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.
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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.
The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention?
A. Bruise behind one ear
B. Blurred vision
C. Nausea and vomiting
D. Headache
A
Bruising behind one ear (over the mastoid process) requires the nurse's immediate attention. Known as "Battle's sign", this injury is seen a day or so following a basilar skull fracture. A CT scan of the brain will confirm a skull fracture. The client may report loss of hearing, smell or vision and he may have blood leaking from the ear. The vomiting and headache could be due to his alcohol intake, as well as the skull fracture.
The parents of a 2 year-old child report that the child has been holding the breath during temper tantrums. What is an appropriate approach for the response by a nurse?
A. Recommend that the parents give in when the child holds the breath to prevent anoxia
B. Advise the parents to ignore breath holding because breathing will begin as a reflex
C. Instruct the parents on how to reason with the child about possible harmful effects
D. Teach the parents how to perform cardiopulmonary resuscitation
B
If temper tantrums are accompanied by breath holding, the parents need to know that this behavior will not result in harm to the child. Ignoring the breath holding is the best response to this benign behavior.
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The nurse enters a client's room just as the client begins to experience a generalized tonic clonic seizure. What action should the nurse take?
A. Place the client on one side
B. Elevate the head of the bed
C. Hold the client's arms at the side
D. Insert a padded tongue blade in client's mouth
A
Clients should be positioned on their side. This position keeps the airway patent and allows saliva to drain from the mouth, which prevents aspiration. The nurse should also protect the client from injury by clearing furniture (if the client is on the floor). The client should not be restrained nor should anything be forced in the client's mouth.
Which statement by an older adult with chronic obstructive lung disease (COPD) indicates an understanding of the major reason to use pursed-lip breathing for episodes of dyspnea?
A. "This position of my lips helps to keep my lungs open."
B. "I can breathe better when I pucker up my lips because I can control how fast I breathe in and out."
C. "I can breathe better using pursed-lip breathing because less air will be trapped in my chest."
D. "My mouth doesn't get as dry when I breathe with pursed lips."
C
Clients with chronic obstructive pulmonary disease (COPD) have difficulty exhaling fully as a result of air trapping in the alveoli due to the weakened alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing, allowing the client to exhale more effectively. This technique facilitates appropriate gas exchange as carbon dioxide-rich air that has been trapped in the lungs is blown off, allowing oxygen-rich air to be inhaled. This is the major reason to use pursed-lip breathing. The other options are additional beneficial effects of this breathing technique.
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The initial response by the nurse manager should be which of these statements?
A. "I would like for you to approach the UAP about the problem the next time it occurs."
B. "I can assure you that I will look into the matter in due time."
C. "I will add this concern to the agenda for the next unit meeting so we can discuss it."
D. "I will arrange for a conference with you and the UAP within the next week"
A
Part of the manager's role is to help the staff manage conflict among themselves. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible. This is an approach at the first level of management. If the two staff members cannot resolve the issue then the manager would have a conference with the two staff to facilitate a negotiation for a win-win result.
Which of these client's behaviors would indicate that the nurse-client relationship has passed from the orientation phase to the working phase?
A. Identifies feelings about situations and expresses them appropriately
B. Revitalizes a relationship with the family to help cope with the death of a child
C. Expresses a desire to be cared for and pampered
D. Recognizes regressive behaviors as a defense mechanism
A
The working phase of the nurse-client relationship is also called exploration or the identification stage. That's because the client identifies his/her problems and works with the nurse to solve problems and develop coping skills, a positive self concept and, eventually, independence. These skills will help the client to adapt and behave more appropriately.
A client is scheduled for a CT scan with contrast. What interventions should be taken by the nurse prior to sending the client to the imaging department? (Select all that apply.)
A. Reassess the client's allergies
B. Administer prescribed medication to sedate the client
C. Confirm that a signed consent is in the chart
D. Ask the client to remove all metal jewelry
E. Ensure the client is well-hydrated
A,C,D
Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety.
A client reports bilateral knee pain from osteoarthritis and is taking the prescribed nonsteroidal anti-inflammatory drug (NSAID). The nurse should instruct the client to make which lifestyle change to manage this condition?
A. Avoid foods high in citric acid
B. Start a regular exercise program
C. Rest the knees as much as possible
D. Keep the legs elevated when sitting
B
A regular exercise program is beneficial in the treatment of osteoarthritis. It can restore self-esteem and improve physical functioning.
The nurse is preparing a client diagnosed with deep vein thrombosis (DVT) for a venous doppler evaluation. Which of these actions should be necessary to prepare the client for this test?
A. Determine if the client has any allergies to the contrast material
B. Ask client not to eat or drink anything after midnight
C. Administer a sedating medication prior to the test
D. Ensure the client is wearing a hospital gown prior to the test
D
A venous doppler examination uses ultrasound to create a 2-dimensional picture of the veins in the legs. The purpose is to detect blood clots. This is a noninvasive test and does not require sedation; a venography would require injecting contrast material into a vein. The client may eat or drink prior to the test.
During a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially take which action?
A. Help staff see the complexity of issues
B. Facilitate creative thinking about staffing
C. Allow the staff to change assignments
D. Clarify reasons for current assignments
B
The manager, as a change agent, can facilitate the staff's solving the problem. Referred to as the "moving phase" of Lewin's change theory, the problem is first viewed from a different perspective and a variety of solutions are examined and decided upon; a new approach for weekend assignments can then be tried out. [Show Less]