A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse should anticipate
... [Show More] which of these findings?
A. Lethargy
B. Diarrhea
C. Heat intolerance
D. Skin eruptions
A
In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption, decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client to report being constipated, tired and unable to get warm.
A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive Moro reflex and slight tremors. The newborn passed one loose, watery stool. Which of these actions is a nursing priority?
A. Hold the infant at frequent intervals
B. Offer fluids to prevent dehydration
C. Administer paregoric to stop diarrhea
D. Assess for neonatal withdrawal syndrome
D
Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyperirritability and gastrointestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the periods of withdrawal.
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Nurse colleagues are discussing their nursing practice during lunch. Which statement is correct?
A. Each state has specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs)
B. The employing agency is ultimately responsible to provide practice guidelines for licensed nurses
C. The federal government ensures the safety of clients by defining the scope of nursing practice
D. National nurses' associations work collaboratively to update the social policy statement for nursing
A
Boards of nursing are state governmental agencies that are responsible for licensing nurses in each state/jurisdiction and enforcing the rules and regulations of the nurse practice act (NPA). The NPA is enacted by the state legislature. The NPA and rules define the scope of practice and responsibilities for nurses. The scope of practice for nurses, especially LPN/VNs, varies from state to state.
An infant who has recently been diagnosed with cystic fibrosis (CF) is being assessed by the nurse. Which finding of this disease would the nurse not expect to see at this time?
A. Bulky, greasy stools
B. Positive sweat test
C. Moist, productive cough
D. Meconium ileus
C
Moist and productive cough is a later sign in CF. Noisy respirations and a dry nonproductive cough are commonly the first respiratory signs to appear in a newly diagnosed client with CF. The other options are the earlier findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
The nurse is caring for a client with orders for complete bed rest. Which action by the nurse is most important in the prevention of the formation of deep vein thrombosis (DVT)?
A. Prevent pressure at back of the knees
B. Elevate the foot of the bed
C. Encourage isometric leg muscle exercises
D. Apply knee high support stockings
A
Prevention of popliteal pressure will minimize venous stasis and deep vein thrombosis. The other actions would also be implemented for clients with orders for bed rest. However, the correct option is the one action directly associated with DVT.
The nurse is assessing a client with portal hypertension. Which findings should the nurse expect during the assessment?
A. Expiratory wheezes
B. Blurred vision
C. Dilated pupils
D. Ascites
D
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites from the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism is decreased with the result of a low serum albumin.
The nurse finds a client unconscious, following a tonic-clonic seizure. What should a nurse do first?
A. Administer the ordered Ativan
B. Place the client in a side-lying position
C. Prepare for suctioning
D. Check the pulse
B
Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. After that, any ordered medication should be given.
A 16 year-old adolescent is admitted for Ewing's sarcoma of the tibia. In discussing the care with the parents, the nurse should understand that the initial treatment for this diagnosis usually includes which approach?
A. Surgical excision of the mass
B. Radiation with adjunctive chemotherapy
C. Amputation above the tumor
D. Bone marrow graft in the affected leg
B
The initial approach for the treatment of Ewing's sarcoma is usually a combination of radiation and chemotherapy to reduce the size of the tumor.
A 2 day-old child with spina bifida and meningomyelocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents?
A. Disbelief
B. Anger
C. Frustration
D. Depression
A
The first phase of the grieving process is shock, denial or disbelief. Then follows anger, bargaining, depression and acceptance. Each stage can take any amount of time to work through. Clients often go back and forth between the stages until acceptance is achieved. Some clients may get stuck in any one or two of the stages to never achieve acceptance.
A client has a serum glucose of 385 mg/dL (21.4 mmol/L). Which of these verbal orders would be a priority for the nurse to question and call back the health care provider for a revision?
A. Repeat glycosolated hemoglobin in 24 hours
B. IV fluids of 0.9% normal saline at 125 mL per hour
C. Document peripheral glucose sticks every four hours
D. Humulin N 20 units IV push over 10 minutes
D
Short-acting insulin, such as regular or semilente insulin, is the only insulin that can be given by the intravenous route. Humulin insulin IV is the order to question. Repeating the glycohemoglobin should also be questioned, although it is not a priority because the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule for the past two to three months; there would be no need to repeat it at this time. A fasting glucose in the morning would be a more appropriate assessment. The other orders are within expected actions in this situation.
While discussing issues with colleagues on the unit, the novice nurse seems surprised when the other nurses state that the manager makes all decisions and rarely asks for staff input. What is the best description of the nurse manager's management style?
A. Ultraliberal or communicative
B. Laissez-faire or permissive
C. Autocratic or authoritarian
D. Participative or democratic
C
Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction. A Participative or democratic style is usually more successful on nursing units with a mix of staff of differing experience.
An 89 year-old with impaired mental status is transferred from a nursing home to the hospital for surgery. When assisting the client with a clear liquid diet postoperatively, the client begins to cough forcefully. What action by the nurse is indicated?
