing muscle tension and relieving anxiety
2. Distraction techniques to help block the painful stimuli
3. Guided imagery to assist with blocking out uncomfortable stimuli
4. ^ Self-education about methods to assist in becoming pain-free
It's unrealistic for the client to expect to be pain-free. The goal of therapy is to reduce the pain and make it more manageable. Relaxation techniques, distraction, and guided imagery are all effective, nonpharmacologic interventions for pain management.
HEARING LOSS TEST- An elderly client comes to the clinic complaining of hearing loss. The nurse performs Weber's test to assess the client's ability to hear. Identify the location where the nurse should place the tuning fork to perform this test.
To perform Weber's test, the tuning fork should be struck and then placed on the midline of the head. Weber's test determines if sound is heard equally in both ears. If the client hears the sound louder in one ear, he probably has unequal hearing loss that requires further intervention.
After suctioning a tracheostomy, the nurse evaluates the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
1. A respiratory rate of 24 breaths/minute with accessory muscle use
2. ^ Clear breath sounds and non-labored respirations
3. Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds
4. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds
Proper suctioning should produce a patent airway, as demonstrated by clear breath sounds and non-labored respirations. The other options suggest ineffective suctioning. A respiratory rate of 24 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.
To help assess a client's cerebral function, the nurse should ask:
1. ^ "Have you noticed a change in your memory?"
2. "Have you noticed a change in your muscle strength?"
3. "Have you had any coordination problems?"
4. "Have you had any problems with your eyes?"
To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, and mental status, including memory. Questions about muscle strength help evaluate the motor system. Questions about coordination help assess cerebellar function. Questions about eyesight help evaluate the cranial nerves associated with vision.
To give a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe. What is the rationale for this action?
1. Adding air decreases pain caused by the injection.
2.^ Adding air prevents the drug from flowing back into the needle track.
3. Adding air prevents the solution from entering a blood vessel.
4. Adding air ensures that the client receives the entire dose.
The added air flushes the drug from the syringe, ensuring that the drug goes into the muscle tissue, and preventing it from flowing back into the needle track, which could cause skin staining. Adding air doesn't decrease pain (which results from the drug's chemical composition), and it has no bearing on whether the drug enters a blood vessel. Adding air isn't necessary to ensure that the client receives the entire dose.
The physician has ordered a wet-to-dry dressing containing normal saline solution for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to accomplish which action?
1. Preventing the spread of the infection
2. ^ Debriding the wound
3. Keeping the wound moist
4. Reducing pain
Because dead tissue adheres to a dry dressing, wet-to-dry dressings containing normal saline solution are used for debriding wounds. The wound isn't kept moist and wet-to-dry dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.
An adolescent boy comes to the emergency department seeking medical attention for severe pain located in the area of the appendix. Identify the area where the nurse would expect the pain to localize.
Pain and tenderness during an acute attack of appendicitis localizes in the right lower quadrant, midway between the umbilicus and the crest of the ilium.
A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in his abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time?
Select all that apply:
1.^ Notifying the client's primary physician
2. ^ Covering the wound with saline-soaked sterile gauze
3. Giving the client a dose of antibiotics
4. Ordering an abdominal binder from the supply department
5. Pushing the organs back into the abdomen
6. Covering the wound with sterile gauze
Dehiscence (the separation of the surgical incision) and evisceration (the protruding of the abdominal organs) are considered medical emergencies. Therefore, the client's physician should be notified immediately and the nurse should prepare the client for surgery. While the nurse is waiting for the physician to arrive, the wound and the abdominal organs should be covered with saline-soaked sterile gauze. Saline is an isotonic solution that prevents damage to the client's tissue, and sterile gauze is used to prevent wound infection. Even though wound infection is the most common cause of dehiscence, administering antibiotics without a physician's order isn't permissible and can result in the loss of a nursing license. An abdominal binder may be appropriate but only after the client returns from the operating room. Pushing the organs back into the abdomen is inappropriate and could result in rupture, hemorrhage, or strangulation of the bowel. The nurse should also monitor the client's vital signs
The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by::
1. keeping the chest drainage system below the level of the chest.
2. keeping the head of the bed slightly elevated.
