A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that
... [Show More] pain associated with an MI is related to which of the following findings?
A. Insufficient oxygenation of the cardiac muscle
B. Fluid volume excess
C. Arrhythmia
D. An electrolyte imbalance
A
Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with the normal cardiac circulation.
Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy?
A. Conserves time spent on planning
B. Considers client and staff needs
C. Frees the nurse manager to handle other priorities
D. Allows requests for special privileges
B
Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level.
Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse?
A. Give two rescue breaths
B. Deliver five abdominal thrusts
C. Maintain an open airway
D. Check for a carotid pulse
D
According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations).
A mother, who has been exclusively breastfeeding her 6 month-old, requests more information about meeting the nutritional needs of her infant. What information will the nurse provide?
A. Begin a regular schedule of meals and snacks, offering a variety of foods
B. Offer finger foods to encourage self-feeding during family meals
C. Cut back on the number of times a day the infant receives breastmilk
D. Gradually begin adding pureed iron-rich meat and/or cereal as the first foods
D
The nurse should recommend increasing the number of times a day that complementary foods are offered while continuing to breastfeed. Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal should be the first complementary foods. After pureed foods, the next transition should be to add strained or mashed foods and then finger foods. From about one year of age, young children begin to have a regular schedule of meals and snacks.
The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin?
A. A school-aged child who has swallowed a handful of iron-fortified vitamins
B. A toddler who has eaten an undetermined number of ibuprofen tablets
C. A preschooler who bit into a laundry detergent pod
D. An infant who is diagnosed with botulism
D
Food-borne botulism can be treated by removing whatever contaminated food is in the stomach by using enemas (or by inducing vomiting) and administering a Botulinum antitoxin. Children with iron poisoning and who are breathing normally can be given a strong laxative fluid; severe poisonings require IV chelation therapy. For NSAID poisoning, sometimes activated charcoal is given (usually within 1 hour of ingestion); massive overdoses may require orogastric lavage because there is no specific antidote for ibuprofen. Since laundry detergent is an alkaline substance, the most commonly used therapy is dilution/irrigation/wash, especially for burns to the skin and eyes. Tracheal intubation with ventilation may be required if the child swallowed the laundry detergent.
The client is prescribed a new antipsychotic medication. The nurse is teaching a client about the medication and possible side effects, including tardive dyskinesia (TD). Which statement is true about tardive dyskinesia?
A. The high fever, sweating and muscle stiffness will last about one week
B. TD occurs within minutes of the first dose of any antipsychotic drug
C. The longer someone is treated with an antipsychotic medication, the higher the risk for developing TD
D. Almost every client treated with antipsychotic medications will eventually develop TD
C
The symptoms of tardive dyskinesia (TD) are characterized by random movements of different muscles and the tongue, lips or jaw. Longer treatment with antipsychotic medication, being female, being African American or Asian American are common risk factors for developing TD. Research shows that the overall risk of developing TD is about 30-50%. Decreasing the dose of the antipsychotic or switching antipsychotic medication can help, but there is no cure. Neuroleptic malignant syndrome is a rare and potentially life-threatening reaction to antipsychotic medications, when the client presents with hyperthermia, rigidity and autonomic dysregulation (hypertension, tachycardia, tachypnea, agitation, diaphoresis).
A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect?
A. Dysphagia
B. Nystagmus
C. Tardive dyskinesia
D. Oculogyric crisis
D
This refers to involuntary muscles spasm of the eye. There are medications to treat such side effects, for example trihexyphenidyl or benztropine.
A nurse is teaching about nonsteroidal anti-inflammatory agents (NSAIDs) to a group of clients diagnosed with arthritis. The nurse should emphasize which of these actions to minimize a side effect of these drugs?
A. Continue to take aspirin for short-term pain relief
B. Use alcohol in moderation when driving or operating heavy machinery
C. Take the medication after meals or with food
D. Report joint stiffness in the morning
C
Taking NSAIDs after meals or with food should help to minimize gastric irritation. The client should also take the medication with a full glass of water and remain in an upright position for 15 to 30 minutes after administration. Clients should be cautioned to avoid concurrent use of aspirin or alcohol with these medications to minimize possible gastric irritation; three or more glasses of alcohol per day may increase the risk of GI bleeding.
The nurse is caring for a 14 year-old child in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan?
A. Assist to stand up at bedside within the first few hours
B. Initiate the antibiotic therapy prescribed for 10 days
C. Evaluate the movement and sensation of extremities
D. Teach client isometric exercises for the legs
C
Following corrective surgery for scoliosis, the neurological status of the extremities requires priority attention in the PACU, as well as on the postop surgical unit. The other options may be done after the neurological status.
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" Which action should the nurse take next?
A. Ask the client to talk about concerns regarding "hot" treatments
B. Report the situation to the health care provider
C. Document the situation and client response in the notes
D. Talk with the client's family about the situation
A
In Hispanic folk medicine, it is believed that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states include pregnancy, hypertension, diabetes and indigestion. "Cold" diseases include pneumonia. These designations are symbolic and do not necessarily indicate temperature or spiciness. Care and treatment regimens can often be negotiated with clients within this framework. Also note that the correct response is the best answer because it is client-centered. [Show Less]