A. Refer the client for a swallowing assessment
B. Add a thickening agent to the fluids
C. Order a soft diet
D. Call the nursing home for more information
A
The nurse should contact the health care provider to request a swallowing assessment for this client. Older adults with impaired mental status are at greater risk for aspiration pneumonia. Thickening fluids and other actions may be required following the swallowing assessment. Also, remember to apply the nursing process - if a new problem develops, then further assessment is indicated.
A health care provider orders digoxin 0.125 mg by mouth daily and furosemide (Lasix) 40 mg daily by mouth. Which of these foods should the nurse reinforce for the client to eat at least one serving daily?
A. Blueberries
B. Wheat cereal
C. Tomato juice
D. Pear nectar
C
Tomato juice is highest in potassium per serving of the given foods. The other three foods are in a category of low potassium foods and will do little to replace potassium lost by the diuretic. Tomato juice (½ cup) has about 400 mg potassium; pear nectar (1 cup) has 33 mg; blueberries (½ cup) is 64 mg; and wheat cereal (1 cup) is 62 mg. The low potassium foods would be recommended for clients diagnosed with renal failure.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
A. Notify the anesthesia department and the surgeon of the client's refusal
B. Ask the client if the preference would be to remove the dentures in the operating room receiving area
C. Explain to the client that the dentures must come out as they may get lost or broken in the operating room
D. Ask the client if there are second thoughts about having the procedure
B
Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.
A client with a documented pulmonary embolism has the following arterial blood gases (ABG): PaO2 70 mm Hg, PaCO2 30 mm Hg, pH 7.48, SaO2 87%, HCO3 22. Based on this data, what is the first nursing action?
A. Have the client do slow, deep breathing
B. Administer the PRN oxygen by nasal cannula
C. Notify the health care provider of the results
D. Review prior ABG data from the prior shift
B
The low PaO2, along with the low oxygen saturation, is a priority. The first priority should be to administer oxygen to the client. Then the client should be guided to do slow, deep breathing because the PaCo2 is low, reflecting a hyperventilation effect of an increased respiratory rate with slight respiratory alkalosis. Prior lab results should be reviewed before notifying the health care provider.
The nurse is caring for the following clients. The nurse understands that which of these clients is at the highest risk for falling?
A. The 59 year-old who had hip replacement surgery four days ago and is going to physical therapy
B. The 67 year-old who is diabetic and has a draining ulcer on the right leg
C. The 81 year-old who fell at home last week and is confused
D. The 79 year-old who has arthritis and walks with the aid of a walker
C
Although all of the individuals might be at risk for falling, evidence shows that the greatest risk of falling is a person who is older than age 80, is confused, and has a history of falling.
A client is admitted with a diagnosis of myocardial infarction (MI). Which lab value is most commonly used to confirm this diagnosis?
A. Elevated C-reactive protein
B. Elevated myoglobin
C. Elevated creatine kinase (CK)
D. Elevated troponin levels
D
All of these lab tests may be elevated during an MI. Although CK-MB (along with total CK) is a very good test, it has been replaced by troponin. Elevation of troponin is the most reliable because it is more specific to heart damage; it elevates within a few hours and remains elevated for about 10 days. CK-MB is one of three separate forms (isoenzymes) of the enzyme creatine kinase (CK); it is found mostly in heart muscle and rises when there is damage to the heart. An elevated C-reactive protein is associated with a risk of cardiovascular disease.
The client is diagnosed with superficial thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
A. Elevate the affected leg
B. Apply cool compresses
C. Apply elastic support stockings
D. Maintain complete bed rest
A
Unlike deep vein thrombosis, superficial venous thrombosis involves a sudden inflammatory reaction (redness, pain, swelling), but it rarely involves an embolism. Treatment involves elevating the leg because dangling the extremity will increase the swelling and the pain. Other treatment options include warm compresses and analgesics (aspirin or another NSAID); sometimes a low-molecular weight heparin is also prescribed. Clients do not need to be on bed rest but they should wear elastic support stockings (or multiple elastic bandages) when out of bed.
The nurse must remove a fecal impaction in a 75 year-old client. During the procedure, the nurse should remember what critical information?
A. Family members should be taught the procedure
B. Cardiac dysrhythmias can result during the process
C. Increased dietary fiber and fluids can minimize such problems
D. The procedure is to be done prior to the bath
B
Cardiac dysrhythmias such as severe bradycardia can occur from vagal nerve stimulation during fecal impaction removal. The other actions are appropriate though they are not the priority consideration.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What information should the nurse know about this procedure when teaching the client?
A. The procedure compresses plaque against the wall of the diseased coronary artery to improve blood flow
B. It is a surgical repair with an incision of a diseased coronary artery to improve blood flow
C. Being a noninvasive radiographic examination of the heart, it has no invasive properties
D. The placement of an automatic internal cardiac defibrillator is done
A
PTCA is performed to open blocked coronary arteries caused by coronary artery disease (CAD). It is performed during a cardiac catheterization. The balloon is inflated once the catheter is in place in the diseased artery and this compresses the fatty tissue, resulti [Show Less]