3. ^ checking and taping all connections.
4. checking patency of the chest tube.
Air leaks commonly occur if the system isn't secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage — not to prevent air leaks. The head of the bed may be elevated to promote drainage. Chest tubes that aren't patent may lead to tension pneumothorax but wouldn't cause an air leak.
After removing an NG tube, the nurse should assess the client for such complications as
abdominal distention, nausea, and vomiting. Flatulence indicates that gas from the small intestine is passing through the colon. Constipation isn't a complication associated with removing an NG tube. Bowel sounds occur when peristalsis is present, which indicates that the GI tract is functioning.
A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?
1. Perform gentle passive range-of-motion exercises.
2. Gently massage the painful joints.
3. ^ Use a bed cradle to keep linens off the joints.
4. Encourage position changes in bed every 2 hours.
In rheumatic fever, the joints may be so painful that even the weight of the bed linens can cause pain. A bed cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased when the affected joint is moved; therefore, passive range-of-motion exercises aren't recommended. Pain isn't likely to be relieved by massaging the joints. The child should be encouraged to change positions at least every 2 hours to reduce the risk of skin breakdown, but this is unlikely to relieve joint pain.
The nurse should first establish unresponsiveness.
After unresponsiveness is confirmed, the nurse should activate the resuscitation team. Next, she should place the client on a firm surface, open his airway, and check for breathing. If the client isn't breathing, the nurse should give two slow breaths using a pocket mask or bag mask. Next, the nurse should check for signs of circulation (breathing, coughing, movement, or presence of carotid pulse). If there are no signs of circulation, the nurse should initiate chest compressions.
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received appropriate skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
1. Inadequate vitamin D intake
2.^ Inadequate protein intake
3. Inadequate massaging of the affected area
4. Low calcium level
Clients on bed rest suffer from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.
Which intervention should the nurse use when administering oxygen by face mask to a client?
1. Secure the elastic band tightly around the client's head.
2. ^ Assist the client to the semi-Fowler position if possible.
3. Apply the face mask from the client's chin up over the nose.
4. Loosen the connectors between the oxygen equipment and humidifier.
By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to skin breakdown. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen.
A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention?
1. Increasing fluids to 2,500 ml/day
2. ^ Teaching the client how to deep-breathe and cough
3. Improving airway clearance
4. Suctioning the client every 2 hours
Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition but doesn't address poor coughing. Improving airway clearance is too vague. Suctioning isn't indicated unless other measures fail to clear the airway.
PRACTICAL NURSING ACTIONS
*collaborate, refer; and protect client rights
*manage time and resources supervise
*prioritize, and maintain ethical, legal, and quality assurance standards
*prevent errors, accidents, and injuries
*report unusual events
*maintain standard precautions, medical and surgical asepsis, and security
HEALTH PROMOTION AND MAINTENANCE
*developmental stages and aging process
*health promotion and screening
*self-care and family interaction patterns
*disease prevention and family planning
*behavioral interventions and management
*coping mechanisms and crisis intervention
*end-of-life concepts, and sensory or perceptual alterations
*spiritual influences and cultural awareness
*Basic care and comfort
*Reduction of Risk
*basic nursing care and comfort
*assist with mobility, nutrition, and hydration
*administer medication safely
*decrease risk, prevent complications
*maintain fluid and electrolyte balance
Practical Nursing activities in the Nursing Process
Assessment- *GATHER; ORGANIZE, AND ANALYZE SUBJECTIVE AND OBJECTIVE DATA
*PERFORM FOCUSED ASSESSMENT
Nursing Diagnosis- *ASSIST THE RN IN FORMULATING RELEVANT NURSING DIAGNOSIS
*COLLECT ADDITIONAL DATA WHEN NECESSARY
*PARTICIPATE IN DETERMINATION OF HEALTH TEAM'S ABILITY TO MEET CLIENT'S NEEDS
Practical Nursing activities in the Nursing Process cont'd
Planning- *ASSIST THE RN IN DEVELOPMENT AND REVISION OF CARE PLAN FOR ASSIGNED CLIENTS
*SELECT APPROPRIATE NURSING INTERVENTIONS BASED ON THE CARE PLAN
Implementation- *DELIVER BASIC AND PREVENTIVE NURSING CARE AND CLIENT EDUCATION BASED ON THE CARE PLAN AND THE PN SCOPE OF PRACTICE
Practical Nursing activities in the Nursing Process cont'd-
Evaluation- *EVALUATE EFFECTIVENESS OF CARE DELIVERED
Response- *INCLUDES POTENTIAL OR ACTUAL HEALTH RESPONSE
*DESCRIBES MEASURABLE OUTCOMES THAT CAN BE DERIVED
*CITIES POTENTIAL FOR CHARGES BASED ON NURSING ACTIONS
*EXAMPLE: ALTERATION IN COMFORT, PAIN
Etiology- *INCLUDES POTENTIAL HEALTH RESPONSE
*ADDRESSES INDEPENDENT, INTERDEPENDENT, AND DEPENDENT NURSING FUNCTIONS
*EXAMPLE: RELATED TO FRACTURED LEFT ANKLE
mental or physical threat to touch without permission, e.g., forcing (without touching) a client to take a medication or treatment
touching without permission, with or without the intent to do harm, e.g., hitting or striking a client. If a mentally competent adult is forced to have treatment he/she has refused, battery occurs
Invasion of Privacy
Intrusion into another's body or into confidential information. Encroachment or trespassing on another's body and /or personality.
Detaining a competent person against his/her will, confinement without authorization
Revealing privileged information
LIBEL: Written statement that may cause harm to a person's reputation
SLANDER: Verbal statement that may cause harm to a person's reputation
myasthenia gravis- WHAT IS IT?
A disease in which acetylcholine receptors on muscle cells are destroyed so that muscles can no longer respond to the acetylcholine signal to contract. Symptoms include muscular weakness and progressively more common bouts of fatigue. The disease's cause is unknown but is more common in females than in males; it usually strikes between the ages of 20 and 50.
myasthenia gravis - nursing management
Offer large meals in the morning
and small meals in the evening.
a) Offer softer consistencies and
moisten dry food.
b) Position the patient upright
with his or her head slightly
forward when eating and
drinking, using compensatory
maneuvers (chin tuck, head
turn) as necessary.
c) Discourage talking and eating
at the same time and avoid
distractions while eating.
d) Review principles of nutrition
and basic food groups so
patients can select foods that
provide a balanced diet.
b. Consult with a dietitian to determine
nutritious food choices.
c. Consult with a speech pathologist to
determine the safest, most effective
Nursing recommendation: Nurses
should adopt the previous protocols to
facilitate swallowing, avoid aspirations,
and optimize nutritional and fluid status
C. Nursing management of fatigue
Nursing assessment of the patient with MG (Vassar,
Batenjany, Koopman, & Ricci, 2008)
A. Symptom description to be obtained during the
1. Location of the weakness
2. Quality or character of the weakness
3. Quantity or severity of the weakness
4. Timing (onset, duration, frequency) of
the weakness and relation to medication
5. Setting in which weakness occurs and/or
6. Aggravating or trigger factors (e.g., change
in emotional state, heat, humidity, infection,
7. Alleviating factors (e.g., rest)
B. Assessment techniques (Table 2 and Table 3)
(Howard, 2008; MGFA, 2000)
1. Ocular muscles
a. Eyelids for ptosis, diplopia (double
vision), extraocular muscles
2. Bulbar muscles
a. Chewing, swallowing, speech
3. Facial muscles
a. Flattening of the nasolabial fold, smile
symmetry, facial expression, resistance
to eyelid and lip closure, inability to
puff out cheeks
4. Head and neck muscles
a. Head drop
5. Limb muscles
myasthenia gravis - nursing management cont'd
Acute management requires comprehensive
care with attention to all systems and ventilatory
support and institution of measures
to minimize neuromuscular blockade.
a. Plasma exchange or IV
b. Identification and removal of offending
myasthenia gravis - nursing management cont'd-
be knowledgeable in the differentiation of
the two different types of MG crises, myasthenic
crisis or cholinergic crisis, and
should recognize that both are care priorities.
In either situation, nurses should
perform a complete respiratory and neuromuscular
assessment, which is essential to
identify ineffective respiratory function and
impaired gag and swallow, and initiate the
appropriate airway-management strategies
and oxygen delivery (Level 3) (Vassar et al.,
3. Assess and document respiratory status,
rate, rhythm, and breath sounds.
4. Assess gag and cough reflexes and quality
of voice; notify the physician of changes
5. Obtain baseline FVC (normal > 60 mg/kg).
6. Obtain NIF (normal > -70 cmH2O) and
continue to monitor (Mehta, 2006; Vassar
et al., 2008).
A chronic autoimmune condition that interferes with proper nerve transmission in the skeletal muscles, causing selective muscle weakness
MYASTHENIA GRAVIS- NURSING MANAGEMENT
swallowing, and chewing impairment,
nursing management for fatigue and energy conservation; stress-reduction techniques, pacing all activities, increased rest or sleep, and aerobic exercise; remain physically active; Identify self-care techniques and develop strategies to decrease activity intolerance and risk for injury and promote energy conservation at home, at work, and in the community. Use interdisciplinary team to screen for depression, need for PT, and/or OT; provide for periods of rest when planning activities; Use consistent routines, allowing for sufficient time; Assess a patient's abilities and restrictions to carry out daily activities including ADLs. Assess for weakness and/or visual impairment associated with self-care deficits and the need for assistive devices.
Which nursing diagnosis takes highest priority for a client with a compound fracture?
Risk for infection related to effects of trauma
A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
Inspecting the skin for petechiae once every shift
Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.
A client with irritable bowel syndrome is being prepared for discharge. Which meal plan should the nurse give the client?
High-fiber, low fat
The client with irritable bowel syndrome needs to be on a diet that contains at least 25 grams of fiber per day. Fatty foods are to be avoided because they may precipitate symptoms
A 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and could her son have something stronger. Which response by the nurse is appropriate?
"Opioids are avoided after a head injury because they may hide a worsening condition."
Opioids may mask changes in the level of consciousness (LOC) that indicate increased ICP and shouldn't be given. Saying acetaminophen is strong enough ignores the mother's question and therefore isn't appropriate. Aspirin is contraindicated in conditions that may cause bleeding, such as trauma, and for children or young adults with viral illnesses because of the danger of Reye syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his LOC.
When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately?
Hoarseness of the voice
Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.
The nurse is planning care for a 52-year-old male client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?
Decreased cardiac output
An acute addisonian crisis is a life-threatening event caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are also appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities during a crisis.
A client with a right stroke has a flaccid left side. Which intervention would best prevent shoulder subluxation?
Putting the affected arm in a sling
Because of the weight of the flaccid extremity, the shoulder may disarticulate. A sling will support the extremity. The other options won't support the shoulder.
The nurse is preparing a client who has been newly diagnosed with asthma for discharge. As part of his discharge orders, the client is prescribed albuterol (Proventil) via nebulizer every 8 hours for 3 days, followed by one dose daily thereafter. Which instruction should the nurse include when teaching the client about nebulizer use?
"You should take your pulse before and after treatment; if your pulse rate increases by more than 30 beats/minute you should notify your physician."
The nurse should show the client how to check his pulse rate. The client should be instructed to check his pulse rate before and after using his nebulizer and to call the physician if his pulse rate increases by more than 30 beats/minute. The nurse should instruct the client to use his nebulizer exactly as prescribed. Using the nebulizer more often than prescribed can cause the drug to lose effectiveness, or to produce uncomfortable adverse effects. The client should also be instructed to notify his physician if his shortness of breath worsens, the drug becomes less effective, or he develops palpitations, nervousness, or a hypersensitivity reaction such as a rash
A toddler is in the hospital. Which response to the parents, who are concerned about the seriousness of the child's illness, would be the most appropriate?
"It must be difficult for you when your child is ill and hospitalized."
Expressing concern about the parents' feelings is the most appropriate response. False reassurance, such as telling parents not to worry, isn't helpful. Encouraging parents to look at how ill other children are also isn't helpful because the focus of the parents is on their own child. Asking what the concern is reinforces the parents' concern without addressing it.
Which type of evaluation occurs continuously throughout the teaching and learning process?
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative isn't a type of evaluation.
The physician orders an I.M. injection for a client. Which factor may affect the drug absorption rate from an I.M. injection site?
Blood flow to the injection site
Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and strength have no effect on drug absorption. The amount of body fat at the injection site may help determine the size of the needle and the technique used to localize the site; however, it doesn't affect drug absorption (unless the nurse inadvertently injects the medication into the subcutaneous tissue instead of the muscle).
A client with chronic renal failure was recently told by his physician that he is a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which of the following responses is appropriate? Select all that apply.
• Take a seat next to the client and sit quietly to reflect on what he said.
• Say to the client, "You're feeling upset about the news you got about the transplant."
Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain a conversation. By reflecting the client's implied feelings, the nurse promotes communication. Using such platitudes as "We all have days when we don't feel like going on" fails to address the client's needs. The nurse should not leave the client alone because he may harm himself. Reminding the client of the treatment frequency doesn't address his feelings.
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect:
left calf circumference 1" (2.5 cm) larger than the right.
Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.
The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?
Current health promotion activities
Recognizing an individual's positive health measures is very useful. General health in the previous 10 years is important; however, the current activities of an 85-year-old client are most significant in planning care. Family history of diseases for a client in later years is of minor significance. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem.
Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance?
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. The nurse should also encourage the client to sleep in a darkened room that's well ventilated and at a comfortable temperature. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if commonsense interventions fail.
A female client taking antidepressant medication complains to the nurse that she has a decreased desire for sex, which is causing significant marital stress. Which response by the nurse would be the most appropriate
"What are your thoughts on how you should handle this?"
Encouraging the client to verbalize her thoughts will help her to problem-solve. Telling her not to stop taking the medication is too directive and doesn't encourage exploration on the part of the client. Asking the client if her husband understands the importance of taking the medication conveys negative judgment. Asking if the client has discussed the issue with her physician might be appropriate, but it may also give the impression that the nurse doesn't want to discuss the problem with the client.
A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention is the most appropriate?
Inviting a client with a similar experience to speak with the client
Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn't need professional help at this time. Discussing the concerns with the client's husband doesn't address the client's needs. In fact, the client may feel that the nurse violated confidentiality.
A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?
With a platelet count of 22,000/μl, the client bleeds easily. Therefore, the nurse should avoid using the I.M. route because the area is highly vascular and can bleed readily when penetrated by a needle.
A client comes to the clinic for diagnostic allergy testing. Why is an intradermal injection used for such testing?
Intradermal drugs diffuse slowly.
Drugs administered intradermally (injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapid introduction of an allergen into a sensitive client could cause a life-threatening allergic reaction.
A client is scheduled to receive levothyroxine (Synthroid) at 0900. When the nurse is finally able to administer the medication at 0930 the client is eating breakfast. The nurse knows that levothyroxine should be administered on an empty stomach. Which action by the nurse is best?
Administer the medication 30 minutes after the client is finished eating.
The nurse should delay the administration for 30 minutes after the client finishes eating because food interferes with the drug's absorption. The nurse should then document in the medication administration record the exact time that the medication was administered. Administering the medication with 8 oz of water won't facilitate absorption. The medication shouldn't be withheld, just delayed.
Which of the following characteristics would the nurse must likely assess in a client who has depersonalization disorder?
Sensation of detachment from body or mind
In depersonalization disorder, the client feels detached from his body and mental processes. The client is usually oriented to time, place, and person. Unexpected and sudden travel to another location is one of the characteristics of dissociative fugue. Clients with depersonalization disorder commonly feel the outside world has changed.
Within 8 hours of her last drink, an alcoholic client experiences tremors, loss of appetite, and disordered thinking. The nurse believes this client is exhibiting signs of alcohol withdrawal. What should the nurse do next?
Obtain a physician's order for lorazepam (Ativan)
A client in alcohol withdrawal should be medicated with a benzodiazepine, such as lorazepam, to prevent progression of symptoms to alcohol-withdrawal delirium, a life-threatening withdrawal syndrome. Disulfiram is used during early recovery, not during detoxification. Progressive muscle relaxation isn't particularly effective during withdrawal. Close monitoring during withdrawal is appropriate after the client has been medicated for withdrawal symptoms.